Module 1: Developmental Stages and Transitions

Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and tells the couple that: If the oral tablets are not successful, the medication will be administered intravenously The primary health care provider should be notified immediately if breast engorgement occurs The couple should engage in coitus once a week during treatment Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which of the following food items does the nurse tell the client contains the highest amount of folic acid? Oranges Pinto beans Lettuce Broccoli

Pinto beans

A mother asks the nurse when her child should have his first dentist visit. The nurse tells the mother: Just before beginning kindergarten At age 3 Soon after the first primary tooth erupts, usually around 1 year of age Twelve months after the first primary tooth erupts

Soon after the first primary tooth erupts, usually around 1 year of age

A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? Notifying the nurse-midwife or primary health care provider Stopping the oxytocin infusion Checking the woman's blood pressure and pulse Increasing the intravenous (IV) rate of the nonadditive solution

Stopping the oxytocin infusion

A female client asks a nurse about the advantages of using a female condom. The nurse tells the client that one advantage is: That it is 100% safe in preventing pregnancy That it does not have to be discarded after use and can be used several times before a new one must be obtained That it offers protection against sexually transmitted infections (STIs) It can be used along with a male condom

That it offers protection against sexually transmitted infections (STIs)

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse tells the client that: A probe coated with gel will be inserted into the vagina That she may need to drink fluids before the test and may not void until the test has been completed She will be positioned on her back for the procedure The procedure takes about 2 hours

That she may need to drink fluids before the test and may not void until the test has been completed

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should tell the parents: To restrict any social privileges until the behavior stops That this is normal behavior for an adolescent That this type of behavior is usually the result of parents' spoiling a child That their daughter will need to see a child psychologist if the behavior continues

That this is normal behavior for an adolescent

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse tells the mother: This is normal for breastfed infants. Decrease the number of feedings by two per day. Stools should be solid and pale yellow to light brown. Monitor the infant for infection and, if a fever develops, contact the pediatrician.

That this is normal for breastfed infants

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. The nurse tells the mother: That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car To secure the infant in the middle of the back seat in a rear-facing infant safety seat That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant

To secure the infant in the middle of the back seat in a rear-facing infant safety seat

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse tells the clients that: They must stay in the house and ask a neighbor or family member to run their errands It is best to do grocery shopping and other errands late in the day Drinking eight 8-oz (240 ml) glasses of fluid each day will reduce the risk of contracting influenza. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question does the nurse ask? "Do you normally have menstrual cramps with your periods?" "Do you engage in strenuous exercise such as jogging?" "Do you smoke cigarettes?" "Are you dieting?"

"Do you smoke cigarettes?"

A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure, the nurse should perform the following actions. Assign the correct order of priority to the items on the list, using 1 to indicate the first action and 5 the last.

(1) Assess the fetal heart rate (2) Assess the color, odor, and other characteristics of the amniotic fluid (3) Check the woman's heart rate and blood pressure (4) Assist the woman in cleaning the perineal area (5) Ask the woman about the need to void

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? 6 weeks 16 weeks 12 weeks 8 weeks

16 weeks

A nurse is assessing a newborn infant for jaundice. Which of the following actions should the nurse take to assess the infant for its presence? Apply pressure with a finger on the infant's forehead Squeeze the infant's nail beds Squeeze the infant's brachial area Apply pressure with a finger over the umbilical area

Apply pressure with a finger on the infant's forehead

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? Contacting the nurse-midwife or primary health care provider Applying an ice pack to the perineum Assisting the woman in taking a warm sitz bath Administering an intravenous (IV) opioid analgesic

Applying an ice pack to the perineum

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client? Aunts, uncles, grandparents, and cousins Spouse's children from a previous marriage Spouse and spouse's parents Foster children and their parents

Aunts, uncles, grandparents, and cousins

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, the nurse ensures that: The woman's husband remains in the examining room at all times Written permission is obtained from the woman to obtain subjective health data The woman is examined without any other people in the examining room A female primary health care provider examines the woman

A female physician examines the woman

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. The nurse interprets this finding as: A reassuring sign A nonreassuring sign An indication of the need to contact the primary health care provider An indication of fetal distress

A reassuring sign

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is:

Gravida 6, para 2

A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult because such clients: Young adults are exposed to hazardous substances Young adults ignore their risk for a serious illness Young adults are unable to afford health insurance Young adults ignore physical symptoms and postpone seeking health care

Ignore physical symptoms and postpone seeking health care

A nurse is determining the estimated date of delivery for a pregnant client, using Nagele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be:

June 6, 2014

A nurse is reviewing the medical notes of a client seen by the physician to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which of the following findings is documented?

Palpable fetal movement

A nurse is telling a pregnant client about the signs that must be reported to the physician or nurse-midwife. The nurse tells the client that the physician or nurse-midwife should be contacted if which of the following occurs? Puffiness of the face Breast tenderness Morning sickness Urinary frequency

Puffiness of the face

A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? Select all that apply. The infant smiles and coos. The infant says "Mama." The infant babbles. Words begin to have meaning for the infant. The infant babbles single consonants. The infant strings vowels and consonants together.

The infant says "Mama." Words begin to have meaning for the infant. The infant strings vowels and consonants together.

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to Dip the infant's pacifier in maple syrup so that the infant will suck Use diluted fluoride and rub the teeth with a soft washcloth Use a small amount of toothpaste and a soft-bristle toothbrush Use water and a cotton swab and rub the teeth

Use water and a cotton swab and rub the teeth

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? "I should eat five or six small meals a day rather than three full meals." "I need to be sure to drink adequate fluids with my meals." "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning." "I need to avoid eating fried or greasy foods."

"I need to be sure to drink adequate fluids with my meals." Correct Understanding is Indicated in these statements: • "I need to avoid eating fried or greasy foods." • "I should eat five or six small meals a day rather than three full meals." • "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning."

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? "I should drink extra fluids during the summer." "I need to wear a hat with a wide brim when I go outdoors." "I should wear cool, light clothing in warm weather." "I need to wear additional antiperspirant and deodorant in warm weather."

"I need to wear additional antiperspirant and deodorant in warm weather."

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she: Uses a cotton-tipped swab to carefully clean inside the infant's nose Washes the diaper area first Washes the infant's chest first Uncovers only the body part being washed

Uncovers only the body part being washed

Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? Rectus femoris muscle Gluteal muscle Deltoid muscle Vastus lateralis muscle

Vastus lateralis muscle

According to Erik Erikson's developmental theory, which of the following choices are developmental tasks of the middle adult? Verbalizing readiness to assume parental responsibilities Willingness to care for others Providing guidance during interactions with children Guiding social interactions with the next generation Making decisions concerning career, marriage, and parenthood Redefining self-perception and capacity for intimacy

Willingness to care for others Providing guidance during interactions with his children Guiding social interactions with the next generation

A nurse is performing an external and ophthalmoscopic examination of an older client. Which age-related change would the nurse would expect to note?

Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula

A nurse is performing an admission assessment on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. The nurse's next action should be to: Document the client's concern in the medical record. Report the client's concern to the primary health care provider. Tell the client that sexual dysfunction is a normal age-related change. Ask the client about medications he is taking.

Ask the client about medications he is taking

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant: At the level of the nipples At the level of the umbilicus 2 inches (5cm) below the nipples In the axillary area

At the level of the nipples

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? Initiative versus guilt Trust versus mistrust Autonomy versus doubt and shame Correct Industry versus inferiority

Autonomy versus doubt and shame

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse tells the mother that: Infection always occurs when body piercing is done Hepatitis B is a concern with body piercing It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV) Body piercing is generally harmless as long as it is performed under sterile conditions

Body piercing is generally harmless as long as it is performed under sterile conditions

A nurse is assessing the motor development of a 24-month-old child. Which of the following activities would the nurse expect the mother to report that the child can perform? Select all that apply. Dress himself appropriately Align two or more blocks Go to the bathroom without help Put on and tie his shoes Turn the pages of a book one at a time Washing and drying hands

• Align two or more blocks • Turn the pages of a book one at a time. Washing and drying hands

A nurse is obtaining assessment data from an older client about sleep patterns. The client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these reported data, the nurse should: Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours Report the findings to the primary health care provider Ask the primary health care provider for a prescription for a nighttime sedative Document the findings in the medical record

Document the findings in the medical record

A nurse performing a physical assessment of a 12-month-old infant notes that the infant's head circumference is the same as the chest circumference. On the basis of this finding, the nurse should: Suspect the presence of hydrocephalus Tell the mother that the infant is growing faster than expected Suggest to the pediatrician that a skull x-ray be performed Document these measurements in the infant's health-care record

Document these measurements in the infant's health-care record

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? Doppler transducer Stethoscope Fetoscope Pulse oximetry on the client and a fetoscope

Doppler transducer

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. The nurse tells the mother that the child should have a dental examination: Every 3 months Once a year Every 6 months Whenever a new primary tooth erupts

Every 6 months

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? Hypertension Headache Vomiting Pruritus

Headache

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse determines that: The client needs to receive the hepatitis B series of vaccines The results indicate that the mother does not have hepatitis B Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth The results are negative

Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which of the following observations would the nurse expect to note as an age-related finding? Bounding dorsalis pedis pulse Loss of hair on the lower legs Thick skin on the lower legs Thin, ridged toenails

Loss of hair on the lower legs

Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus?

Midway between the symphysis pubis and umbilicus Sinks to the level of the umbilicus Rises

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow?

Moderate

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which of the following actions should the nurse include in the plan of care? Ensuring that most of the diet consists of liquids Monitoring the client during meals to ensure that food is swallowed Consulting with the health care provider regarding feeding through an enteral tube Encouraging the client to feed herself

Monitoring the client during meals to ensure that food is swallowed

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. On the basis of these findings, what is the most appropriate nursing action? Document the findings in the client's medical record Recheck the vital signs in 1 hour Notify the nurse-midwife of the findings Continue collecting subjective and objective data

Notify the nurse-midwife of the findings

A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant: Uses short sentences Uses facial expressions or gestures Speaks at a normal rate and volume Overarticulates words

Overarticulates words

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? Sterilization Diaphragm Male condom Spermicide

Sterilization

A nurse reviews the health history of a client who will be seeing the physician to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which of the following findings in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? The client has been treated for breast cancer. The client is being treated for hypertension. The client has hyperlipidemia. The client has type 2 diabetes mellitus.

The client has been treated for breast cancer.

A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications?

The client's mother

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is: Obtaining adequate nutrition Keeping up with schoolwork Body image Obtaining adequate rest and sleep

Body image

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over the: Back of the fetus Brachial area of one extremity of the fetus Carotid artery in the neck of the fetus Chest of the fetus

Back of the fetus

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? "I need to keep large toys out of the crib." "The drop side needs to be impossible for my infant to release." "Wood surfaces on the crib need to be free of splinters and cracks." "The distance between the slats needs to be no more than 4 inches (10 cm) wide to prevent entrapment of my infant's head or body."

"The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body."

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which of the following toys are most appropriate for these activities? Simple board games and puzzles Blocks and push-pull toys Finger paints and card games Videos and cutting-and-pasting toys

Blocks and push-pull toys

A nurse performing a neurological assessment of a client in later adulthood notes that the client has tremors of the hands. On the basis of this finding, the nurse should Obtain a prescription for a muscle relaxant Ask the primary health care provider about referring the client to a neurological specialist Notify the primary health care provider immediately Document the findings

Document the findings

A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. On the basis of this finding, which priority action should the nurse take? Continuing to check the client's vital signs every 15 minutes Checking the client's uterine fundus Documenting the vital signs in the client's medical record Notifying the nurse-midwife immediately

Checking the client's uterine fundus

A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. On the basis of this result, which action should the nurse take first? Hold the next scheduled feeding Ask the laboratory to draw another blood sample in 2 hours and repeat the test Contact the nurse-midwife or primary health care provider Document the results in the newborn's medical record

Contact the nurse-midwife or physician

A nurse monitoring a client in labor notes this fetal heart rate pattern (early decelerations) on the electronic fetal monitoring strip. The most appropriate nursing action would be to: Notify the nurse-midwife or primary health care provider Administer oxygen with a face mask at 8 to 10 L/min Continue to monitor the client and fetal heart rate patterns Stop the oxytocin (Pitocin) infusion

Continue to monitor the client and fetal heart rate patterns

A nurse is reviewing the medical record of an older client with presbycusis. Which of the following findings would the nurse expect to note in the client's record? Difficulty hearing low-pitched tones Difficulty hearing whispered words in the voice test Gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve Improved hearing ability during conversational speech Unilateral conductive hearing loss Difficulty hearing consonants during conversational speech

Difficulty hearing whispered words in the voice test Gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve Difficulty hearing consonants during conversational speech

A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client's ability to maintain a patent airway because the normal aging process: The normal aging process decreases the number of alveoli and increases the function of those remaining The normal aging process decreases an older client's ability to clear secretions The normal aging process increases the production of surfactant The normal aging process increases respiratory system compliance

Decreases an older client's ability to clear secretions

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is: Determination of fetal lung maturity Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid Checking the amniotic fluid for intrauterine infection Checking the fetal cells for chromosomal abnormalities

Determination of fetal lung maturity

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which of the following tasks represents the primary developmental task of this child? Select all that apply. Developing a sense of trust in the world Developing a sense of accomplishment Engaging in tasks they can complete Gaining independence from parents Mastering useful skills and tools Developing a sense of control over self and body functions

Developing a sense of accomplishment Engaging in tasks they can complete Mastering useful skills and tools

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. The nurse should: Document the findings Wait 15 minutes and then recheck the FHR Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time Notify the primary health care provider of the finding

Document the findings

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which of the following actions should the nurse include in the plan? Encouraging at least one daytime nap Discouraging the use of a night light at bedtime Discouraging social interaction, particularly at bedtime Encouraging bedtime reading or listening to music

Encouraging bedtime reading or listening to music

A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? Recheck the score in 5 minutes Initiate cardiopulmonary resuscitation Provide no action except to support the infant's spontaneous efforts Gently stimulate the infant by rubbing his back while administering oxygen

Gently stimulate the infant by rubbing his back while administering oxygen

An older female client asks a nurse why her hair has turned gray. Which of the following responses is most appropriate for the nurse to make to the client? "The number of sweat glands and blood vessels decreases in the normal aging process." "The skin on the scalp becomes thin, causing moisture to escape." "A loss of melanin occurs in the normal aging process." "It is caused by hereditary factors."

"A loss of melanin occurs in the normal aging process."

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? "Meats are really important for iron, and I should start feeding meats to my infant right away." "I can mix the food in my infant's bottle if he won't eat the food." "Egg white should not be given to my infant because of the risk for an allergy." "Fluoride supplementation is not necessary until permanent teeth come in."

"Egg white should not be given to my infant because of the risk for an allergy."

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing Autonomy A sense of industry A sense of trust Initiative

A sense of industry

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which of the following findings is noted on the electronic monitoring recording strip? Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement Absence of accelerations after fetal movement Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline

Absence of accelerations after fetal movement

The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in a:

Booster seat with one of the car's seat belts placed over the child

A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should: Brush and floss their teeth every morning and at bedtime Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime Brush their teeth every morning and at bedtime Brush and floss their teeth after meals and at bedtime

Brush and floss their teeth after meals and at bedtime

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take on the basis of this finding? Document the findings. Report the findings to the nurse-midwife. Obtain a sample of the amniotic fluid for laboratory analysis. Check the client's temperature.

Document the findings.

A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. On the basis of this finding, what is the most appropriate action for the nurse to take? Wrap an extra blanket around the infant Place the infant in an oxygen tent Document the findings Contact the pediatrician

Documenting the findings

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. The nurse instructs the mother to: Obtain an over-the-counter (OTC) topical medication for gum-pain relief Rub the infant's gums with baby aspirin that has been dissolved in water Give the infant cool liquids or a Popsicle and hard foods such as dry toast Schedule an appointment with a dentist for a dental evaluation

Give the infant cool liquids or a Popsicle and hard foods such as dry toast

A client in labor complains of back discomfort. Which position that will best aid in relieving the discomfort does the nurse encourage the mother to assume? Standing Hands and knees Prone Supine

Hands and knees

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? "The immune system of an infant is immature, and the infant is at risk for infection." "Yes, your infant is protected from all infections." "If you breastfeed, your infant is protected from infection." "The transfer of your antibodies protects your infant until the infant is 12 months old."

The immune system of an infant is immature, and the infant is at risk for infection."

A nurse provides information to a client about the use of a diaphragm. Which of the following statements indicates to the nurse that the client needs further information on how to use the diaphragm? "I can leave the diaphragm in place as long as I want after intercourse." "I need to reapply spermicidal cream with repeated intercourse." "The diaphragm needs to be filled with spermicidal cream before insertion." "The diaphragm can be inserted as long as 6 hours before intercourse."

"I can leave the diaphragm in place as long as I want after intercourse." Statements indicating correct understanding include: • "I need to reapply spermicidal cream with repeated intercourse." • "The diaphragm needs to be filled with spermicidal cream before insertion." • "The diaphragm can be inserted as long as 6 hours before intercourse."

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? Holding her breath and using the Valsalva maneuver Cleansing breaths Blowing repeatedly in short puffs Deep inspiration and expiration at the beginning and end, respectively, of each contraction

Blowing repeatedly in short puffs

A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, the nurse should: Check the infant for jaundice Request that a hepatitis blood screen be performed on the infant Check the infant's temperature Obtain parental consent to administer the vaccine

Obtain parental consent to administer the vaccine

A nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? Work and home schedules Personal preference Family planning goals Desire to have children in the future

Personal preference

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. On the basis of this finding, which action by the nurse is most appropriate? Reporting the finding to the nurse-midwife or primary health care provider immediately Helping the woman get out of bed and walk Documenting the finding Performing active and passive range-of-motion exercises

Documenting the finding

A nurse is assessing language development in a toddler from a bilingual family. The nurse expects that the child's language development: Is slower than expected Will require assistance from a speech therapist Will need more time to communicate with others Is developing as expected Could exhibit some lack of confidence related to communicating with others Is more advanced than expected

Is slower than expected Will need more time to communicate with others Could exhibit some lack of confidence related to communicating with others

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately: Notify the nurse-midwife or primary health care provider Insert a gloved finger into the mother's vagina to feel for cord compression Position the mother so that her hips are elevated Perform a vaginal examination on the mother

Position the mother so that her hips are elevated

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, the nurse tells the group that infants: Tolerate a great deal of frustration and discomfort to develop a healthy personality Experience frustration to allow an infant to cry for a while before meeting his or her needs Rely on the fact that their needs will be met Ignore needs for short periods to develop a healthy personality

Rely on the fact that their needs will be met

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. The nurse should ell the mother that the infant's weight is increasing as expected Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate Tell the mother to decrease the daily number of feedings because the weight gain is excessive

Tell the mother that the infant's weight is increasing as expected

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse tells the client that: She must have been exposed to the rubella virus at some point in her life The test results are normal The test will need to be repeated during the pregnancy She has developed immunity to the rubella virus

The test will need to be repeated during the pregnancy

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which of the following findings is noted? The fingers curl tightly and the toes curl forward. The infant turns to the side that is touched. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. The toes flare and the big toe is dorsiflexed.

The toes flare and the big toe is dorsiflexed.

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). The nurse tells the adolescent that: Use of a latex condom can prevent transmission of STIs Use of a latex condom is a good method for preventing pregnancy A spermicide needs to be used along with a condom to prevent transmission of STIs The only way to prevent transmission of STIs is abstinence

Use of a latex condom can prevent transmission of STIs

A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which of the following actions does the nurse tell the client to take? Select all that apply. Apply cool compresses to the hemorrhoids Sleep lying on her back Shower daily but avoid sitting in a bathtub Contact the nurse-midwife if any bleeding occurs Elevate her hips on a pillow when resting or during sleep

• Apply cool compresses to the hemorrhoids • Elevate her hips on a pillow when resting or during sleep

A nurse is conducting a psychosocial assessment of a young adult. Which of the following observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. The young adult verbalizes unrealistic fears. The young adult verbalizes satisfaction with friendships. The young adult verbalizes disappointment with life. The young adult is sensitive to criticism. The young adult has a sense of meaning and direction in life.

• The young adult verbalizes satisfaction with friendships. • The young adult has a sense of meaning and direction in life.

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant's being brought into the home. Which of the following statements is the most appropriate response for the nurse to make to the client? "Don't be concerned; any 2-year-old would welcome a newborn." "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned." "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist."

"Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth."

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information? "My temperature needs to remain within a normal range." "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." "Frequent urination and burning when I urinate are expected." "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs."

"Frequent urination and burning when I urinate are expected."

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse tells the client that: Devices that apply pressure alone are available over the counter It is all right to try any type of complementary alternative therapy to relieve the nausea The primary health care provider or nurse-midwife needs to provide a prescription for acupressure Complementary alternative therapies should not be used during pregnancy

Devices that apply pressure alone are available over the counter

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should: Spend as much time as possible with the toddler Allow the toddler to play with other children in the nursing unit playroom Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room Keep hospital routines as similar as possible to those at home

Keep hospital routines as similar as possible to those at home

A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. The nurse should tell the mother: That if the behavior continues, she will need to bring her children to a child psychologist That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity To separate her children during playtime To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes that the menstrual pad was saturated in 15 minutes. What should be the nurse's next action? Immediately contact the primary health care provider. Do nothing. This is normal. Place the client in a modified Sims' position. Remove the menstrual pad and replace with two pads

Immediately contact the primary health care provider. Correct

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. Asks the mother to lie still while both the FHR and the radial pulse rate are counted. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.

Move the fetoscope to another area on the mother's abdomen to locate the fetal heart.

A nurse is reviewing the medical notes of a client seen by the primary health care provider to determine whether the client is pregnant. What positive signs/symptoms of pregnancy would the nurse expect to see in the client's medical notes? Select all that apply.

Palpable fetal movement Visualization of the fetus with sonography Auscultation of fetal heart sounds

The mother of a 9-year-old child who is 5 feet 1 inch (155 cm) in height asks a nurse about car safety seats. What should the nurse tell the mother to use? Forward-facing car seat Rear seat using lap and shoulder seat belts Rear convertible seat Front booster seat

Rear seat using lap and shoulder seat belts

After delivery, the nurse assesses the woman's uterine fundus. At what locations does the nurse expect to be able to palpate the fundus during the first 24 hours? Select all that apply. Sinks to the level of the umbilicus In the pelvic cavity Rises to a level just above the umbilicus 2 cm above the umbilicus Midway between the symphysis pubis and umbilicus At the level of the umbilicus

Sinks to the level of the umbilicus Rises to a level just above the umbilicus Midway between the symphysis pubis and umbilicus

A nurse is determining the estimated date of delivery for a pregnant client, using Nägele's rule. Put the components for Nägele's rule in priority order. Subtracting 3 months Dividing the final number by 9 Adding 7 days Determining the first day of last menstrual period Correcting the year Multiplying weeks by 2

Subtracting 3 months Adding 7 days Determining the first day of last menstrual period Correcting the year

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the GTPAL, what does the nurse determine?

T = 1 A = 3 L = 2 P = 1 G = 6

A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating: (Select all that apply) That the cervix was seen to be violet That cervical softening is present Occurs at about 4 weeks of pregnancy A positive sign of pregnancy Increased vascularity of the pelvic organs A thinning of the cervix

That the cervix was seen to be violet Occurs at about 4 weeks of pregnancy Increased vascularity of the pelvic organs

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse tells the mother: To remove the crust, using a warm, wet face cloth and a mild soap That the crust is to be expected as a normal part of healing To bring the infant to the pediatrician's office to be checked That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours

That the crust is to be expected as a normal part of healing

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which of the following observations is a sign of physical readiness? The child no longer has temper tantrums. The child can eat using a fork and knife. The child can remove his or her own clothing. The child has been walking for 2 years.

The child can remove his or her own clothing.