maternal prepU

What is a definitive test for cystic fibrosis?

Sweat chloride

The pregnant mother and her partner ask the nurse why the health care provider chose a chorionic villus sampling (CVS) procedure over an amniocentesis. The nurse is correct to highlight which benefits of CVS over amniocentesis. Select all that apply.

Quicker results Able to be completed earlier in pregnancy

A new mother of twins asks the nurse if there is any way she can feed them both at the same time. Which piece of equipment would the nurse recommend for this situation?

pillow supports designed with wider sides to allow the twins to feed at the same time

Which is the best place to perform a heel stick on a newborn?

the fat pads on the lateral aspects of the foot

A postpartum woman is experiencing subinvolution. When reviewing the client's history for factors that might contribute to this condition, which factors would the nurse identify? Select all that apply.

uterine infection prolonged labor hydramnios

A client is in the third stage of labor. Which finding would alert the nurse that the placenta is separating?

uterus becomes globular

On admission to the labor and delivery unit for a scheduled elective induction, a 21-year-old P1001 expresses to the nurse her desire to bottle-feed. What is the best response from the nurse?

"Would you like any information on breastfeeding?"

A woman, who has been in labor for a few hours, is now complaining of being hungry. Which response by the nurse would be best if the client asks for some food to eat?

"You could have some hard candy to suck on."

Which question should the nurse include when conducting a review of systems with a patient during the first prenatal visit?

"Have you had any urinary tract infections?"

After several weeks of caring for a child who is dying, a nurse finds herself hoping that the child will die on the weekend she is scheduled to be off work. This behavior is consistent with which stage of grief?

Bargaining

A new mother exhibits signs of feeling abandoned shortly before being released from the hospital. The mother gave birth to a healthy newborn 2 days ago. Which nursing intervention would be most appropriate in this case?

Mention to the mother how it is common to feel "left out" when all of the attention shifts from the pregnant mother to the newborn

The nurse is caring for an infant. Which nursing action will facilitate psychosocial growth of the infant?

Be consistently attentive to the infant's basic needs.

A nurse is starting an intravenous (IV) line in the antecubital fossa of a small child. What restraint would be best for the nurse to use to maintain patency of the IV?

Elbow restraint

The nurse is organizing an indoor play area for preschoolers. What play materials are least important?

Electronic teaching toys

A 13-month-old is having a dressing changed on a packed leg wound. Which action from the parents should be encouraged by the nurse during the treatment?

Encourage the father to talk quietly to the child.

A nursing student is explaining to a newly pregnant woman what happens during each stage of fetal development. At which stage does the nurse inform the woman that the lungs are fully shaped?

End of 16 weeks

The nurse is teaching a prenatal class about a cesarean delivery. What benefit of a low transverse uterine incision should the nurse point out in the teaching?

Least likely to rupture during subsequent labors.

The nurse in a community clinic is caring for a 6-month-old infant and parent. Which intervention is the priority to promote adequate growth?

Monitoring the infant's weight and height

A 3-month-old infant has a Moro reflex. Which statement is most true of this reflex?

Most 3-month-old infants still have a Moro reflex.

The parents of a 2-year-old boy report to the nurse because their child is "such a picky eater." Which recommendation would be most helpful for developing healthy eating habits in this child?

Offering a variety of foods along with the foods the child likes

The nurse is recommending food items for an 18-month-old girl. Which ones will benefit the child's neurologic system most?

Peanut butter on crackers, cheese, and whole milk At 18 months, the child's neurologic system is still developing rapidly and needs dietary fat for myelinization. Peanut butter on crackers, cheese, and whole milk all provide this. The other foods are appropriate for the toddler as part of a balanced diet.

A 3-hour old newborn is assessed and is tachypneic with a respiratory rate of 44. Heart rate is 168, temperature is 97.3°F (36.3°C) and blood glucose is 90. What is the first action the nurse should take?

Place the newborn away from drafts and under a blanket.

What effect does progesterone have on normal gallbladder function?

Progesterone interferes with gallbladder contraction, leading to stasis of bile.

A nurse is instructing the mother of a newborn about bathing and skin care. When discussing bathing, the nurse includes which of the following besides hygiene as an important reason for bathing?

Promoting parental bonding

The nurse is teaching the parents of an overweight 18-month-old girl about diet. Which intervention will be most effective for promoting proportionate growth?

Remove high-calorie, low-nutrient foods from the diet.

A 1-day-old newborn is being examined by the nurse practitioner, who makes the following notation: face and sclera appear mildly jaundiced. What causes this finding?

The breakdown of RBCs release bilirubin, which the liver cannot excrete.

A 15-month-old boy has been brought to the clinic because he is pale and listless. Iron deficiency anemia is suspected. The nurse interviews the mother about the child's diet. Which of the following would the nurse identify as a possible contributing factor?

The child drinks 4 cups of milk per day

Which assessment finding is most important as labor progresses?

The uterus relaxes completely between contractions.

Which change in client status suggests that labor is anticipated?

The woman can breathe easier throughout the day.

What purpose does amniotic fluid serve in fetal development? Select all that apply.

To allow the fetus to move about in-utero Reservoir for fetal urine and respiratory tract secretions

A patient having a cesarean birth will have a low segment incision. What should the nurse explain to the patient as an advantage for this type of incision?

Vaginal deliveries can occur with future births.

The nurse is caring for a breastfed infant hospitalized for gastroenteritis. What method can be used to most accurately measure intake?

Weigh the infant before and after feeding and subtract weight.

How will the nurse measure urine output in the hospitalized toddler who is partially potty trained?

Weigh the wet pull-up or diaper and subtract the weight of a dry diaper

A nurse is caring for a pregnant client who has been diagnosed with lordosis. The nurse offers preventive measures for which consequence of lordosis when caring for this client?

chronic backache

Eliminating drafts in the birth room and in the nursery will help to prevent heat loss in a newborn through which mechanism?

convection

The student nurse is learning about normal labor. The teacher reviews the cardinal movements of labor and determines the instruction has been effective when the student correctly states the order of the cardinal movements as follows:

descent, flexion, internal rotation, extension, external rotation, expulsion (Did Fred interview Ed externally and explode)

When assessing a woman at follow-up prenatal visits, the nurse would anticipate which procedure to be performed?

fundal height measurement

The physician has just examined the patient and determined that she needs to have a cesarean section. He notifies the nurse that he will be doing a low cervical vertical incision into the uterus. The nurse knows that the physician has chosen this type of incision over the classical incision because the low cervical vertical incision:

reduces the risk of uterine rupture.

The nurse conducting a 6-month well-baby check-up assesses for the presence/absence of the asymmetric tonic neck reflex. At this age the reflex:

should have disappeared.

The pediatric nurse is planning quiet activities for a hospitalized 18-month-old. What would be an appropriate activity for this age group?

stacking blocks

A nurse is assessing a newborn. Which finding would alert the nurse to the possibility of respiratory distress in a newborn?

sternal retractions

While observing care being provided to an infant, the new mother looks at the nurse repeatedly and asks, "Am I doing this the right way?" Which nursing diagnosis should the nurse select to guide the care needs of the mother at this time?

Health-seeking behaviors related to care of newborn

A client is being prepared for a scheduled cesarean delivery by the medical team. Which intervention will be most critical for the team to monitor in the first 24 hours post cesarean delivery?

Urinary output

Which statement is false regarding bathing the newborn?

To reduce the risk of heat loss, the bath should be performed by the nurse, not the parents, within 2 to 4 hours of birth.

In observing an infant who is 6 months of age, which fine motor skill would the infant have most recently attained?

The infant can hold a bottle.

After teaching a group of students about therapeutic play, the instructor determines that additional teaching is needed when the students identify what as a characteristic of therapeutic play?

Use of a highly structured format

A nurse is meeting with a client who developed overdistention of the abdominal muscles during her pregnancy. Which action should the nurse prioritize to best assist this client recover from this situation?

suggest proper exercise

A client who recently gave birth to her third child expresses a desire to have her older two children come to the hospital for a visit. What should the nurse say in response to this request?

"As long as they are well, absolutely. Why don't we give you a dose of pain medication beforehand so that you will enjoy the visit?"

The health care provider has prescribed a rectal temperature for an 11-month-old infant. The thermometer has been lubricated with a water-soluble lubricant. How far into the rectum would the nurse insert the thermometer?

1/4 to 1/2 inch (0.64 to 1.27 cm)

A patient at 6 weeks' gestation asks if she can listen to the fetal heart sounds. The nurse informs the patient that fetal heart sounds cannot be heard with a Doppler until when?

10 to 12 weeks

Which strategies is the nurse correct to utilize when attempting to awaken a potentially sleeping fetus? Select all that apply.

Clap near the mother's abdomen Provide the mother a cold beverage Place hands on the abdomen to move the fetus Use vibroacoustic stimulation

A 15-year-old adolescent is brought to the emergency department by his parents. The adolescent is febrile with chills that started suddenly. He states, "I had a sinus infection and sore throat a couple of days ago." The nurse suspects bacterial meningitis based on which findings? Select all that apply.

Complaints of stiff neck Photophobia Vomiting

In which manner is the fetal status best assessed during the active and transition stages of labor?

Fetal heart rate at the peak of a contraction

What action shows an example of Erik Erikson's developmental task for the infant?

The infant cries and the caregiver picks the child up.

A child who knows his disease is terminal tells you that when he gets better he is going to be a doctor and cure everyone in the whole world. This statement is most likely a manifestation of:

a bargaining stage of grief.

Many changes occur in the body of a pregnant woman. Some of these are changes in the integumentary system. What is one change in the integumentary system called?

melasma (chloasma)

A 16-year-old has suffered a thoracic-level spinal injury from a diving accident. To initiate CPR at the poolside, which measure would be most important?

Elevate the mandible to assess airway with the head in a neutral position.

The nurse is concerned that a pregnant patient is not adjusting emotionally to being pregnant. Which statement indicates that the patient may need additional counseling?

"I need to get right back to work after delivery."

A nurse is serving as a doula to a client who is now in labor at an alternative birthing center. The client has opted for a water birth, and the nurse is now drawing the water into a large tub. What temperature should the nurse keep the water at?

37°C

At which age would the nurse expect to find the beginning of object permanence?

6 months

Which assessment findings indicate a distressed fetus? Select all that apply.

Absent accelerations Late deceleration patterns Persistent bradycardia

A newborn male has just returned to the mother's room after being circumcised. Which behaviors will concern the nurse?

Being restless and crying

Which finding would alert the nurse to suspect that a newborn is experiencing respiratory distress?

asymmetrical chest movement

A school-aged child is prescribed an enema in preparation for a colonoscopy. Which type of solution and amount should the nurse prepare for the child?

150 mL normal saline

Neonatal screening is done before the infant leaves the hospital. Blood is drawn through a heel stick and tested for several disorders that can cause lifelong disabilities. When is the ideal time to collect this specimen?

24 hours after the newborn's first protein feeding

Following the death of a grandparent a child is heard saying, "Gramma died and she is in heaven." Twenty minutes later the same child is heard saying, "Let's go have supper at Gramma's house." These statements would most likely have been said by a child of which age?

3 years old--The toddler may fear separation from beloved caregivers but have no recognition of the fact that death is nearing and irreversible. Older children have a better notion of the irreversibility of death, though this is often not solidified until age 8 or 9.

Mrs. Atkins is 40 weeks' pregnant by ultrasound, and the induction of labor is being discussed by Mrs. Atkins and her birth attendant. The birth attendant tells Mrs. Atkins, "I am going to do a pelvic exam so that I can assess your readiness for labor. I will obtain what is known as a Bishop Score, and it will tell me how ready you are to go into labor." What Bishop Score would indicate a favorable response to oxytocin-induced labor?

8 or above

One assessment parameter that the LPN/LVN is responsible for is fluid volume loss. It would be important to assess the umbilical cord for any sign of bleeding. What would be important to assess for if the infant has an unusually large cord?

A loose clamp

A patient makes an appointment at the prenatal clinic because she thinks she might be pregnant. Which assessment is a probable sign of pregnancy?

A positive pregnancy test

A nurse is teaching about bottle-feeding and breastfeeding. The nurse states that because commercial formulas have higher concentrations of fatty acids, the infant should be assessed for which possible complication?

tetany

The nurse is providing prenatal care to a young couple who is pregnant with their first child. In what period of development would the nurse explain to the couple that most congenital defects would occur?

the period of the embryo

The nurse is assessing a pregnant woman on a routine prenatal visit. Which breast assessment finding will the nurse document as a normal and expected finding?

tingling sensations and tenderness

The nurse is developing a teaching plan for toddler safety to present at a parenting seminar. Which safety intervention should the nurse address?

Advise parents to use a forward-facing car seat with harness straps and a clip, placed in the backseat of the car.

After teaching a class about cystic fibrosis, the nursing instructor determines that the teaching was successful when the students identify the condition as which type of genetic condition?

Autosomal recessive

The nurse is caring for a newborn immediately following birth. Which body system is priority for the nurse to monitor during the transition phase?

Cardiopulmonary

A pediatric nurse practitioner is assessing the development of a child. The nurse's assessment of development will focus on which of the following?

Changes in thoughts, feelings, and behaviors

Which assessment findings should the nurse expect to see in the infant diagnosed with pulmonary stenosis and heart failure? Select all that apply.

Cyanosis Murmur Right ventricular hypertrophy

The nurse is instructing a patient who is in the third trimester of pregnancy on the difference between false and true labor contractions. What should the nurse emphasize as being characteristics of false labor contraction? Select all that apply.

False labor contractions are irregular. False labor contractions do not increase in duration, frequency, and intensity.

After learning about the need for a cesarean birth, the pregnant patient begins to cry and hyperventilate. Which nursing diagnosis should the nurse use to guide the care that the patient needs at this time?

Fear related to impending surgery

The nurse is correct to identify which group of symptoms as present with acute laryngotracheobronchitis?

Fever and labored respirations

When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal?

Five to 10 per minute

The nurse finds the diet of a 30-month-old girl to be low in calcium. What suggestion can significantly increase this toddler's calcium intake?

Give her slices of cheddar cheese as a snack.

A client at 16 weeks' gestation comes to the office for a routine exam. At what location within the abdomen would the nurse anticipate the uterus to be found?

Halfway between the symphysis pubis and the umbilicus

What method would the nurse use to teach an 8-year-old client how to swallow medications?

Have the child practice swallowing an ice chip.

The obstetrician is examining a woman who is in early labor to determine the positioning of the fetus. The nurse knows that which of the following fetal attitudes would be the most advantageous for birth?

Head flexed forward so much that the chin touches the sternum

When providing anticipatory guidance to the parents of a toddler, which of the following would the nurse include as most appropriate for enhancing their child's self-esteem?

Including the child in activities that interest the adult

An elective induction is when the birth attendant and the pregnant woman agree to the induction of labor without medical indications. What should the birth attendant explain to the woman before she can give informed consent to induce her labor?

Induced labor can result in higher costs for the delivery.

The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply.

Inspect the episiotomy for sutures and to ensure that the edges are approximated. Note any hemorrhoids. Gently palpate for any hematomas.

The nurse is describing the nutritional requirements of an adolescent to a local parent group. Which of the following would the nurse include as needing to be increased in the adolescent's diet? Select all that apply.

Iron Folate Calcium

A nursing instructor is conducting a class on the various types of pelvic shapes to a group of nursing students. The instructor determines the class is successful when the students correctly choose which factor is specific for an anthropoid pelvis?

Is narrow transversely

The nurse is reviewing common problems seen in formula-fed newborns with a mother who chose to bottle-feed her baby. What problems would be included in this session? Select all that apply.

It is normal for the baby to have a small amount of emesis after feeding occasionally. Infants can develop "bottle mouth syndrome" from being given a nighttime bottle that the infant sucks on throughout the night.

The nurse is assessing a newborn, 4 hours old, weighing 9 lbs, 2 oz (4088 g). While doing the initial assessment the RN mentioned that the mother's history showed her to be morbidly obese. Which assessment findings should the nurse prioritize as the newborn is continued to be monitored?

Jitteriness and irritability

Which activity will the nurse include when caring for a toddler to assist in achieving Erikson's developmental task of the toddler period?

Let the toddler select an outfit each day and get dressed independently

A nurse places an external fetal monitor on a woman in labor. Which instruction would be best to give her?

Lie on her side so she is comfortable.

A new mother asks the nurse when toothbrushing should begin for the baby. Which response is the most appropriate for the nurse to make at this time?

Now Toothbrushing can begin even before teeth erupt by rubbing a soft washcloth over the gum pads. This eliminates plaque and reduces the presence of bacteria, creating a clean environment for the arrival of first teeth. Dental care should begin before the age of 12 months, before solid food is eaten, and before the first tooth appears.

The nurse is concerned that the nares of a newborn are not patent bilaterally. What can the nurse do to address this concern?

Occlude the nares one at a time by applying pressure to each side to see if the newborn can breath comfortably.

The nurse is caring for a client who is at 37 weeks' gestation and has a biophysical profile of 10. Which nursing action is best?

Schedule a health care provider appointment for one week.

A postpartum patient is experiencing painful hemorrhoids. Which position should the nurse suggest the patient use when resting?

Sims position

Which of the following is true regarding the newborn's fontanelles?

The anterior fontanelle is diamond shaped and measures about 3.5 cm. The posterior fontanelle is triangular shaped and measures about 1 cm.

The nurse is assessing the heart rate of a healthy school-age child. The nurse expects that the child's heart rate will be in what range?

The normal heart rate for a school-age child is 60 to 100 bpm, for an infant is 90 to 160 bpm, for a toddler or preschooler is 80 to 115 bpm.

The nurse is presenting a nutritional plan to a primigravida client who is questioning the addition of iodized salt to her diet. Which explanation should the nurse prioritize in answering this client?

Thyroid activity, which depends on iodine intake, increases during pregnancy.

The nurse observes a mother telling a toddler that pasta and potatoes will make the child fat. What should the nurse instruct the mother about these food items?

Toddlers need carbohydrates for brain function.

The nurse teaches a primigravida client that lightening occurs about 2 weeks before the onset of labor. The mother will most likely experience which of the following at that time?

Urinary frequency

The nurse is examining an 8-month-old girl for appropriate development during a regular check-up. Which observation points to a developmental risk?

Uses only the left hand to grasp

Which measurements were most likely obtained from a normal newborn delivered at 38 weeks to a healthy mother with no maternal complications?

Weight = 3500 g, length = 20 inches, head circumference = 34 cm, and chest circumference = 32 cm

A nurse is assessing several children between the ages of 1 and 4 years. The nurse would expect which child to know his or her own gender?

a 3-year old

A woman's obstetrician prescribes vitamin K supplements for a client who is on antiepileptic medications beginning at 36 weeks' gestation. The mother asks the nurse why she is taking this medication. The nurse's best response would be:

antiepileptic therapy can lead to vitamin K-deficient hemorrhage of the newborn.

Which effect would the nurse identify as a normal physiologic change in the renal system due to pregnancy?

dilation of the renal pelvis

The nurse pulls the 5-month-old to sitting position from supine and notes head lag. The nurse's response is to:

refer the infant for developmental and/or neurologic evaluation. (there should be no more head lag after 4 months)

A nurse has been assisting a client who has been in labor. The nurse determines the client is moving into the transition phase based on which assessment findings? Select all that apply.

strong desire to push irritability with restlessness

When the nurse is reinforcing teaching with the caregiver of a 3-year-old child being discharged following a tonsillectomy, the caregiver states to the nurse, "I understand why there might be bleeding in the first 24 hours, but I do not understand why there might be bleeding in 1 week or so." What is the most appropriate explanation for the nurse to give this caregiver?

"Bleeding can occur at this time because the clots dissolve and new tissue is not yet present."

A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?

"Did you use any medications like aspirin for the fever?"

After delivery, a postpartum mother discusses nutritional needs with her nurse related to breast-feeding. Which statement by the mother demonstrates understanding of the nurse's teaching on the subject?

"I will need to eat more meat and whole grains to increase my zinc intake while I am nursing."

The hospital is providing a class on newborn care to a group of parents prior to their discharge with their newborns. Which statement by a parent would indicate that further teaching is needed

"If our baby turns red in the face and strains to have a stool that means she is constipated."

A client who is breastfeeding asks the nurse if she can give the newborn a pacifier. Which nursing response is most appropriate?

"It is recommended to wait until breastfeeding is well-established before introducing a pacifier."

A new mother who is about to be discharged expresses concern about how to know her baby is getting enough breast milk. Which response should the nurse prioritize?

"Observe if your baby is eating 8-12 times a day."

A woman has just arrived to the recovery room after an emergency cesarean delivery and is anxious to begin breast-feeding her baby. What is the best response from the nurse?

"Sure, let me help you with that."

The nurse assesses the client and tells her the baby is at +1 station. Which is the best response by the nurse when asked by the client what this means concerning the location of the baby?

1 cm below the ischial spine.

The nurse is caring for a pregnant woman determined to be at high risk for gestational diabetes. The nurse prepares to rescreen this client at which time frame?

24 to 28 weeks

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform?

Assist the client to semi-Fowler position, assess the fetal heart rate, start an IV bolus of 500 ml, and administer oxygen via face mask.

The nurse working in the child clinic observes infant Max. He is 8 months old. What type of activity should the nurse be observing?

Max is on the floor picking up blocks from a bucket.

Microorganisms are sometimes spread by what is called a vehicle. Of the following, which would fit into this category of transmission? Select all that apply.

Microorganisms spread by food Microorganisms spread by water Microorganisms spread by blood

The maternal health RN is caring for a client in active labor with a history of a previous cesarean section delivery. Which statement(s) made by the client would make the nurse suspect the client is experiencing a uterine rupture? Select all that apply.

My chest hurts." "I just felt a popping sensation in my abdomen." "My abdomen is rock hard."

While the nurse is assessing the prenatal client's understanding of the information provided at a recent appointment, the client states, "I want to avoid the pain and long hours of labor, so I'm electing to have a cesarean birth." How should the nurse respond?

"A cesarean birth is a method to be used when vaginal birth is not possible—it is not a true option."

The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education?

"Auscultated all four quadrants for a full minute each."

The nurse is caring for a client in the transition phase of the labor process. Which client statement requires nursing action?

"My lips and fingers are tingling."

A woman who delivered her newborn by cesarean birth is admitted to the postpartum unit. During the delivery, the mother received two doses of morphine sulfate. The nurse notes that the client's respiratory rate is 11 and her oxygen saturation is 93%. What should the nurse do first?

Notify the health care provider of the findings.

A nurse is teaching first-time parents about bathing their infant. The nurse instructs the parents to wait until which day to give the baby a tub bath?

7-10 days after birth

The client appears at the clinic stating that she is 8 months pregnant and has had no prenatal care due to a lack of health insurance. She states not feeling well with blurred vision and a terrible headache. The client's blood pressure is 190/100 and edema is present in her lower extremities. Which diagnostic test will provide additional pertinent data?

A urine dipstick test to check for protein

A father and his 4-year-old son are waiting in an exam room when the nurse enters and greets them. Which activity that the nurse observes the boy doing would best demonstrate the primary developmental task of the preschool-age child, according to Erikson?

Opening drawers in the room, pulling out supplies, and examining them

The nurse caring for newborns knows that infants exhibit phenomenal increases in their gross motor skills over the first 12 months of life. Which statements accurately describe the typical infant's achievement of these milestones? Select all that apply.

At 1 month the infant lifts and turns the head to the side in the prone position. At 7 months the infant sits alone with some use of hands for support. At 9 months the infant crawls with the abdomen off the floor. At 12 months the infant walks independently.

The nurse is preparing a subcutaneous insulin injection for a preschooler. How and where should the nurse administer the insulin?

At a 45- to 90-degree angle into the elevated tissue of the upper arm

A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner?

Average birth weight for a newborn is between 5 lb, 8 oz (2500 g) and 8 lb, 13 oz. (4000 g). Average length at birth for a newborn is between 19 and 21 inches (48 to 53 cm).

When entering the second phase of labor, a patient tells the nurse that the pain is severe and is unsure if pain medication should be used. Which nursing diagnosis should the nurse use to guide the care of the patient at this time?

Decision conflict related to the use of analgesia during labor

The nurse is caring for a client who is experiencing a noneventful labor process. Which assessment findings may occur as the client progresses through the stages of labor? Select all that apply.

Dry mucous membranes Nausea Increased white blood cell count Increased urine specific gravity Hyperventilation

A gravida 3 para 2 client has been in labor for 4 hours and is experiencing severe back pain with each contraction. She is extremely uncomfortable and distressed because she never had this type of pain with her other labors. Which intervention can the nurse point out is best for this client to try to address her pain?

Effleurage

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 woman with known cardiac disease from childhood presents at the obstetrician's office 6 weeks' pregnant. What recommendations would the nurse make to the client to address the known cardiac problems for this pregnancy? Select all that apply.

Plan periods of rest into the workday. Receive pneumococcal and influenza vaccines. Let the physician know if you become short of breath or have a nighttime cough.

A nurse is caring for a pregnant client who inquires about the benefits of breast feeding. The nurse explains that secretory immunoglobulin A found in breast milk helps the infant by:

Protecting the gastrointestinal tract from foreign proteins

The nurse is examining an 8-year-old boy with tachycardia and tachypnea. The nurse anticipates which test as most helpful in determining the extent of the child's hypoxia?

Pulse oximetry

A child with gastroenteritis has been unable to keep oral medication down. What nursing intervention would be appropriate for this client?

Request an intravenous form of the medication.

Fentanyl has been administered to a client in labor. What assessment should the nurse prioritize?

Respiratory status

After teaching a class about conception, the nursing instructor asks the attendees to explain the process of fertilization. Which statement indicates the students need additional teaching? Select all that apply.

Sperm are viable for only about 48 hours after ejaculation. Sperm are able to fertilize the ovum up to 12 hours after ejaculation, and the ovum remains fertile for at least 24 hours after ovulation.

The nurse knows that the school-age child is in Erikson's stage of industry versus inferiority. Which best examplifies a school-aged child working toward accomplishing this developmental task?

The child signs up for after-school activities.

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse?

The nurse is assessing a 2-hour-old newborn and notes that the infant has irregular patterns of breathing rate, depth, and rhythm. Which is the best action made by the nurse?

The nurse in the emergency center admits a 16-year-old girl who looks like she weighs more than her stated weight. After collecting data from the adolescent, the nurse suspects the child is a runaway. Which of the following topics would be most important for the nurse to gather data about?

The possibility that the adolescent is pregnant

If the child is gaining weight at an expected rate, a child who weighs 36 lb (16.3 kg) at 3 years of age would weigh what amount at age 5?

The preschool age child gains about 4 to 5 lb (1.8 to 2.3 kg) each year and grows about 2.5 to 3 in (6.3 to 7.6 cm). So a 36 lb (16.3 kg) child at 3 years gaining 4 to 5 lb (1.8 to 2.3 kg) per year would be 44 to 46 lb (36 lb + 8 lb = 44 lb; 36 lb + 10 lb = 46 lb).

A hospice nurse has been preparing parents for the death of their child. How does the nurse recognize that the parents are dealing with anticipatory grief?

The parents have prepared a scrapbook of pictures of their child.

In recording a postpartum mother's urinary output, the nurse notes that she is voiding between 100 to 200 ml with each hourly void. How would the nurse interpret this finding?

The urinary output is normal.

A nurse in an obstetric clinic is preparing the staff for a prenatal appointment with an incarcerated pregnant woman. What does the nurse explain is the main difference when an incarcerated client comes to the clinic?

There will be correction officers with the woman throughout her appointment.

A nurse is administering a liquid oral medication to a 5-month-old. Which nursing action provides the correct dosage? Select all that apply.

Using a medicine dropper Gently restraining the child's arms and head Administering the medicine such that it flows slowly into the child's mouth

Following a cesarean birth, a patient is prescribed to receive intravenous fluids. At which time should the nurse anticipate that this patient will be able to resume an oral intake?

When bowel sounds return

The public health nurse is choosing to focus community education for parents of young children about awareness of the hospital. When is the best time to educate the children about the hospital?

When the children are capable of understanding basic functions of community resources

When applying the ultrasound transducer for continuous external electronic fetal monitoring, the nurse would place the transducer at which location on the client's body to record the FHR?

between the umbilicus and the symphysis pubis

The nurse is caring for an infant recovering from surgery for a cleft palate. Which type of restraint would be appropriate for the nurse to use when caring for this infant?

elbow

A teen mom asks the discharge nurse if it is okay to sleep in bed with her baby. She says her mom always did it with her siblings and it seemed okay. How should the nurse respond?

"Baby can sleep in your room in an infant crib, but not in an adult bed."

A community health nurse is conducting a parenting class on respiratory syncytial virus (RSV). What statement made by a parent indicates that the teaching has been successful?

"Exposure to second- or thirdhand smoke increases the risk for developing RSV."

Which client statements indicate to the nurse that the client is entering the second stage of labor? Select all that apply.

"I feel a lot of pressure." "I feel a burning between my legs." "I think the baby is coming." "I need to have a bowel movement."

A nurse is teaching a parent ways to reduce fever in a child. What statement made by the parent would require further education?

"I will give my child a tepid sponge bath to reduce the fever."

A client at 9 weeks' gestation asks the nurse, "What is a diagonal conjugate?" What is the nurse's best response?

"It is a measurement to determine if the pelvis size is adequate for a vaginal birth.

Which approach by the nurse best demonstrates the correct way to prepare a Hispanic child for a planned hospital admission?

Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening.

The nurse is preparing to assess the duration of contractions for a patient in labor. Which process should the nurse use to time the contractions?

The interval between the beginning and the end of one contraction

After teaching the mother of a 13-month boy old about suggestions for bathing and hygiene, the nurse determines that the teaching was successful when the mother states:

"It might be best to give him a bath in the evening."

The nurse is reinforcing teaching with a group of caregivers related to the nutritional needs of the infant. One caregiver asks why the 6-month-old infant needs to have solid foods when breast milk is such a good source of nutrition. What would be the best response by the nurse?

"Milk will not fully provide the child's needs for iron, which is found in solid foods."

The nurse is instructing a primipara who has concerns about the need for a cesearan section due to her sister's obstetrical history. Which statement by the client needs further instruction?

"My sister had a cesarean section with the first and then needs it for all subsequent pregnancies."

The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lb. How much formula should the nurse teach the parents to provide each day?

20 to 24oz (2.5 to 3.0 oz of fluid per pound of body weight per day)

The maternal health nurse is caring for multiple women who wish to attempt a vaginal birth after cesarean (VBAC). Which client will not be able to attempt a VBAC due to contraindications?T

28-year-old with a placenta previa

n working with infants, the nurse would expect the posterior fontanel to be closed in an infant who is which age?

3 months

The nurse is helping the mother of a 5-month-old boy understand the importance of developmentally appropriate play. Which one of the toys best meets the needs of this child?

A yellow rubber duck for the bath The rubber duck is most appropriate. It is safe, visually stimulating while bobbing on the water, and adds pleasure to bath time. A push-pull toy promotes skill for a walking infant. Pots and pans from the kitchen cupboard are played with successfully after sitting is mastered. A 5-month-old does not have the fine motor coordination to use stacking toys.

What is the most effective way to stimulate circulation after cesarean birth?

Ambulation within 4 hours of birth

When measuring the diagonal conjugate of a woman's pelvis, the distance between which of the following anatomic landmarks would be used?

Anterior surface of the sacral prominence and the anterior surface of the symphysis pubis

A woman has just entered the recovery room after cesarean birth of a baby weighing 9 lb 14 oz. After connecting the client to the blood pressure monitor, it is noted her HR is 120 and BP is 80/40. What nursing action should be a priority?

Assess for bleeding

The parents of a newborn become concerned when they notice that their baby seems to stop breathing for a few seconds. After confirming the parents' findings which action should the nurse prioritize?

Assess the newborn for signs of respiratory distress.

The school nurse is performing health assessments on students in middle school. Of what developmental milestone should the nurse be aware?

Peak height velocity (PHV) occurs at approximately 12 years of age in girls or about 6 to 12 months after menarche.

Within three days of birth, a newborn has developed a yellowish tinge that extends from face to mid-chest, is lethargic, and has to be awoken to feed. Which condition does the nurse suspect this infant is manifesting?

Physiologic jaundice.

Which documentation in the health record is most correct for the third stage of labor?

Begins with the time of delivery of the fetus and ends with the time of the delivery of the placenta.

After inserting a nasogastric tube (NG) into a young child, how will the nurse tape the tube in place?

Below nose and to cheek

The nurse is caring for an infant whose oxygen saturation levels frequently drop below 90%. Which data is most important to relate to the health care provider?

Blood gases

David, age 2, is diagnosed with stomach flu and is suffering from vomiting and diarrhea. What is the most important factor in determining the correct dosage for his infection?

Body surface area

A nurse is teaching a new mother about how newborns regulate their temperature. As part of the teaching, the nurse explains brown fat. Which information would the nurse include? Select all that apply.

Brown fat is brown and rich in blood vessels and nerve endings. The newborn keeps itself warm by oxidizing brown fat in response to exposure to the cold. Only mature newborns have brown fat. The most common places to find brown fat are the scapulae, neck, mediastinum, and areas near the kidneys and adrenals.

A client's membranes spontaneously ruptured, as evidenced by a gush of clear fluid with a contraction. What would the nurse do next?

Check the fetal heart rate

A client at 10 weeks' gestation is complaining of ptyalism over the past 2 weeks. What intervention would the nurse recommend to this client? Select all that apply.

Chew gum. Suck on hard candies.

Which activity would the nurse expect to find in an 18-month-old?

Climbing stairs with assistance

The nurse is caring for client at risk for requiring a cesarean birth. What action by the nurse may reduce this risk?

Continuous support by a health care provider

The nurse is assessing a newborn who appears healthy and at term. Which assessment finding of the feet does the nurse predict to observe to confirm the status of at-term birth?

Creases on two-thirds of the foot

A 13-month-old child is brought to the clinic for a well-child visit. The child's parent expresses concern that the child has not started to walk yet. What is the best action should the nurse take?

Explain that children can take their first steps as late as 18 months of age.

The nurse is counseling a young woman who has just entered her second trimester, after an uneventful first trimester. She tells the nurse, "It still doesn't seem real. It's just hard to believe that I will really have a baby." Which future events should the nurse point out that will help the young woman come to believe it is real? Select all that apply.

Feeling the baby kick Seeing an ultrasound image of the baby

A new mother is concerned about how she will know whether her newborn is receiving enough breast milk. The nurse should explain that which factor is the least accurate measure of how much nutrition the baby is receiving?

How long the baby nurses

A health care provider has written several prescriptions for a 7-pound newborn with jaundice. Which prescription does the nurse need to question?

IV normal saline 20 ml/hour

The lactation nurse is working with a woman who is experiencing some difficulties getting her newborn to "latch on" to her breast. They are trying various positions to see which is best for this infant. The nurse will document which nursing problem related to this teaching session?

Imbalanced nutrition, less than body requirements related to poor latch

The nurse observes an infant interacting with his parents. What are normal social behavioral developments for this age group? Select all that apply.

The infant exhibits a first real smile at age 2 months. By about 3 months of age the infant will start an interaction with a caregiver by smiling widely and possibly gurgling. The 3- to 4-month-old will also mimic the parent's facial movements, such as widening the eyes and sticking out the tongue. Separation anxiety may also start in the last few months of infancy. Around the age of 8 months the infant may develop stranger anxiety. At 6 to 8 months of age the infant may enjoy socially interactive games such as patty-cake and peek-a-boo.

The nurse is assessing a postpartum woman and is concerned the client may be hemorrhaging. Which assessment finding is the nurse finding most concerning?

increased heart rate

A client in labor has been admitted to the labor and birth suite. The nurse assessing the woman notes that the fetus is in a cephalic presentation. Which description should the nurse identify by the term presentation?

part of the fetal body entering the maternal pelvis first

The school nurse notices that a child has puffy eyes. Further assessment of the child leads the nurse to suspect viral conjunctivitis based on what finding?

photophobia--Viral conjunctivitis is characterized by lymphadenopathy, photophobia, and tearing. Mild pain is associated with bacterial conjunctivitis. Itching and watery discharge are associated with allergic conjunctivitis.

A nurse is educating a group of nursing students about the molding of the fetal skull during the birth process. What would the nurse include as the usual cause of molding?

poorly ossified bones of the cranial vault

The nurse is caring for a newborn who is lethargic, apneic, and not eating well, and has an axillary temperature of 36.2ºC. Which might the nurse have a concern about?

sepsis

Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50. The nurse's first action would be to:

turn her on her left side or raise her legs.