Labor Chronic Illness Abuse Dying Congenital

A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?

"After birth it is easier to develop an infection in the urinary system, we need to see you today"

A client asks why she should learn breathing patterns for labor. After instruction is given, the nurse determines teaching has been effective when the client states:

"Breathing patterns are distraction techniques taught to decrease pain in labor"

A woman's primary care provider has told her he wants to use an episiotomy for birth. She asks the nurse what the purpose of this is. Which answer would be best?

"It relieves pressure on the fetal head"

The nurse is explaining to a group of nursing students the proper technique to obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor related to taking a temperature?

"Rectal temperatures should not be taken on a child with diarrhea"

A parent calls the nurse in the emergency department and reports giving a tepid bath to decrease temperature in a feverish child. The parent states the child is shivering and wants to know if this means the bath was effective. What is the best response by the nurse?

"Shivering means the child is chilling, which will cause the body temperature to increase"

The nurse is preparing to administer a medication to a 5-year-old who weighs 35 pounds. The prescribed single dose is 1 to 2 mg/kg/day. Which is the appropriate dose rand for this child?

16 to 32 mg

The nurse is measuring the head circumference of a newborn during a well-child visit. Until which age should the nurse take this measurement?

24 months

At approximately what age do children understand the permanence of death?

8

Dilation follows effacement in the primiparous mother. To be fully dilated, the cervix should have a distance of what measurement?

8 to 10 cm

The labor and delivery nurse has responsibility for monitoring fetal heart rate patterns. Which of the following values would indicate fetal tachycardia?

>160 bpm

Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn?

Barlow sign and Ortlani click

The nurse determines that the fetal heart rate averages approximately 140 bpm over a 10-min period. The nurse identifies this as:

Baseline FHR

A woman has been seen and treated in the emergency room several times for injuries that are deemed suspicious. The woman is reluctant to participate in a screening process. How best can the nurse provide reassurance to this woman?

Being nonjudgmental

A nurse is monitoring the vital signs of a client 24 hours after birth. She notes that the client's blood pressure is 100/60 mm Hg. Which postpartum complication should the nurse most suspect in this client, based on this finding?

Bleeding

The father of a 4-year-old boy with leukemia tells the nurse that he believes his son was misdiagnosed by his two previous oncologists and that the lab results were in error. Thus, he has switched doctors in hopes of "finding someone who can diagnose his son accurately." Which stage of grief does the nurse suspect this father to be in?

Denial

The nurse is caring for a preoperative pediatric client. What would be best for the nurse to do with this client?

Determine how much the child knows and is capable of understanding

A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

Determining the chief complaint

A 29-year-old client has gestational diabetes. The nurse is teaching her about managing her glucose levels. Which therapy would be most appropriate for this client?

Diet

Which assessment findings ae most prominent in the infant with Tetralogy of Fallot and significant pulmonary stenosis?

Dyspnea on limited exertion, fatigue, cynosis

A child with acute bronchitis has just been hospitalized. The nurse overhears the child's mother say to the child that if he is not good, she will leave and not come back until he is ready to return home. What should the nurse suspect in this situation?

Emotional abuse

A 4-year-old-child is facing death and cries frequently for the parents. What is the nurse's most therapeutic action?

Encourage the parents to remain with their child

The labor and delivery nurse knows that internal monitoring during labor is an invasive technique. She correctly identifies an increase in the risk of which of the following for both mother and fetus if this is done?

Infection

The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2F (38.4C), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

Infection

A woman is pregnant and has asthma. Her primary care provider has told her to continue taking prednisone during pregnancy, but she is concerned the drug may be teratogenic. What advice would be best to give her regarding this?

Prednisone is considered safe in the doses prescribed by her care provider

A woman in labor suddenly reports shard fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

Premature separation of the placenta

Which technique should the nurse use to administer ear drops to a 4-year-old child?

Pull the pinna of the ear up and back

A 4-year-old child is admitted to the hospital for surgery. Before you administer medicine, the best way to identify the child would be to:

Read the child's armband

The injection of a local anesthetic to block specific nerve pathways is referred to as:

Regional block

The nurse is observing fa set of new parents to ensure that they are bonding with their newborn. What displayed behavior would indicate that the parents bonding is maladaptive?

The mother is reluctant to touch the newborn for fear of hurting her

The nurse is aware that cord compression is not continuous when variable decelerations occur and that compression happens when which of the following takes place?

The uterus contracts and squeezes the cord against the fetus

The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will the nurse and specialist prioritize to assist this child in better understanding what will be happening in the treatment of the cancer?

Therapeutic play

A nursing student studying reproduction identifies which of the following statements to be correct?

Twenty-two of the 23 pairs of chromosomes are autosomes and the remaining pair is the sex chromosomes

The nurse is preparing a presentation depicting the various ways pathogens are spread around. The nurse will illustrate that pathogens passed around via insects is referred to as which mechanism?

Vector

A student nurse is learning about congenital heart defects in newborns and correctly identifies which of the following to be the most common intracardiac defect?

Ventricular septal defect

Which client characteristic is identified as normal behavior when demonstrated by a terminally ill 12-year-old client?

Verbal or physical aggression

It is determined that a client's blood Rh is negative and her partner's is positive. To help prevent Rh isoimmunization, the nurse would expect to administer Rho(D) immune globulin at which time?

At 28 weeks' gestation and again within 72 hours after birth

A woman in labor received an opioid close to the time of birth. The nurse would assess the newborn for which effect?

Respiratory depression

Which type of fracture is most indicative of child abuse?

Spiral fracture

The parents state they are afraid to have their child vaccinated and ask the nurse for more information. Which response by the nurse is most appropriate?

"Vaccinations are very effective at preventing serious disease and infection."

To prevent thrombophlebitis following a cesarean birth, which of the following would be most important to implement?

Encourage the woman to ambulate

The parent of a dying 10-year-old states she is unable to handle watching her child die and starts to leave the unit. What is the priority intervention by the nurse?

Ensure that the child has support during the dying process

A group of nursing students are preparing a presentation which will illustrate various components of the birthing process. When presenting the pelvis, the students should point out that it is often referred to as which term?

Passageway

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant?

Patent airway

A woman is in the hospital only 15 min when she begins to give birth precipitously. The fetal head begins to emerge as the nurse walks into the labor room. The nurse's best action would be to:

Place a hand gently on the fetal head to guide birth

During a child's last stage of dying, her parents ask, "Is she able to hear us?" What is your best response?

"Yes, she can hear and may also understand most of what is being said."

An 8-month-old infant is being held by her mother and the nurse needs to obtain her vital signs. Which approach would most likely ensure accurate readings?

Allow the mother to continue to hold the infant, listen to the child's heart rate, count respirations by the abdominal rise, then take an axillary temperature

A student observing in labor and delivery watches a physician introduce a hard plastic instrument with a hook on the end into the vagina during a digital examination. The physician proceeds to guide the hook to snag a hole into the membranes. This process causes the body to release prostaglandins, which induces labor and is known as which of the following?

Artificial rupture of membranes

The nurse is caring for a child whose family recently immigrated from a developing country. While completing the admission history, the parents report all the child's immunizations are up to date. Which nursing action is most appropriate?

Ask parents which immunizations have been given

The maternal health nurse assists the birth attendant in a forceps-assisted birth. After the birth of the infant, what is the nurse's priority?

Assess the infant for trauma

A new mother, who is an adolescent, was cautious at first when holding and touching her newborn. She seemed almost afraid to make contact with baby and only touched it lightly and briefly. However, 48 hours after the birth, the nurse now notices that the new mother is pressing the newborn's cheek against her own and kissing her on the forehead. The nurse recognizes these actions as which behavior?

Attachment

A pregnant client with type 1 diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to:

Check her blood sugars frequently and adjust insulin accordingly

A patient is 3 hours post-cesarean delivery. The nurse notes the Foley catheter bag has 30 mL of urine and it has been 2 hours since it was last checked. What is the appropriate nursing intervention?

Check the Foley tubing

Which nursing consideration is most important when communicating with pediatric clients at the end of life?

Client's developmental level

In the labor and delivery unit, which is the best way to prevent the spread of infection?

Complete hand hygiene

When describing chronic conditions to a group of students, which of the following would the instructor include as a characteristic?

Condition lasting at least 6 months

A nurse who is caring for a child who has died begins to cry while talking with the family. What is the most appropriate action by the nurse?

Continue to care for the child and family in an unobtrusive manner

The nurse is preparing to assess the respiratory rate of a crying 15-month-old boy. To get the most accurate assessment, what approach should the nurse take?

Count after the child stops crying and is comfortable

The nurse is feeding a 2-day-old in the nursery when the infant begins chocking and becomes cyanotic. Frothy sputum is observed coming from the mouth. What congenital malformation does the nurse understand these symptoms indicate?

Esophageal atresia

The nurse is caring for a 12-year-old girl with a chronic endocrine condition that has resulted in weight gain, facial hair, and acne. During a routine examination, the girls confides that she doesn't participate in any extracurricular activities or have any social life because she is so unattractive. She feels it is pointless to get involved with anything or anyone because she is always going to be "fat and ugly." When responding to the girl, which of the following would be the priority?

Exploring the girl's perception of her body image and health status

The nurse is caring for a young child whose parents have been charged with physical abuse. Which child reaction is notes as a result of the parental behavior?

Fretful and shrinks away when approached

A nursing instructor is explaining the stages of fetal development to a group of nursing students. The instruction determines the session is successful after the students correctly choose which time period as representing the pre-embryonic stage?

From fertilization and to the end of the second week

From which pair of metabolic disorders must the nurse instruct the parents to eliminate breast and cow's milk from the diet?

Galactosemia and phenylketonuria

A parent of an 8-year-old with asthma tells the nurse, "I allow him to play soccer at school as long as he has his inhaler. He has been instructed when and how to use his inhaler." What type of caregiver response is this parent exhibiting?

Gradual acceptance

The parents of a terminally ill child do not want the child dying in the hospital. What can the nurse suggest to help the parents' needs?

Have hospice provided through home care

A pregnant woman has a ruptured tubal pregnancy. What does the nurse anticipate the treatment will be?

Immediate surgical removal of the pregnancy and affected tube

In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition?

Imperforate anus

A nurse is caring for a pregnant client with rhythmic uterine contractions. Which feature should the nurse identify as associated with true labor?

Increase in frequency of the contractions

The parent reports that the health care provider said that the infant had a hernia but she can't remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated?

Inguinal hernia

A 25-year-old client at 22 weeks' gestation is notes to have proteinuria and dependent on her routine prenatal visit. Which additional assessment should the nurse prioritize and alert the RN or health care provider?

Initial BP 100/70 mm Hg, current BP 140/90 mm Hg

When teaching the pregnant patient about self-medicating for pain during labor, why did the nurse instruct the patient to avoid taking acetylsalicylic acid (aspirin)?

Interference with blood coagulation with increased risk of bleeding in mother or infant

A newborn is diagnosed with congenital hypothyroidism prior to discharge from the hospital. What medication does the nurse anticipate administering to the newborn?

Levothyroxine

The nurse is assessing an infant diagnoses with shaken baby syndrome. Clinical manifestations of shaken baby syndrome effect which bodily system the most?

Nervous system

The nurse is caring for a pediatric client with the injury pictured. When asking the caregivers about the way in which the client received these injuries, which communication manner is essential? (bruising on the back)

Nonjudgmental manner

The doctor orders a urinalysis on a 15-month-old toddler. The mother states that the child is not potty trained. What is the best way for the nurse to collect the specimen?

Place a urine collection bag on the child after cleaning off the perineum

What is the organ with a rich blood supply that supplies the developing organism with food and oxygen and carries away waste for excretion by the mother?

Placenta

A patient who is in her 9th month of pregnancy comes to the emergency department and reports that bright red blood is coming from her vagina. She denies having any pain. What needs to be rules out before a vaginal examination can be performed?

Placenta previa

Which assessment finding in a client reporting uterine contractions would be most consistent as an indicator of approaching labor?

Rupture of amniotic membranes

Which educational topic is often overlooked when teaching an adolescent about living with a chronic condition?

Sexuality

The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticipate performing care?

Spina bifida with myelomeningocele

The nurse is administering 8 p.m. medications when a 9-year-old child expresses concern about dying sometime during the night. Which action by the nurse is most appropriate?

Stay with the child and encourage further discussion

An adolescent girl and her caregiver present at the pediatrician's office. The adolescent reports severe abdominal pain. A diagnosis of pelvic inflammatory disease (PID) is made. The nurse notes in the child's chart that this is the third time she has been treated for PID. Which action by the nurse would be most appropriate?

Take the child to a private room and interview her regarding her sexual history and partners

The nurse is caring for a neonate in the newborn nursery with congenital talipes equinovarus (bilateral clubfoot). If nonsurgical treatment is chosen, which nursing action is anticipated?

holding feet/ankles in position for casting