RN HESI Maternal Newborn Study Set
A pregnant woman presents with hyperemesis gravidarum, what is the best nursing intervention?
Administer prescribed IV solution.
A care healthcare provider prescribes a maintenance dose of magnesium sulfate 2 grams per hour intravenously for clients with preeclampsia. The IV bag contains magnesium sulfate 20 grams. How much in mL/hr should the nurse program the infusion pump? (enter numerical value only)
100 ml per hour
The healthcare provider prescribes Amoxicillin 500mg PO every 8hrs for a child who weighs 22 pounds. The available suspension is labeled; Amoxicillin Suspension 250mg/5ml. The recommended maximum dose is 50mg/kg/24hr. How many ml should the nurse administer in a single dose based on the child's weight? (Enter numerical value only. If rounding is required, round to the whole number.)
10mL
Who receives Palivizumab (synagis)?
A high risk baby
A child with leukemia is admitted for Chemotherapy with a nursing diagnosis of "altered nutrition, less than body requirements related to anorexia, nausea and vomiting". Which intervention should the nurse include in this child plan of care?
Allow the child to eat any food desired and tolerated.
A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
Ask the mother to stop the feeding, comfort the infant, and then assist the mother to help the baby latch on.
What intervention would you do to a newborn with a yellow abdomen and chest?
Assess bilirubin level
A blind little girl, 8 years old was admitted to the hospital. What should be brought to help comfort her during her hospital stay?
Bring familiar toys from home such as bear, doll.
What animal is recommended be avoided by a pregnant patient?
Cat
Why is propranolol used in children?
Decrease headaches
A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the condition, what information is most important for the nurse to provide?
Maternal blood pressure
What is the priority assessment for a child that presents with HIV?
Respiratory assessment
Patient presents with Duchenne Muscular Dystrophy Disease. The nurse should explain to the mother that this condition is inherited how?
This condition is inherited by an X-linked recessive chromosome pattern.
A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess? a. Abruptio placenta b. Placenta previa c. Preeclampsia d. Maternal bradycardia
a. Abruptio placenta Cocaine increases the risk for vasoconstriction and possible abruptio placenta
A nurse is assessing a newborn who has a weak cry and is grimacing. The nurse notes the newborn has a heart rate of 102/min, blueish extremities, and a flaccid muscle tone. Which of the following reflects the appropriate APGAR score? a. 4 b. 5 c. 6 d. 7
b. 5
A woman who is 38 weeks gestation is receiving magnesium sulfate for severe preeclampsia. Which assessment finding warrants immediate intervention by the nurse? a. Dizziness while standing b. Sinus tachycardia c. Lower back pain d. Absent patellar reflexes.
d. Absent patellar reflexes.
A client who delivered a healthy newborn an hour ago asked the nurse when can she go home. Which information is most important for the nurse to provide the client? a. After the baby no longer demonstrates acrocyanosis. b. After the vitamin K injection is given to the baby. c. When ambulating to avoid does not cause dizziness. d. When there is no significant vaginal bleeding.
d. When there is no significant vaginal bleeding.
A primigravida client in labor is receiving oxytocin 4 mu/minute to help promote an effective contraction pattern. The available solution is lactated ringer's 1,000 ml with oxytocin 20 units. The nurse should program the machine to deliver how many ML per hour?
12 ml per hour will give 4 mu per minute. Dose/Available stock x Quantity (4mu/20,000 mu)x1000 ml=0.2 ml x 60 min = 12 ml
A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D5W. How many ml of the solution should the nurse administer?
13mL
A 34-week primigravida woman with preeclampsia is receiving Lactated Ringer's 500ml with magnesium sulfate 20 grams at the rate of 3g/hr. How many ml/hr should the nurse program the infusion pump? (Enter numeric value only.)
75 ml/hr
What helps relieve pain associated with mastitis?
Ice packs
A nurse on the newborn unit is planning discharge for four clients. Which of the following will require care beyond that of a standard follow-up visit with the provider after delivery? a. A newborn being sent home after 22 hours after birth b. A newborn at 38 weeks of gestational age c. A newborn who is bottle feeding d. Twin newborns with Apgar scores of 8 and 9
a. A newborn being sent home after 22 hours after birth Screening tests must be repeated if they were performed before the newborn was 24 hours old.
The nurse is planning discharge teaching for four mothers. Which postpartum client is at highest risk for psychological difficulties during the postpartum period? a. A primiparas woman who has recently migrated to the US with a spouse. b. A multiparous client who lives with her husband and his family members. c. A multiparous female with a large family living in a community. d. A primiparas adolescent living at home with their parents and significant other.
a. A primiparas woman who has recently migrated to the US with a spouse.
What should be the primary focus of nursing care in the transitional phase of labor for a client who anticipates an unmedicated delivery? a. Assessing the strength of uterine contractions b. Re-evaluate the need for medication c. Remind her to push 3 times with each contraction. d. Assessing her to maintain control.
a. Assessing the strength of uterine contractions
The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What maternal prescription is most important in preventing this fetus from developing respiratory syndrome? a. Betamethasone (Celestone) 12mg deep IM. b. Butorphanol 1mg IV push q2h PRN pain. c. Ampicillin 1g IV push q8h. d. Terbutaline (Brethine) 0.25mg subcutaneously q15 minutes x3.
a. Betamethasone (Celestone) 12mg deep IM.
What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia and a tracheoesophageal (TE) fistula? a. Body temperature. b. Level of pain. c. Time of first void. d. Number of vessels in the cord.
a. Body temperature.
While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first? a. Change the maternal position. b. Administer oxygen at 10/l by mask. c. Prepare for a potential cesarean. d. Allow the client to begin pushing.
a. Change the maternal position.
One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15,000/mm3. What action should the nurse take first? a. Check the differential, since the WBC is normal for this client. b. Assess the client's temperature, pulse, and respirations q4h. c. Notify the healthcare provider, since this finding is indicative of infection. d. Assess the client's perineal area for signs of a perineal hematoma.
a. Check the differential, since the WBC is normal for this client.
A nurse is providing teaching about nonpharmacological pain management for a postpartum client who is breastfeeding and has engorgement. Which of the following methods should the nurse recommend? a. Cold cabbage leaves b. Modified lanolin cream c. A breast binder d. Breast shells
a. Cold cabbage leaves Application of this is an effective nonpharmacological method to relieve pain associated with engorgement
A new mother who is a lacto-ovo vegetarian plans to breast feed her infant. Which information should the nurse provide prior to discharge? a. Continue prenatal vitamins with B12 while breastfeeding b. Avoid using Lanolin-based nipple cream or ointment. c. Offer iron fortified supplemental formula daily. d. Weigh the baby weekly to evaluate the newborns growth.
a. Continue prenatal vitamins with B12 while breastfeeding
The health care provider prescribes 10 units per liter of oxytocin via IV drip to augment a client's labor because she's experiencing a prolonged active phase. Which finding would cause the nurse to immediately discontinue the oxytocin? a. Contraction duration of 100 seconds. b. Four contractions in 10 minutes. c. Uterus is soft. d. Early deceleration of fetal heart rate.
a. Contraction duration of 100 seconds.
A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? a. Discuss the need for cortisol and aldosterone replacement therapy after discharge b. Support the parents in their decision to assign sex of their child according to their preference c. Offer information about ultrasonography and genotyping to determine sex assignment d. Explain that corrective surgical procedures consistent with sex assignment can be delayed
a. Discuss the need for cortisol and aldosterone replacement therapy after discharge
A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why is my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply.) a. Explain that newborns get milk from their mothers in this way. b. Reassure the older brother that is does not hurt his mother. c. Remind him that his mother breastfed him too. d. Suggest that the baby can also drink from a bottle. e. Clarify the breastfeeding is his mother's choice.
a. Explain that newborns get milk from their mothers in this way. b. Reassure the older brother that is does not hurt his mother. c. Remind him that his mother breastfed him too.
A client at 30 weeks gestation reports that she has not felt the baby move in the last 24 hours. Concerned, she arrives in a panic at the obstetric clinic where she is immediately sent to the hospital. Which assessment warrants immediate intervention by the nurse? a. Fetal Heart rate of 60 beats per minute b. Ruptured amniotic membrane c. Onset of uterine contractions d. Leaking amniotic fluid.
a. Fetal Heart rate of 60 beats per minute
A nurse is providing dietary teaching to a client who has hyperemesis gravidarum. Which of the following statements by the client indicates an understanding of the teaching? a. I should eat to taste instead of trying to balance my meals b. I will avoid having a snack at bedtime c. I will have 8 oz of hot tea with each meal d. I should pair my sweets with a starch instead of eating them alone
a. I should eat to taste instead of trying to balance my meals Eat to taste to avoid nausea
A nurse in a clinic is caring for a client who is at 32 weeks of gestation. Which of the following clinical findings should alert the nurse to a potential complication? a. Fundal height is 34 cm b. Client reports diarrhea for 3 days c. Client reports ankle edema d. Blood pressure is 130/80
b. Client reports diarrhea for 3 days Indicates illness or infection
A nurse is providing discharge instructions to a client who had a vaginal delivery and is breastfeeding her newborn. Which of the following statements indicates an understanding of the teaching? a. I will need to eat an additional 330 calories a day while I'm breastfeeding b. I will change my perineal pad at least twice a day c. I will massage my uterus daily for 7 days d. I will breastfeed my baby every 2 hours
a. I will need to eat an additional 330 calories a day while I'm breastfeeding
A newborn nursery protocol includes a prescription for ophthalmic erythromycin 5% ointment to both eyes upon a newborn admission. What action should the nurse take to ensure adequate installation for the client? a. Instill a thin ribbon into each lower conjunctival sac b. Occlude the inner canthus after retracting the eyelids c. Mummy wrap the infant before instilling the ointment d. Stabilize the instilling hand on the neonate's head
a. Instill a thin ribbon into each lower conjunctival sac
A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication? a. Jaundice. b. Poor appetite. c. Brain damage. d. Hypoglycemia.
a. Jaundice.
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? a. Keep airway equipment at the bedside. b. Allow liberal family visitation c. Monitor blood pressure, pulse, and respirations q4h d. Assess temperature q1h
a. Keep airway equipment at the bedside.
A nurse is caring for a client who is to receive oxytocin (Pitocin) to augment her labor. Which of the following contraindicates the initiation of the oxytocin infusion and requires notification of the provider? a. Late decelerations b. Baseline variability c. Cessation of uterine dilation d. Prolonged active phase of labor
a. Late decelerations Oxytocin is contraindicated based on late decelerations noted on fetal assessment findings because they indicate uteroplacental insufficiency.
What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia to a client who is at 40-weeks gestation? a. Maternal blood pressure. b. Level of pain sensation c. Station of presenting part. d. Variability of fetal heart rate.
a. Maternal blood pressure.
Insulin therapy is initiated for a 12-year-old child who is admitted with diabetic ketoacidosis (DKA). Which action is most important for the nurse to include in the child's plan of care? a. Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R). b. Determine the child's compliance schedule for subcutaneous NPH insulin (Humulin N). c. Demonstrate to parents how to program an insulin pen for daily glucose regulation. d. Consult with healthcare provider about use of insulin detemir (Levemir Flex Pen).
a. Monitor serum glucose for adjustment in infusion rate of regular insulin (Novolin R).
The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing intervention has the highest priority? a. Monitor urinary output b. Auscultate bowel sounds c. Observe appearance of stool d. Record percent of diet eaten
a. Monitor urinary output
Four clients at full term present to the labor and delivery unit at the same time. Which client should a nurse access first? a. Multipara with contractions occurring every three minutes. b. Multiple scheduled for non stress test and biophysical profile. c. Primipara with vaginal show and leaking membranes. d. Primipara with burning on urination and urinary frequency.
a. Multipara with contractions occurring every three minutes.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? a. Place the infant in a knee-chest position. b. Administer morphine sulfate. c. Start intravenous fluids. d. Provide 100% oxygen by face mask.
a. Place the infant in a knee-chest position.
A primipara has delivered a stillborn fetus at 30-weeks gestation. To assist the parents with the grieving process, which intervention is most important for the nurse to implement? a. Provide an opportunity for the parents to hold their infant in privacy. b. Assist the couple in completing a request for autopsy. c. Encourage the couple to seek family counseling within the next few weeks. d. Explain the possible causes of fetal demise.
a. Provide an opportunity for the parents to hold their infant in privacy.
*A client at 38 weeks gestation is admitted to the labor and delivery unit with a complaint of contractions 5 minutes apart. While the client is in the bathroom changing into a hospital gown, the nurse hears the noise of a baby. What action should the nurse take first? a. Push the call light for help b. Inspect the clients perineum c. Notify a health care provider d. Turn on the infant warmer
a. Push the call light for help
The nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child? a. Reduce cerebral edema and lower intracranial pressure b. Avert hypotension and septic shock c. Prevent cardiac arrhythmias and heart failure d. Promote kidney perfusion and normal blood pressure.
a. Reduce cerebral edema and lower intracranial pressure
A postpartum client who is Rh-negative refuses to receive RhoGAM after delivery of an infant who is Rh-positive. Which information should the nurse provide this client? a. RhoGAM prevents maternal antibody formation for future Rh-positive babies. b. RhoGAM is not necessary unless all her pregnancies are Rh-positive. c. The R-positive factor from the fetus threatens her blood cells. d. The mother should receive RhoGAM when the baby is Rh-negative.
a. RhoGAM prevents maternal antibody formation for future Rh-positive babies.
A primigravida client being treated for preeclampsia with magnesium sulfate delivered a 7 pound infant 4 hours ago by cesarean delivery. Which nursing problem has the highest priority? a. Risk for injury related to uterine atony. b. Ineffective breastfeeding related to fatigue. c. Acute pain related to abdominal incision. d. Impaired parenting related to inexperience.
a. Risk for injury related to uterine atony.
A client at 35 weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse notes the client's temperature to be 101.2 F (38.4 C), with severe abdominal or uterine tenderness on palpation. The nurse knows that these findings are indicative of what condition? a. Round ligament strain. b. Chorioamnionitis. c. Abruptio placenta. d. Viral infection.
b. Chorioamnionitis.
Examination reveals that the laboring client's cervix is dilated to 2 centimeters, 70% effaced, with the presenting part at -2 station. The client tells the nurse "I need my epidural now, this hurts". The nurses response to the client is based on which information? a. The client will need to be catheterized before the epidural can be administered. b. Administering an epidural at this point would slow down labor process. c. The client should be dilated to at least 8 centimeters before receiving an epidural. d. The baby needs to be at a zero station before an epidural can be administered.
a. The client will need to be catheterized before the epidural can be administered.
The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask "how can our son have this disease? We are wondering if we should have any more children." What information should the nurse provide these parents? a. This is an inherited X-linked recessive disorder, which primarily affects male children in the family. b. The male infant had a viral infection that went unnoticed and untreated, so muscle damage was incurred. c. The XXXX muscle groups of males can be impacted by a lack of the protein dystrophy in the mother. d. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles.
a. This is an inherited X-linked recessive disorder, which primarily affects male children in the family.
A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which assessment finding indicates to the nurse that the infant is becoming dehydrated? a. Weak cry without any tears. b. Bulging fontanel. c. Visible peristaltic wave. d. Palpable mass in the right upper quadrant.
a. Weak cry without any tears.
A nurse is providing discharge teaching to a client who is postpartum about resuming sexual activity. Which of the following instructions should the nurse include in the teaching? a. You should use a water soluble gel for lubrication b. You can resume sexual activity in 10 days c. Your physical reaction to sexual stimulation will not be altered d. You will not ovulate for 3 months after delivery
a. You should use a water soluble gel for lubrication This will prevent discomfort
A two year old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement? a. Determine the pulse deficit b. Administer the scheduled dose c. Calculate the safe dose range d. Review the serum digoxin level
b. Administer the scheduled dose
A nurse is caring for a client newly admitted to the PACU following a cesarean birth. Which of the following is the priority nursing assessment? a. Parent-child attachment b. Amount of postpartum lochia c. Patency of the IV catheter d. Quality and quantity of urine output
b. Amount of postpartum lochia The greatest risk to the client is bleeding. The amount of lochia can assist the nurse in determining if excessive bleeding is occurring. Assess the client for postpartum hemorrhage.
The nurse is planning care for a client at 30 weeks gestation who is experiencing preterm labor. Which intervention is most important in preventing this fetus from developing respiratory distress syndrome? a. Ampicillin 1 gram IV push q8h b. Betamethasone 12 mg deep IM c. Terbutaline 0.25 mg subcutaneously q 15 minutes X 3 d. Butorphanol tartrate 1mg IV push q2h PRN.
b. Betamethasone 12 mg deep IM
The nurse places one hand above the symphysis while massaging the fundus of a multiparous client whose uterine tone is boggy 15 minutes after delivering a 7 pound 10 ounce (3220 gram) infant. Which information should the nurse try to provide the client about this finding? a. The uterus should be firm to prevent an intrauterine infection b. Both the lower uterine segment and the fundus must be massaged c. A firm uterus prevents the endometrial lining from being sloughed d. Clots may form inside a boggy uterus and needs to be expelled
b. Both the lower uterine segment and the fundus must be massaged
A child who received multiple blood transfusions after correction of a congenital heart defect is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider? a. CO combining power b. Calcium c. Sodium d. Chloride
b. Calcium
A multiparous client at 36 hours postpartum reports increased bleeding and cramping. On examination, the nurse finds the uterine fundus 2 centimeters above the umbilicus. Which action should the nurse take first? a. Increase the intravenous fluid to 150ML/hr. b. Call the health care provider. c. Encourage the client to void. d. Administer ibuprofen 800 milligrams by mouth.
b. Call the health care provider.
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4hrs to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticarial, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? a. Auscultate the lungs for respiratory pneumonia. b. Change to latex-free gloves when handling infant. c. Draw blood to analyze for streptococcal infection. d. Apply zinc oxide to perineum with each diaper change.
b. Change to latex-free gloves when handling infant.
A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? a. Carrots b. Chicken c. Yogurt d. Cheese
b. Chicken
The nurse is conduction postpartum teaching with a mother who is breastfeeding her infant. When discussing birth control which method should the nurse recommend to this client as best for her to use in preventing unwanted pregnancy? a. Breastfeed exclusively at least every 3 to 4 hours. b. Condoms and contraceptive foam or gel. c. Rhythm method (natural family planning). d. Combined estrogen-progesterone oral contraceptives.
b. Condoms and contraceptive foam or gel.
Following a traumatic delivery, an infant receives an initial Apgar score of 3. Which intervention is most important for the nurse to implement? a. Page the pediatrician STAT b. Continue resuscitative efforts c. Repeat the Apgar assessment in 5 minutes d. Inform the parents of the infant's condition.
b. Continue resuscitative efforts
A newborn with a respiratory rate of 40 breaths per minute at one minute after birth is demonstrating cyanosis of the hands and feet. What action should a nurse take. a. Assess bowel sounds. b. Continue to monitor. c. Assist with intubation. d. Rub the infant's back.
b. Continue to monitor.
A client at 26 weeks gestation was informed this morning that she has an elevated alpha fetal protein (AFP) level. After the health care provider leaves the room, the client asks what she should do next. What information should the nurse provide? a. Reassure the client that the AFP results are likely to be a false reading. b. Explain that the sonogram should be scheduled for definitive results. c. Inform her that a repeat alpha fetoprotein AFP should be evaluated. d. Discuss options for intrauterine surgical correction of congenital defects.
b. Explain that the sonogram should be scheduled for definitive results.
A newborn assessment reveals spina bifida occulta. Which maternity factors should the nurse identify as having the greatest impact on the development of this newborn complication? a. Short interval pregnancy b. Folic acid deficiency c. Preeclampsia d. Tobacco use
b. Folic acid deficiency
A newborn assessment reveals spina bifida occulta. Which maternal factor should the nurse identify as having the greatest impact on the development of this newborn complication? a. Tobacco use. b. Folic acid deficiency. c. Short interval pregnancy. d. Preeclampsia.
b. Folic acid deficiency.
A 3-hour old male infant presents with hands and feet that appear cyanotic, axillary temperature of 96.5 degrees Fahrenheit (35.8 degrees Celsius), respiratory rate of 40 breaths per minute, and a heart rate of 165 beats per minute. What nursing action should nurse implement? a. Administer oxygen by mouth at 2L/min b. Gradually warm the infant under a radiant heat source. c. Notify the pediatrician of the infant's vital signs d. Perform a heel-stick to maintain blood glucose level
b. Gradually warm the infant under a radiant heat source.
A 4-year-old boy was recently diagnosed with Duchenne muscular dystrophy (DMD). Which characteristic of the disease is most important for the nurse to focus on during the initial teaching? a. Lower legs become progressively weaker, causing a waddling, unsteady gait. b. Growth and development have been abnormal since birth. c. Muscular strength can be regained with physical exercise and therapy. d. Respiratory dysfunction and aspiration are prime concerns at this stage of disease.
b. Growth and development have been abnormal since birth.
A nurse is caring for a client who has a history of rheumatic disease, but no physical symptoms prior to pregnancy. The client begins to experience dyspnea, orthopnea, and pulmonary edema. Which of the following biological alterations explains this change? a. Increased maternal weight b. Increased blood volume c. Change in hematocrit levels d. Change in heart size
b. Increased blood volume Increase in blood volume during pregnancy increase the workload of the heart, which causes the symptoms
A male infant with a 2-day- history of fever and diarrhea is brought to the clinic by his mother who tells the nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no tears. Which prescription is most important to implement? a. Provide a bottle of electrolyte solution. b. Infuse normal saline intravenously. c. Administer an antipyretic rectally. d. Apply external cooling blanket.
b. Infuse normal saline intravenously.
A 5-year-old child is admitted to the pediatric unit with a fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? a. Obtain a culture of any sputum or wound drainage b. Initiate normal saline IV at 50 ml/hr c. Administer a loading dose of penicillin IM d. Administer the initial dose of folic acid PO
b. Initiate normal saline IV at 50 ml/hr
A 16 year old gravida 1 para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She's not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? a. Allow liberal family visitation b. Keep an airway at the bedside c. Assess temperature every hour d. Monitor blood pressure, pulse, and respiration every 4 hours.
b. Keep an airway at the bedside
A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring? a. Assessment of dilation and effacement b. Leopold maneuvers c. Sterile speculum exam d. Nitrazine test
b. Leopold maneuvers Helps the nurse assess the position of the fetus to best determine the optimal placement for the fetal monitoring transducer.
A primigravida patient at 36 weeks gestation is RH negative and experienced abdominal trauma in a motor vehicle collision. Which assessment finding is most important for the nurse to report to the health care provider? a. Fetal heart rate at 162 beats /minute b. Mild contractions every 10 minutes. c. Trace of protein in the urine d. Positive fetal hemoglobin testing
b. Mild contractions every 10 minutes.
A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? a. Alert the neonatal team and prepare for neonatal resuscitation b. Notify the healthcare provider from the client's bedside c. Obtain written consent for an emergency cesarean section d. Draw a blood sample for stat hemoglobin and hematocrit
b. Notify the healthcare provider from the client's bedside
A client who is 24 weeks gestation arrives to the clinic reporting swollen hands. On examination, the nurse notes the client has had a rapid weight gain over six weeks. Which action should the nurse implement next? a. Review previous blood pressures in the chart. b. Obtain the clients blood pressure. c. Observe and time the client's contractions. d. examine the client for pedal edema
b. Obtain the clients blood pressure.
A 10-year-old is admitted to the orthopedic unit with a diagnosis of slipped femoral capital epiphysis (SFCE). What focus should the nurse include in this child's plan of care? a. Ambulation with a walking cast. b. Pin and incisional care after surgery. c. Use of injections for pain control. d. Administration of growth hormone.
b. Pin and incisional care after surgery.
A mother spontaneously delivers a newborn infant in the taxi-cab while on the way to the hospital. The emergency room nurse reported that the mother has active herpes (H5V III) lesions on the vulva. Which intervention should the nurse implement first when admitting the neonate to the nursery? a. Document the temperature on the flow sheet. b. Place the newborn in the isolation area of the nursery. c. Obtain blood specimen for serum glucose level. d. Administer the vitamin K injection
b. Place the newborn in the isolation area of the nursery.
A client at 34 weeks gestation comes to the birthing center complaining of vaginal bleeding that began one hour ago. The nursing assessment reveals approximately 30mL of bright red vaginal bleeding, fetal rate of 130 - 140 beats per minute, no contractions, and no complaints of pain. What is the most likely cause of the client's bleeding. a. Abruptio Placenta b. Placenta Previa c. Normal bloody show indicting induction of labor d. A ruptured blood vessel in the vaginal vault.
b. Placenta Previa
A 6-month-old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should the nurse plan to implement? a. Obtain the healthcare provider's advice as to when the restraints should be removed. b. Remove restraints one at a time to provide range of motion exercises. c. Record observation of the restraints q2h and ensure that they are in place at all times. d. Remove restraints q4h for 30 minutes and place gloves on the child's hands.
b. Remove restraints one at a time to provide range of motion exercises.
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic sudden aimless movements of the arms and legs. Which information should the nurse provide to the parents? a. Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged. b. The chorea or movements are temporary and will eventually disappear c. Permanent life-style changes need to be made to promote safety in the home d. Consistent discipline is needed to help the child control the movements
b. The chorea or movements are temporary and will eventually disappear
A nurse is caring for a newborn who was transferred to the nursery 30 min after delivery. Which of the following actions should the nurse take first? a. Confirm the newborn's Apgar score b. Verify the newborn's identification c. Administer vitamin K IM to the newborn d. Determine the obstetrical risk factors
b. Verify the newborn's identification Mandatory to continue ongoing identification of the newborn whenever the newborn is removed from the mother's direct presence and care.
A nurse is providing family planning education to a client who has decided to use a diaphragm. Which of the following should the nurse include in the plan of care? a. You should replace the diaphragm every 3 years b. You should leave the diaphragm in place for at least 6 hours after intercourse c. You should use an oil based product as a lubricant when inserting the diaphragm d. You should insert the diaphragm when your bladder is full
b. You should leave the diaphragm in place for at least 6 hours after intercourse
During the admission procedure of a 6-year-old, the child states, "I'm going to have an operation." Which response is best for the nurse to provide to this child? a. "Are you scared?" b. "We're going to do everything we can to take very good care of you." c. "Tell me what an operation is." d. "I'm glad your mother told you why you were coming to the hospital."
c. "Tell me what an operation is."
A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history, which finding should the nurse expect to obtain? a. High blood cholesterol level on routine screening b. Increased thirst and urination c. A recent strep throat infection d. A recent DPT immunization
c. A recent strep throat infection
A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The fetal monitor shows uterine contractions every 6 min, lasting 20-25 seconds, and an FHR of 150/min. The provider prescribed betamethasone (celestone) 12 mg IM. Which of the following outcomes should the nurse expect? a. Decreased uterine contractions b. An increase in the client's hemoglobin levels c. A reduction in respiratory distress in the newborn d. Increased production of antibodies in the Newborn
c. A reduction in respiratory distress in the newborn Given to stimulate fetal lung maturity and prevent respiratory distress
The nurse is assessing a 9-year old boy who has been admitted to the hospital with possible acute post streptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? a. Back pain for a few days b. A history of hypertension c. A sore throat last week d. Diuresis during the nights
c. A sore throat last week
A primiparas woman presents in labor with the following labs: Hemoglobin 10.9 g/dl (109 g/dl), Hematocrit 29% (0.29), Hepatitis Surface Antigen positive, Group B Streptococcus positive, and Rubella non-immune. Which intervention should the nurse implement? a. Transfuse 2 units packs red blood cells. b. Give measles mumps rubella vaccine 0.5 ML. c. Administer ampicillin 2 grams intravenously. d. Inject hepatitis B immune globulin 0.5 milliliters.
c. Administer ampicillin 2 grams intravenously.
A nurse is caring for a client who is pregnant and has epilepsy. The nurse observes the client having a seizure. After turning the client's head to one side, which of the following actions should the nurse take next? a. Monitor the fetal heart rate b. Assess uterine activity c. Administer oxygen via a non-rebreather mask d. Start a bolus of IV fluids
c. Administer oxygen via a non-rebreather mask
A 6-year-old with heart failure (HF) gained 2 pounds in the last 24 hours. Which intervention is more important for the nurse to implement? a. Graph the daily weight for the past week. b. Decrease IV flow rate. c. Assess bilateral lung sounds. d. Restrict intake of oral fluids.
c. Assess bilateral lung sounds.
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? a. Turn the client to her left side b. Contact the healthcare provider c. Assess the fetal heart rate d. Check the cervical dilation
c. Assess the fetal heart rate
A nurse is caring for a client who is in active labor and reports back pain. The nurse performs a vaginal exam and determines the client is 8cm dilated, 100% effaced, and -2 station. The fetus is in the occiput posterior position. Which of the following is an appropriate intervention? a. Perform effleurage during contractions b. Place the client in lithotomy position c. Assist the client to the hands and knees position d. Apply a fetal scalp electrode
c. Assist the client to the hands and knees position Helps relieve back pain and help the fetus rotate
The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? a. Respiratory rate of 22 breaths/min b. A large amount of lochia rubra c. Blood pressure 149/90 d. Positive Homan's sign
c. Blood pressure 149/90
A newborn's head circumference is 12 inches (30.5 cm) and his chest measurement is 13 inches (33 centimeters). The nurse notes that this infant has no molding, and it had a bridge presentation delivered by cesarean section. What action should the nurse take based on this data? a. No action needs to be taken; it is normal for an infant born by caesarean section to have a small head circumference. b. Notify the pediatrician immediately. These signs support the possibility of hydrocephalus. c. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal. d. Record the findings on the chart. They are within normal limits.
c. Call these findings to the attention of the pediatrician. The head/chest ratio is abnormal.
The nurse is providing care for a newborn who was delivered vaginally assisted by forceps. The nurse observes red marks on the head with swelling that does not cross the suture line. Which condition should the nurse documents in the medical record? a. Caput succedaneum b. Hydrocephalus c. Cephalohematoma d. Microcephaly
c. Cephalohematoma
The nurse notes on the fetal monitor that a laboring client has a variable deceleration. Which action should the nurse implement first? a. Turn off the oxytocin infusion b. Assess cervical dilation c. Change the client's position d. Administer oxygen via facemask
c. Change the client's position
A client at 40-weeks- gestation presents to the obstetrical floor and indicates that the amniotic membranes ruptured spontaneously at home. She is in active labor, and feels the need to bear down and push. What information is most important for the nurse to obtain first? a. Estimated amount of fluid. b. Any odor noted when membranes ruptured. c. Color and consistency of fluid. d. Time the membranes ruptured.
c. Color and consistency of fluid.
A primigravida patient arrives at the maternity unit because she thinks she is in labor. The nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140 beats per minute and contractions are occurring irregularly every 10 to 15 minutes. Which assessment finding confirms to the nurse that the client is not in labor at this time? a. Membranes are intact. b. 2+ pitting edema in lower extremities. c. Contractions decrease with walking. d. Cervical dilation is 1 centimeter.
c. Contractions decrease with walking.
A client at 31 weeks gestation with a fundal height measurement of 25 cm is scheduled for a series of ultrasounds to be performed every two weeks. Which explanation should the nurse provide? a. Assessment for congenital anomalies. b. Recalculation of gestational age. c. Evaluation of fetal growth. d. Determination of fetal presentation.
c. Evaluation of fetal growth.
The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? a. Begin a training program lifting weights and running b. Splint affected joints during activity c. Exercise in a swimming pool d. Perform passive range of motion exercises twice daily
c. Exercise in a swimming pool
A client at 37 weeks gestation presents to labor and delivery with contractions every two minutes the nurse observes several shallow small vesicles on her pubis labia and perineum. The nurse should recognize the client is exhibiting symptoms of which condition? a. Genital Warts b. Syphilis c. Herpes Simplex Virus d. German Measles
c. Herpes Simplex Virus
12 hours after the birth of a healthy infant, the mother complains of feeling constant vaginal pressure. The nurse determines the fundus is firm and at midline, with moderate rubra lochia. Which action should the nurse take? a. Check the suprapubic area for distention. b. Inform the client to take a warm sitz bath c. Inspect the client's perineal and rectal areas d. Apply a fresh pad and check in 1 hour.
c. Inspect the client's perineal and rectal areas
A client who is pregnant presents to a prenatal clinic for her first visit. She tells the nurse that her last normal menstrual period began Oct 13. Using Nagele's rule, the nurse should determine the client's estimated date of delivery as which of the following? a. July 6 b. July 13 c. July 20 d. July 27
c. July 20 Add a year, subtract 3 months, add 7 days
A nurse is assessing a young adult client in a women's health clinic who asks for a contraceptive. The client reports to the nurse a familial history of osteoporosis. Which of the following contraceptive methods is contraindicated for this client? a. Combined estrogen-progestin oral contraceptives b. An intrauterine device c. Medroxyprogesterone acetate (Depo-Provera) d. Norelgestromin/ethinyl estradiol (Ortho Evra)
c. Medroxyprogesterone acetate (Depo-Provera) Causes a decrease in bone mineral density and places the client at risk for the development of osteoporosis
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis
c. Metabolic acidosis
A child that has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
c. Metabolic alkalosis
A young girl with a fractured radius has a cast applied. As the cast is drying, it is elevated above the level of her heart. Which assessment finding should the nurse report to the healthcare provider immediately? a. Itching sensation under the cast. b. Swelling of fingers with brisk capillary refill. c. Numbness and inability to move fingers. d. Visible bruising above the cast.
c. Numbness and inability to move fingers.
A 30-year-old primigravida delivers a nine-pound (4082 gram) infant vaginally after a 30-hour labor. What is the priority nursing action for this client? a. Assess the blood pressure for hypertension. b. Gently massage fundus every four hours. c. Observe for signs of uterine hemorrhage. d. Encourage direct contact with the infant.
c. Observe for signs of uterine hemorrhage.
The nurse measuring the frontal occipital circumference (FOC) of a 3-month-old infant notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next? a. Measure the infant's head to heel length b. Observe the infant for sunset eyes c. Palpate the anterior fontanel for tension and bulging d. Plot the measurement on the infant's growth chart
c. Palpate the anterior fontanel for tension and bulging
A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes three contractions in 10 min with late decelerations occurring with two of the contractions. Which of the following findings should the nurse report to the provider? a. Reactive b. Nonreactive c. Positive d. Negative
c. Positive Indicates an adverse reaction by the fetus and should be reported to the provider
A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes three contractions in 10 min with late decelerations occurring with two of the contractions. Which of the following findings should the nurse report to the provider? a. Reactive b. Nonreactive c. Positive d. Negative
c. Positive Indicates an adverse reaction by the fetus and should be reported to the provider
A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse respond? a. Advise the mother to wait at least another month before starting any solid foods. b. Instruct the mother to offer a few spoons of 2 or 3 pureed fruits at each meal. c. Reassure the mother that the infant is old enough to eat iron-fortified cereal. d. Encourage the mother to schedule a developmental assessment of the infant.
c. Reassure the mother that the infant is old enough to eat iron-fortified cereal.
The nurse is assessing a 2-hour-old infant born by cesarean delivery at 39-weeks gestation. Which assessment finding should receive the highest priority when planning the infant's care? a. Blood pressure 76/42 mmHg. b. Faint heart murmur. c. Respiratory rate of 76 breaths/minute. d. Blood glucose 45mg/gl.
c. Respiratory rate of 76 breaths/minute.
A full term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first? a. Suction the oral and nasal passages. b. Give oxygen by positive pressure. c. Stimulate the infant to cry. d. Turn the infant onto the right side.
c. Stimulate the infant to cry.
A nurse is assessing a client during a weekly prenatal visit that is at 38 weeks of gestation. Which of the following client findings should the nurse report to the provider? a. Blood pressure 136/88 b. Report of insomnia c. Weight gain of 2.2 kg d. Report of Braxton-Hicks contractions
c. Weight gain of 2.2 kg Above the expected reference range and could indicate complications
Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis? a. Encourage fluid intake b. Promote complete bed rest c. Weight the child daily d. Administer vitamin supplements
c. Weight the child daily
After administering varicella vaccine to a 5-year-old child, which instruction should the nurse provide to the child's parent? a. Chewable children's aspirin will help prevent inflammation. b. Keep the child home from daycare for the next two days. c. Any level of fever is serious and should be reported right away. d. Apply a cool pack to the injection site to reduce discomfort.
d. Apply a cool pack to the injection site to reduce discomfort.
A community health nurse visits a family in which a 16-year-old unmarried daughter is pregnant with her first child and is at 32-weeks gestation. The client tells the nurse that she has been having intermittent back pain since the night before. What is the priority nursing intervention? a. Ask the client's mother to call an ambulance for transport to the hospital immediately. b. Determine what physical activates the client has performed for the past 24hrs. c. Teach the client how to perform pelvic rock exercises and observe for correct feedback. d. Ask the client if she has experienced any recent changes in vaginal discharge.
d. Ask the client if she has experienced any recent changes in vaginal discharge.
A client in the first trimester of pregnancy calls the prenatal clinic to report she's nauseated, and her stools are black and thick since she started taking iron supplements last week. How should the nurse respond? (select all that apply) a. Come to the clinic today. b. Drink a full glass of tea with each iron tablet. c. Increase the consumption of milk while taking iron. d. Changes in color and consistency of stool are normal. e. Take iron supplement at bedtime.
d. Changes in color and consistency of stool are normal.
During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder". How should the nurse respond? a. Explain that the risk of inhering the disorder decrease by 50% with each child the couple has. b. Acknowledge that the next child will inherit the disorder since the first child did not. c. Encourage the couple to reconsider their decision since the inheritance pattern may be sex linked. d. Confirm that there is a 50% chance of their future children inheriting the disorder.
d. Confirm that there is a 50% chance of their future children inheriting the disorder.
A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? a. Pain level b. Blood pressure c. Infusion site d. Contraction pattern
d. Contraction pattern
The nurse is caring for a multiparous client who is 8 centimeters dilated, 100% effaced, and the fetal head is at 0 station. The client is shivering and states extreme discomfort with the urge to bear down. Which intervention should the nurse implement? a. Administer IV pain medication b. Perform a vaginal exam c. Reposition to side lying d. Encourage pushing with each contraction
d. Encourage pushing with each contraction
A 17 year old client gave birth 12 hours ago. She states that she doesn't know how to care for her baby. To promote parent-infant attachment behaviors, which intervention should the nurse implement? a. Ask if she has help to care for the baby at home. b. Provide a video on newborn safety and care. c. Explore the basis of fears with the client. d. Encourage rooming in while in the hospital.
d. Encourage rooming in while in the hospital.
The parents of a newborn tell the nurse that their baby is already trying to walk. How should the nurse respond? a. Encourage the parents to report this to the healthcare provider. b. Acknowledge the parents observation. c. Schedule the newborn for further neurological testing. d. Explain the newborn's normal stepping reflex.
d. Explain the newborn's normal stepping reflex.
The nurse is scheduling a client with gestational diabetes for an amniocentesis because the fetus has an estimated weight of 8 pounds (3629 grams) at 36 weeks gestation. This amniocentesis is being performed to obtain which information? a. Presence of a neural tube defect. b. Chromosomal abnormalities. c. Gender of the fetus. d. Fetal lung maturity.
d. Fetal lung maturity.
On the first postpartum day, the nurse examines the breast of a new mother. Which condition is the nurse most likely to find. a. Firm, larger, and very tender to touch. b. Slightly firm with immediate let-down response. c. Soft with no change from before delivery. d. Filling and secreting colostrum.
d. Filling and secreting colostrum.
A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? a. Bilateral bronchial breath sounds b. Diaphragmatic respiration c. A resting respiratory rate of 35 breathe per minute d. Flaring of the nares
d. Flaring of the nares
A client whose labor is being augmented with an oxytocin (Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam performed 1 hour ago were: 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first? a. Decrease the oxytocin infusion rate b. Determine current cervical dilation c. Request placement of the epidural d. Give a bolus of intravenous fluids
d. Give a bolus of intravenous fluids
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces of orange juice. What should the nurse do next? a. Tell the mother to follow the iron drops with infant formula instead of orange juice. b. Suggest placing the iron drops in the orange juice and then feeding the infant. c. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops. d. Give the mother positive feedback about the way she administered the medication.
d. Give the mother positive feedback about the way she administered the medication.
A client tells the nurse that she thinks she's pregnant. Which signs or symptoms provide the best indication that the client is pregnant? a. Morning sickness. b. Breast tenderness c. Amenorrhea. d. Hegar's sign.
d. Hegar's sign.
The nurse is planning care for a 4-year-old girl who is diagnosed as having a developmental disability. What should be the primary focus of treatment for this child? a. Teach her social skills. b. Assist in preventing further disability. c. Ensure her participation in group activities. d. Help her achieve her maximum potential.
d. Help her achieve her maximum potential.
A nurse is teaching a client about Rho(D) immunoglobulin (RhoGAM). Which of the following statements by the client indicates an understanding of the teaching? a. I will receive this medication if my baby is Rh-negative b. I will receive this medication at time of delivery c. I will need a second dose of this medication when my baby is 6 weeks old d. I will need this medication if I have an amniocentesis
d. I will need this medication if I have an amniocentesis Recommended because of the potential of fetal RBCs entering the maternal circulation
The mother of a breastfeeding 24-hour old infant is very concerned about the techniques involved in breastfeeding. She calls the nurse with each feeding to seek reassurance that she is doing it right. She tells the nurse, "How will I know if my daughter is not getting enough to eat". Which response would be best for the nurse to make? a. Feed your baby hourly until you feel confident that your child is receiving enough milk. b. Don't worry, soon your milk will come in and you will feel how full your breasts are. c. Since you are so concerned, you should probably supplement breastfeeding with formula. d. If your baby's urine is straw colored, she's getting enough milk
d. If your baby's urine is straw colored, she's getting enough milk
The nurse is caring for a female client, a primigravida with preeclampsia. Findings include +2 proteinuria, BP 172/112 mmHg, facial and hand swelling, complaints of blurry vision and a sever frontal headache. Which medication should the nurse anticipate for this client? a. Clonidine hydrochloride. b. Carbamazepine c. Furosemide d. Magnesium sulfate.
d. Magnesium sulfate.
The nurse is receiving report for a laboring client who arrived in the emergency center with ruptured membranes that the client did not recognize occurred. What is the priority nursing action to implement when the client is admitted to the labor and delivery suite? a. Begin a pad count. b. Prepare to start an IV. c. Take the clients temperature. d. Monitor amniotic fluid for meconium.
d. Monitor amniotic fluid for meconium.
A nurse is admitting a client to the labor and delivery unit when the client states, "my water just broke", which of the following is the priority intervention for the nurse to take? a. Perform Nitrazine testing b. Assess the amniotic fluid c. Check cervical dilation d. Monitor the fetal heart rate
d. Monitor the fetal heart rate Rupture of the membranes places the fetus at risk for umbilical cord prolapse.
At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement? a. Initiate an intravenous infusion. b. Observe the FHR pattern for 30 more minutes. c. Schedule a biophysical profile. d. Place an acoustic stimulator on the abdomen.
d. Place an acoustic stimulator on the abdomen.
The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used? a. Place the infant in side-lying position to facilitate the exam. b. Hold the penis and retract the foreskin gently. c. Cleanse the penis with an antiseptic-soaked pad. d. Place the infant in a warm room and use a calm approach.
d. Place the infant in a warm room and use a calm approach.
The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and the 12 year old sibling are at the child's bedside. Which instruction best shows family support? a. While waiting for the healthcare provider, only one visitor may stay with the child. b. All of you should leave while the healthcare provider sutures the child's forehead c. It is best if the sibling goes to the waiting room until the suturing is completed d. Discussing who will stay when the healthcare provider begins suturing
d. Please decide who will stay when the healthcare provider begins suturing
The nurse is preparing to administer phytonadione to a newborn. Which statement made by the parents indicates understanding of why the nurse is administering this medication? a. Improve insufficient dietary intake. b. Stimulates the immune system c. Help an immature liver. d. Prevent hemorrhagic disorders.
d. Prevent hemorrhagic disorders.
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having desired effect? a. Weight gain. b. Reduction of fever. c. Improved caloric intake. d. Reduction of edema.
d. Reduction of edema.
A nurse is conducting an initial prenatal visit for a client who is at 6 weeks gestation. Which of the following laboratory tests should be performed? a. 24 hour urine for protein b. Group B streptococcus culture c. 3-hr glucose tolerance d. Rubella titer
d. Rubella titer Obtained at the initial prenatal visit to determine immunity to rubella
The mother of a preschool-aged child calls the school nurse to report that her child was bitten by a tick while on a school outing last week. The mother tells the nurse that she removed the tick and flushed it down the toilet. What action should the school nurse take? a. Refer the mother to the center for disease control. b. Report the incident to the school principal. c. Culture the site when the child returns to school. d. Schedule a test for Lyme disease if rash appears.
d. Schedule a test for Lyme disease if rash appears.
The nurse is reviewing the serum laboratory finding for a 5-day-old infant with congenital adrenal hyperplasia. Which laboratory results should be reported to the healthcare provider immediately? a. Bilirubin of 1.5 mg/dl. b. Glucose of 80 mg/dl. c. Potassium of 4.5 mEq/L. d. Sodium of 119 mEq/L.
d. Sodium of 119 mEq/L.
A 38-week primigravida patient is admitted to the labor and delivery unit after a non-reactive result on a nonstress test (NST). The nurse begins a contraction stress test (CST) with an oxytocin infusion. Which finding is most important for the nurse to report to the health care provider? a. A pattern of fetal late decelerations. b. Fetal heart rate accelerations with fetal movement. c. Absence of uterine contractions within 20 minutes. d. Spontaneous rupture of membranes.
d. Spontaneous rupture of membranes.
A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn? a. Warm the heel prior to the puncture b. Request a prescription for IM analgesic c. Use a manual lance blade to pierce the skin d. Swaddle the newborn after the heel puncture
d. Swaddle the newborn after the heel puncture Effective technique to diminish the pain experience for the newborn.
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (t4) and high levels of thyroid stimulating hormone (TSH). What is the best explanation for this finding? a. The thyroxine level is low because the TSH level is high. b. High thyroxine levels normally occur in breastfeeding infants. c. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth. d. The TSH is high because of the low production of t4 by the thyroid.
d. The TSH is high because of the low production of t4 by the thyroid.
A pregnant client mentions in a history that she changes the cats litter box daily. Which test should the nurse anticipate the health care provider to prescribe? a. Biophysical profile. b. Fern test. c. Amniocentesis. d. Torch screening.
d. Torch screening.
