Exam 4 practice questions
2 5. Which would be an early sign of respiratory distress in a 2-month-old? 1. Breathing shallowly. 2. Tachypnea. 3. Tachycardia. 4. Bradycardia.
2. Tachypnea is an early sign of distress and is often the fi rst sign of respiratory illness in infants.
13. While assessing a newborn with respiratory distress, the nurse auscultates a machine-like heart murmur. Other fi ndings are a wide pulse pressure, periods of apnea, increased Pa CO2, and decreased P O2. The nurse suspects that the newborn has: 1. Pulmonary hypertension. 2. Patent ductus arteriosus (PDA). 3. Ventricular septal defect (VSD). 4. Bronchopulmonary dysplasia.
2. The main identifi er in the stem is the machine-like murmur, which is the hallmark of a PDA.
48. A nurse is assessing the fundus of a client during the immediate postpartum period. Which of the following actions indicates that the nurse is performing the skill correctly? 1. The nurse measures the fundal height using a paper centimeter tape. 2. The nurse stabilizes the base of the uterus with the nondominant hand. 3. The nurse palpates the fundus with the tips of the fingers. 4. The nurse precedes the assessment with a sterile vaginal exam.
2. The nurse should stabilize the base of the uterus with the nondominant hand.
4 7. Which is diagnostic for epiglottitis? 1. Blood test. 2. Throat swab. 3. Lateral neck x-ray of the soft tissue. 4. Signs and symptoms.
3. A lateral neck x-ray is a defi nitive test to diagnose epiglottitis. The child is at risk for complete airway obstruction and should always be accompanied by a nurse to the x-ray department.
4 5. What information should the nurse provide the parent of a child diagnosed with nasopharyngitis? 1. Complete the entire prescription of antibiotics. 2. Avoid sending the child to day care. 3. Use comfort measures for the child. 4. Restrict the child to clear liquids for 24 hours.
3. Nursing care for nasopharyngitis is primarily supportive. Keeping the child comfortable during the course of the illness is all the parents can do. Nasal congestion can be relieved using normal saline drops and bulb suction. Acetaminophen (Tylenol) can also be given for discomfort or a mild fever.
21. In the lactation clinic, a nurse is caring for a client who delivered 3 weeks ago and has recently started treatment for postpartum depression. This is the client's third child. The nurse should expect to observe which behavior? 1. Feelings of infanticide. 2. Difficulty with breastfeeding latch. 3. Feelings of failure as a mother. 4. Concerns about sibling jealousy
3. Mothers who experience postpartum depression often feel like failures because they anticipate euphoria and confidence. They are surprised by the anxiety and incompetence they feel in their new role.
19. The nurse should suspect puerperal infection when a client exhibits which of the following? 1. Temperature of 100.2° F (37.8° C). 2. White blood cell count of 14,500 cells/mm 3 . 3. Diaphoresis during the night. 4. Malodorous lochial discharge.
4. A malodorous lochial flow is a common sign of a puerperal infection.
38. A postpartum woman has been diagnosed with postpartum psychosis. Which of the following signs/symptoms would the client exhibit? 1. Hallucinations. 2. Polyphagia. 3. Induced vomiting. 4. Weepy sadness.
. 1. The client with postpartum psychosis will experience hallucinations.
4 3. What would the nurse advise the parent of a child with a barky cough that gets worse at night? 1. Take the child outside into the more humid night air for 15 minutes. 2. Take the child to the ED immediately. 3. Give the child an over-the-counter cough suppressant. 4. Give the child warm liquids to soothe the throat.
. 1. The humid night air will help decrease subglottic edema, easing the child ' s respiratory effort. The coughing should diminish signifi cantly, and the child should be able to rest comfortably. If the symptoms do not improve after taking the child outside, the parent should have the child seen by a health-care provider.
40. A client is receiving an epidural infusion of a narcotic for pain relief after a cesarean section. Which of the following assessments would the nurse report to the anesthe - sia provider? 1. Respiratory rate 8 per minute. 2. Complaint of thirst. 3. Urinary output of 250 mL/hr. 4. Numbness of feet and ankles
. 1. This action is appropriate. This client's respiratory rate of 8 is below normal and should be reported to the anesthesia provider.
14. Which are the most serious complications for a child with Kawasaki disease (KD)? Select all that apply. 1. Coronary thrombosis. 2. Coronary stenosis. 3. Coronary artery aneurysm. 4. Hypocoagulability. 5. Decreased sedimentation rate. 6. Hypoplastic left heart syndrome.
1, 2, 3. 1. Thrombosis, stenosis, and aneurysm affect blood vessels. The child with KD has hypercoagulability and an increased sedimentation rate due to infl ammation. 2. Thrombosis, stenosis, and aneurysm affect blood vessels. The child with KD has hypercoagulability and an increased sedimentation rate due to infl ammation. 3. Thrombosis, stenosis, and aneurysm affect blood vessels. The child with KD has hypercoagulability and an increased sedimentation rate due to infl ammation.
3. Tetralogy of Fallot (TOF) involves which defects? Select all that apply. 1. Ventricular septal defect (VSD). 2. Right ventricular hypertrophy. 3. Left ventricular hypertrophy. 4. Pulmonic stenosis (PS). 5. Pulmonic atresia. 6. Overriding aorta. 7. Patent ductus arteriosus (PDA)
1, 2, 4, 6. 1. TOF is a congenital defect with a ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 2. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta. 4. TOF is a congenital defect with ventricular septal defect, right ventricular hypertrophy, pulmonary valve stenosis, and overriding aorta.
49. Which is the nurse ' s best response to the parent of a child diagnosed with epiglottitis who asks what the treatment will be? 1. Complete a course of intravenous antibiotics. 2. Surgery to remove the tonsils. 3. 10 days of aerosolized ribavirin. 4. No intervention.
1. Epiglottitis is bacterial in nature and requires intravenous antibiotics. A 7- to 10-day course of oral antibiotics is usually ordered following the intravenous course of antibiotics.
3 2. Which is the nurse ' s best response to a parent who asks what can be done at home to help an infant with upper respiratory infection (URI) symptoms and a fever get better? 1. "Give your child small amounts of fluid every hour to prevent dehydration." 2. "Give your child Robitussin at night to reduce his cough and help him sleep." 3. "Give your child a baby aspirin every 4 to 6 hours to help reduce the fever." 4. "Give your child an over-the-counter cold medicine at night."
1. It is essential that parents ensure their children remain hydrated during a URI. The best way to accomplish this is by giving small amounts of fl uid frequently.
71. A postpartum client has been diagnosed with postpartum psychosis. Which of the following is essential to be included in the family teaching for this client? 1. The client should never be left alone with her infant. 2. Symptoms rarely last more than one week. 3. Clinical response to medications is usually poor. 4. The client must have her vitals assessed every two days.
1. It is essential that the client never be left alone with her baby.
2 0. Which should the nurse administer to provide quick relief to a child with asthma who is coughing, wheezing, and having diffi culty catching her breath? 1. Prednisone. 2. Montelukast (Singulair). 3. Albuterol. 4. Fluticasone (Flovent).
3. Albuterol is the quick-relief bronchodilator of choice for treating an asthma attack.
16. A client received general anesthesia during her cesarean section 4 hours ago. Which of the following postpartum nursing interventions is important for the nurse to make? 1. Place the client flat in bed. 2. Assess for dependent edema. 3. Auscultate lung fields. 4. Check patellar reflexes.
3. As with any postoperative client, it is important for the nurse to auscultate the client's lung fields every 4 hours to assess for rales.
2 2. Which breathing exercises should the nurse have an asthmatic 3-year-old child do to increase her expiratory phase? 1. Use an incentive spirometer. 2. Breathe into a paper bag. 3. Blow a pinwheel. 4. Take several deep breaths.
3. Blowing a pinwheel is an excellent means of increasing a child ' s expiratory phase. Play is an effective means of engaging a child in therapeutic activities. Blowing bubbles is another method to increase the child ' s expiratory phase.
7. The parent of a child with cystic fi brosis (CF) asks the nurse what will be done to relieve the child ' s constipation. Which is the nurse ' s best response? 1. "Your child likely has an obstruction and will require surgery." 2. "Your child will likely be given IV fl uids." 3. "Your child will likely be given MiraLAX." 4. "Your child will be placed on a clear liquid diet."
3. CF clients with constipation commonly receive a stool softener or an osmotic solution such as polyethylene glycol 3350 (MiraLAX) orally to relieve their constipation.
4. The parent of an infant with cystic fi brosis (CF) asks the nurse how to meet the child ' s increased nutritional needs. Which is the nurse ' s best suggestion? 1. "You may need to increase the number of fresh fruits and vegetables you give your infant." 2. "You may need to advance your infant ' s diet to whole cow ' s milk because it is higher in fat than formula." 3. "You may need to change your infant to a higher-calorie formula." 4. "You may need to increase your infant ' s carbohydrate intake."
3. Often infants with CF need to have a higher-calorie formula to meet their nutritional needs. Infants may also be placed on hydrolysate formulas that contain medium-chain triglycerides.
4 2. How will a child with respiratory distress and stridor who is diagnosed with RSV be treated? 1. Intravenous antibiotics. 2. Intravenous steroids. 3. Nebulized racemic epinephrine. 4. Alternating doses of acetaminophen (Tylenol) and ibuprofen (Motrin).
3. Racemic epinephrine promotes mucosal vasoconstriction
1 1. A child ' s parent asks the nurse what treatment the child will need for the diagnosis of strep throat. Which is the nurse ' s best response? 1. "Your child will be sent home on bedrest and should recover in a few days without any intervention." 2. "Your child will need to have the tonsils removed to prevent future strep infections." 3. "Your child will need oral penicillin for 10 days and should feel better in a few days." 4. "Your child will need to be admitted to the hospital for 5 days of intravenous antibiotics."
3. The child will need a 10-day course of penicillin/amoxicillin to treat the strep infection. It is essential that the nurse always tell the family that, although the child will feel better in a few days, the entire course of antibiotics must be completed.
50. The nurse is assessing the laboratory report on a G1 P1001 client who delivered 2 days ago. The client had a normal postpartum assessment this morning. Which of the following results should the nurse report to the primary healthcare provider? 1. White blood cells, 12,500 cells/mm 3 . 2. Red blood cells, 4,500,000 cells/mm 3 . 3. Hematocrit, 26%. 4. Hemoglobin, 11 g/dL
3. The client's hematocrit is well below normal. This value should be reported to the client's primary healthcare provider.
29. The nurse is evaluating the uterine involution of a client who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? 1. Fundus 1 cm above the umbilicus, lochia rosa. 2. Fundus 2 cm above the umbilicus, lochia alba. 3. Fundus 3 cm below the umbilicus, lochia rubra. 4. Fundus 4 cm below the umbilicus, lochia serosa
3. The fundus is usually 3 cm below the umbilicus on day 3 and the lochia continues to be red, or rubra until day 4.
31. Which plan would be appropriate in helping to control congestive heart failure (CHF) in an infant? 1. Promoting fl uid restriction. 2. Feeding a low-salt formula. 3. Feeding in semi-Fowler position. 4. Encouraging breast milk.
3. The infant has a great deal of diffi culty feeding with CHF, so even getting the maintenance fl uids is a challenge. The infant is fed in the more upright position so that fl uid in the lungs can go to the base of the lungs, allowing better expansion.
29. In which of the following situations should a nurse report a possible deep vein thrombosis (DVT)? 1. The woman complains of numbness in the toes and heel of one foot. 2. The woman has cramping pain in a calf that is relieved when the foot is dorsiflexed. 3. The calf of one of the woman's legs is swollen, red, and warm to the touch. 4. The veins in the ankle of one of the woman's legs are spider-like and purple.
3. These findings—swelling, redness, and warmth—indicate the possible presence of a DVT.
32. In which congenital heart defect (CHD) would the nurse need to take upper and lower extremity BPs? 1. Transposition of the great vessels. 2. Aortic stenosis (AS). 3. Coarctation of the aorta (COA). 4. Tetralogy of Fallot (TOF).
3. With COA there is narrowing of the aorta, which increases pressure proximal to the defect (upper extremities) and decreases pressure distal to the defect (lower extremities). There will be high BP and strong pulses in the upper extremities and lower-than-expected BP and weak pulses in the lower extremities.
5. The parent of a child with cystic fi brosis (CF) is excited about the possibility of the child receiving a double lung transplant. What should the parent understand? 1. The transplant will cure the child of CF and allow the child to lead a long and healthy life. 2. The transplant will not cure the child of CF but will allow the child to have a longer life. 3. The transplant will help to reverse the multisystem damage that has been caused by CF. 4. The transplant will be the child ' s only chance at surviving long enough to graduate from college.
2. A lung transplant does not cure CF, but it does offer the client an opportunity to live a longer life. The concerns are that, after the lung transplant, the child is at risk for rejection of the new organ and for development of secondary infections because of the immunosuppressive therapy.
5 2. A 5-year-old is brought to the ED with a temperature of 99.5°F (37.5°C), a barky cough, stridor, and hoarseness. Which nursing intervention should the nurse prepare for? 1. Immediate IV placement. 2. Respiratory treatment of racemic epinephrine. 3. A tracheostomy set at the bedside. 4. Informing the child ' s parents about a tonsillectomy.
2. The child has stridor, indicating airway edema, which can be relieved by aerosolized racemic epinephrine.
26. Which of the following laboratory values would the nurse expect to see in a normal postpartum client? 1. Hematocrit, 39%. 2. White blood cell count, 16,000 cells/mm3 . 3. Red blood cell count, 5 million cells/mm3 . 4. Hemoglobin, 15 grams/dL.
2. The nurse would expect to see an elevated white cell count.
44. The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see? 1. Moderate serosanguinous drainage. 2. Well-approximated edges. 3. Ecchymotic area distal to the episiotomy. 4. An area of redness adjacent to the incision.
2. The nurse would expect to see well approximated edges.
71. A medication order reads: Methylergonovine 0.2 mg PO q 6 h × 4 doses. For which of the following clients should the nurse question the dose before administering the medication? 1. Client with heavy flow. 2. Client with a blood pressure (BP) of 140/90. 3. Client with type 1 diabetes.
2. The order should be questioned for this client. A systolic blood pressure of 140 or higher, or a diastolic pressure of 90 or higher, or both, meet criteria for hypertension. Methylergonovine should not be given to clients with hypertension
4 6. Which assessment is of greatest concern in a 15-month-old? 1. The child is lying down and has moderate retractions, low-grade fever, and nasal congestion. 2. The child is in the tripod position and has diminished breath sounds and a muffl ed cough. 3. The child is sitting up and has coarse breath sounds, coughing, and fussiness. 4. The child is restless and crying, has bilateral wheezes, and is feeding poorly.
2. When children are sitting in the tripod position, they are having diffi culty breathing. The child is sitting and leaning forward in order to breathe more easily. Diminished breath sounds are indicative of a worsening condition. A muffl ed cough indicates that the child has some subglottic edema. This child has several signs and symptoms of a worsening respiratory condition.
9. A 7-month-old has a low-grade fever, nasal congestion, and a mild cough. What should the nursing care management of this child include? Select all that apply. 1. Maintaining strict bedrest. 2. Avoiding contact with family members. 3. Instilling saline nose drops and bulb suctioning. 4. Keeping the head of the bed flat. 5. Providing humidity, and propping the head of the bed up.
3, 5. 3. Infants are nose breathers and often have increased diffi culty when they are congested. Nasal saline drops and gentle suctioning with a bulb syringe are often recommended. 5. Other helpful suggestions for infants with colds are to provide humidity with a cool mist humidifi er or take them into a steamy bathroom; in addition, raising the head of the bed helps with drainage of secretions.
20. Which of the following statements is true about breastfeeding mothers as compared to bottle-feeding mothers? 1. Breastfeeding mothers usually complete uterine involution completely by 3 weeks postpartum. 2. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life. 3. Breastfeeding mothers show higher levels of bone density after menopause. 4. Breastfeeding mothers are prone to fewer bouts of infection immediately postpartum.
2. There is evidence to show that women who breastfeed their babies are less likely to develop type 2 diabetes later in life.
4 4. Which child is in the greatest need of emergency medical treatment? 1. A 3-year-old who has a barky cough, is afebrile, and has mild intercostal retractions. 2. A 6-year-old who has high fever, no spontaneous cough, and frog-like croaking. 3. A 7-year-old who has abrupt onset of moderate respiratory distress, a mild fever, and a barky cough. 4. A 13-year-old who has a high fever, stridor, and purulent secretions.
2. This child has signs and symptoms of epiglottitis and should receive immediate emergency medical treatment. The patient has no spontaneous cough and has a frog-like croaking because of a signifi cant airway obstruction
69. A nurse is counseling a client about postpartum blues. Which of the following should be included in the discussion? 1. The father may become sad and weepy. 2. Postpartum blues last about a week or two. 3. Medications are available to relieve the symptoms. 4. Very few women experience postpartum blues.
2. This information is correct. The blues usually resolve within 2 weeks of delivery, in contrast to postpartum depression that can linger much longer and which may require medication and/or talk therapy
81. A maternity nurse knows that obstetric clients are most at high risk for cardiovas - cular compromise during the one hour immediately following a delivery because of which of the following? 1. Weight of the uterine body is significantly reduced. 2. Excess blood volume from pregnancy is circulating in the client's peripheral circulation. 3. Cervix is fully dilated and the lochia flows freely. 4. Maternal blood pressure drops precipitously once the baby's head emerges
2. This response is true. Once the placenta is delivered and the uterus contracts, the uterine circulatory reservoir for the mother's large blood volume is gone. Her peripheral circulation receives a 300 to 500 mL auto-transfusion of blood that once circulated throughout the uterus.
94. A nurse is performing a postpartum assessment on a client who delivered at 30 weeks' gestation. Her baby is in the neonatal intensive care unit (NICU). The woman states, "The baby's doctor tells me that I should pump my breast milk for the baby, but I really don't want to breastfeed." Which of the following responses is appropriate for the nurse to make? 1. "You have the right to determine which type of feeding method you wish for your baby." 2. "Since you hadn't planned to breastfeed, you might not be aware of the benefits of breast milk for preterm babies when they are fed breast milk instead of formula." 3. "Mothers who pump milk for their babies seem to be ready to take their babies home sooner than those who bottle feed." 4. "You will be charged less money for your baby's care if you pump because your breast milk is free."
2. This statement is correct. Because breast milk contains many anti-infective properties, preterm babies are less likely to develop severe illnesses, most notably necrotizing enterocolitis, if breastfed.
12. A breastfeeding client has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? 1. She pumps her breasts after each feeding. 2. She feeds her baby every 2 to 3 hours. 3. She feeds her baby 10 minutes on each side. 4. She supplements each feeding with formula.
2. This statement is true. The best way to prevent engorgement is to feed the baby on demand, or at least every 2 to 3 hours.
1 8. Which is the nurse ' s best response to parents who ask what impact asthma will have on the child ' s future in sports? 1. "As long as your child takes prescribed asthma medication, the child will be fine." 2. "The earlier a child is diagnosed with asthma, the more significant the symptoms." 3. "The earlier a child is diagnosed with asthma, the better the chance the child has of growing out of the disease." 4. "Your child should avoid playing contact sports and sports that require a lot of running."
2. When a child is diagnosed with asthma at an early age, the child is more likely to have signifi cant symptoms on aging.
66. The nurse is developing a plan of care for the postpartum client during the "taking hold" phase. Which of the following should the nurse include in the plan? 1. Provide the client with a nutritious meal. 2. Encourage the client to take a nap. 3. Assist the client with activities of daily living. 4. Assure the client that she is meeting the needs of her baby very well
4. Clients in the taking hold phase need assurance that they are learning the skills they will need to care for their new baby
5 0. A mother is crying and tells the nurse that she should have brought her son in yesterday when he said his throat was sore. Which is the nurse ' s best response to this parent whose child is diagnosed with epiglottitis and is in severe distress and in need of intubation? 1. "Children this age rarely get epiglottitis; you should not blame yourself." 2. "It is always better to have your child evaluated at the fi rst sign of illness rather than wait until symptoms worsen." 3. "Epiglottitis is slowly progressive, so early intervention may have decreased the extent of your son ' s symptoms." 4. "Epiglottitis is rapidly progressive; you could not have predicted his symptoms would worsen so quickly."
4. Epiglottitis is rapidly progressive and cannot be predicted.
1 7. What is the most important piece of information that the nurse must ask the parent of a child in status asthmaticus? 1. "What time did your child eat last?" 2. "Has your child been exposed to any of the usual asthma triggers?" 3. "When was your child last admitted to the hospital for asthma?" 4. "When was your child ' s last dose of medication?"
4. The nurse needs to know what medication the child had last and when the child took it in order to know how to begin treatment for the current asthmatic condition.
25. A 16-year-old being treated for hypertension has a history of asthma. Which drug class should be avoided in treating this client ' s hypertension? 1. Beta blockers. 2. Calcium channel blockers. 3. ACE inhibitors. 4. Diuretics.
. 1. Beta blockers are not generally used in clients with asthma and hypertension because of concern the beta agonist will cause severe asthma attacks.
10. Indomethacin (Indocin) may be given to close which congenital heart defect (CHD) in newborns?
Patent ductus arteriosus (PDA).
61. Which assessments indicate that the parent of a 7-year-old is following the prescribed treatment for congestive heart failure (CHF)? Select all that apply. 1. HR of 56 beats per minute. 2. Elevated red blood cell count. 3. 50th percentile height and weight for age. 4. Urine output of 0.5 cc/kg/hr. 5. Playing basketball with other children his age.
. 3, 5. 3. The 50th percentile height and weight for age shows good growth, indicating good nutrition and perfusion. 5. Playing basketball with children his age indicates he is following the prescribed treatment and responding well to it.
47 The fl ow of blood through the heart with an atrial septal defect (ASD) is _____________________.
. Left to right. The pressures in the left side of the heart are greater, causing the fl ow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood fl ow with the extra blood
42. A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is: 1. Feeding formula that is supplemented with additional calories. 2. Allowing the infant to nurse at each breast for 20 minutes. 3. Providing large feedings every 5 hours. 4. Using firm nipples with small openings to slow feedings.
1. Formula can be supplemented with extra calories, either from a commercial supplement, such as Polycose, or from corn syrup. Calories in formula could increase from 20 kcal/oz to 30 kcal/oz or more
54. Which physiological changes occur as a result of hypoxemia in congestive heart failure (CHF)? 1. Polycythemia and clubbing. 2. Anemia and barrel chest. 3. Increased white blood cells and low platelets. 4. Elevated erythrocyte sedimentation rate and peripheral edema.
1. The hypoxemia stimulates erythropoiesis, which causes polycythemia, in an attempt to increase oxygen by having more red blood cells carry oxygen. Clubbing of the fi ngers is a result of the polycythemia and hypoxemia.
33. A 10-year-old has undergone a cardiac catheterization. At the end of the procedure, the nurse should fi rst assess: 1. Pain. 2. Pulses. 3. Hemoglobin and hematocrit levels. 4. Catheterization report.
2. Checking for pulses, especially in the canulated extremity, would assure perfusion to that extremity and is the priority post procedure.
55. Aspirin has been ordered for the child with rheumatic fever (RF) in order to: 1. Keep the patent ductus arteriosus (PDA) open. 2. Reduce joint infl ammation. 3. Decrease swelling of strawberry tongue. 4. Treat ventricular hypertrophy of endocarditis
2. Joint infl ammation is experienced in RF; aspirin therapy helps with infl ammation and pain.
46. The parents of a 3-month-old ask why their baby will not have an operation to correct a ventricular septal defect (VSD). The nurse ' s best response is: 1. "It is always helpful to get a second opinion about any serious condition like this." 2. "Your baby ' s defect is small and will likely close on its own by 1 year of age." 3. "It is common for health-care providers to wait until an infant develops respiratory distress before they do the surgery." 4. "With a small defect like this, they wait until the child is 10 years old to do the surgery."
2. Usually a VSD will close on its own within the fi rst year of life.
34. Which statement by the mother of a child with rheumatic fever (RF) shows she has good understanding of the care of her child? Select all that apply. 1. "I will apply heat to his swollen joints to promote circulation." 2. "I will have him do gentle stretching exercises to prevent contractures." 3. "I will give him his ordered anti-infl ammatory medication for pain and infl ammation." 4. "I will apply cold packs to his swollen joints to reduce pain." 5. "I will take my child every month to the health-care provider ' s offi ce for his penicillin shot."
3, 5. 3. Anti-infl ammatory medications are the drugs of choice for treatment of RF because RF is a systemic infl ammatory disease that can follow strep infections. 5. The parent will take the child to the clinic monthly for a penicillin injection to prevent recurrent strep infections.
36. A nurse has administered methylergonovine 0.2 mg PO to a grand multiparous client who delivered vaginally 30 minutes earlier. Which of the following outcomes indicates that the medication is effective? 1. Blood pressure 120/80. 2. Pulse rate 80 bpm and regular. 3. Fundus firm at umbilicus. 4. Increase in prothrombin time
3. The fundal response indicates that the medication was effective in contracting the uterus.
35. A child has been diagnosed with valvular disease following rheumatic fever (RF). During patient teaching, the nurse discusses the child ' s long-term prophylactic therapy with antibiotics for dental procedures, surgery, and childbirth. The parents indicate they understand when they say: 1. "She will need to take the antibiotics until she is 18 years old." 2. "She will need to take the antibiotics for 5 years after the last attack." 3. "She will need to take the antibiotics for 10 years after the last attack." 4. "She will need to take the antibiotics for the rest of her life."
4. Valvular involvement indicates signifi cant damage, so antibiotics would be taken for the rest of her life.
28. Who is at the highest priority to receive the fl u vaccine? 1. A healthy 8-month-old who attends day care. 2. A 3-year-old who is undergoing chemotherapy. 3. A healthy 7-year-old who attends public school. 4. An 18-year-old who is living in a college dormitory.
1. Children between the ages of 6 and 23 months are at the highest risk for having complications as a result of the fl u. Their immune systems are not as developed, so they are at a higher risk for influenza related hospitalizations
11. A postpartum client who is breastfeeding is being assessed. She delivered 3 days ago. Her breasts are firm and warm to the touch. When asked when she last fed the baby her reply is, "I fed the baby last evening. I let the nurses feed him in the nursery last night. I needed to rest." Which of the following actions should the nurse take at this time? 1. Explain the benefits of exclusive breastfeeding. 2. Have the client massage her breasts hourly. 3. Obtain an order to culture her expressed breast milk. 4. Take the temperature and pulse rate of the client.
1. Clients should be strongly encouraged to exclusively breastfeed their babies to prevent engorgement and to maintain milk supply.
7. Which fi nding might delay a cardiac catheterization procedure on a 1-year-old? 1. 30th percentile for weight. 2. Severe diaper rash. 3. Allergy to soy. 4. Oxygen saturation of 91% on room air.
2. A child with severe diaper rash has potential for infection if the interventionist makes the standard groin approach.
2 7. Which should the nurse instruct children to do to stop the spread of infl uenza in the classroom? Select all that apply. 1. Stay home if they have a runny nose and cough. 2. Wash their hands after using the restroom. 3. Wash their hands after sneezing. 4. Have a flu shot annually. 5. Drink lots of water during the day
2. Children should always wash their hands after using the restroom. In order to decrease the spread of infl uenza, however, it is more important for the children to wash their hands after sneezing or coughing. 3. It is essential that children wash their hands after any contact with nasopharyngeal secretions.
73. The nurse should warn a client who is about to receive methylergonovine of which of the following side effects? 1. Headache. 2. Nausea. 3. Cramping. 4. Fatigue
3. Cramping is an expected outcome of the administration of methylergonovine.
3 8. A parent asks the nurse how it will be determined whether their child has respiratory syncytial virus (RSV). Which is the nurse ' s best response? 1. "We will do a simple blood test to determine whether your child has RSV." 2. "There is no specifi c test for RSV. The diagnosis is made based on the child ' s symptoms." 3. "We will swab your child ' s nose and send that specimen for testing." 4. "We will have to send a viral culture to an outside lab for testing."
3. The child is swabbed for nasal secretions. The secretions are tested to determine whether a child has RSV.
8. The nurse is caring for a child who has undergone a cardiac catheterization. During recovery, the nurse notices the dressing is saturated with bright red blood. The nurse ' s fi rst action is to: 1. Call the interventional cardiologist. 2. Notify the cardiac catheterization laboratory that the child will be returning. 3. Apply a bulky pressure dressing over the present dressing. 4. Apply direct pressure 1 inch above the puncture site.
4. Applying direct pressure 1 inch above the puncture site will localize pressure over the vessel site.
1 5. The nurse is reviewing discharge instructions with the parents of a child who had a tonsillectomy a few hours ago. The parents tell the nurse that the child is a big eater, and they want to know what foods to give the child for the next 24 hours. What is the nurse ' s best response? 1. "The child ' s diet should not be restricted at all." 2. "The child ' s diet should be restricted to clear liquids." 3. "The child ' s diet should be restricted to ice cream and cold liquids." 4. "The child ' s diet should be restricted to soft foods."
4. Soft foods are recommended to limit the child ' s pain and to decrease the risk for bleeding.
6. A 2-year-old has just been diagnosed with cystic fi brosis (CF). The parents ask the nurse what early respiratory symptoms they should expect to see in their child. Which is the nurse ' s best response? 1. "You can expect your child to develop a barrel-shaped chest." 2. "You can expect your child to develop a chronic productive cough." 3. "You can expect your child to develop bronchiectasis." 4. "You can expect your child to develop wheezing respirations."
4. Wheezing respirations and a dry, nonproductive cough are common early symptoms in CF.
4 1. Which physical fi ndings would be of most concern in an infant with respiratory distress? 1. Tachypnea. 2. Mild retractions. 3. Wheezing. 4. Grunting.
4. Grunting is a sign of impending respiratory failure and is a very concerning physical fi nding.
52. Which statement by the mother of a child with rheumatic fever (RF) shows an understanding of prevention for her other children? 1. "Whenever one of them gets a sore throat, I will give that child an antibiotic." 2. "There is no treatment. It must run its course." 3. "If their culture is positive for group A Streptococcus, I will give them their antibiotic." 4. "If their culture is positive for Staphylococcus A, I will give them their antibiotic."
3. RF is caused by a streptococcal infection, not by Staphylococcus
40. A woman states that all of a sudden her 4-day-old baby is having trouble feeding. On assessment, the nurse notes that the mother's breasts are firm, red, and warm to the touch. The nurse teaches the mother to manually express a small amount of breast milk from each breast. Which observation indicates that the nurse's intervention has been successful? 1. The mother's breasts are soft to the touch. 2. The baby swallows after every fifth suck. 3. The baby's pre- and post-feed weight change is 20 grams. 4. The mother squeezes her nipples during manual expression.
1. If the woman has manually removed milk from her breasts, her breasts will soften to the touch.
16. The nurse is caring for a child with Kawasaki disease (KD). A student nurse who is on the unit asks if there are medications to treat this disease. The nurse ' s response to the student nurse is: 1. Immunoglobulin G and aspirin. 2. Immunoglobulin G and ACE inhibitors. 3. Immunoglobulin E and heparin. 4. Immunoglobulin E and ibuprofen (Motrin)
1. High-dose immunoglobulin G and salicylate (aspirin) therapy for infl ammation are the current treatment for KD.
10. To prevent infection, the nurse teaches postpartum clients to perform which of the following tasks? 1. Apply antibiotic ointment to the perineum daily. 2. Change the peripad at each voiding. 3. Void at least every two hours. 4. Spray the perineum with povidone-iodine after toileting.
2. Clients should be advised to change their pads at each voiding.
28. The nurse is discharging five Rh-negative clients from the maternity unit. The nurse knows that the teaching was successful when the clients who had which of the following deliveries state that they understand why they must receive a Rh immune globulin (RhIG) injection? Select all that apply. 1. Abortion at 10 weeks' gestation. 2. Amniocentesis at 16 weeks' gestation. 3. Fetal demise at 24 weeks' gestation. 4. Birth of Rh-negative twins at 35 weeks' gestation. 5. Delivery of a 40-week-gestation, Rh-positive baby
Answers 1, 2, 3, and 5 are correct. 1. The client should receive an Rh immune globulin (RhIG) injection after a spontaneous abortion since the fetal blood type is unknown. 2. The client should receive an Rh immune globulin (RhIG) injection after an amniocentesis since the baby's blood type is unknown. 3. The client should receive an Rh immune globulin (RhIG) injection after the delivery of a fetal demise since the baby's blood type is unknown. 5. The client should receive an Rh immune globulin (RhIG) injection after the birth of an Rh-positive baby.
19. Hypoxic spells in the infant with a congenital heart defect (CHD) can cause which of the following? Select all that apply. 1. Polycythemia. 2. Blood clots. 3. Cerebrovascular accident (CVA). 4. Developmental delays. 5. Viral pericarditis. 6. Brain damage. 7. Alkalosis.
. 1, 2, 3, 4, 6. 1. Hypoxia causes polycythemia, which can lead to increased blood viscosity, which can lead to blood clots and a stroke (CVA). 2. Hypoxia causes polycythemia, which can lead to increased blood viscosity, which can lead to blood clots and a stroke (CVA). 3. Hypoxia causes polycythemia, which can lead to increased blood viscosity, which can lead to blood clots and a stroke (CVA). 4. Developmental delays can be caused by multiple hospitalizations and surgeries. The child usually catches up to the appropriate level.
3. The parent of a 4-month-old with cystic fibrosis (CF) asks the nurse what time to begin the child ' s first chest physiotherapy (CPT) each day. Which is the nurse ' s best response? 1. "Thirty minutes before feeding the child breakfast." 2. "After deep-suctioning the child each morning." 3. "Thirty minutes after feeding the child breakfast." 4. "Only when the child has congestion or coughing."
. 1. CPT should be done in the morning prior to feeding to avoid the risk of the child vomiting.
8. The parents of a 5-week-old have just been told that their child has cystic fi brosis (CF). The mother had a sister who died of CF when she was 19 years of age. The parents are sad and ask the nurse about their child ' s projected life expectancy. What is the nurse ' s best response? 1. "The life expectancy for CF patients has improved significantly in recent years." 2. "Your child might not follow the same course that the mother ' s sister did." 3. "The health-care provider will come to speak to you about treatment options." 4. The nurse answers their questions briefly, listens to their concerns, and is available later after they've processed the information.
4. The nurse ' s best intervention is to listen as the parents express their concerns and fears. The nurse ' s answers should be brief, knowing that the parents are not able to process information right now. The nurse should be available later if the parents have any other concerns or questions or if they just need someone with whom to talk.
5 3. Which intervention is most appropriate to teach the mother of a child diagnosed with a URI and a dry, hacking cough that prevents him from sleeping? 1. Give cough suppressants at night. 2. Give an expectorant every 4 hours. 3. Give cold and fl u medication every 8 hours. 4. Give ½ teaspoon of honey four to fi ve times per day.
4. Warm fl uids, humidifi cation, and honey are the best treatments for a URI. But honey is not used in children less than 1 year of age because of the association with botulism.
61. A nurse is caring for the following 4 postpartum clients. Which clients should the nurse be prepared to monitor closely for signs of postpartum hemorrhage (PPH)? Select all that apply. 1. G1 P0100, delivered a fetal demise at 29 weeks' gestation. 2. G2 P2002, prolonged first stage of labor. 3. G2 P1011, delivered by cesarean section for failure to progress. 4. G3 P3003, delivered vaginally at 42 weeks, a 4 lb 8 oz (2200 grams) neonate. 5. G4 P4004, with a succenturiate placenta.
Answers 2 and 5 are correct. 2. Clients who have had a prolonged first stage of labor are at high risk for postpartum hemorrhage (PPH). 5. Clients with a succenturiate placenta are at high risk for PPH.
15. A client informs the nurse that she intends to bottle feed her baby. Which of the following actions should the nurse encourage the client to perform? Select all that apply. 1. Increase her fluid intake for a few days. 2. Massage her breasts every 4 hours. 3. Apply heat packs to her axillae. 4. Wear a supportive bra 24 hours a day. 5. Stand with her back toward the shower water.
Answers 4 and 5 are correct. 4. The mother should be advised to wear a supportive bra 24 hours a day for a week or so. 5. The mother should be advised to stand with her back toward the warm shower water.
28. The nurse is caring for a 9-month-old who was born with a congenital heart defect (CHD). Assessment reveals a HR of 160, capillary refi ll of 4 seconds, bilateral crackles, and sweat on the scalp. These are signs of _____________________.
Congestive heart failure (CHF).
6 1. What does the therapeutic management of cystic fi brosis (CF) patients include? Select all that apply. 1. Providing a high-protein, high-calorie diet. 2. Providing a high-fat, high-carbohydrate diet. 3. Encouraging exercise. 4. Minimizing pulmonary complications. 5. Encouraging medication compliance.
1, 3, 4, 5. 1. Children with CF have diffi culty absorbing nutrients because of the blockage of the pancreatic duct. Pancreatic enzymes cannot reach the duodenum to aid in digestion of food. These children often require up to 150% of the caloric intake of their peers. The nutritional recommendation for CF patients is high-calorie and high-protein. 3. Exercise is effective in helping CF patients clear secretions. 4. Minimizing pulmonary complications is essential to a better outcome for CF patients. Compliance with CPT, nebulizer treatments, and medications are all components of minimizing pulmonary complications. 5. Medication compliance is a necessary part of maintaining pulmonary and gastrointestinal function.
9. Which interventions decrease cardiac demands in an infant with congestive heart failure (CHF)? Select all that apply. 1. Allow parents to hold and rock their child. 2. Feed only when the infant is crying. 3. Keep the child uncovered to promote low body temperature. 4. Make frequent position changes. 5. Feed the child when sucking the fists. 6. Change bed linens only when necessary. 7. Organize nursing activities.
1, 4, 5, 6, 7. 1. Rocking by the parents will comfort the infant and decrease demands 4. Frequent position changes will decrease the risk for infection by avoiding immobility with its potential for skin breakdown. 5. An infant sucking the fi sts could indicate hunger. 6. Change bed linens only when necessary to avoid disturbing the child. 7. Organize nursing activities to avoid disturbing the child.
3 9. Which statement indicates the parent needs further teaching on how to prevent his other children from contracting respiratory syncytial virus (RSV)? 1. "I should make sure that both my children receive palivizumab (Synagis) injections for the remainder of this year." 2. "I should be sure to keep my infected child away from his brother until he has recovered." 3. "I should insist that all people who come in contact with my children thoroughly wash their hands before playing with them." 4. "I should insist that anyone with a respiratory illness avoid contact with my children until well."
1. Palivizumab (Synagis) will not help the child who has already contracted the illness. Palivizumab (Synagis) is an immunization and a method of primary prevention.
16. The nurse in the obstetric clinic received a telephone call from a bottle-feeding mother whose baby is 3 days old. The mother states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client to perform? 1. Intermittently apply ice packs to her axillae and breasts. 2. Apply lanolin to her breasts and nipples every 3 hours. 3. Express milk from the breasts every 3 hours. 4. Ask the primary healthcare provider to order a milk suppressant.
1. The client should apply ice packs to her axillae and breasts.
86. A nurse is assessing a postpartum client on the day after she delivered. She had a spontaneous vaginal delivery over an intact perineum. The fundus is firm at the umbilicus, lochia moderate, and perineum edematous. One hour after receiving ibuprofen 600 mg PO, the client is complaining of perineal pain at level 9 on a 10-point scale. Based on this information, which of the following is an appropriate conclusion for the nurse to make about the client? 1. She should be assessed by her doctor. 2. She should have a sitz bath. 3. She may have a hidden laceration. 4. She needs a narcotic analgesic.
1. The client should be assessed by her healthcare practitioner.
19. Which statement by the parent of a child using an albuterol inhaler leads the nurse to believe that further education is needed on how to administer the medication? 1. "I should administer two quick puffs of the albuterol inhaler using a spacer." 2. "I should always use a spacer when administering the albuterol inhaler." 3. "I should be sure that my child is in an upright position when administering the inhaler." 4. "I should always shake the inhaler before administering a dose."
1. The parent of an asthmatic child should always give one puff at a time and wait 1 minute before administering the second puff.
30. A child diagnosed with congestive heart failure (CHF) is receiving maintenance doses of digoxin (Lanoxin) and furosemide (Lasix). She is rubbing her eyes when she is looking at the lights in the room, and her HR is 70 beats per minute. The nurse expects which laboratory fi nding? 1. Hypokalemia. 2. Hypomagnesemia. 3. Hypocalcemia. 4. Hypophosphatemia.
1. The rubbing of the child ' s eyes may mean that she is seeing halos around the lights, indicating digoxin (Lanoxin) toxicity. The HR is slow for her age and also indicates digoxin toxicity. A decrease in serum potassium because of the furosemide (Lasix) can increase the risk for digoxin toxicity
4 0. Which child is at highest risk for requiring hospitalization to treat respiratory syncytial virus (RSV)? 1. A 2-month-old who was born at 32 weeks. 2. A 16-month-old with a tracheostomy. 3. A 3-year-old with a congenital heart defect. 4. A 4-year-old who was born at 30 weeks.
1. The younger the child, the greater the risk for developing complications related to RSV. This infant is at highest risk because of age and premature status.
70. An Asian client's temperature 10 hours after delivery is 100.2° F (37.8° C) but, when encouraged to drink ice water, she refuses. Which of the following nursing actions is most appropriate? 1. Ask the client what she would like instead. 2. Notify the client's healthcare provider. 3. Reassess the temperature in one-half hour. 4. Remind the client that drinking is very important.
1. This action is appropriate. Although many Asian people believe in the hot-cold theory of disease and will often not drink cold fluids or eat cold foods during the postpartum period, the nurse must not assume this is the case.
74. The third stage of labor has just ended for a client who has decided to bottle feed her baby. Which of the following maternal hormones will increase sharply at this time? 1. Estrogen. 2. Prolactin. 3. Human placental lactogen. 4. Human chorionic gonadotropin
2. Prolactin will elevate sharply in the client's bloodstream.
2 1. Which child with asthma should the nurse see fi rst? 1. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 93%. 2. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 93%. 3. A 9-year-old who is quiet, is pale in color, and is wheezing bilaterally with an oxygen saturation of 92%. 4. A 16-year-old who is speaking in short sentences, is wheezing, is sitting upright, and has an oxygen saturation of 93%.
1. This child is exhibiting signs of severe asthma. This child should be seen fi rst. The child no longer has wheezes and now has diminished breath sounds.
35. A client on her first day after delivery is being monitored carefully after a significant postpartum hemorrhage. Which of the following should the nurse report to the obstetrician? 1. Urine output 200 mL for the past 8 hours. 2. Weight decrease of 2 pounds since delivery. 3. Drop in hematocrit of 2% since admission. 4. Pulse rate of 68 beats per minute.
1. This output is below the accepted minimum for 8 hours.
1 3. A school-age child has been diagnosed with strep throat. The parent asks the nurse when the child can return to school. Which is the nurse ' s best response? 1. "Forty-eight hours after the first documented normal temperature." 2. "Twenty-four hours after the first dose of antibiotics." 3. "Forty-eight hours after the first dose of antibiotics." 4. "Twenty-four hours after the first documented normal temperature."
2. Children with strep throat are no longer contagious 24 hours after initiation of antibiotic therapy.
40. The nurse is caring for an 8-year-old girl whose parents indicate she has developed spastic movements of her extremities and trunk, facial grimace, and speech disturbances. They state it seems worse when she is anxious and does not occur while sleeping. The nurse questions the parents about which recent illness? 1. Kawasaki disease (KD). 2. Rheumatic fever (RF). 3. Malignant hypertension. 4. Atrial fi brillation.
2. Chorea can be a manifestation of RF, with a higher incidence in females.
65. The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following should the nurse include in the plan? 1. Teach baby-care skills such as diapering. 2. Discuss the labor and birth with the mother. 3. Discuss contraceptive choices with the mother. 4. Teach breastfeeding skills such as pumping.
2. During the taking in phase, clients need to internalize their labor experiences. Discussing the labor process is appropriate for this postpartum phase.
87. A breastfeeding mother calls the obstetrician's office with a complaint of pain in one breast. Upon inspection, a diagnosis of mastitis is made. Which of the following nursing interventions is appropriate? 1. Advise the woman to apply ice packs to her breasts. 2. Encourage the woman to breastfeed frequently. 3. Inform the woman that she should wean immediately. 4. Direct the woman to notify her pediatrician as soon as possible
2. Encouraging the woman to breastfeed frequently is appropriate.
1. How does the nurse interpret the laboratory analysis of a stool sample containing excessive amounts of azotorrhea and steatorrhea in a child with cystic fibrosis (CF)? The values indicate the child is: 1. Not compliant with taking her vitamins. 2. Not compliant with taking her enzymes. 3. Eating too many foods high in fat. 4. Eating too many foods high in fiber
2. If the child were not taking enzymes, the result would be a large amount of undigested food, azotorrhea, and steatorrhea in the stool. Pancreatic ducts in CF clients become clogged with thick mucus that blocks the fl ow of digestive enzymes from the pancreas to the duodenum. Therefore, clients must take digestive enzymes with all meals and snacks to aid in absorption of nutrients. Often, teens are noncompliant with their medication regimen because they want to be like their peers.
3 0. A 6-week-old is admitted to the hospital with infl uenza. The child is crying, and the father tells the nurse that his son is hungry. The nurse explains that the baby is not to have anything by mouth. The parent does not understand why the child cannot eat. Which is the nurse ' s best response to the parent? 1. "We are giving your child intravenous fl uids, so there is no need for anything by mouth." 2. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." 3. "When your child eats, he burns too many calories; we want to conserve the child ' s energy." 4. "Your child has too much nasal congestion; if we feed the child by mouth, the distress will likely increase."
2. Infants are at higher risk of aspiration because their airways are shorter and narrower than those of adults. An infant with infl uenza has lots of nasal secretions and coughs up mucus. With all the secretions, the infant is at an even higher risk of aspiration.
27. While looking through the chart of an infant with a congenital heart defect (CHD) of decreased pulmonary blood fl ow, the nurse would expect which laboratory fi nding? 1. Decreased platelet count. 2. Polycythemia. 3. Decreased ferritin level. 4. Shift to the left.
2. Polycythemia is the result of the body attempting to increase the oxygen supply in the presence of hypoxia by increasing the total number of red blood cells to carry the oxygen.
60. Family discharge teaching has been effective when the parent of a toddler diagnosed with Kawasaki disease (KD) states: 1. "The arthritis in her knees is permanent. She will need knee replacements." 2. "I will give her diphenhydramine (Benadryl) for her peeling palms and soles of her feet." 3. "I know she will be irritable for 2 months after her symptoms started." 4. "I will continue with high doses of Tylenol for her infl ammation."
3. Children can be irritable for 2 months after the symptoms of the disease start.
3 3. Which should be included in instructions to the parent of a child prescribed amoxicillin to treat an ear infection? 1. "Continue the amoxicillin until the child ' s symptoms subside." 2. "Administer an over-the-counter antihistamine with the antibiotic." 3. "Administer the amoxicillin until all the medication is gone." 4. "Allow your child to administer his own dose of amoxicillin."
3. It is essential that all the medication be given.
1 4. A school-age child is admitted to the hospital for a tonsillectomy. During the nurse ' s postoperative assessment, the child ' s parent tells the nurse that the child is in pain. Which of the following observations would be of most concern to the nurse? 1. The child ' s heart rate and blood pressure are elevated. 2. The child complains of having a sore throat. 3. The child is refusing to eat solid foods. 4. The child is swallowing excessively.
4. Excessive swallowing is a sign that the child is swallowing blood. This should be considered a medical emergency, and the health-care provider should be contacted immediately. The child is likely bleeding and will need to return to surgery
2. Which would the nurse explain to parents about the inheritance of cystic fibrosis? 1. CF is an autosomal-dominant trait passed on from the child ' s mother. 2. CF is an autosomal-dominant trait passed on from the child ' s father. 3. The child of parents who are both carriers of the gene for CF has a 50% chance of acquiring CF. 4. The child of a mother who has CF and a father who is a carrier of the gene for CF has a 50% chance of acquiring CF.
4. If the child is born to a parent with CF and the other parent is a carrier, the child has a 50% chance of acquiring the disease and a 50% chance of being a carrier of the disease.
6. Which statement by a parent of an infant with congestive heart failure (CHF) who is being sent home on digoxin (Lanoxin) indicates the need for further education? 1. "I will give the medication at regular 12-hour intervals." 2. "If he vomits, I will not give a make-up dose." 3. "If I miss a dose, I will not give an extra dose." 4. "I will mix the digoxin in some formula to make it taste better."
4. If the medication is mixed in his formula, and he refuses to drink the entire amount, the dose will be inadequate.
9. A client with an obstetrical history of G2 P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2° F (37.8° C). Which of the following is the ap - propriate nursing intervention at this time? 1. Notify the doctor to get an order for acetaminophen. 2. Request an infectious disease consult from the doctor. 3. Provide the client with cool compresses. 4. Encourage intake of water and other fluids.
4. It is likely that this client is dehydrated. She should be advised to drink fluids.
13. A breastfeeding client at 2 days postpartum states, "I am sick of being fat. When can I go on a diet?" Which of the following responses is appropriate? 1. "It is fine for you to start dieting right now as long as you drink plenty of milk." 2. "Your breast milk will be low in vitamins if you start to diet while breastfeeding." 3. "You must eat at least 3,000 calories per day in order to produce enough milk for your baby." 4. "Many mothers lose weight when they breastfeed because the baby consumes about 600 calories a day."
4. Many mothers who consume approximately the same number of calories while breastfeeding as they did when they were pregnant do lose weight while breastfeeding.
1 2. A child is complaining of throat pain. Which statement by the mother indicates that she needs more education regarding the care and treatment of her child ' s pharyngitis? 1. "I will have my child gargle with salt water three times a day." 2. "I will offer my child ice chips several times a day." 3. "I will give my child Tylenol every 4 to 6 hours as needed." 4. "I will ask the nurse practitioner for some amoxicillin."
4. Pharyngitis is a self-limiting viral illness that does not require antibiotic therapy. Pharyngitis should be treated with rest and comfort measures, including acetaminophen (Tylenol), throat sprays, cold liquids, and Popsicles.
67. A nurse massages the uterus of a postpartum woman after making a hypothesis of uterine atony. Which of the following outcomes would indicate that the client's condition had improved? 1. Heavy lochial flow. 2. Decreased pain level. 3. Stable blood pressure. 4. Fundus firm at or below the umbilicus.
4. The expected outcome would be a well-contracted uterus at or below the umbilicus.
18. During a well-child checkup for an infant with tetralogy of Fallot (TOF), the child develops severe respiratory distress and becomes cyanotic. The nurse ' s fi rst action should be to: 1. Lay the child fl at to promote hemostasis. 2. Lay the child fl at with legs elevated to increase blood fl ow to the heart. 3. Sit the child on the parent ' s lap, with legs dangling, to promote venous pooling. 4. Hold the child in knee-chest position to decrease venous blood return.
4. The increase in the SVR would increase afterload and increase blood return to the pulmonary artery.
75. The nurse hears the following information on a newly delivered client during shift report: 21 years old, married, G1 P1001, 8 hours post-spontaneous vaginal delivery over an intact perineum; vitals 110/70, 98.6° F (37° C), pulse 82, respiratory rate 18; fundus firm at umbilicus; moderate lochia rubra; ambulated 4 times to the bathroom to void; breastfeeding every 2 hours. Which of the following conditions should the nurse anticipate in planning care for this client? 1. Fluid volume deficit r/t excess blood loss. 2. Impaired skin integrity r/t vaginal delivery. 3. Impaired urinary elimination r/t excess output. 4. Knowledge deficit r/t lack of parenting experience.
4. This client is a primigravida. The nurse would anticipate that she is in need of teaching regarding newborn care as well as self-care.
52. A client, 2 days postpartum from a spontaneous vaginal delivery, asks the nurse about postpartum exercises. Which of the following responses by the nurse is appropriate? 1. "You must wait to begin to perform exercises until after your 6-week postpartum checkup." 2. "You may begin Kegel exercises today, but do not do any other exercises until the doctor tells you that it is safe." 3. "By next week you will be able to return to the exercise schedule you had before you were pregnant." 4. "You can do some Kegel exercises today and then slowly increase your toning exercises over the next few weeks."
4. This statement is correct. The client should begin with Kegel exercises shortly after delivery, move to abdominal tightening exercises in the next couple of days, and then slowly progress to stomach crunches, and so on.
5 1. The parent of a child with croup tells the nurse that her other child just had croup and it cleared up in a couple of days without intervention. She asks the nurse why this child is exhibiting worse symptoms and needs to be hospitalized. Which is the nurse ' s best response? 1. "Some children just react differently to viruses. It is best to treat each child as an individual." 2. "Younger children have wider airways that make it easier for bacteria to enter and colonize." 3. "Younger children have short and wide eustachian tubes, making them more susceptible to respiratory infections." 4. "Children younger than 3 years usually exhibit worse symptoms because their immune systems are not as developed."
4. Younger children have less developed immune systems and usually exhibit worse symptoms than older children
61. During a postpartum assessment, it is noted that a client with an obstetrical history of G1 P1001 who delivered vaginally over an intact perineum has a cluster of hemorrhoids. Which of the following would be appropriate for the nurse to include in the client's health teaching? Select all that apply. 1. The client should use a sitz bath daily as a relief measure. 2. The client should digitally replace external hemorrhoids into her rectum. 3. The client should breastfeed frequently to stimulate oxytocin to reduce the size of the hemorrhoids. 4. The client should be advised that the hemorrhoids will increase in size and quantity with subsequent pregnancies. 5. The client should apply topical anesthetic as a relief measure
Answers 1, 2, and 5 are correct. 1. Sitz baths do have a soothing effect for clients with hemorrhoids. 2. Clients often feel some relief when external hemorrhoids are reinserted into the rectum 5. Topical anesthetics can provide relief from the discomfort of hemorrhoids.
56. The nurse has admitted a client to the postpartum unit and has taught her about pericare. Which of the following indicates that the client understands the proce - dure? Select all that apply. 1. The client performs the procedure twice a day. 2. The client washes her hands before and after the procedure. 3. The client sits in warm tap water for 10 minutes three times a day. 4. The client sprays her perineum from front to back. 5. The client mixes warm tap water with hydrogen peroxide.
Answers 2 and 4 are correct 2. This statement is correct. The client should wash her hands before and after performing pericare. 4. This statement is accurate. The client sprays the water from front to back.
48. Patent ductus arteriosus causes what type of shunt? _____________________
Left to right. Blood fl ows from the higher-pressure aorta to the lower-pressure pulmonary artery, resulting in a left to right shunt.
45. A 3-month-old has been diagnosed with a ventricular septal defect (VSD). The fl ow of blood through the heart is _____________________.
Left to right. The pressures in the left side of the heart are greater, causing the fl ow of blood to be from an area of higher pressure to lower pressure, or left to right, increasing the pulmonary blood fl ow with the extra blood
