Maternal
The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize?
signs that birth is imminent
A client and partner are excited to discover they are expecting twins. The nurse is prepared to monitor the twins for which potential situation after noting they share an amniotic sac?
cord entanglement
The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?
the urge to push occurs
The nurse is caring for a child who weighs 31 kg. A medication is ordered for this child with a dosage range of 20 to 40 mg per kg of body weight per dose. Which dosage would be appropriate for the nurse to administer to this child in one dose?
1,000 mg per dose
The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client?
further testing is required
An 8-month-old infant in being held by her mother and the nurse needs to obtain the infant's 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.
The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?
postpartum psychosis
The nurse is caring for a mother within the first four hours after a cesarean birth. Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?
Ambulate the client as soon as her vital signs are stable.
A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action?
Ambulation ad lib
The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?
The tint is due to jaundice.
When taking the history of her postpartum client and infant couplet, the nurse is aware which prenatal factor might have resulted in the infant being larger than average?
gestational diabetes
A caregiver who works in the hospital brings his 9-year-old son to the emergency room with a spiral fracture of the tibia. The caregiver reports that the injury occurred when the boy's 5-year-old sister hit him with wooden bat. The injury is inconsistent with an impact and with the sister's strength. Which of the following would be appropriate for the nurse to do in this situation?
Leave the treatment area and call the social services department in the hospital.
The mother of a 4-year-old returns to the hospital after being away for 3 days. She is anxious and excited to be back; however, the toddler turns his back to her and scoots away as she attempts to pick him up. Which response should the nurse prioritize in this situation?
"His distrust is normal and may have lingering effects, but you should touch and soothe him as much as possible."
The nurse is teaching a prenatal class on the functions of the various structures involved with a pregnancy. The nurse determines the class is successful when the class correctly chooses which function of amniotic fluid?
"It helps cushion the baby"
The postpartum client and her husband are excited about their new baby. However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?
"Ovulation may return as soon as 3 weeks after birth."
The health care provider is unsure of physical symptoms and diagnosis of a pediatric client. The health care provider is prescribing diagnostic testing to determine possible poisoning by the parent. When the parent asks why laboratory work is being drawn, which response is best?
"Since we have not found the cause of the illness yet, the health care provider has ordered more blood tests."
The health care provider has determined a client should be admitted for induction of labor and begins the process with cervical ripening overnight. Which teaching should the nurse prioritize for the client and her partner when describing this procedure?
"The cervix needs to be soft and thinning to be induced for labor; this helps soften the cervix."
The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age?
20 Weeks
A pregnant client in her second trimester reports feeling tired all the time. The nurse notes pale skin and low normal hemoglobin on assessment. Which recommendation should the nurse prioritize for this client?
An iron supplement
The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?
Assess for warmth, erythema, and pedal edema.
The nurse is preparing a postpartum client for discharge 72 hours after birth. The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?
Engorgement
The nurse is assessing a 5-month-old infant at a well-child visit. In measuring and weighing the child, the nurse will prioritize which action?
Hold one hand within 1 inch (2.54 cm) of the child.
The nurse has an order to administer a rectal suppository to a 3-month-old child. In addition to lubricating the suppository, which intervention will help assure appropriate administration of the medication?
Holding the buttocks tightly together for 1 to 2 minutes after insertion
The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?
Thoroughly wash the hands before and after client contact.
The nurse is assessing a new client who is being admitted for induction of labor. The client is very upset and keeps mentioning that she has an infection. The nurse interprets this to indicate the client most likely has which condition?
chorioamnionitis
The nurse recognizes in working with children that the child who has polyphagia will likely exhibit which of the following?
compulsive overeating
The nurse is meeting with a group of families to assist them in dealing with the hospitalization of their child. Which comment by a family member should alert the nurse to assist the family in coping with the situation?
"Sometimes I wonder if the reason she is sick is because I have so many responsibilities at work and at home."
The nurse is working with a group caregivers of children who are diagnosed with autism. Which statement made by the parents shows an example of echolalia?
"When she watches TV and hears a commercial, she repeats one word from the commercial but doesn't seem to understand what she is saying." Rationale: Echolalia ("parrot speech") is typical of autistic children; they echo words they have heard, such as from a television commercial, but they offer no indication that they understand the words.
A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?
Blood is trapped in the vena cava in a supine position. Rationale: Supine hypotension syndrome, or an interference with blood return to the heart, occurs when the weight of the fetus rests on the vena cava. Cerebral arteries should not be affected. Mean arterial pressure is high enough to maintain perfusion of the uterus in any orientation. The sympathetic nervous system will not be affected by the supine position.
The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?
Blood sugar 42 mg/dl Rationale: Any blood sugar lower than 50 mg/dl is considered hypoglycemic and should be further assessed. In the scenario described, the infant's temperature, heart rate, and respiratory rate are all considered within normal limits.
A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?
Elevate the head of the bed.
The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?
Pad count Rationale: The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.
A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lb (43 kg), and has gained 25 lb (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment?
cannot be determined Rationale: Pelvis shape cannot be determined by the information included in the statement. The gynecoid is the most common; however, there is no way to predict it. Early in the pregnancy, particularly if a woman has never given birth to a baby vaginally, the practitioner may take pelvic measurements to estimate the size of the true pelvis. This helps to determine if the size is adequate for vaginal birth. However, these measurements do not consistently predict which women will have difficulty giving birth vaginally, so most practitioners allow the woman to labor and attempt a vaginal birth.
The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?
8-10 CM
A nurse is discussing the importance of good nutrition to a young pregnant client. The nurse would point out that the growing fetus is getting nutrition from the mother via which structure?
Placenta
The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?
Palpate her fundus
The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?
dilation of cervix
The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately?
dyspnea
The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize?
hemorrhage
The nurse is caring for a child admitted with a head injury and is conducting an ongoing assessment. The nurse prepares to utilize the Glasgow coma scale to achieve which priority nursing intervention?
Have a comparison of the child's status from one check to another.
The health care provider has prescribed an over-the-counter antacid for a pregnant client in her first trimester who is having ongoing nausea, vomiting, and heartburn. Which instruction concerning the antacid should the nurse prioritize after noting the client is also prescribed a multivitamin supplement?
Take antacid 1 hour after the multivitamin.
. A 5-year-old boy is brought to the emergency room with a possible broken arm. His 18-year-old sister, who is also his primary caregiver, has come with him. The boy is relatively calm, but his sister is so upset she is nearly hysterical. The nurse notes that as her behaviors show more anxiety, the boy is getting more upset and his anxiety is also increasing. What initial action would be best for the nurse to take in this situation?
. While attending to the child, reassure the sister and suggest interventions she can help with.
The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?
Maternal tachycardia and falling blood pressure
The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?
Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples Rationale: All women have Montgomery glands (Montgomery tubercles). They become more prominent during pregnancy and help to prepare the nipples for breastfeeding. The bumps are not specific to pregnancy and are not a sign of cancer. They are not the result of stretching.
The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?
Moro
The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?
Neglects to engage or provide care or show interest in infant. Rationale: A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with postpartum blues.
The nurse is reinforcing teaching with the caregiver of 5-year-old twins regarding urinary tract infections (UTIs). The caregiver is puzzled about why her daughter has had three urinary tract infections but her son has had none. She reports that their diets and fluid intake is similar. Which statement would be accurate for the nurse to tell this mother?
"A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily."
The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K?
Provides blood clotting factors
The nurse at a pediatric clinic is preparing a 5-year-old child for admission to the hospital for surgery. Which response should the nurse prioritize when asked by the child what happens at the hospital?
"Some people go here to have babies, or when they're sick or hurt, so they can try to get better."
A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?
"The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks." Rationale: The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.
The newborn weighing 6 lb 6 oz (2856 g) now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?
"This is a normal response."
A young mother is concerned for her baby and asks the LPN if her baby is okay. What is the best response if the nurse notes RR 66, nostrils flaring, and grunting sounds during respiration?
"Your baby is having a little trouble breathing. I'll let the RN know."
The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?
1 cm below the umbilicus
The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period?
5 at 1 minute; 6 at 5 minutes
The new mother has decided to formula-feed her infant and is unsure when to introduce soft foods. Which age should the nurse point out will be appropriate to introduce her infant to mashed fruit and vegetables?
6- 8 months
What information is most correct regarding the nervous system of the child?
As the child grows, the gross and fine motor skills increase
At a 12-week visit, the nurse assesses a pregnant woman who is questioning what the baby may look like at this point. Based on the current stage, which structures would the nurse point out to the client?
Audible heartbeat and identifiable sex characteristics
The nurse is assisting with the physical exam on a 2-year-old child. The nurse predicts the order of the exam will be in which sequence?The nurse is assisting with the physical exam on a 2-year-old child. The nurse predicts the order of the exam will be in which sequence?
Back and extremities; head and neck; then the eyes, ears, nose, and mouth
The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?
Baldder distention Rationale: Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.
The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?
Change the position of the mother
The nurse is caring for a child with an eating disorder. Which is the priority treatment for the disorder?
Correct fluid and electrolyte imbalances Rationale: If the child's condition is at a critical stage with fluid and electrolyte deficiencies, parenteral fluids should be administered immediately to hydrate the client before additional treatment can be implemented.
The nurse is meeting with a group of expectant parents to discuss the feeding options available for their soon-to-be infant. The nurse predicts which factor will exert the strongest influence on their choice?
Culture
The nurse is preparing discharge instructions for a new mother who has been learning to breastfeed. Which response should the nurse prioritize when the mother questions her ability to produce enough milk for her infant?
Drink lots of fluid
The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?
Fetal position Rationale: When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.
The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out?
In approximately 10 days
The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step?
Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth.
The nurse is conducting a prenatal class explaining the various activities that will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?
Prevent infection of the eyes from vaginal bacteria
The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis?
Projectile vomiting
. A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize?
Quickly evaluate the perineum Rationale: The woman is showing signs of advanced labor, possibly in transition or stage 2. She needs to be managed as an imminent birth and a vaginal assessment performed, as there may not be time to get to Labor and Delivery. Vital signs would be assessed next. Medical/obstetrical history and her room assignment can be taken care of later in the process.
The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first?
Respiratory Distress Rationale: It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.
A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?
Rest when possible with feet elevated at or above the heart.
The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?
Rubella
The primigravida client is surprised by the continued uterine contractions while holding her newborn. Which explanation by the nurse explains the primary reason the contractions occur?
Seals off the blood vessels at the site of the placenta
The nurse is preparing a client for an emergent cesarean delivery. Which action should the nurse prioritize?
Sign informed consent.
The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?
Teach that adequate hydration helps clear the infection quicker.
A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?
The client reports back pain, and the cervix is effacing and dilating. Rationale: True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins
The nurse is assisting a pregnant client who underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?
The fetal heart rate increases with activity and indicates fetal well-being. Rationale: A nonstress test is a noninvasive way to monitor fetal well-being. A reactive NST is a positive sign the fetus is tolerating pregnancy well by demonstrating heart rate increase with activity, and this indicates fetal well-being. This test is not used to determine congenital anomalies or deformities. It does not determine the speed by which fetus is developing. Further evaluation would be necessary if the results were nonreactive.
A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip, bruising and abrasions noted to the groin area. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?
The possibly of sexual abuse should be explored further by the healthcare professional Rationale: Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse (child mistreatment) and should be further explored.
The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?
Wrap the infant in a warm, dry blanket.
The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4, three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry?
clear liquids but no solid food Rationale: The nurse should offer clear liquids but no solid foods. She is moving closer to active labor nearing the end of the latent phase. It would not be advisable to offer her solid foods, but she needs to continue her nourishment with fluids to her thirst. Solid foods may lead to nausea and vomiting. Intravenous fluids are too extreme as long as she is able to drink.
Which is essential in working with caregivers who have been affected by abuse?
developing a therapeutic relationship
. The nurse is caring for a young child whose parents have been charged with physical abuse. Which child reaction is noted as a result of the parental behavior?
fretful and shrinks away when approached Rationale: Behaviors of the young child are intuitive. The child is fretful and shrinks away when approached. This is related to the conduct of the parents as they would punish the child. A young child may take time to trust the nurse. The nurse may provide crayons and paper for drawing to get the child to open up about fears and feelings. Otherwise, it may be difficult to communicate. Aggression can be common, including temper tantrums. Typically the child will not make eye contact with the nurse.
Most urinary tract infections seen in children are caused by:
intestinal bacteria.
The nurse advises a pregnant client to keep a small high-carbohydrate, low-fat snack at the bedside. The nurse should point out this will assist with which condition?
nausea and vomiting
The nurse is monitoring a client who is recovering from a cesarean birth with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine?
slow respiration, less than 12 breaths per minute
When providing care for a newborn to a mother who was a smoker during her pregnancy, the nurse will anticipate the size of the infant to be what?
smaller than average
An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?
tachypnea
Which adolescent behavior is most common if the parents have substance use problems?
taking on adult responsibilities
The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?
uterine atony
The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue?
Oxytocin Rationale: Oxytocin is the drug used first for uterine atony. Other medications which may be ordered include ergonovine, methylergonovine, carboprost, and misoprostol. Ibuprofen, penicillin, or digoxin would have no effect on uterine atony.
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 3-year-old client has been hospitalized for 1 week with her mother rooming-in; however, the mother has gone home to tend to other family responsibilities for a few days. After being inconsolable for the first 24 hours after the mother's departure, the nurse notes the child is now lying quietly in bed sucking her thumb. Which response should the nurse prioritize in this situation?
"Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts."
A client with limited prenatal care presents in labor and is requesting a VBAC. What is the nurse's response after verifying the client had a classical incision with the last cesarean birth?
"Based on your history, a vaginal delivery is not recommended, it might cause your uterus to rupture."
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with Kwashiorkor. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of Kwashiorkor?
"It is important to increase the intake of protein for these children."
The caregiver of a 2-year-old calls the clinic concerned that her child may have pushed paper into her ears, and she asks the nurse what to do. The mother found the child pushing on her ears with torn paper on the floor in front of her. What would be the appropriate response by the nurse?
"The child should be seen by a care provider. Don't put anything in her ear and bring her in right away."
A client calls the nurse in a panic after a home pregnancy test indicates she is pregnant. She reports that that she consumed a lot of alcohol on the night that she thinks the pregnancy occurred. The next day she had taken several acetaminophen. For the past 3 weeks, she has had her usual nightly glass of wine with dinner but no other alcohol. What is an appropriate response for the nurse to make when the client questions if she has caused irreversible damage to the fetus?
"The fetus is not exposed to the mother's blood until after it implants about 6 days after fertilization, so the first night is not an issue. But it is best to avoid alcohol while you are pregnant."
The nurse is discussing discipline issues with a group of caregivers of preschool-aged children who have a cognitive impairment. One father tells the group that after he tells his child to stop doing something, the child just continues. Parents in the group make the following statements. Which statement indicates an understanding of disciplining the cognitively impaired child?
"We wait until a behavior happens a second time and immediately put our child in time-out."
The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on?
Accepting the pregnancy
A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?
clear to straw colored fluid
The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize?
Assess the infant's blood sugar.
The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize?
Be certain she is aware of potential complications. Rationale: The client should be aware of the potential complications and risks, and should sign an informed consent. Opioids are contraindicated for pregnant woman due to side effects. She should maintain bed rest for the remainder of the day, with light housework the following day and a return to normal activities on the third day. It may take 2 or 3 weeks before the test results come back from the laboratory.
The health care provider has ordered a cesarean birth for an exhausted client who has been in labor for many hours with the fetus now showing increasing signs of distress. As the client and partner express disappointment in not having a natural birth (and anxiety in not knowing what will now happen), which response will the nurse prioritize?
Briefly describe what will be experienced, explain each procedure, and encourage the partner to participate.
The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor?
Ecchymosis with edema on the scalp is where the infant was pushed out of the canal.
Why are newborns born to diabetic mothers prone to hypoglycemia?
Elevated insulin production metabolized glucose faster. Rationale: When the mother is diabetic, she has levels of insulin and blood sugars different from a pregnant woman without diabetes. Therefore the infant/fetus develops elevated levels of insulin to combat the elevated sugars. The infant is then at risk of low blood sugar once he or she is born. Infants born to diabetic mothers do not have excess subcutaneous fat that reduces blood flow to the tissues; they do not have increased metabolic stress because of stress on the mother's body; and their immature liver is not the reason the newborn is prone to hypoglycemia.
The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason?
Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. Rationale: Collecting a complete family health history helps the nurse learn if there are certain behaviors or risk factors for the family; this will hopefully educate the family in how to improve both their health and the child's health, as well as reduce the incidence of diseases and chronic conditions.
The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?
Involution
The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?
It keeps alveoli from collapsing with breaths.
The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?
Place an ice pack.
The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus?
Supine
The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse (child maltreatment). Which finding might alert the nurse to this possibility that the child may have been abused?
The child has a burn that has not been treated.
A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?
The frequency of the contractions is every 5 minutes.
A mother observes the office nurse charting her son's height and weight on a growth chart and asks the nurse the purpose of plotting this information for her child. The nurse would reply with which explanation?
The height and weight of each client is plotted on a growth chart at each visit to note how the child is growing and compare the growth to the norm. Rationale: Plotting a child's height and weight are very important to determine if a child is growing normally or is too large or too small for their age. This is determined by plotting these measurements on a standardized growth chart. This data gives the health care provider a good clue as to the child's health status.
The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?
The intestines are displaced by the growing fetus.
The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements. Which statement is most accurately related to the diagnosis of colic?
There are recurrent on and off bouts of abdominal pain Rationale: Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, with a severe narrowing of its lumen. The pylorus is thickened to as much as twice its size, is elongated, and has a consistency resembling cartilage. As a result of this obstruction at the distal end of the stomach, the stomach becomes dilated. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.
The parents of a 1-day-old newborn are concerned the newborn is cold. Which action should the nurse prioritize to best prevent heat loss?
Warm all surfaces and objects that come in contact with the newborn.
The nurse is giving a newborn his first bath. What should the nurse prioritize?
Wash off all traces of blood and leave the vernix in place.
The nurse is observing a group of 2- and 3-year-olds in a play group. Which behavior noted in one of the children indicates to the nurse that the child may have autism spectrum disorder (ASD)?
While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack Rationale: Children with ASD become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. If these movements are interrupted or if objects in the environment are moved, a violent temper tantrum may result. These tantrums may include self-destructive acts such as hand biting and head banging. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree coupled with an almost total lack of response to other people
The nurse has gathered the following data on four different children. Which child will likely be further assessed and tested for autism spectrum disorder?
a 14-month-old whose reaction to his caregiver leaving him is to calmly repeat the statement, "Bye bye, Will. Bye bye, Will." Rationale: Children with autism spectrum disorder do not show the normal fear of separation from parents that most toddlers exhibit. Echolalia ("parrot speech") is typical of autistic children; they echo words they have heard, such as a television commercial, but offer no indication that they understand the words. Although autistic children are self-centered, their speech indicates that they seem to have no sense of self, because they never use the pronouns "I" or "me." Children with autism do not develop a smiling response to others nor an interest in being touched or cuddled. During their second year, autistic children become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. Their bodily movements are as follows: rocking, twirling, flapping arms and hands, walking on tiptoes, twisting and turning fingers. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree, coupled with an almost total lack of response to other people.
Which physical assessment data would the nurse find concerning and would warrant reporting to the primary care provider?
a blood pressure of 128/80 in a preschool-aged child Rationale: The normal blood pressure for a preschooler is 89-112 systolic and 46-72 diastolic, so a blood pressure of 128/80 is abnormal and needs reporting to the physician. The chest circumference for a child is 2 to 3 inches greater than the head circumference. The normal heart rate for a school-aged child is 60-110. The posterior fontanel (fontanelle) closes around 2 to 3 months of age in infants.
The nurse is caring for a small child who has been admitted with a diagnosis of abusive head trauma (shaken baby syndrome). Which condition or concern often occurs with shaken baby syndrome?
loss of vision and intellectual disabilityloss of vision and intellectual disability
The nurse in the well-child clinic observes that a 5-year-old child in the waiting room is having trouble using a crayon to color. During the visit, the same child climbs off the table several times even after the nurse has asked him to stay on the table. Each time the nurse reminds him he says, "Oh, yeah," and happily climbs back up. The nurse suspects that the child has:
attention deficit hyperactivity disorder (ADHD) Rationale: The child with ADHD may have these characteristics: Impulsiveness, easy distractibility, frequent fidgeting or squirming, difficulty sitting still, problems following through on instructions despite being able to understand them, inattentiveness when being spoken to, frequent losing of things, going from one uncompleted activity to another, difficulty taking turns, frequent excessive talking, and engaging in dangerous activities without considering the consequences.
A group of nursing students are preparing a presentation for a health fair illustrating the structures found during a pregnancy. Which structures should the students point out form a protective barrier around the developing fetus?
chorion and amnion
When caring for an infant who is hospitalized with Haemophilus influenzae meningitis, an important nursing intervention for the child would be for the nurse to:
check the child's neurologic status every 2 hours Rationale: The nursing interventions for the child with meningitis are related to the goals for this child, which include monitoring for complications related to neurologic compromise, preventing aspiration, keeping the child safe from injury during a seizure, and monitoring fluid balance. During a seizure, stay with the child, protect the child from injury, but do not restrain him or her. To prevent aspiration, position the child in a side-lying position, watch for and remove excessive mucus as much as possible, and use suction sparingly. Every 2 hours, observe the child for seizure activity, vital signs, neurologic changes, and change in level of consciousness. The child is placed on fluid restrictions if he or she has decreased urinary output, hyponatremia, increased weight, nausea, and irritability.
The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help prevent the risk of transmitting infection to other clients, the nurse should:
follow standard precautions
The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?
infection
. A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?
mastitis
A group of nurses is discussing child abuse (child maltreatment) and one nurse suggests that inadequate parenting skills may lead to child maltreatment. The nurse recognizes that sometimes child maltreatment occurs because the parent:
may have unrealistic expectations of the child.
The first method of choice for obtaining a urine specimen from a 3-year-old child with a possible urinary tract infection is:
obtaining a clean catch voided urine
A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client?
on her side with the weight of the uterus on the bed
A group of nursing students are preparing a presentation that will illustrate various components of the birthing process. When discussing the pelvis, the students should point out that the pelvis is often referred to as which term?
passageway Rationale: The passageway is one of the 4 Ps and involves the pelvis, both bony pelvis and the soft tissues, cervix, and vagina. The passenger refers to the fetus. The primary powers are the involuntary contractions of the uterus, whereas the secondary powers come from the maternal abdominal muscles. The psyche refers to the mother's mental state.
A young child has been admitted with a diagnosis of enterobiasis (pinworm infection). This child will most likely have a history of:
perianal itching.
The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?
second
The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?
vernix
