ATI Adaptive Quiz PEDS/OB - Hard Questions

A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak

C. The child reports tightness at the wrist Correct Answer: C. The child reports tightness at the wrist The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome. Incorrect Answers:A. The nurse should expect the child to have mild to moderate pain due to the fracture; therefore, a pain level of 5 on a scale of 0 to 10 is an expected finding. If the pain becomes severe and is unrelieved by analgesics, it could indicate an impairment in circulation. B. The nurse should monitor the child for indications of impaired circulation after a cast is applied. The nurse should be concerned if only the casted extremity is cool but not if the finding is bilateral. D. The nurse should expect the child to have impaired function such as a weak grasp due to the fracture. However, if the child develops paralysis of the extremity, it could indicate an impairment in circulation.

A nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "Your child will need to begin the vaccination series over again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine is due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5°F and head congestion." Check Answer Question Feedback Show Explanation Grade Pause Previous

Correct Answer: A. "Initial vaccines should be administered between birth and 2 weeks of age." The first dose of the hepatitis B vaccine should be administered within the first 2 weeks after birth. The dose should be given before discharge from the hospital if the mother is hepatitis B surface antigen (HBsAg) negative. Incorrect Answers:B. If a client receives an initial dose in a series but misses a subsequent dose, the client will not need to begin the series again. The client should receive the missed dose as soon as possible. C. Allergic reactions to vaccines are most often caused by the inactive parts of the vaccine, which are used to enhance the effectiveness of the vaccine. Examples of inactive ingredients that might cause an allergic reaction include purified culture medium proteins such as egg and antibiotics such as neomycin. D. A vaccination does not need to be postponed for minor illnesses such as a common cold. A rectal temperature of 37.5°C (99.5°F) is considered within the expected reference range. However, all immunizations should be postponed for a severe febrile illness.

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should consume 1,000 calories per day." B. "My child should have 4 oz of protein per day." C. "I should give my child 32 oz (4 cups) of milk per day." D. "I should feed my child 4 oz (1/2 cup) of vegetables per day."

Correct Answer: A. "My child should consume 1,000 calories per day." Toddlers who are 2 years old should consume 1,000 calories daily. Incorrect Answers:B. Toddlers who are 2 years old should have 2 oz of protein daily. C. Toddlers who are 2 years old should have no more than 24 oz (3 cups) of milk per day. D. Toddlers who are 2 years old should consume 8 oz (1 cup) of vegetables per day.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous, bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she asks about this finding? A. "This will resolve in 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This appearance is expected at birth, so you don't need to worry."

Correct Answer: A. "This will resolve in 3 to 6 weeks without treatment." This discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum. It will resolve within 2 to 6 weeks. Incorrect Answers:B. A caput succedaneum is present at birth and extends across suture lines. It is edema of the scalp and will resolve in 3 to 4 days. C. The provider will not aspirate the fluid due to the risk of infection when puncturing the skin. D. This finding is not expected in most newborns.

A nurse in a clinic is providing education to a client at 32 weeks of gestation who has pruritus gravidarum. Which of the following pieces of information should the nurse provide? A. "You should slightly increase your exposure to sunlight." B. "You will need extensive dermatological treatment for this condition after you deliver your baby." C. "Your provider will schedule weekly lab testing to monitor your liver function." D. "Your provider will prescribe isotretinoin cream."

Correct Answer: A. "You should slightly increase your exposure to sunlight." Pruritus gravidarum is a condition of pregnancy that causes generalized itching without the presence of a rash. This occurs due to the stretching of the skin. Exposure to sunlight can reduce itching. Incorrect Answers:B. Pruritus gravidarum is a condition of pregnancy that causes generalized itching that occurs due to the stretching of the skin. It will resolve without extensive treatment after delivery. C. Pruritus gravidarum is a condition of pregnancy that will go away after delivery. It has no effect on the liver. Therefore, the client will not require weekly liver function studies. D. Isotretinoin cream is used to treat acne. It should not be prescribed to a client who is pregnant due to its teratogenic effects on the fetus.

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations

Correct Answer: A. Administer ibuprofen The nurse should administer ibuprofen or acetaminophen for mild to moderate pain. If pain is not relieved, the nurse should administer an opioid analgesic. Incorrect Answers:B. The nurse should encourage the child to increase daily fluid intake to reduce blood viscosity and prevent sickling of red blood cells. C. Cold compresses increase vasoconstriction and increase pain. Therefore, the nurse should apply warm compresses to painful joints. D. The nurse should ensure the child receives all immunizations to prevent infection. Infection is a major cause of death in children who have sickle cell anemia.

A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure

Correct Answer: A. Bulky stools The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools. Incorrect Answers:B. The nurse should identify that a weakened rectal sphincter is not a manifestation of cystic fibrosis. C. The nurse should identify that a prolapsed rectum is associated with insufficient pancreatic enzymes. D. The nurse should identify that a prolapsed rectum is associated with increased intra-abdominal pressure.

A nurse is caring for a client during her first prenatal visit and notes that she is lactose-intolerant. Which of the following foods should the nurse include on a list of calcium sources for this client? A. Collard greens B. Cottage cheese C. Orange juice D. Broccoli

Correct Answer: A. Collard greens Collard greens are a good source of lactose-free calcium. One cup of collard greens provides approximately the same amount of calcium as the equivalent volume of 240 mL (8 oz) of milk. Collard greens also contain folic acid, which is a nutrient women should consume during pregnancy to prevent birth defects. Incorrect Answers:B. Cottage cheese is a good source of calcium but contains lactose, which the client cannot tolerate. C. Orange juice is high in vitamin C, but unless the orange juice is calcium-fortified, it is not a rich source of calcium. D. Broccoli is high in folic acid, but it is not a rich source of calcium.

A nurse in a labor and delivery unit is caring for a client who is in the second stage of labor. Which of the following actions should the nurse take? A. Encourage the client to frequently change positions. B. Instruct the client to take breaths and hold them for 10 seconds while pushing C. Assess maternal vital signs every 1 hour D. Assist the client to the restroom

Correct Answer: A. Encourage the client to frequently change positions. During the second stage, frequent position changes can promote the descent of the fetus through the birth canal. The nurse should assist the client in finding optimal positions of comfort which allow the client to rest between contractions but also enhances expulsive efforts. Incorrect Answers:B. Having the client hold her breath while pushing increases intrathoracic and cardiovascular pressure and decreases the amount of oxygen that reaches the fetus. C. The nurse should assess the client's vital signs every 5 to 30 minutes while the client is in the second stage of labor. D. The client should remain on bedrest during this stage of labor due to impending delivery.

A nurse is assessing a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Fastening buttons on a shirt B. Tying shoelaces C. Parting and combing hair D. Cutting the meat at dinner

Correct Answer: A. Fastening buttons on a shirt The nurse should expect a 4-year-old child to have the fine motor ability to fasten buttons on a shirt; however, the child may have difficulty if the buttons are small. Incorrect Answers:B. The nurse should expect a 4-year-old child to have the fine motor ability to lace shoes; however, tying shoelaces is a fine motor skill expected of a 5-year-old child. C. The nurse should expect a 7-year-old child to have the fine motor ability to part and comb his/her hair without the need of assistance. D. The nurse should expect a 7-year-old child to have the fine motor ability to cut tender pieces of meat with a table knife.

A nurse is reviewing the laboratory findings of a 24-hour-old newborn. Which of the following findings should the nurse report to the provider? A. Hemoglobin 12 g/dL B. Platelet count 200,000/mm^3 C. Total bilirubin 4 mg/dL D. Glucose 50 mg/dL

Correct Answer: A. Hemoglobin 12 g/dL The nurse should report a hemoglobin level of 12 g/dL to the provider because it is below the expected reference range of 14 to 24 g/dL. Incorrect Answers:B. The expected reference range for a newborn's platelet count is 150,000 to 300,000/mm^3. C. The expected reference range for this newborn's total bilirubin level is 2 to 6 mg/dL. D. The expected serum glucose level for this newborn is 40 to 60 mg/dL.

A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include? A. Higher body fat content is associated with earlier onset of menarche B. Pubic hair is typically present prior to breast development C. Ovulation begins after sexual maturation is complete D. Menarche signals the beginning of puberty

Correct Answer: A. Higher body fat content is associated with earlier onset of menarche The nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche. Incorrect Answers:B. The nurse should inform the parents that breast development usually begins around 8 to 12 years of age, followed 2 to 6 months later by the appearance of pubic hair. C. The nurse should inform the parents that ovulation is stimulated by the increasing amount of estrogen that develops after the onset of menarche. This increased level of estrogen promotes further sexual maturation. D. The nurse should inform the parents that menarche is an indication of late puberty. The onset of menstrual periods is preceded by an increase in height, breast development, and the appearance of pubic hair.

A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg

Correct Answer: A. Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site. Incorrect Answers:B. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the upper arms during basketball competitions. C. Basketball involves both the arms and legs. Therefore, the client should avoid making injections in the thighs during basketball competitions. D. The lower leg is not a recommended injection site for insulin. Insulin is administered subcutaneously into adipose or fat tissue over a muscle. Recommended injection sites for insulin are the abdomen, hips, buttocks, upper arms and thighs. When participating in vigorous exercise, the nurse should instruct the client to select an injection site that is not on an extremity involved in the activity.

A nurse is caring for a client who is scheduled to receive a spinal anesthetic. Which of the following actions should the nurse plan to perform? A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure B. Assess the fetal heart rate pattern for 10 min prior to the procedure C. Position the client upright and erect on the edge of the bed prior to the procedure D. Monitor vital signs every 15 min after the anesthetic is placed

Correct Answer: A. Infuse a 500 mL bolus of 0.9% sodium chloride immediately prior to the procedure The nurse should infuse a fluid bolus of 500 to 1,000 mL of 0.9% sodium chloride or lactated Ringer's 15 to 30 minutes before the procedure to offset the potential complication of hypotension. Incorrect Answers:B. The nurse should assess the fetal heart rate pattern for a minimum of 20 to 30 minutes prior to the procedure. C. The nurse should position the client with the spine flexed to open the intervertebral spaces and allow the placement of the spinal needle. D. The nurse should monitor the client's blood pressure, pulse, respirations, and fetal heart rate every 5 to 10 minutes after the introduction of the anesthetic agent.

A nurse is planning care for a newborn who was born at 30 weeks gestation. The nurse should plan to assess the newborn for which of the following potential complications associated with prematurity? A. Intraventricular hemorrhage B. Hyperglycemia C. Hyperthermia D. Meconium aspiration syndrome

Correct Answer: A. Intraventricular hemorrhage When an infant is born before 34 weeks gestation, the blood vessels in the brain are fragile. Additionally, premature infants have an impaired coagulation process and fluctuating blood pressure. Combined, these factors increase the risk of bleeding into the ventricles of the brain and subsequent neurological damage. Incorrect Answers:B. A premature infant has an increased risk of hypoglycemia due to decreased glycogen stores and increased metabolic needs. These infants are typically unable to meet nutritional needs with oral intake. C. Due to limited subcutaneous and brown fat stores and an inability to maintain a flexed position, a premature infant has a greatly increased risk of hypothermia. D. Meconium aspiration syndrome is typically a complication of post-term infants. Insufficient gas exchange from an aging placenta can lead to hypoxic episodes during which the fetus releases meconium into the amniotic sac.

A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include? A. Monitor the child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

Correct Answer: A. Monitor the child's oxygen saturation level When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and allows adequate oxygenation of the surrounding tissue. Incorrect Answers:B. The nurse should administer prescribed antibiotics to treat any existing infection. However, another intervention is the priority to include in the plan of care. C. The nurse should encourage fluid intake to prevent dehydration and clumping of red blood cells. However, another intervention is the priority to include in the plan of care. D. The nurse should apply a warm compress to the joints to reduce pain and inflammation. However, another intervention is the priority to include in the plan of care.

A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death? A. People can come back to life after they die. B. Death eventually occurs for all people. C. Death is a scary monster that causes people to die. D. People are unable to be anything but alive.

Correct Answer: A. People can come back to life after they die. A preschooler typically views death as temporary and interchangeable with life. Incorrect Answers:B. An understanding that death is inevitable is usually not achieved until age 9 to 10. C. School-age children might view death as a monster. D. Toddlers are typically unable to comprehend the meaning of death; however, a preschooler has usually moved beyond this level of egocentricity.

A school nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints

Correct Answer: A. Potential for sustaining abdominal trauma An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen. Incorrect Answers:B. Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, after returning to school, he should not have deficient dietary intake. C. Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. D. An adolescent who has mononucleosis will not have joint inflammation.

A nurse is providing dietary teaching to the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

Correct Answer: A. Provide a high-fat diet for the toddler Children who have cystic fibrosis have impaired intestinal absorption of fat. Therefore, the toddler will require an increased intake of fat. Incorrect Answers:B. The parent does not need to restrict the toddler's intake of sodium. C. The parent should increase the toddler's daily caloric intake. An increase in foods high in folic acid is not required for children who have cystic fibrosis. D. The parent should increase the toddler's daily caloric intake by 110% to 200% to meet increased nutritional needs. Therefore, the toddler should not skip meals.

A nurse is assessing a client who is at 34 weeks gestation and has a cardiac disorder. The nurse should notify the provider about which of the following assessment findings? A. The client reports a frequent cough. B. The client reports that none of her shoes fit anymore. C. The client reports a weight gain of 2 lb in a 2-week period. D. The client reports leg cramps in the evening.

Correct Answer: A. The client reports a frequent cough. A frequent cough could be an indication of cardiac decompensation and should be reported to the provider. Incorrect Answers:B. Edema of the lower extremities is a common occurrence in pregnancy and does not warrant provider notification. Generalized edema should be reported. C. This weight gain is within the expected range during the second and third trimester of pregnancy for a client of average pre-pregnant weight. It does not warrant notification of the provider. Excessive weight gain could be a sign of cardiac decompensation and should be reported. D. Leg cramps are a frequent occurrence during pregnancy due to compression of lower-extremity nerves from the enlarging uterus. This finding does not warrant notification of the provider.

A nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of the great arteries B. Ventricular septal defect C. Coarctation of the aorta D. Patent ductus arteriosus

Correct Answer: A. Transposition of the great arteries An infant who has transposition of the great arteries will have severe cyanosis because reversal of the anatomical position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation. Incorrect Answers:B. An infant who has a ventricular septal defect (a hole in the septal wall between the ventricles) can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for systemic circulation. C. An infant who has coarctation of the aorta (constricted segment of the aorta that obstructs blood flow to the body) is unlikely to have cyanosis. Even though the left ventricle must generate higher than normal pressures for adequate stroke volume, oxygenation of the blood remains adequate for the systemic circulation. D. An infant who has a patent ductus arteriosus will have a blood vessel connecting the pulmonary artery to the aorta. The infant can have increased pulmonary vascular resistance, but oxygenation of the blood remains adequate for systemic circulation.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate of 125/min C. Soft, flat fontanel D. Systemic murmur

Correct Answer: A. Weight gain of 1.8 kg (4 lb) A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider. Incorrect Answers:B. A heart rate of 125/min is an expected finding in a 2-month-old infant. C. A soft, flat fontanel is an expected finding in a 2-month-old infant. D. A systemic murmur is an expected finding in an infant who has a ventricular septal defect.

A nurse is providing teaching for a 14-year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."

Correct Answer: B. "Keep hair off your forehead." Hair and scalp care can provide relief from the manifestation of acne. Frequent shampooing and keeping hair away from the face can improve acne. Incorrect Answers:A. Abrasive skin agents such as exfoliating cleansers can worsen acne and cause trauma to the skin. Only gentle skin cleansers should be used. C. Tetracycline should be taken on an empty stomach to improve the absorption of the medication. D. The nurse should instruct the client not to squeeze or pick acne lesions. Squeezing acne lesions ruptures glands and causes sebum to spread into the skin, which increases inflammation.

A nurse is admitting a client who is in post-term labor. Which of the following statements should the nurse identify as the priority? A. "I had blood-streaked discharge a few hours ago." B. "When my water broke, it was not clear." C. "I have not felt my baby move as much today." D. "I feel like I cannot breathe when I walk up the stairs."

Correct Answer: B. "When my water broke, it was not clear." The greatest risk to this client is an injury to the newborn from meconium aspiration; therefore, addressing this statement is the nurse's priority. Incorrect Answers:A. The nurse should confirm that there is no active bleeding and reassure the client that this event could have been the bloody show; however, addressing another statement is the nurse's priority. C. The nurse should confirm the heartbeat of the fetus via Doppler to reassure the client or take action if the heartbeat is not identifiable; however, addressing another statement is the nurse's priority. D. The nurse should assess the client's respiratory pattern to confirm that the client's shortness of breath is due to elevation of the diaphragm from the enlarging uterus and not a respiratory infection; however, addressing another statement is the nurse's priority.

A nurse is teaching a client about using the Lamaze method to manage pain during labor. Which of the following pieces of information should the nurse include? A. "Learning about childbirth will reduce any fear you might have, which will help you focus more on abdominal breathing during contractions." B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing." C. "During labor, you will be encouraged to disassociate by using an internal focal point." D. "During labor, you will use conscious relaxation and levels of progressive breathing."

Correct Answer: B. "You will learn how to prevent pain during labor by focusing your mind to control your breathing." The Lamaze philosophy is based on prophylaxis by using the mind. The method is based on the theory that through stimulus-response conditioning, clients can learn to use controlled breathing to reduce pain during labor. Incorrect Answers:A. This response is representative of the Dick-Read method of managing pain during childbirth because it focuses on reducing fear. Fear is reduced through education prior to labor. C. This response is representative of the Bradley or partner-coached method. This method is based on the premise that pregnancy and childbirth are joyful, natural processes and that a woman's partner should play an active role during pregnancy, labor, and the early newborn period. D. The psychosexual method includes a program of conscious relaxation and levels of progressive breathing that encourage a woman to flow with rather than struggle against contractions.

A nurse is reviewing recommended immunizations with the guardian of a 2-month-old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella vaccine at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine before 6 months of age." D. "You baby can start the measles, mumps, and rubella vaccine now."

Correct Answer: B. "Your baby can start the pneumococcal vaccine now." The infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age. Incorrect Answers:A. The nurse should instruct the guardian that the infant should not receive the varicella vaccine until 1 year of age. C. The nurse should instruct the guardian that the infant can receive an annual influenza vaccine beginning at 6 months of age. D. The nurse should instruct the guardian that the infant can receive the first dose of the measles, mumps, and rubella vaccine beginning at 12 months of age.

A nurse is caring for several clients. Which of the following clients should the nurse identify as a candidate for oral contraceptives? A. A client who smokes 2 packs of cigarettes per week B. A client who is breastfeeding a 7-month-old infant C. A client who is taking an anticonvulsant medication D. A client who is taking anti-HIV protease inhibitors

Correct Answer: B. A client who is breastfeeding a 7-month-old infant A client can begin using oral contraceptives 4 weeks after childbirth; therefore, this client is a candidate for oral contraceptive therapy. Incorrect Answers:A. Smoking is a contraindication for oral contraceptive use because both smoking and oral contraceptive use increase the client's risk of myocardial infarction and stroke. C. Many medications interact negatively with oral contraceptives, including anticonvulsants and systemic antifungals. D. Many medications interact negatively with oral contraceptives, including anti-HIV protease inhibitors and antituberculosis medications.

A nurse is planning care for a client in labor who is positive for HIV. Which of the following actions should the nurse take after the baby is born? A. Encourage the mother to breastfeed B. Administer the hepatitis B vaccine prior to discharge C. Implement contact and droplet precautions when providing care for the infant D. Collect a cord blood specimen to test for the presence of HIV

Correct Answer: B. Administer the hepatitis B vaccine prior to discharge Infants who are exposed to HIV should receive all routine vaccinations. Infants who are infected with HIV can receive all inactivated vaccinations. Incorrect Answers:A. In the United States and Canada, breastfeeding should be avoided by mothers who are HIV-positive. C. The nurse should use standard precautions when caring for a newborn who has been exposed to HIV. D. To test a newborn for the presence of HIV, a sample of the newborn's blood must be obtained. Maternal antibodies will be present in the cord blood and can affect the test results.

A nurse is assessing the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? A. Position each child with their heels at a line that is 6 m (20 ft) away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart

Correct Answer: B. Allow each child to wear his or her glasses during the exam The nurse should allow each child to wear his or her glasses during a screening for visual acuity. Incorrect Answers:A. The nurse should position each child so that the heels are at a line that is 3 m (10 ft) away from the Snellen chart. C. The nurse should start the screening by testing each child's right eye first. D. The nurse should start the screening by having each child read the 20/20 line of letters on the chart. If they are unable to do so, the nurse should move up to the next larger line of letters on the chart until the child can read at least 4 out of 6 letters correctly.

A nurse administers betamethasone to a client who is at 33 weeks gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability

Correct Answer: B. Decreased blood glucose Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. The nurse must assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable. Incorrect Answers:A. Betamethasone does not affect the newborn's ability to maintain body temperature. Hyperthermia is not an adverse effect of betamethasone. C. Betamethasone administered to an antepartum client does not affect the newborn's vital signs. If the newborn has a rapid apical pulse, it is related to another cause like prematurity or respiratory insufficiency. D. Irritability is not an adverse effect of betamethasone.

A nurse is assessing a client who is at 26 weeks of gestation and has mild preeclampsia. Which of the following findings should the nurse report to the provider? A. Platelet count 97,000/mm^3 B. Deep tendon reflexes 4+ C. Urine protein 1+ D. BUN 22 mg/dL

Correct Answer: B. Deep tendon reflexes 4+ Hyperactive deep tendon reflexes demonstrate a progression from mild preeclampsia to severe gestational hypertension or preeclampsia with severe features. This finding indicates the need for hospitalization and treatment with magnesium sulfate to prevent eclamptic seizures. Incorrect Answers:A. With preeclampsia, a client's platelet count is usually below 100,000/mm^3. There is no need to report this finding. C. With preeclampsia, a client's proteinuria is usually above 1+ on a urine reagent strip. There is no need to report this finding. D. With preeclampsia, a client's BUN level is usually above 20 mg/dL. There is no need to report this finding.

A nurse is caring for a client who is in labor. The nurse decides to switch from intermittent auscultation to continuous fetal monitoring. Which of the following data can only be obtained from continuous electronic fetal monitoring? A. Determination of a baseline B. Determination of variability C. Presence of accelerations D. Presence of decelerations

Correct Answer: B. Determination of variability Continuous electronic fetal monitoring is required to determine variability since the nurse needs a monitor tracing to quantify variability. Incorrect Answers:A. Both intermittent auscultation and continuous electronic fetal monitoring provide enough information to determine a baseline. C. Intermittent auscultation can reveal auditory accelerations and continuous electronic fetal monitoring can show accelerations on the tracing. D. Intermittent auscultation allows the nurse to hear decelerations and continuous electronic fetal monitoring plots decelerations on the strip.

A nurse is assessing a 4-year-old child's cognitive development during a well-child visit. Which of the following should the nurse expect the child to display? A. Conservation B. Development of the superego C. Concrete operational thought D. Separation anxiety

Correct Answer: B. Development of the superego This is the development of a conscience. Preschoolers begin to develop an understanding of right from wrong. While they might be unable to understand the "why" of acceptable vs unacceptable behaviors, they learn the concept through punishment and reward and the principles to which their parents adhere. Incorrect Answers:A. Conservation is the ability to understand that quantity does not change if shape changes. The ability to understand conservation typically develops in a school-age child. C. This is the ability to use previous experiences to solve current problems, which typically develops in the school-aged child. D. Preschoolers are typically able to tolerate brief periods of separation from their parents and interact with unfamiliar persons. Separation anxiety typically develops in infants around 10 months of age.

A nurse is providing teaching for new parents about formula feeding. Which of the following instructions should the nurse include? A. The bedtime bottle can be placed in the crib after the infant is 6 months of age. B. Discard opened cans of formula after 48 hr refrigeration. C. Powdered and concentrated formula can be reconstituted with tap water straight from the faucet. D. Bottles and nipples can be hand-washed in hot, soapy water.

Correct Answer: B. Discard opened cans of formula after 48 hr refrigeration. Opened cans and prepared bottles of formula must be refrigerated and discarded after 48 hours due to the risk of bacterial contamination. Incorrect Answers:A. Infants should not be left alone when feeding. Infants who fall asleep with a bottle in their mouth are prone to choking and tooth decay. C. Tap water needs to be sterilized prior to reconstituting formula. The tap water needs to be boiled for 2 minutes, cooled, and used within 30 minutes to mix the formula. D. Bottles, nipples, nipple rings, and caps must be boiled for 5 minutes prior to the first use. After that, the feeding equipment can be placed in the dishwasher for cleaning. If no dishwasher is available, the feeding equipment must be boiled between uses.

A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing from 1 hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting

Correct Answer: B. Dropping a cube when passing from 1 hand to the other The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider. Incorrect Answers:A. The pincer grasp is an expected fine motor skill for a 9-month-old infant. C. Falling down to a sitting position from a standing position is an expected gross motor skill for a 9-month-old infant. D. A 9-month-old infant should have the gross motor ability to maintain balance while leaning forward in a sitting position; however, the infant does not yet have the ability to maintain balance while leaning sideways. Practice Connection: A 9-month old infant should be able to bear weight on legs with support, sit with help, babble ("mama", "baba", "dada"), play games involving back-and-forth play, respond to own name, recognize familiar people, look where you point, and transfer toys from one hand to the other.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb sucking C. Showing interest in nearby toys D. Attempting to escape and find the parent

Correct Answer: B. Inactivity and thumb sucking A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair. Incorrect Answers:A. Protest is the first stage of separation anxiety, which includes crying and screaming. C. Denial or detachment is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. Protest is the first stage of separation anxiety, which includes attempting to escape the area to find a parent.

A nurse is caring for an infant who is postoperative following a myelomeningocele repair. Which of the following is the priority action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure

Correct Answer: B. Measure the infant's head circumference Increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; therefore, measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circumference measurements. Incorrect Answers:A. Measuring the infant's intake and output is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. C. Checking the infant's lower-extremity function is an essential component of postoperative care. However, the greatest risk to this infant is neurological complications. Therefore, this action is not the nurse's priority. D. Monitoring the infant's blood pressure is an essential component of postoperative care. However, the greatest risk to this client is neurological complications. Therefore, this action is not the nurse's priority.

A nurse is caring for a client who requests an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease

Correct Answer: B. Menorrhagia An IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or a history of ectopic pregnancy. Incorrect Answers:A. An IUD is an appropriate method of contraception for women who have hypertension. It is a good alternative to the estrogen-based oral contraceptives that cannot be taken by women who have hypertension. C. A history of multiple gestations is not a contraindication for an IUD. D. An IUD is an appropriate method of contraception for women who have a history of thromboembolic disease because an IUD is not associated with clotting problems and is a good alternative to oral contraceptives, which are contraindicated for women who have a history of thromboembolic disease.

A nurse is preparing to administer an IV infusion of oxytocin for labor induction to a client who is at 41 weeks of gestation. Which of the following actions should the nurse plan to take? A. Administer the oxytocin with manual IV tubing B. Monitor the fetal heart rate every 15 minutes initially C. Begin the infusion at 10 milliunits/min D. Titrate the dosage until the client has 1 contraction every minute

Correct Answer: B. Monitor the fetal heart rate every 15 minutes initially The nurse should plan to monitor the fetal heart rate (FHR) every 15 minutes through the first stage of labor and then every 5 minutes during the second stage. Additionally, the nurse should document the FHR with every change of the oxytocin dosage. Incorrect Answers:A. The nurse should administer oxytocin with an infusion pump to ensure accurate flow rate delivery. C. The nurse should begin the infusion at 1 milliunit/min and should increase the infusion slowly every 30 to 60 minutes by no more than 1 to 2 milliunits/min until the desired response is achieved. D. The nurse should titrate the dosage until the client has 1 contraction every 2 to 3 minutes. One contraction every minute is an indication of uterine tachysystole.

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure

Correct Answer: B. Murmur at the left sternal border A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area. Incorrect Answers:A. A diastolic murmur is an expected finding in a child who has an atrial septal defect. C. Cyanosis that increases with crying is an expected finding in a child who has an atrioventricular canal defect. D. Widened pulse pressure is an expected finding in a child who has patent ductus arteriosus.

A nurse is providing teaching about baclofen to the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A. Bradycardia B. Muscle weakness C. Diarrhea D. Dry skin

Correct Answer: B. Muscle weakness Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea. Incorrect Answers:A. Bradycardia is not an adverse effect of baclofen. This medication can cause hypotension. C. Diarrhea is not an adverse effect of baclofen. This medication can cause constipation. D. Dry skin is not an adverse effect of baclofen. This medication can cause increased sweating.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A. Perform a vaginal examination to determine cervical dilation B. Obtain blood samples for baseline laboratory values C. Place a spiral electrode on the fetal presenting part D. Prepare the client for a transvaginal ultrasound

Correct Answer: B. Obtain blood samples for baseline laboratory values The nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels. Incorrect Answers:A. The nurse should not perform a vaginal examination on a client who is experiencing vaginal bleeding. A vaginal examination can lead to hemorrhage if the client has placenta previa. C. The nurse should not perform a vaginal examination on a client who is experiencing vaginal bleeding. A spiral electrode can be placed only when the client's membranes are ruptured, the cervix is sufficiently dilated, and placenta previa is ruled out to avoid hemorrhage. D. The client should be on strict pelvic rest because she is experiencing bright red vaginal bleeding.

A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A. Supine B. Semi-Fowler's C. Sims' D. Orthopneic

Correct Answer: B. Semi-Fowler's Maintaining a semi-Fowler's position promotes adequate ventilation. Flexing the knees slightly will likely be the most comfortable position for the child. Additionally, this promotes drainage of the cecum downward into the pelvis instead of upward toward the lungs. Incorrect Answers:A. Maintaining a supine position will not promote adequate ventilation and can cause painful tugging on or stretching of the incisional area. C. Maintaining Sims' position will not promote adequate ventilation, and the degree of flexion required by the upper leg can cause painful compression of the incisional area. D. This position is used for clients who have difficulty breathing and can cause painful pressure on or compression of this client's incisional area.

A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? A. Bottle formula with added protein B. Small, frequent bottle feedings of electrolyte solution C. Continuous nasoduodenal tube feedings D. Bolus feedings via gastrostomy tube

Correct Answer: B. Small, frequent bottle feedings of electrolyte solution Feedings begin 4 to 6 hours after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water. Incorrect Answers:A. Small, incremental formula feedings will resume 24 hours after surgery if small, frequent feedings of electrolyte solution are retained by the infant. C. Nasoduodenal tube feedings are indicated for children who have brain injuries or are on mechanical ventilation. D. Gastrostomy feedings are indicated for children who cannot have any foods or fluid by mouth or for whom the passage of a tube through the esophagus is contraindicated.

A nurse is providing education about newborn skin care for a group of new parents. Which of the following instructions should the nurse include? A. Gently retract the foreskin to wash the glans with soap and water B. Sponge bathe the newborn every other day C. Use an antimicrobial soap for bathing D. Bathe the newborn with water between 46° and 49°C (115° and 120°F)

Correct Answer: B. Sponge bathe the newborn every other day Daily bathing can disrupt the acid mantle of the newborn's skin and alter skin integrity. The parents should sponge bathe the infant until the cord stump has detached and the area has healed. Incorrect Answers:A. In uncircumcised males, the foreskin adheres to the glans of the penis. Parents should not attempt to retract the foreskin before the age of 3 years. Parents should wash the penis with soap and water. C. The parents should avoid using antimicrobial soaps and instead use soap with a neutral pH and no preservatives to protect the acid mantle of the newborn's skin. D. The parents should maintain the bath water temperature between 38° and 40°C (100° and 104°F).

A nurse is preparing to perform Leopold maneuvers on a client who is in labor. Which of the following actions should the nurse plan to take? A. Ensure the client has a full bladder B. Stand at the client's right side if the nurse is right-handed C. Assist the client onto her back with knees extended. D. Palpate the outline of the fetus's head with the palms of the hands

Correct Answer: B. Stand at the client's right side if the nurse is right-handed The nurse should stand facing the client on the side that correlates with the nurse's dominant hand; therefore, if the nurse is right-handed, the nurse should stand at the client's right side. Incorrect Answers:A. The nurse should assist the client to empty her bladder prior to performing Leopold maneuvers. C. Placing the client in a supine position increases the risk of supine hypotension; therefore, the nurse should place a pillow under the client's head and a rolled towel under her hip with the knees flexed. D. The nurse should palpate the outline of the fetus's head with the fingertips.

A nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. Which of the following reactions by the infant should the nurse expect? A. The infant gives the nurse a social smile. B. The infant turns away when the nurse approaches. C. The infant reaches out to the nurse to be held. D. The infant is responsive and alert as the nurse comes closer.

Correct Answer: B. The infant turns away when the nurse approaches. The nurse should expect an 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger. Incorrect Answers:A. The nurse should expect social smiles to begin at 6 weeks of age; however, the nurse should not expect this from an 8-month-old infant upon initially entering the room due to the infant's expected fear of strangers. C. The nurse should not expect an 8-month-old infant to reach out as the nurse enters the room due to the infant's expected fear of strangers. D. Once the infant is 12 months old, the nurse should expect an alert response to strangers once again.

A nurse is teaching the guardian of a newborn about caring for the newborn's umbilical cord. For which of the following reasons should the nurse instruct the guardian to avoid using antimicrobial agents on the cord? A. They can cause increased pain from the cord. B. They can cause delayed cord separation. C. They can cause swelling of the surrounding tissue. D. They can cause skin discoloration.

Correct Answer: B. They can cause delayed cord separation. There is no evidence that antimicrobial preparations are of any benefit in the process of the drying and detachment of the umbilical cord stump. Keeping the cord moist with any kind of preparation prevents drying and separation and also increases the risk for infection. Incorrect Answers:A. The tissue of the cord is no longer functioning; therefore, the cord cannot cause the newborn pain. C. Swelling around the cord is an indication of infection. Antimicrobial agents would not cause an infection, but the provider might prescribe them to treat the infection. D. Most antiseptics are colorless. Povidone-iodine is an exception, but it would only cause temporary discoloration from the antiseptic, not permanent discoloration of the skin.

A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? A. "A 7-year-old child prefers to play with children of a different gender." B. "A 6-year-old child should understand the concept of cause and effect." C. "A 6-year-old child should be able to count 13 coins." D. "An 8-year-old child should be able to wash his or her own hair independently."

Correct Answer: C. "A 6-year-old child should be able to count 13 coins." A 6-year-old child should be able to count 13 coins, identify morning and afternoon, and be able to identify right and left hands. Incorrect Answers:A. A 7-year-old child prefers playing with groups of friends of the same gender. B. A child who is 8 to 9 years old understands the concept of cause and effect. D. A child who is 10 to 12 years old should be able to wash his or her hair independently. An 8-year-old child should be able to brush his or her own hair.

A nurse at a prenatal clinic is teaching a client how to perform a kick count. Which of the following statements should the nurse include in the teaching? A. "Drop by the clinic any day this week so we can count your baby's kicks." B. "Count fetal kicks once a day for a total of 30 minutes." C. "Before bedtime is a good time to start counting the kicks." D. "Wear loose clothing when performing the kick count."

Correct Answer: C. "Before bedtime is a good time to start counting the kicks." Clients should be instructed to perform a kick count, which is the daily fetal movement count (DFMC), before bedtime or after meals for 2 hours, or until 10 movements are counted. Alternatively, the client can count all fetal movements in a 12-hour period each day until at least 10 movements are counted. Incorrect Answers:A. The kick count is performed at home and is noninvasive. The client does not need to come to the clinic for this diagnostic test. B. The kick count can be performed only once a day, but it should be counted for a total of 60 minutes if done once per day. D. When performing a kick count, the client does not have to wear loose clothing. The kicks come from inside the body, and clothing does not obstruct fetal movement or make counting difficult.

A nurse is teaching the guardian of a preschooler. The guardian states that the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse give the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." D. "Set limits by not allowing your child to have the imaginary friend present during family meals."

Correct Answer: C. "Have your child take responsibility for actions if he tries to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination among this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior. The nurse should inform the guardian of the need to have the preschooler take responsibility for his actions. Incorrect Answers:A. Imaginary playmates are common during the preschool years due to the high level of imagination among this age group. B. Imaginary playmates are common during the preschool years and are not a cause for concern as long as the preschooler also socializes with other children. D. The nurse should instruct the guardian that this behavior is expected and that pretending with the preschooler is okay.

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I should clean my diaphragm with alcohol each time I use it." B. "I should leave the diaphragm in place for 4 hours after intercourse." C. "I should replace my diaphragm every 2 years." D. "I should use a vaginal lubricant to insert my diaphragm."

Correct Answer: C. "I should replace my diaphragm every 2 years." A diaphragm is a flexible rubber cup that is filled with spermicide and inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by a provider and should be replaced every 2 years. Incorrect Answers:A. A diaphragm should be cleaned with mild soap and water and dried gently. Alcohol can dry out the diaphragm and can weaken the rubber, which will reduce its effectiveness for birth control. B. A diaphragm should remain in place for at least 6 hours after intercourse. D. A diaphragm should be rinsed with water, and contraceptive jelly should be applied prior to placing the device into the vagina. Vaginal lubricants, mineral oil, and baby oil should not be used on the diaphragm because they can weaken the rubber.

A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."

Correct Answer: C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury. Incorrect Answers:A. The absence of oral or pharyngeal burns does not eliminate the possibility of esophageal burns. The existence and extent of burns depend on the substance and the length of time it has been in contact with tissues. A burn may be present in the esophagus but not in the mouth. B. Neutralization can result in heat injury to tissues due to an exothermic reaction. This might cause both chemical and thermal burns of tissues. D. Activated charcoal is not administered to an adolescent who has ingested a corrosive substance because it can infiltrate any tissue that is burned.

A nurse is talking with the parent of a preschool-aged child who tells the nurse, "My child has suddenly become disinterested in certain foods." Which of the following statements should the nurse make? A. "During this phase, feed your child anything that she will eat." B. "Increase the amount of calories and water your child consumes." C. "Keep a diary of the foods your child eats each day." D. "Provide a large variety of fruit juices for your child to choose from."

Correct Answer: C. "Keep a diary of the foods your child eats each day." The nurse should encourage the parent to keep a diary of the foods the child eats throughout the day for 1 week. This can help the parent realize that the child may be eating better than expected. Evidence suggests that children can self-regulate their caloric intake. When they eat less at a meal, they can compensate by eating more at another meal or by having a snack. Incorrect Answers:A. The nurse should inform the parent that children's dietary habits can change from day to day. It is important to feed the child healthy foods and focus on the quality of food rather than the quantity of food during this time. B. The nurse should inform the client that calorie and fluid requirements decrease slightly in a preschool-aged child. The nurse should not promote an increase of calories and water in the child's diet. D. The nurse should inform the parent that excessive consumption of sweetened beverages, including fruit juices, can be associated with adverse health effects such as dental caries, obesity, and metabolic syndrome.

A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make? A. "The nursing staff will bathe your child and take care of his daily needs." B. "Your child will be most comfortable in a low-stimulation environment." C. "Would you like assistance in planning where your child will die?" D. "Would you like hospice to continue providing curative care in your home?"

Correct Answer: C. "Would you like assistance in planning where your child will die?" The nurse should inform the parents that they can choose to keep the child in a hospital setting or take the child home to die. The nurse should be aware that active participation in planning for the location of the child's death promotes positive bereavement outcomes. The nurse should provide assistance to the parents in making and implementing this plan. Incorrect Answers:A. The nurse should ask the parents if they would like to participate in providing care for their child. Active participation in the child's care promotes positive bereavement outcomes. B. The nurse should support the parents' and child's decisions and should allow the parents to participate in activities of their choosing (e.g. having multiple visitors, playing games, and going on family outings). If the child and parents choose a low-stimulation environment, then the nurse should ensure it is provided. D. The nurse should discuss the option of hospice care with the parents; however, the nurse should inform the parents that hospice care will provide palliative rather than curative care.

A nurse is providing teaching for a client who is pregnant and has type 1 diabetes mellitus. Which of the following statements should the nurse include in the teaching? A. "You should expect to increase your insulin dosage during the first trimester of pregnancy." B. "You should expect to decrease your insulin dosage during the second and third trimesters of pregnancy." C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." D. "You will need to increase your insulin dosage if you are breastfeeding."

Correct Answer: C. "You should expect to decrease your insulin dosage immediately after you deliver your baby." The client will immediately lose insulin resistance upon the delivery of the placenta. Clients who have type 1 diabetes mellitus should expect to need only 50% to 60% of the pre-delivery dosage of insulin. Incorrect Answers:A. Clients who are pregnant and have diabetes mellitus typically need lower insulin dosages during the first trimester of pregnancy due to hormonal changes that create an improved response to the insulin. B. Clients who are pregnant and have diabetes mellitus should expect to have increased insulin needs during the second and third trimesters of pregnancy due to placental hormones that cause insulin resistance. D. Clients who breastfeed typically require half of their pregnancy insulin dosages due to the carbohydrates used in the process of producing breast milk.

A nurse is assessing a client before administering the hepatitis B vaccine. Which of the following allergies should the nurse identify as a contraindication to receiving this vaccine? A. Shellfish B. Gelatin C. Baker's yeast D. Eggs

Correct Answer: C. Baker's yeast An allergy to baker's yeast is a contraindication to receiving the hepatitis B vaccine. The nurse should notify the client's provider. Incorrect Answers:A. Clients with an allergy to shellfish should not receive IV contrast dye, which contains iodine. Therefore, this client can receive the hepatitis B vaccine. B. A client who has an allergy to gelatin should not receive the measles, mumps, or rubella vaccine. Therefore, this client can receive the hepatitis B vaccine. D. A client who has an allergy to eggs should not receive the influenza vaccine and should consult the provider. Therefore, this client can receive the hepatitis B vaccine.

A nurse is caring for a client who is in the first stage of labor. Which of the following findings should the nurse identify as a cause for concern? A. Pink, mucoid vaginal discharge B. Brownish vaginal discharge C. Contractions lasting 100 seconds D. Contractions occurring every 4 to 5 minutes

Correct Answer: C. Contractions lasting 100 seconds Contractions during the first stage of labor range from 45 to 80 seconds. They should not exceed 90 seconds. Incorrect Answers:A. This describes the bloody show, an expected finding during labor. B. This could be the result of cervical trauma from vaginal examinations or recent vaginal intercourse. D. Contraction frequency ranges from 2 to 5 contractions per 10 minutes during labor, so this frequency is within the expected range.

A nurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 15 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms

Correct Answer: C. Examine the infant's throat at the end of the examination The nurse should perform noninvasive assessments first to avoid causing the infant to cry, which can make the remainder of the examination difficult. Incorrect Answers:A. The nurse should pull the infant's pinna downward and toward the back of the head when examining the ears. The ear canal is curved upward until approximately 3 years of age. Pulling the pinna down and back straightens the ear canal and allows easier visualization of the tympanic membrane. B. The nurse should assess the infant's heart rate by auscultating the apical pulse for 1 min. D. The nurse should not measure the blood pressure in an 11-month-old infant. Blood pressure is routinely measured starting at 3 years of age.

A nurse is assessing a newborn at birth who was delivered at 32 weeks gestation. Which of the following findings should the nurse anticipate? A. Heel creases over the entire sole of the foot B. Pendulous testes C. Extended extremities D. Leathery cracked skin

Correct Answer: C. Extended extremities An infant born at 32 weeks gestation has poorly developed muscle tone and is unable to maintain the flexed position seen in infants born at full term. Incorrect Answers:A. A newborn delivered at 32 weeks gestation will have few creases present on the sole of the foot. B. The testes complete the process of descending by week 40, which results in pendulous testes with deep rugae on the scrotal sac. An infant born at 32 weeks gestation will have testes only partially descended into the sac and only a few rugae present. D. This is a characteristic of a newborn who was delivered after 42 weeks gestation. The lack of vernix in-utero causes a dry, peeling appearance of the skin.

A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

Correct Answer: C. FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age. Incorrect Answers:A. The nurse should identify that the FACES pain scale is used for children aged 3 years and older. The scale is composed of 6 cartoon faces that range from smiling to crying with tears. B. The nurse should identify that the CRIES pain scale is used for preterm newborns. CRIES is an acronym for crying, requires increased oxygen, increased vital signs, expression, and sleeplessness. D. The nurse should identify that the Premature Infant Pain Profile (PIPP) is used for preterm newborns.

A nurse is caring for a client who has eclampsia and just had a tonic-clonic seizure. After turning the client's head to the side, which of the following actions should the nurse take next? A. Administer magnesium sulfate 4 g IV bolus B. Insert an indwelling urinary catheter C. Give oxygen at 10 L/min via face mask D. Keep the environment quiet and the lights dimmed

Correct Answer: C. Give oxygen at 10 L/min via face mask The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach to client care is to administer oxygen to help stabilize the client's respiratory status. Incorrect Answers:A. The nurse should administer magnesium sulfate to prevent further seizure activity; however, there is another action the nurse should take first. B. The nurse should insert an indwelling urinary catheter to monitor the client's fluid output. Fluids should be restricted for a client who has eclampsia, but the client's output should be at least 25 mL/hr. However, there is another action the nurse should take first. D. The nurse should reduce environmental stimuli to help prevent further seizure activity and to promote rest following the seizure; however, there is another action the nurse should take first.

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area B. Initiate contact isolation precautions C. Give the child flavored popsicles D. Administer phytonadione

Correct Answer: C. Give the child flavored popsicles Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children often accept flavored popsicles as a source of fluid. Incorrect Answers:A. Cool compresses cause vasoconstriction and might prompt further occlusions. B. A child who has an infection transmitted by direct contact (e.g. Clostridium difficile) requires contact precautions. D. A client who has a warfarin overdose should receive phytonadione. A child who has sickle cell anemia should not receive a warfarin antidote.

A charge nurse is providing teaching for a newly hired nurse about the potential side effects of an epidural anesthetic for a laboring client. Which of the following effects should the charge nurse include in the teaching? A. Newborn respiratory depression at birth B. Impaired ability of the neonate to maintain body temperature C. Impaired placental perfusion D. Decreased fetal heart rate (FHR) variability

Correct Answer: C. Impaired placental perfusion Maternal hypotension can occur in 10% to 30% of women who receive epidural or spinal anesthesia. This can result in decreased blood flow to the placenta and impair the delivery of oxygen to the fetus. Incorrect Answers:A. Respiratory depression in the newborn may occur if narcotic agonist-antagonist analgesics are administered to the mother within 1 to 4 hours of birth. B. The use of diazepam in labor can disrupt newborn thermoregulation and result in hypothermia. D. Minimal or absent FHR variability is a side effect of administering opioids to a laboring client.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities B. Administer meperidine every 4 hr until the crisis has resolved C. Maintain the child on bed rest D. Decrease the child's fluid intake for 8 hr

Correct Answer: C. Maintain the child on bed rest The nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs. Incorrect Answers:A. Cold compresses are contraindicated because they enhance sickling and vasoconstriction. B. Meperidine is not recommended because this central nervous system stimulant can produce anxiety, tremors, and generalized seizures. D. A child who has sickle cell anemia and is in a vaso-occlusive crisis requires increased fluid intake to prevent sickling.

A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

Correct Answer: C. Palpate the abdomen for bladder distension A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder. Incorrect Answers:A. The nurse should not place a diaper on the infant until after the defect has been repaired and healed due to the risk of tearing the sac. The nurse should place padding under the infant to absorb urine and stool and provide frequent skin care. B. Povidone-iodine is neurotoxic and should not come into contact with the spinal malformation. D. The nurse should keep the meningocele sac from drying by applying sterile nonadherent dressings moistened with 0.9% sodium chloride every 2 to 4 hours. A dry dressing might stick to the sac and cause tearing.

A nurse is caring for a client who experienced a spontaneous rupture of membranes and has prolonged decelerations on the fetal monitor. Which of the following conditions should the nurse expect? A. Uterine rupture B. Placental abruption C. Prolapsed umbilical cord D. Amniotic fluid embolus

Correct Answer: C. Prolapsed umbilical cord The nurse should identify that prolonged deceleration during a uterine contraction is a sign of cord prolapse. This is an emergent condition that should be reported to the provider immediately. Incorrect Answers:A. Signs of uterine rupture include constant abdominal pain, loss of fetal station, abnormal fetal heart rate tracing, and cessation of contractions. It is not related to rupture of membranes. B. Manifestations of placenta abruption include abdominal pain, vaginal bleeding, uterine tenderness, and contractions. Rupture of membranes is not a contributing factor. D. Signs of amniotic fluid embolus include maternal respiratory distress, and hemodynamic instability. Spontaneous rupture of membranes is not a contributing factor.

A nurse is assessing a client who is in the fourth stage of labor. Which of the following findings should the nurse expect? A. Breast engorgement B. Hypothermia C. Urinary retention D. Rupture of membranes

Correct Answer: C. Urinary retention After delivery, many clients have a reduced urge to urinate. This can result from birth trauma, a larger bladder capacity after birth, analgesia, pelvic soreness, an episiotomy, and other factors. Incorrect Answers:A. Breast engorgement does not generally become problematic until 3 to 5 days after birth. B. Hypothermia is unlikely during the fourth stage of labor. The nurse should measure the client's temperature at this time, then every 4 hours for the first 8 hours, and then at least every 8 hours after that. The client might feel chilly during this stage; if so, the nurse should provide a warmed blanket. D. Rupture of membranes occurs spontaneously or via amniotomy prior to the second stage of labor.

A nurse is caring for a client who has a BMI of 22.6 and expresses concern about weight gain during pregnancy. Which of the following responses should the nurse make? A. "You're eating for 2, so you should double your caloric intake." B. "You'll lose weight easily after the birth of your baby." C. "Plan to gain a total of 15 to 20 pounds during pregnancy." D. "Gaining weight will promote a healthy pregnancy."

Correct Answer: D. "Gaining weight will promote a healthy pregnancy." A weight gain of 11.3 to 15.9 kg (25 to 35 lb) during pregnancy is essential for supporting the growth and development of the fetus. Limiting caloric intake can result in using fat stores for energy and developing ketonemia, which is a risk factor for preterm labor. Incorrect Answers:A. Pregnancy slightly increases caloric demand, but it does not double it. In the first trimester, there should be no increase in the client's caloric intake. During the second trimester, the nurse should recommend the client consume an additional 340 calories per day. During the third trimester, the nurse should recommend an increase of 452 calories per day over the client's prepregnancy intake. B. Excessive weight gain of more than 3 kg (6.6 lb) per month can be difficult to lose after delivery. Furthermore, it can be a contributing factor to ongoing obesity and further weight gain. C. The recommended weight gain during pregnancy for a woman who has a BMI of 22.6 is 11.3 to 15.9 kg (25 to 35 lb).

A nurse is providing nutritional teaching for a pregnant client who had a prepregnancy body mass index (BMI) of 38. Which of the following statements by the client demonstrate an understanding of the teaching about her recommended weight gain during pregnancy? A. "I should plan to gain 12.7 to 18.1 kg during my pregnancy." B. "I should plan to gain 11.3 to 15.9 kg during my pregnancy." C. "I should plan to gain 6.8 to 11.3 kg during my pregnancy." D. "I should plan to gain 5 to 9.1 kg during my pregnancy."

Correct Answer: D. "I should plan to gain 5 to 9.1 kg during my pregnancy." Clients with a prepregnancy BMI of greater than 30 are considered to be obese and should plan to limit their weight gain to 5 to 9.1 kg (11 to 20 lb) during pregnancy. Incorrect Answers:A. Clients with a prepregnancy BMI of less than 18.5 are considered underweight and should plan to gain between 12.7 to 18.1 kg (28 to 40 lb) during pregnancy. B. Clients with a prepregnancy BMI of 18.5 to 24.9 are considered to be of normal weight and should plan to limit their weight gain to 11.3 to 15.9 kg (25 to 35 lb) during pregnancy. C. Clients with a prepregnancy BMI of 25 to 29.9 are considered to be overweight and should plan to limit their weight gain to 6.8 to 11.3 kg (15 to 25 lb) during pregnancy.

A nurse is preparing to administer meperidine hydrochloride to a client who is in labor. Which of the following statements should the nurse make to the client? A. "This medication can cause your blood pressure to rise." B. "This medication can cause dry mouth." C. "This medication can cause you to urinate excessively." D. "This medication can make you sleepy."

Correct Answer: D. "This medication can make you sleepy." Meperidine hydrochloride is an opioid analgesic used for moderate to severe pain during labor. It binds to the brain's opioid receptors and alters the client's response to pain. The client should be informed of the possible adverse effects of this medication such as hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention. Incorrect Answers:A. B. C. Possible adverse effects of this medication include hypotension, confusion, sedation, headaches, respiratory depression, constipation, and urinary retention.

A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."

Correct Answer: D. "You will be able to participate in physical exercises." Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided. Incorrect Answers:A. Passive range-of-motion exercises are not done after a bleeding episode because rebleeding can occur. Active motion is best to allow activity to be tailored to the child's pain level. B. A manifestation of hemophilia A is hemarthrosis (bleeding into a joint capsule). This can result in numbness, tingling, or pain, along with discoloration, warmth, and swelling of the affected joint. The nurse should instruct the child to rest the joint, elevate it above the level of the heart, and apply ice to decrease the rate of bleeding into the joint capsule. C. Intracranial hemorrhage is a leading cause of death in clients who have hemophilia A. The nurse should instruct the child to avoid the use of aspirin because it has antiplatelet properties that can increase bleeding.

A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compresses to the child's forehead D. Administer an antipyretic to the child

Correct Answer: D. Administer an antipyretic to the child When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers:A. Reducing the room temperature is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the toddler's temperature when implemented about 1 hour following the administration of an antipyretic. Therefore, this is not the first action the nurse should take. C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.

A nurse is creating a plan of care for a client who is in the active stage of labor and expresses a desire to use nonpharmacological methods of pain relief. Which of the following interventions should the nurse include? A. Encourage the client to listen to music B. Instruct the client how to use informational biofeedback C. Ask the client to reconsider using a regional anesthetic D. Assist the client into a warm shower

Correct Answer: D. Assist the client into a warm shower Assisting the client into a warm shower is a nonpharmacological method used to decrease labor pain. This method stimulates the release of endorphins and increases circulation. Research supports the use of hydrotherapy as an effective method of labor pain management. Incorrect Answers: A. Music can provide distraction and relaxation while a client is in early labor, but evidence does not support the effectiveness of music as a method of pain relief during active labor. B. Informational biofeedback can be an effective method of increasing relaxation; however, this method must be taught and practiced during the prenatal period to be effective during labor. C. Asking the client to reconsider using regional anesthetics such as epidural or spinal anesthetics does not support the client's wishes to utilize nonpharmacological methods of pain control.

A nurse is assessing a newborn who has a congenital diaphragmatic hernia. Which of the following findings should the nurse expect? A. Distended abdomen B. Increased blood pressure C. Generalized petechiae D. Barrel-shaped chest

Correct Answer: D. Barrel-shaped chest The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a barrel-shaped chest as the abdominal organs have shifted into the chest cavity. Incorrect Answers:A. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit a scaphoid abdomen as abdominal contents have shifted into the chest cavity. B. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit decreased blood pressure and cyanosis. C. The nurse should expect a newborn who has congenital diaphragmatic hernia to exhibit cyanosis and respiratory distress, not petechiae.

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron B. Avoid people who have infections C. Administer PRN oxygen D. Encourage quiet play

Correct Answer: D. Encourage quiet play A platelet count of 20,000/mm^3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk of injury, thereby reducing the chance of hemorrhage. Incorrect Answers:A. Iron is given to a child who has anemia. A platelet count of 20,000/mm^3 is not an indication of an anemic condition. B. Platelets are the blood component associated with clotting. C. RBCs are the blood component responsible for carrying oxygen to body tissues.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints B. Massage the child's pressure areas C. Increase the child's fluid intake D. Encourage the child to use an incentive spirometer

Correct Answer: D. Encourage the child to use an incentive spirometer The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Encouraging the child to use an incentive spirometer will promote adequate oxygenation and is the priority nursing action. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Incorrect Answers:A. The nurse should perform passive range of motion for unaffected joints; however, a different action is the nurse's priority. B. The nurse should massage the child's pressure areas; however, a different action is the nurse's priority. C. The nurse should increase the child's fluid intake; however, a different action is the nurse's priority.

A postpartum nurse is caring for a client who reports abdominal cramping. Which of the following actions should the nurse take? A. Teach the client to lie on her side B. Request a prescription for an opioid analgesic C. Offer a sitz bath to the client D. Encourage the client to interact with the newborn

Correct Answer: D. Encourage the client to interact with the newborn Interacting with the baby can help provide a distraction and decrease the discomfort of uterine contractions. While it is important to let the parent know that afterpains are more intense during and after breastfeeding, it is also necessary to encourage the planning of methods that provide the most effective and timely relief. Other nonpharmacological interventions can include distraction, therapeutic touch, imagery, hydrotherapy, acupressure, aromatherapy, music therapy, massage therapy, and transcutaneous electrical nerve stimulation (TENS). Incorrect Answers:A. The nurse should recommend a prone position to help reduce the discomfort of uterine contractions. Side-lying is helpful in decreasing the discomfort of perineal lacerations and an episiotomy. B. For relieving the pain of the client's uterine contractions, the nurse should request a prescription for ibuprofen or acetaminophen, not an opioid. C. A sitz bath is recommended to decrease perineal discomfort. Relaxation techniques can be used to help reduce postpartum discomfort caused by uterine contractions.

A nurse on a pediatric unit is caring for a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the environment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure that staff visits with the child are kept short

Correct Answer: D. Ensure that staff visits with the child are kept short Children who have autism spectrum disorders have difficulty adjusting to new situations. The staff members should keep interactions with the child as brief as possible. Incorrect Answers:A. Children who have autism spectrum disorders have difficulty adjusting to new situations. The nurse should assign this child to a private room with decreased auditory and visual stimulation to assist the child's adaptation. B. Children who have autism spectrum disorders prefer minimal physical contact. The nurse should refrain from holding or restraining the child and should reduce eye contact as much as possible to prevent outbursts. C. Children who have autism spectrum disorders have difficulty redirecting their focus and changing activities. The nurse should clearly state expectations and instructions at the appropriate developmental level and should not provide choices about scheduling planned care.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

Correct Answer: D. Exaggerated reflexes A newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability. Incorrect Answers:A. Extended periods of sleep indicate CNS depression, not hyperactivity. B. A newborn with neonatal abstinence syndrome has increased muscle tone. Hypotonia is not an expected finding for a newborn who has narcotic withdrawal. C. Newborns who have neonatal abstinence syndrome often experience respiratory distress, which is manifested by respirations >60/min. A respiratory rate of 50/min is within the expected reference range.

A nurse is providing education to a female client of child-bearing age. The nurse should state that which of the following structures expels the mature ovum? A. Blastocyst B. Fallopian tube C. Corpus luteum D. Graafian follicle

Correct Answer: D. Graafian follicle The Graafian follicle expels the mature ovum. Incorrect Answers:A. A blastocyst is a group of cells formed during embryonic development, usually shortly after fertilization. B. A fallopian tube is a structure through which the egg moves from the ovaries to the uterus. C. The corpus luteum is a structure within the ovary that produces the progesterone needed to establish and maintain pregnancy.

A nurse at a prenatal clinic is assessing an adolescent who is pregnant and is visiting the clinic for the first time. Which of the following factors is the nurse's priority to evaluate? A. Psychological readiness B. Partner support C. Socioeconomic status D. Nutritional status

Correct Answer: D. Nutritional status When using Maslow's hierarchy of needs, the nurse should determine that the priority factor to evaluate is the adolescent's nutritional status. According to Maslow's hierarchy of needs, the most basic needs that take priority over all others are physiological needs, which include nutrition. Incorrect Answers:A. The nurse should evaluate the adolescent's psychological readiness to determine whether the adolescent has developed readiness for parenthood. According to Maslow's hierarchy, this parameter falls under self-esteem needs; therefore, there is another factor that has a higher priority for evaluation. B. The nurse should evaluate the adolescent's partner support because adolescents are at increased risk for postpartum depression if they lack social support and do not have a good relationship with a partner. According to Maslow's hierarchy, this parameter falls under love and belonging needs; therefore, there is another factor that has a higher priority for evaluation. C. The nurse should evaluate the adolescent's socioeconomic status because adolescents typically do not have access to substantial financial earnings and might need assistance providing for the basic needs of themselves and their children. According to Maslow's hierarchy, this parameter falls under safety and security needs; therefore, there is another factor that has a higher priority for evaluation.

A nurse is caring for a pregnant client who is at 37 weeks of gestation and who had a biophysical profile with a total score of 4. Which of the following actions should the nurse anticipate taking? A. Discharge the client to home B. Administer betamethasone C. Perform an amnioinfusion D. Prepare for delivery of the infant

Correct Answer: D. Prepare for delivery of the infant Delivery is considered when a biophysical profile score of 6 or lower is obtained at or after 36 weeks of gestation or with a score of 4 or lower at any gestational age. Incorrect Answers:A. A biophysical profile score of 4 indicates possible chronic fetal asphyxia. It would not be appropriate to discharge the client to home. B. Betamethasone is administered to promote fetal lung development and to decrease the risk of respiratory distress syndrome if delivery is anticipated between 24 and 34 weeks of gestation. C. An amnioinfusion is performed during labor to relieve transient fetal hypoxia caused by umbilical cord compression.

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelets 120,000/mm^3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

Correct Answer: D. Serum cholesterol 700 mg/dL A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids. Incorrect Answers: A. A platelet count of 120,000/mm^3 is below the expected reference range. Children with nephrotic syndrome have an increased platelet count because of hemoconcentration. B. A serum sodium level of 160 mEq/L is above the expected reference range. Children who have nephrotic syndrome have a serum sodium level that is lower than expected because of hemoconcentration. C. A hemoglobin level of 9 g/dL is below the expected reference range. Children who have nephrotic syndrome will have hemoglobin levels that are within the expected reference range or elevated.

A nurse is performing a physical assessment of a male newborn. Which of the following findings should the nurse report to the provider? A. Superficial cracking and peeling are evident on the skin of the hands and feet. B. The palmar grasp occurs spontaneously when newborn is sucking. C. The bulge of the testes is palpable in the inguinal canal. D. There is decreased abdominal movement with breathing.

Correct Answer: D. There is decreased abdominal movement with breathing. The nurse should report this finding to the provider. Decreased abdominal movement with breathing is a deviation from an expected finding and could indicate phrenic nerve palsy or a congenital diaphragmatic hernia. The nurse should expect the newborn to have diaphragmatic breathing with synchronous abdominal and chest movements. Incorrect Answers:A. Slightly thickened skin on the hands and feet with superficial cracking and peeling is an expected finding in a newborn. B. A palmar grasp that occurs spontaneously when sucking or when the palm is stroked is an expected finding in a newborn. C. The testes should be palpable on each side and can present as a palpable bulge in the inguinal canal. This is an expected finding in a newborn.

A nurse is caring for a client in labor whose cervix is dilated to 9 cm. She is experiencing strong contractions every 2 min lasting 75 sec. The nurse should recognize that the client is in which of the following phases or stages of labor? A. Latent phase of first stage B. Active phase of first stage C. Second stage D. Transition phase of first stage

Correct Answer: D. Transition phase of first stage These findings indicate the transition phase of the first stage of labor. The first stage ends with the transition phase in which the cervix dilates to 8 to 10 cm. Uterine contractions are strong, occurring every 2 to 3 minutes and lasting 45 to 90 seconds. Incorrect Answers:A. The latent phase is characterized by some cervical effacement and dilation from 0 to 3 cm, with little progress in the descent of the presenting part. B. The active phase is characterized by cervical dilation from 4 to 7 cm and significant descent of the presenting part. In this phase, the client has moderate to strong uterine contractions every 3 to 5 min that last 40 to 70 seconds. C. The second stage begins with complete cervical dilation and ends with the birth of the newborn.

A nurse is providing teaching to the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (Select all that apply.) A. "My child will likely be irritable for the next few weeks." B. "I will notify my child's doctor if the skin on her hands or feet begins to peel." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." E. "My child will have joint stiffness primarily at the end of the day."

Correct Answers: A. "My child will likely be irritable for the next few weeks." C. "I will ensure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." A child who is diagnosed with Kawasaki disease will likely be irritable for up to 2 months. A child who has Kawasaki disease receives high doses of gamma globulin during the initial phase, which might result in the inability to produce adequate antibodies in response to a live vaccine; therefore, these vaccines should be delayed for 11 months. Also, the temperature of this child who has Kawasaki disease should be recorded until she has been afebrile for several days. Incorrect Answers:B. Peeling of the skin of the hands and feet is expected for a child who has Kawasaki disease. The peeling does not cause any pain and usually occurs between the second and third week. There is no need to report this manifestation to the child's provider. E. A child who has Kawasaki disease will likely have joint stiffness and arthritis-related symptoms for several weeks. The joint stiffness is typically worse during cold weather and in the morning.

A nurse is caring for a client who is 8 hr postpartum and is experiencing hemorrhage. Which of the following actions should the nurse implement after notifying the provider? (Select all that apply.) A. Massage the fundus B. Give oxygen at 2 L/min via nasal cannula C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30°

Correct Answers: A. Massage the fundus C. Administer oxytocin with IV fluids D. Insert an indwelling urinary catheter E. Place the client in a lateral position with her legs elevated 30° The nurse should massage the fundus to expel clots and help the uterus contract. The nurse should add oxytocin to the intravenous drip and insert an indwelling urinary catheter to monitor urinary output and perfusion to the kidney. Finally, the nurse should place the client in a lateral position with her legs elevated 30°. Incorrect Answer:B. The nurse should administer oxygen 10 L/min via nonrebreather face mask.

A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min

Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress. Incorrect Answer:A. The nurse should plan to provide the infant with feedings every 3 hours. This frequency allows the infant to get adequate rest between feedings while keeping the volume of feeding at a tolerable level.

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor

Correct Answers: B. Nausea D. Urticaria E. Stridor A common gastrointestinal response to excessive histamine release is nausea. A common skin manifestation of excessive histamine release is hives, also known as urticaria. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor. Incorrect Answers:A. Histamine is a potent vasodilator; therefore, a client who is going into anaphylaxis will exhibit tachycardia. C. Histamine is a potent vasodilator, so the child will exhibit hypotension.