Mother Baby Exam 1

The nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths per minute. On the basis of this finding, which action is most appropriate? 1. Administer oxygen. 2. Document the findings. 3. Notify the pediatrician. 4. Reassess the respiratory rate in 15 minutes.

2. Document the findings. Rationale: The normal respiratory rate in a 12-month-old infant is 20 to 40 breaths per minute. The normal apical heart rate is 90 to 130 beats per minute, and the average blood pressure is 90/56 mm Hg. The nurse would document the findings.

The parent of an 8-year-old child tells the clinic nurse that they are concerned about the child because the child seems to be more attentive to friends than anything else. Using Erikson's psychosocial development theory, the nurse would make which response? 1. "You need to be concerned." 2. "You need to monitor the child's behavior closely." 3. "At this age, the child is developing his own personality." 4. "You need to provide more praise to the child to stop this behavior."

3. "At this age, the child is developing his own personality."

The prenatal clinic nurse asks a nursing student to identify the physiological adaptations of the cardiovascular system that occur during pregnancy. The nurse determines that the student understands these physiological changes if the student makes which statement? 1. "An increase in pulse rate occurs." 2. "A decrease in blood volume occurs." 3. "A decrease in cardiac output occurs." 4. "The blood pressure increases by 20 mm Hg."

1. "An increase in pulse rate occurs." Rationale: Between 14 and 20 weeks' gestation, the maternal pulse rate increases slowly by 10 to 15 beats/minute, which lasts until term. Cardiac output and blood volume increase. Blood pressure decreases in the first half of pregnancy and returns to baseline in the second half of pregnancy.

Which statement, if made by the laboring client, most likely indicates that the client is in the second stage of labor? 1. "I feel like I need to push." 2. "My contractions seem to be getting stronger." 3. "I am glad that I have several minutes to rest between contractions." 4. "Warm fluid is running down my legs each time I have a contraction."

1. "I feel like I need to push." Rationale: The second stage of labor begins when the cervix is completely dilated and ends with birth of the infant. At this time, the laboring client typically experiences the desire to push. Contractions becoming stronger are experienced throughout labor and do not indicate that the client has reached stage 2. Having several minutes to rest between contractions does not describe the end of transition. Leaking of amniotic fluid does not mean that the client is completely dilated.

The nurse is providing instructions to the parent of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the parent indicates a need for further teaching? 1. "I need to place a steam vaporizer in my child's room." 2. "I will take my child out into the cool, humid night air." 3. "I could place a cool-mist humidifier in my child's room." 4. "I will have my child inhale the steam from warm running water."

1. "I need to place a steam vaporizer in my child's room." Rationale: Steam from running water in a closed bathroom will assist in keeping secretions thin so that they can be easily expectorated. Steam from a vaporizer however can present a danger of scald burns because of the more direct effect than that provided from steam from running water. A cool mist from a bedside humidifier may be effective in reducing mucosal edema. Cool-mist humidifiers are recommended over steam vaporizers. Taking the child out into the cool, humid night air may also relieve mucosal swelling.

The maternity nurse is providing instructions to a new parent regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the parent to take which measure? 1. Allow the newborn infant to signal a need. 2. Anticipate all needs of the newborn infant. 3. Attend to the newborn infant immediately when crying. 4. Avoid the newborn infant during the first 10 minutes of crying.

1. Allow the newborn infant to signal a need.

The nurse is preparing to teach a prenatal class about fetal circulation. Which statements would be included in the teaching plan? Select all that apply. 1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 3. "The normal fetal heart beat range is 100 to 110 beats per minute in early pregnancy." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." 5. "Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta."

1. "The ductus arteriosus allows blood to bypass the fetal lungs." 2. "One vein carries oxygenated blood from the placenta to the fetus." 4. "Two arteries carry deoxygenated blood and waste products away from the fetus to the placenta." Rationale: The ductus arteriosus is a unique fetal circulation structure that allows the nonfunctioning lungs to receive only a minimal amount of oxygenated blood for tissue maintenance. Oxygenated blood is transported to the fetus by one umbilical vein. The normal fetal heart rate range is considered to be 110 to 160 beats per minute. Arteries carry deoxygenated blood and waste products from the fetus, and the umbilical vein carries oxygenated blood and provides oxygen and nutrients to the fetus. Blood pumped by the embryo's heart leaves the embryo through two umbilical arteries.

The parent of a 5-year-old child tells the nurse that the child scolds the floor or a table if the child hurts themself on the object. The nurse educates the parent according to Piaget's theory of cognitive development and its terminology and definitions. Which statement by the parent indicates that the teaching has been effective? 1. "This is an example of animism." 2. "This is an example of egocentric speech." 3. "This is an example of object permanence." 4. "This is an example of global organization."

1. "This is an example of animism." Rationale: Animism means that all inanimate objects are given living meaning. Egocentric speech occurs when the child talks just for fun and cannot see another's point of view. Object permanence, the realization that something out of sight still exists, occurs in the later phases of the sensorimotor stage of development. Global organization means that if any part of an object or situation changes, the whole thing has changed. Options 2 and 4 occur during the preoperational stage.

A student nurse is caring for a hospitalized child who has hypotonic dehydration. Which serum sodium level would the student expect to observe? 1. 125 mEq/L (125 mmol/L) 2. 135 mEq/L (135 mmol/L) 3. 145 mEq/L (145 mmol/L) 4. 155 mEq/L (155 mmol/L)

1. 125 mEq/L (125 mmol/L) Rationale: Hypotonic dehydration occurs when the loss of electrolytes is greater than the loss of water; in this type of dehydration, the serum sodium level is less than 130 mEq/L (130 mmol/L). Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal at 135 to 145 mEq/L (135 to 145 mmol/L).

The nurse is providing care to a child admitted for acute otitis media. What is the nurse's priority concern for this child? 1. Acute pain 2. Problems with skin integrity 3. Risk for interrupted breathing patterns 4. Mucous membrane dryness and cracking

1. Acute pain Rationale: In acute otitis media, symptoms and signs such as acute ear pain, fever, and a bulging yellow or red tympanic membrane usually are present. Nursing interventions focus on relieving pain. Analgesic medications such as acetaminophen or ibuprofen are used to treat mild pain. The priority concern for this condition would be acute pain. Skin integrity, interrupted breathing patterns, and mucous membrane dryness and cracking are not priority concerns and are not specifically related to the condition.

An ambulatory care nurse makes a follow-up telephone call to the parent of a child who underwent a myringotomy with insertion of tympanoplasty tubes on the previous day. The parent of the child tells the nurse that the child is complaining of discomfort. What would the nurse instruct the parent to do? 1. Administer acetaminophen. 2. Give one children's aspirin with water. 3. Call the pharmacist for a stronger analgesic. 4. Call the primary health care provider immediately.

1. Administer acetaminophen.

The nurse in the labor room is caring for a client in the active stage of the first phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. What is the most appropriate nursing action? 1. Administer oxygen via face mask. 2. Place the client in a supine position. 3. Increase the rate of the oxytocin intravenous infusion. 4. Document the findings and continue to monitor the fetal patterns.

1. Administer oxygen via face mask. Rationale: Late decelerations are due to uteroplacental insufficiency and occur because of decreased blood flow and oxygen to the fetus during the uterine contractions. Hypoxemia results; oxygen at 8 to 10 L/minute via face mask is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client needs to be turned onto the side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency resulting from stimulation of contractions by this medication. Although the nurse would document the occurrence, option 4 would delay necessary treatment.

The nurse is monitoring a client who is in the active stage of labor. The nurse documents that the client is experiencing labor dystocia. The nurse determines that which risk factors in the client's history placed the client at risk for this complication? Select all that apply. 1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility 4. Administration of oxytocin for induction 5. Potassium level of 3.6 mEq/L (3.6 mmol/L)

1. Age 54 2. Body mass index of 28 3. Previous difficulty with fertility Rationale: Risk factors that increase a client's risk for dysfunctional labor include the following: advanced age, being overweight, electrolyte imbalances, previous difficulty with fertility, uterine overstimulation with oxytocin, short stature, prior version, masculine characteristics, uterine abnormalities, malpresentations and position of the fetus, cephalopelvic disproportion, maternal fatigue, dehydration, fear, administration of an analgesic early in labor, and use of epidural analgesia. Age 54 is considered advanced age, and a body mass index of 28 is considered overweight. Previous difficulty with infertility is another risk factor for labor dystocia. A potassium level of 3.6 mEq/L (3.6 mmol/L) is normal and administration of oxytocin alone is not a risk factor; risk exists only if uterine hyperstimulation occurs.

The nursing instructor asks a nursing student to explain the characteristics of the amniotic fluid. The student responds correctly by explaining which as characteristics of amniotic fluid? Select all that apply. 1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function 5. Prevents large particles such as bacteria from passing to the fetus 6. Provides an exchange of nutrients and waste products between the parent and the fetus

1. Allows for fetal movement 2. Surrounds, cushions, and protects the fetus 3. Maintains the body temperature of the fetus 4. Can be used to measure fetal kidney function Rationale: The amniotic fluid surrounds, cushions, and protects the fetus. It allows the fetus to move freely and maintains the body temperature of the fetus. In addition, the amniotic fluid contains urine from the fetus and can be used to assess fetal kidney function. The placenta prevents large particles such as bacteria from passing to the fetus and provides an exchange of nutrients and waste products between the parent and the fetus.

The nurse assists the primary health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure? 1. Assess the fetal heart rate. 2. Check the client's temperature. 3. Change the pads under the client. 4. Check the client's respiratory rate.

1. Assess the fetal heart rate.

The nurse is performing an assessment on a client who suspects being pregnant and is checking the client for probable signs of pregnancy. The nurse would assess for which probable signs of pregnancy? Select all that apply. 1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test 5. Fetal heart rate detected by a nonelectronic device 6. Outline of fetus via radiography or ultrasonography

1. Ballottement 2. Chadwick's sign 3. Uterine enlargement 4. Positive pregnancy test Rationale: The probable signs of pregnancy include uterine enlargement, Hegar's sign (compressibility and softening of the lower uterine segment that occurs at about week 6), Goodell's sign (softening of the cervix that occurs at the beginning of the second month), Chadwick's sign (violet coloration of the mucous membranes of the cervix, vagina, and vulva that occurs at about week 4), ballottement (rebounding of the fetus against the examiner's fingers on palpation), Braxton Hicks contractions, and a positive pregnancy test for the presence of human chorionic gonadotropin. Positive signs of pregnancy include fetal heart rate detected by electronic device (Doppler transducer) at 10 to 12 weeks and by nonelectronic device (fetoscope) at 20 weeks of gestation, active fetal movements palpable by the examiner, and an outline of the fetus by radiography or ultrasonography.

A 4-year-old child is diagnosed with otitis media. The parent asks the nurse about the causes of this illness. Which risk factors would the nurse include in response to this parent? Select all that apply. 1. Bottle-feeding 2. Household smoking 3. A history of urinary tract infections 4. Exposure to illness in other children 5. Congenital conditions such as cleft palate

1. Bottle-feeding 2. Household smoking 4. Exposure to illness in other children 5. Congenital conditions such as cleft palate Rationale: Factors that increase the risk of otitis media include bottle-feeding, household smoking, exposure to illness from other children in day care centers, and congenital conditions such as Down's syndrome and cleft palate. The use of a pacifier beyond age 6 months has been identified as another risk factor. Allergies are also thought to precipitate otitis media.

A client calls the primary health care provider's office to schedule an appointment because the client has missed two menstrual cycles and has always been very regular. The client receives an appointment for the next day. The nurse would expect which findings to be present at this prenatal visit if the client is pregnant? Select all that apply. 1. Chadwick's sign 2. Vertex presentation 3. Positive pregnancy test 4. Fetal heart rate audible by fetoscope 5. Fetal movement detectable by the client

1. Chadwick's sign 3. Positive pregnancy test Rationale: Having missed two menstrual cycles with a normal history, the client is at approximately 8 weeks' gestation. Hormonal changes lead to vascular congestion in the cervix and vagina. The tissues have an appearance of looking "blue," and this change is identified by the term Chadwick's sign (hCG) is produced by trophoblastic cells that surround the developing embryo. This hormone is responsible for a positive pregnancy test. The pregnancy is not advanced enough to be able to determine a presentation. Fetal heart rate is not audible by fetoscope until approximately 20 weeks. the earliest a pregnant parent experiences fetal movement is approximately 14 weeks.

The nurse is monitoring a client in labor whose membranes ruptured spontaneously. What is the initial nursing action? 1. Determine the fetal heart rate. 2. Provide peripads for the client. 3. Take the client's blood pressure. 4. Note the amount, color, and odor of the amniotic fluid.

1. Determine the fetal heart rate. Rationale: When the membranes rupture in the birth setting, the nurse immediately assesses the fetal heart rate to detect changes associated with prolapse or compression of the umbilical cord. Taking the blood pressure and noting the characteristics of the amniotic fluid are also appropriate actions but are not the initial actions in this situation. The nurse may assist the client in cleaning, changing clothing, and providing peripads, but determining the fetal heart rate is the initial action.

A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be implemented to alleviate the child's fears? 1. Encourage the child's parents to stay with the child. 2. Encourage play with other children of the same age. 3. Advise the family to visit only during the scheduled visiting hours. 4. Provide a private room, allowing the child to bring favorite toys from home.

1. Encourage the child's parents to stay with the child.

The clinic nurse is assessing a child for dehydration. The nurse determines that the child is moderately dehydrated if which finding is noted on assessment? 1. Oliguria 2. Flat fontanels 3. Pale skin color 4. Moist mucous membranes

1. Oliguria Rationale: In moderate dehydration, the fontanels would be slightly sunken, the mucous membranes would be dry, and the skin color would be dusky. Also, oliguria would be present.

The nurse is preparing to care for a newborn with respiratory distress syndrome. Which initial action would the nurse plan to best facilitate bonding between the newborn and the parents? 1. Encourage the parents to touch their newborn. 2. Identify specific caregiving tasks that may be assumed by the parents. 3. Explain the equipment that is used and how it functions to assist the newborn. 4. Give the parents pamphlets that will help them understand their newborn's condition.

1. Encourage the parents to touch their newborn. Rationale: The best initial action to begin the attachment process and promote bonding is to encourage the parents to touch their newborn. The parents' initial need is to become acquainted with their newborn. Caregiving tasks may be frightening to the parents because of the condition of the newborn and the unfamiliarity of high-risk newborn care practices. This option will be appropriate later, as the newborn's condition becomes stable. Explaining equipment is important but is not specific to parent-newborn bonding activities. Providing pamphlets is inappropriate initially. Requiring parents to focus on pamphlets or literature does not enhance the parent-newborn bond.

An emergency department nurse is caring for a child with suspected acute epiglottitis. Which nursing interventions apply in the care of this child? Select all that apply. 1. Ensure a patent airway. 2. Obtain a throat culture. 3. Maintain the child in a supine position. 4. Obtain a pediatric-size tracheostomy tray. 5. Prepare the child for a chest radiographic study. 6. Place the child on an oxygen saturation monitor.

1. Ensure a patent airway. 4. Obtain a pediatric-size tracheostomy tray. 5. Prepare the child for a chest radiographic study. 6. Place the child on an oxygen saturation monitor. Rationale: Acute epiglottitis is a serious obstructive inflammatory process that requires immediate intervention. The nurse immediately ensures a patent airway. To reduce respiratory distress, the child needs to sit upright. Examining the throat with a tongue depressor or attempting to obtain a throat culture is contraindicated because it could precipitate further obstruction. A complete blood count is obtained, and the child is placed on an oxygen saturation monitor. Lateral neck and chest radiographic films are obtained to determine the degree of obstruction, if present. A pediatric-size tracheostomy tray needs to be readily available, and intubation may be necessary if respiratory distress is severe.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which occurred? 1. Forceps delivery 2. Schultz presentation 3. Hypotonic contractions 4. Weak bearing-down efforts

1. Forceps delivery Rationale: Excessive fundal pressure, forceps delivery, violent bearing-down efforts, tumultuous labor, and shoulder dystocia can place a client at risk for traumatic uterine rupture. Schultz presentation is the expulsion of the placenta with the fetal side presenting first and is not associated with uterine rupture. Hypotonic contractions and weak bearing-down efforts do not add to the risk of rupture because they do not add to the stress on the uterine wall.

The client is being seen at 24 weeks' gestation at the prenatal clinic. At her last routine visit, the fundus was located at the umbilicus. Today, the fundus is measured and found to be 23 cm. How would the nurse interpret this finding? 1. Fundus is at the appropriate level. 2. Fundus is larger than expected height. 3. Fundus is smaller than expected height. 4. Growth pattern indicates intrauterine growth restriction (IUGR).

1. Fundus is at the appropriate level. Rationale: At the previous routine visit at 20 weeks' gestation, the fundus was located at the umbilicus. For each subsequent week after 20 weeks, fundal height would increase by approximately 1 cm/week. At 24 weeks' gestation, the appropriate fundal height would be 24 cm plus or minus 2 cm. By 36 weeks' gestation, the fundus reaches its highest level at the xiphoid process.

The instructor asks a nursing student to identify the phases of the ovarian cycle learned in class that day. Which phases identified by the nursing student indicate an understanding of the ovarian cycle? Select all that apply. 1. Luteal phase 2. Follicular phase 3. Menstrual phase 4. Ovulatory phase 5. Proliferative phase

1. Luteal phase 2. Follicular phase 4. Ovulatory phase Rationale: The ovarian cycle consists of three phases: follicular, ovulatory, and luteal. The menstrual and proliferative phases are phases of the endometrial cycle.

A client with a 38-week twin gestation is admitted to a birthing center in early labor. One of the fetuses is a breech presentation. Which intervention is least appropriate in planning the nursing care of this client? 1. Measure fundal height. 2. Attach electronic fetal monitoring. 3. Prepare the client for a possible cesarean section. 4. Visually examine the perineum and vaginal opening.

1. Measure fundal height. Rationale: Measuring fundal height is least appropriate because it would be measured at each antepartum clinic visit, not in the intrapartum period. All other options are priorities. Intrapartum management and assessment require careful attention to maternal and fetal status. The fetuses need to be monitored by dual electronic fetal monitoring, and any signs of distress must be reported to the primary health care provider. A cesarean section may be necessary if a fetus is breech. The nurse would examine the perineum and vaginal opening visually for signs of the cord, which sometimes prolapses through the cervix.

The goal for a client with partial premature separation of the placenta is: "The client will not exhibit signs of fetal distress." Which outcome, documented by the nurse, indicates that this goal has been achieved? 1. Moderate variability present 2. Variable decelerations present 3. FHR of 170 to 180 beats/minute 4. No accelerations of fetal heart rate (FHR)

1. Moderate variability present Rationale: Reassuring signs in the fetal heart tracing include an FHR of 110 to 160 beats/minute, accelerations of the FHR, no variable decelerations, and the presence of moderate variability. The moderate variability indicates that the fetus is able to make the necessary adjustments to the stresses of the labor. Variable decelerations indicate cord compression.

A nurse is caring for an infant with a respiratory infection and is monitoring the infant for signs of dehydration. What is the nurse's best action to determine fluid loss in the infant? 1. Monitor body weight. 2. Obtain a temperature. 3. Monitor intake and output. 4. Assess the mucous membranes.

1. Monitor body weight. Rationale: Body weight is the most reliable method of measuring body fluid loss or gain. One kilogram of weight change represents 1 L of fluid loss or gain. The remaining options are also appropriate measures to assess for dehydration, but the most reliable method is to monitor body weight.

A client in active labor has requested a regional anesthetic. The client is currently 5 cm dilated. The primary health care provider has prescribed an epidural block. Which nursing intervention would be implemented after the epidural block has been placed? 1. Palpate the bladder at frequent intervals. 2. Encourage the client to walk to progress the labor. 3. Assess the blood pressure frequently for hypertension. 4. Encourage the client to assume a supine position after the epidural has been placed.

1. Palpate the bladder at frequent intervals. Rationale: The effect of the epidural is that anesthesia is felt from the fifth lumbar space to the sacral region of the vertebral column. The client loses the sensation of the need to urinate. The nurse must palpate the bladder frequently because a full bladder will impede progression of the fetus during the laboring process. Ambulation is not allowed because of the anesthesia. The client is encouraged to lie on the side to increase placental perfusion to the fetus. Hypotension, not hypertension, is a concern.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions would the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask, gown, and gloves when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

1. Place the infant in a private room. 3. Wear a mask, gown, and gloves when in contact with the infant. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children. Rationale:RSV is a highly communicable disorder and is transmitted via droplets or contact with respiratory secretions. The use of contact, droplet, and standard precautions during care (wearing gloves, mask, and a gown) reduces nosocomial transmission of RSV. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV needs to be placed in a private room. The infant would be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.

A child has been diagnosed with acute otitis media of the right ear. Which interventions would the nurse include in the plan of care? Select all that apply. 1. Provide a soft diet. 2. Position the child on the left side. 3. Administer an antihistamine twice daily. 4. Irrigate the right ear with normal saline every 8 hours. 5. Administer ibuprofen for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

1. Provide a soft diet. 5. Administer ibuprofen for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

The nurse in a labor room is preparing to care for a client with hypertonic uterine contractions. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. What is the priority nursing action? 1. Provide pain relief measures. 2. Prepare the client for an amniotomy. 3. Promote ambulation every 30 minutes. 4. Monitor the oxytocin infusion closely.

1. Provide pain relief measures. Rationale: Hypertonic uterine contractions are painful, occur frequently, and are uncoordinated. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern. An amniotomy and oxytocin infusion are not treatment measures for hypertonic contractions; however, these treatments may be used in clients with hypotonic dysfunction. A client with hypertonic uterine contractions would not be encouraged to ambulate every 30 minutes but would be encouraged to rest.

Which interventions are appropriate for the care of an infant? Select all that apply. 1. Provide swaddling. 2. Talk in a loud voice. 3. Provide the infant with a bottle of juice at naptime. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. 6. Allow the infant to cry for at least 10 minutes before responding.

1. Provide swaddling. 4. Hang mobiles with black and white contrast designs. 5. Caress the infant while bathing or during diaper changes. Rationale:Holding, caressing, and swaddling provide warmth and tactile stimulation for the infant. To provide auditory stimulation, the nurse would talk to the infant in a soft voice and would instruct the parent to do so also. Additional interventions include playing a music box, radio, or television, or having a ticking clock or metronome nearby. Hanging a bright shiny object in midline within 20 to 25 cm of the infant's face and hanging mobiles with contrasting colors, such as black and white, provide visual stimulation. Crying is an infant's way of communicating; therefore, the nurse would respond to the infant's crying. The parent is taught to do so also. An infant or child would never be allowed to fall asleep with a bottle containing milk, juice, soda pop, sweetened water, or another sweet liquid because of the risk of nursing (bottle-mouth) caries.

The nurse notes that a 6-year-old child does not recognize that objects exist even when the objects are outside of the visual field. Based on this observation, which action would the nurse take? 1. Report the observation to the pediatrician. 2. Move the objects in the child's direct field of vision. 3. Teach the child how to visually scan the environment. 4. Provide additional lighting for the child during play activities.

1. Report the observation to the pediatrician.

The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take? 1. Report the observation to the pediatrician. 2. Move the objects in the child's direct field of vision. 3. Teach the child how to visually scan the environment. 4. Provide additional lighting for the child during play activities.

1. Report the observation to the pediatrician. Rationale: According to Jean Piaget's theory of cognitive development, it is normal for the infant or toddler not to recognize that objects continue to be in existence if out of the visual field; however, this is abnormal for the 6-year-old. If a 6-year-old child does not recognize that objects still exist even when outside the visual field, the child is not progressing normally through the developmental stages. The nurse would report this finding to the pediatrician so that both medical and psychosocial follow-up can be initiated. Options 2, 3, and 4 delay necessary follow-up and treatment.

A parent of a 3-year-old tells a clinic nurse that the child is rebelling constantly and having temper tantrums. Using Erikson's psychosocial development theory, which instructions would the nurse provide to the parent? Select all that apply. 1. Set limits on the child's behavior. 2. Ignore the child when this behavior occurs. 3. Allow the behavior because this is normal at this age period. 4. Provide a simple explanation of why the behavior is unacceptable. 5. Punish the child every time the child says "no" to change the behavior.

1. Set limits on the child's behavior. 4. Provide a simple explanation of why the behavior is unacceptable. Rationale: According to Erikson, the child focuses on gaining some basic control over self and the environment and independence between ages 1 and 3 years. Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or "mine" and having temper tantrums are common during this period of development. Being consistent and setting limits on the child's behavior are necessary elements. Providing a simple explanation of why certain behaviors are unacceptable is an appropriate action. Options 2 and 3 do not address the child's behavior. Option 5 is likely to produce a negative response during this normal developmental pattern.

The purpose of a vaginal examination for a client in labor is to specifically assess the status of which findings? Select all that apply. 1. Station 2. Dilation 3. Effacement 4. Bloody show 5. Contraction effort

1. Station 2. Dilation 3. Effacement Rationale: The vaginal examination for a client in labor specifically determines effacement 0% to 100%, dilation 0 to 10 cm, and station -5 cm (above the maternal ischial spine) to +5 cm (below the maternal ischial spine). Bloody show is the brownish or blood-tinged cervical mucus that may be passed preceding labor and is not a specific part of the assessment when performing a vaginal examination. Contraction effort is not determined by vaginal examination.

A pregnant client tells the clinic nurse about wanting to know the sex of the baby as soon as it can be determined. The nurse informs the client that the sex of the baby could be determined at 12 weeks' gestation because of which factor? 1. The appearance of the fetal external genitalia 2. The beginning of differentiation in the fetal groin 3. The fetal testes are descended into the scrotal sac 4. The differences in external genitalia are apparent

1. The appearance of the fetal external genitalia Rationale: Sex differentiation begins in the embryo during the seventh week. External genitalia are indistinguishable until after the ninth week. Distinguishing characteristics of external genitalia appear around the ninth week and are fully differentiated by the twelfth week. By the end of the twelfth week, the external genitalia of the fetus have developed to such a degree that the sex of the fetus can be determined visually. Testes descend into the scrotal sac at the end of the thirty-eighth week.

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse would tell the staff that which child behavior is characteristic of the formal operations stage? 1. The child has the ability to think abstractly. 2. The child begins to understand the environment. 3. The child is able to classify, order, and sort facts. 4. The child learns to think in terms of past, present, and future.

1. The child has the ability to think abstractly.

The nurse is preparing to describe Piaget's cognitive developmental theory to pediatric nursing staff. The nurse would plan to tell the staff that which child behavior is characteristic of the formal operations stage? 1. The child's basic abilities to think abstractly and problem-solve are similar to an adult's. 2. The child learns to think in a concrete fashion and expects others to view the world in the same way. 3. The child begins to understand the environment and conceptualize objects that are no longer visible. 4. The child is able to classify, order, and sort facts and is able to see a variety of solutions to a problem.

1. The child's basic abilities to think abstractly and problem-solve are similar to an adult's. Rationale: In the formal operations stage, the child's basic abilities to think abstractly and problem-solve are similar to an adult's. Option 2 identifies the preoperational stage; the child learns to think in a concrete fashion and expects others to view the world in the same way, called egocentric thinking. Option 3 identifies the sensorimotor stage; object permanence is achieved around 9 months of age and the child can conceptualize objects that are no longer visible. Option 4 identifies the concrete operational stage; the child is able to see another's point of view and is able to classify, order, and sort facts and see a variety of solutions to a problem.

On March 10, the nurse performed an initial assessment on a client admitted to the labor and delivery unit for "rule out labor." The client has not received prenatal care but is certain that the first day of the last menstrual period (LMP) was July 7 the previous year. The nurse plans care based on which interpretation? 1. The client is possibly in preterm labor. 2. The fetus may not be viable at delivery. 3. The client may require labor augmentation. 4. The fetus is at high risk for shoulder dystocia.

1. The client is possibly in preterm labor. Rationale: According to Naegele's rule, by subtracting 3 months and adding 7 days and 1 year to this client's LMP the nurse can determine that the estimated date of delivery (EDD) is April 14. This client is in the labor and delivery unit to be evaluated for the presence of labor more than 1 month before the EDD; therefore, the client is possibly in preterm labor. Viability is said to occur between the 22nd and 25th weeks of gestation. This fetus is approximately 4 weeks before term. If this client truly is in labor, the primary health care provider's plan would be to try to stop the labor in order to prevent delivery at this early stage in the pregnancy. This would eliminate option 3, labor augmentation. Because of the typical 36-week gestational size of a fetus, 2200 to 2900 g, there would be no risk for a difficult shoulder delivery.

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to this stage of development? 1. This stage is associated with toilet training. 2. This stage is characterized by the gratification of self. 3. This stage is characterized by a tapering off of conscious biological and sexual urges. 4. This stage is associated with pleasurable and conflicting feelings about the genital organs.

1. This stage is associated with toilet training.

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a loss of variability. What is the initial nursing action? 1. Turn the client on the side and administer oxygen by face mask at 8 to 10 L/min. 2. Turn the client on the back and administer oxygen by face mask at 8 to 10 L/min. 3. Turn the client on the side and administer oxygen by nasal cannula at 2 to 4 L/min. 4. Turn the client on the back and administer oxygen by nasal cannula at 2 to 4 L/min.

1. Turn the client on the side and administer oxygen by face mask at 8 to 10 L/min. Rationale: If a fetal heart rate begins to slow or a loss of variability is observed, this could indicate fetal distress. To facilitate oxygen to the parent and the fetus, the client is turned to the client's side, which reduces the pressure of the uterus on the ascending vena cava and descending aorta. Oxygen at 8 to 10 L/min is applied to the client by face mask.

The nurse is caring for a 4-year-old child. When experiencing pain, the nurse anticipates which about the child? Select all that apply. 1. Views pain as a punishment 2. Verbalizes the reason for the pain 3. Blames someone else for the pain 4. Believes pain will disappear magically 5. Fears losing control during the painful episode 6. Will be able to explain the sequence of events leading to the pain

1. Views pain as a punishment 3. Blames someone else for the pain 4. Believes pain will disappear magically Rationale: Children from the ages of 2 to 7 years experience preoperational thought. Concepts of pain within this stage include viewing pain as punishment for wrongdoing, thinking that pain will disappear magically, believing that someone else is accountable for the pain, and relating to pain primarily as a physical and concrete experience. Verbalizing the reason for the pain, fearing loss of control due to the pain, and explaining the events that led to the pain are not associated with concepts about pain for a child of this age.

The nurse is assisting in providing an educational session to new parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which statement by a parent in the group indicates a need for further teaching? 1. "I need to feed my infant in an upright position." 2. "I need to stop breast/chest-feeding as soon as possible." 3. "Bottle-feeding would be stopped as soon as possible." 4. "I would not provide my infant with a bottle during naptime."

2. "I need to stop breast/chest-feeding as soon as possible."

A pregnant client in the first trimester calls the nurse at a health care clinic and reports noticing a thin, colorless vaginal drainage. The nurse would make which statement to the client? 1. "Come to the clinic immediately." 2. "The vaginal discharge may be bothersome but is a normal occurrence." 3. "Report to the emergency department at the maternity center immediately." 4. "Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours."

2. "The vaginal discharge may be bothersome but is a normal occurrence." Rationale: Leukorrhea begins during the first trimester. Many clients notice a thin, colorless or yellow vaginal discharge throughout pregnancy. Some clients become distressed about this condition, but it does not require that the client report to the health care clinic or emergency department immediately. If vaginal discharge is profuse, the client may use panty liners, but would not wear tampons because of the risk of infection. If the client uses panty liners, the client needs to change them frequently.

A 2-year-old child has been admitted to the hospital for management of pneumonia. The child is placed in an oxygen tent. Taking into consideration the child's age and developmental level and the treatment being administered, which statement is appropriate for the nurse to make to the parents? 1. "Your child can play in the tent with blocks and plush stuffed animals." 2. "You can sit next to your child and hold hands through the tent, but your child needs to remain inside of it." 3. "At your child's age, separation anxiety is high, so bringing in the wool blanket that your child usually sleeps with is a good idea." 4. "Before you leave for the night, it is a good idea to rock your child to sleep. Your child can be out of the tent for up to 60 minutes without any consequences."

2. "You can sit next to your child and hold hands through the tent, but your child needs to remain inside of it." Rationale: Oxygen therapy is an important component of management of pneumonia and is effective only if it is used appropriately. It is important to maintain the toddler in the oxygen environment at all times. With the addition of oxygen therapy, the hospitalized toddler is at risk for increased anxiety. Attachment is critical to optimal growth and development of children, particularly in the infant and toddler years. Therefore, sitting with the child and holding the child's hand is important. Wool blankets, stuffed toys, and many toy cars can produce sparks, which could lead to an oxygen tent's catching fire. It is important to educate parents and family members not to bring these types of objects to the hospital.

The parent of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What would the nurse tell the parent about CF? 1. Transmitted as an autosomal dominant trait 2. A chronic multisystem disorder affecting the exocrine glands 3. A disease that causes the formation of multiple cysts in the lungs 4. A disease that causes dilation of the passageways of many organs

2. A chronic multisystem disorder affecting the exocrine glands Rationale: CF is a chronic multisystem disorder that affects the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait. It does not cause the formation of multiple cysts in the lungs. Options 1, 3, and 4 are incorrect.

The nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the electronic fetal monitor, what is the next nursing action? 1. Identify the types of accelerations. 2. Assess the baseline fetal heart rate. 3. Determine the intensity of the contractions. 4. Determine the frequency of the contractions.

2. Assess the baseline fetal heart rate. Rationale: Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate can be identified if they occur. The intensity of contractions is assessed by an internal fetal monitor, not an external fetal monitor. Options 1 and 4 are important to assess but not as the first priority. Fetal heart rate is evaluated by assessing baseline and periodic changes. Periodic changes occur in response to the intermittent stress of uterine contractions and the baseline beat-to-beat variability of the fetal heart rate.

After the spontaneous rupture of the membranes of a client in labor, the fetal heart rate drops to 85 beats/minute. Which would be the nurse's priority action? 1. Reposition the client to knee-chest. 2. Assess the vagina and cervix with a gloved hand. 3. Notify the primary health care provider of the need for an amnioinfusion. 4. Document the description of the fetal bradycardia in the nursing notes.

2. Assess the vagina and cervix with a gloved hand. Rationale: It is most common to see an umbilical cord prolapsed directly after the rupture of membranes, when gravity washes the cord in front of the presenting part. A cord prolapse can be evidenced by fetal bradycardia with variable decelerations occurring with uterine contractions. Because the fetal heart rate became bradycardic immediately following the spontaneous rupture of the client's membranes, the nurse's initial action would be to glove the examining hand and insert two fingers into the vagina to assess for the presence of a prolapsed cord and then to relieve compression of the cord by exerting upward pressure on the presenting part. Repositioning the client to a knee-chest position is a correct intervention for prolapsed cord, but confirmation of the prolapsed cord and relieving compression are the first interventions that need to be implemented; therefore, option 1 can be eliminated. An amnioinfusion may be used to minimize the effects of cord compression in utero, but not a prolapsed cord, so option 3 can be eliminated. Although documentation of this occurrence is important, it is not the priority in this situation, so option 4 can also be eliminated.

The nurse at a well-baby clinic is providing nutrition instructions to the parent of a 1-month-old infant. What instruction would the nurse give to the parent? 1. Introduce strained fruits one at a time. 2. Breast milk or formula is the main food. 3. Introduce strained vegetables one at a time. 4. Offer rice cereal mixed with breast milk or formula.

2. Breast milk or formula is the main food. Rationale: Breast/chest milk or formula is the main food throughout infancy. Rice cereal mixed with breast milk or formula is introduced at 4 months of age. Strained vegetables, fruits, and meats are introduced one at a time and can begin at 6 months of age.

The nurse is caring for a client who is experiencing a precipitous labor and is waiting for the primary health care provider to arrive. When the infant's head crowns, what instruction would the nurse give the client? 1. Bear down. 2. Breathe rapidly. 3. Hold your breath. 4. Push with each contraction.

2. Breathe rapidly. Rationale: During a precipitous labor, when the infant's head crowns, the nurse instructs the client to breathe rapidly to decrease the urge to push. The client is not instructed to push or bear down. Holding the breath decreases the amount of oxygen to the birthing parent and the fetus.

A 2-year-old child with acute diarrhea has been diagnosed with mild dehydration. Which rehydration methods would the nurse expect the pediatrician to prescribe? 1. Increase intake of water with a diet high in carbohydrates. 2. Consume oral rehydration fluid, advancing to a regular diet. 3. Begin fluid replacement immediately with intravenous fluids. 4. Begin a diet of bananas, rice, apples, pears, and toast with juice.

2. Consume oral rehydration fluid, advancing to a regular diet.

A labor room nurse is performing an assessment on a client in labor and notes that the fetal heart rate (FHR) is 158 beats/minute and regular. The client's contractions are every 5 minutes, with a duration of 40 seconds and of moderate intensity. On the basis of these assessment findings, what is the appropriate nursing action? 1. Contact the obstetrician. 2. Continue to monitor the client. 3. Report the FHR to the anesthesiologist. 4. Prepare for imminent delivery of the fetus.

2. Continue to monitor the client. Rationale: The FHR normally is 110 to 160 beats/minute. Signs of potential complications of labor are contractions consistently lasting 90 seconds or longer or consistently occurring 2 minutes or less apart; fetal bradycardia, tachycardia, or persistently decreased variability; and irregular FHR. The assessment findings identified in the question are not signs of potential complications.

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action? 1. Notify the primary health care provider. 2. Discontinue the infusion of oxytocin. 3. Place oxygen on at 8 to 10 L/minute via face mask. 4. Contact the client's primary support person(s) if not currently present.

2. Discontinue the infusion of oxytocin. Rationale: The priority nursing action is to stop the infusion of oxytocin. Oxytocin can cause forceful uterine contractions and decrease oxygenation to the placenta, resulting in decreased variability. After stopping the oxytocin, the nurse would reposition the laboring client. Notifying the primary health care provider, applying oxygen, and increasing the rate of the intravenous (IV) fluid (the solution without the oxytocin) are also actions that are indicated in this situation but not the priority action. Contacting the client's primary support person(s) is not the priority action at this time.

The nurse is monitoring a 3-month-old infant with hydrocephalus for signs of increased intracranial pressure. On palpation of the fontanels, the nurse notes that the anterior fontanel is soft and flat. On the basis of this finding, which nursing action is most appropriate? 1. Increase oral fluids. 2. Document the finding. 3. Elevate the head of the bed to 90 degrees. 4. Notify the primary health care provider (PHCP).

2. Document the finding.

A client in labor is dilated 10 cm. At this point in the labor process, at least how often would the nurse assess and document the fetal heart rate? 1. Hourly 2. Every 15 minutes 3. Every 30 minutes 4. Before each contraction

2. Every 15 minutes Rationale: The second stage of labor begins when the cervix is dilated completely (10 cm). Maternal pulse, blood pressure, and fetal heart rate are assessed every 5 to 15 minutes, depending on agency protocol; some agency protocols recommend assessment after each contraction. Hourly and every 30 minutes represent lengthy time intervals for assessment in this stage of labor.

The nurse is performing an assessment of a client who is scheduled for a cesarean delivery at 39 weeks of gestation. Which assessment finding indicates the need to contact the primary health care provider (PHCP)? 1. Hemoglobin of 11 g/dL (110 mmol/L) 2. Fetal heart rate of 180 beats/minute 3. Maternal pulse rate of 85 beats/minute 4. White blood cell count of 12,000 mm3 (12.0 × 109/L)

2. Fetal heart rate of 180 beats/minute Rationale: A normal fetal heart rate is 110 to 160 beats/minute. A fetal heart rate of 180 beats/minute could indicate fetal distress and would warrant immediate notification of the PHCP. By full term, a normal maternal hemoglobin range is 11 to 13 g/dL (110 to 130 mmol/L) because of the hemodilution caused by an increase in plasma volume during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/minute over prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration. White blood cell counts in a normal pregnancy begin to increase in the second trimester and peak in the third trimester, with a normal range of 11,000 to 15,000 mm3 (11 to 15 × 10 9/L), up to 18,000 mm3 (18 × 109/L). During the immediate postpartum period, the white blood cell count may be 25,000 to 30,000 mm3 (25 to 30 × 109/L) because of increased leukocytosis that occurs during delivery.

The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse there is no history of any type of abortion or fetal demise. Using GTPAL, what would the nurse document in the client's chart? 1. G = 3, T = 2, P = 0, A = 0, L = 1 2. G = 2, T = 1, P = 0, A = 0, L = 1 3. G = 1, T = 1, P = 1, A = 0, L = 1 4. G = 2, T = 0, P = 0, A = 0, L = 1

2. G = 2, T = 1, P = 0, A = 0, L = 1 Rationale: Pregnancy outcomes can be described with the acronym GTPAL (included in gravida if before 20 weeks of gestation; included in parity if past 20 weeks of gestation); and L is the number of current living children. A person who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.

The parents of a toddler inform the nurse that their child has frequent temper tantrums. The nurse would instruct the parents to implement which measure to deal with the temper tantrums? 1. Restrain the child. 2. Ignore the behavior. 3. Leave the child unattended. 4. Allow the child to bang their head.

2. Ignore the behavior. Rationale: During temper tantrums the parent would ignore the behavior, providing that the behavior is not injurious to the child, such as banging the head on the floor. The parent would continue to be present to provide a feeling of control and security to the child once the tantrum has subsided.

The nurse is observing a caregiver minimize misbehavior when a child is playing with an excessively noisy toy. The nurse recognizes that further instruction is needed about the appropriate way to do this if the caregiver takes which action? 1. Tells the child, "Put that toy down." 2. Instructs the child, "Don't touch that toy." 3. Interacts with the child in a quiet, calm voice. 4. Offers the child a quiet toy in exchange for the noisy one.

2. Instructs the child, "Don't touch that toy." Rationale: Minimizing misbehavior includes teaching desirable behavior through example, such as using a quiet, calm voice rather than screaming. Requests for appropriate behavior need to be phrased positively, such as "Put that toy down" rather than "Don't touch that toy." Alternatives, such as offering a quiet toy in exchange for one that is excessively noisy, would be offered in response to annoying actions.

The parent of an 18-month-old child tells the clinic nurse that the child has been having some mild diarrhea and describes the child's stools as "mushy." The parent tells the nurse that the child is tolerating fluids and solid foods. The most appropriate suggestion regarding the child's diet would be to give the child which items? 1. Applesauce, bananas, wheat toast 2. Mashed potatoes with baked chicken 3. Gelatin, strained cabbage, and custard 4. Fluids only, until the "mushy" stools stop

2. Mashed potatoes with baked chicken Rationale: The continued feeding of a normal diet can prevent dehydration, reduce stool frequency and volume, and hasten recovery. Common foods that are especially well tolerated during diarrhea are bland but nutritional foods, including complex carbohydrates (rice, wheat, potatoes, cereals), yogurt containing live cultures, cooked vegetables, and lean meats. Oral rehydration solutions are also helpful. The foods in options 1 and 3 may worsen the diarrhea. Fluids only will affect nutritional status.

The nurse has created a plan of care for a client experiencing dystocia and includes several nursing actions in the plan of care. What is the priority nursing action? 1. Providing comfort measures 2. Monitoring the fetal heart rate 3. Changing the client's position frequently 4. Keeping the significant other informed of the progress of the labor

2. Monitoring the fetal heart rate Rationale: Dystocia is difficult labor that is prolonged or more painful than expected. The priority is to monitor the fetal heart rate. Although providing comfort measures, changing the client's position frequently, and keeping the significant other informed of the progress of the labor are components of the plan of care, the fetal status would be the priority.

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a private room. 3. Leave the infant in the present room, because RSV is not contagious. 4. Inform the staff that using standard precautions is all that is necessary when caring for the child.

2. Move the infant to a private room. Rationale: RSV is a highly communicable disorder and is transmitted via droplets and direct contact with respiratory secretions. The use of contact, droplet, and standard precautions during care is necessary. Good handwashing technique and protection with gloves, gown, and a mask are needed to prevent transmission. An infant with RSV would be placed in a private room to prevent transmission. Enteric precautions are unnecessary.

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate? 1. Continue to monitor the fetal heart rate. 2. Notify the primary health care provider (PHCP). 3. Encourage the client to continue pushing with each contraction. 4. Instruct the client's coach to continue to encourage breathing techniques.

2. Notify the primary health care provider (PHCP). Rationale: A normal fetal heart rate is 110 to 160 beats/minute, and the fetal heart rate needs to be within this range between contractions. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the PHCP or nurse-midwife needs to be notified. Options 1, 3, and 4 are inappropriate nursing actions in this situation and delay necessary intervention.

A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome. The student plans to write on a handout that it is best to place an infant in which position for sleep? 1. On the back, or prone 2. On the back, or supine 3. On the stomach, or prone 4. On the stomach, or supine

2. On the back, or supine Rationale: Healthy infants would only be placed on their backs for sleep. This is also referred to as the supine position. The prone position (on the stomach) is not recommended; avoiding this position assists in preventing sudden infant death syndrome.

The nurse is caring for an infant with gastroenteritis who is being treated for dehydration. The nurse reviews the health record and notes that the primary health care provider has documented that the infant is mildly dehydrated. Which assessment finding would the nurse expect to note in mild dehydration? 1. Anuria 2. Pale skin color 3. Sunken fontanels 4. Dry mucous membranes

2. Pale skin color Rationale: In mild dehydration, the skin color is pale. Anuria and sunken fontanels are assessment characteristics of severe dehydration. Dry mucous membranes are an assessment characteristic of moderate dehydration.

On assessment of the fetal heart rate (FHR) of a laboring client, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations? 1. Episodic, late decelerations that indicate uteroplacental insufficiency 2. Periodic, early decelerations that indicate fetal head compression 3. Periodic, variable decelerations that indicate cord compression 4. Episodic, early decelerations that may be a result of maternal hypotension

2. Periodic, early decelerations that indicate fetal head compression Rationale: An early deceleration is described as a visually apparent gradual decrease of the FHR with a gradual return to the FHR baseline. Late decelerations do not return to the FHR baseline until after the uterine contraction is over, thus eliminating option 1. Variable decelerations are defined as having a rapid onset of less than 30 seconds with a rapid return to FHR baseline, which does not match the description of the FHR described; therefore, eliminate option 3. Early decelerations are caused by fetal head compression, resulting from uterine contractions, vaginal examination, or fundal pressure, which would eliminate option 4.

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action? 1. Gently push the cord into the vagina. 2. Place the client in Trendelenburg's position. 3. Find the closest telephone and page the primary health care provider (PHCP) stat. 4. Call the delivery room to notify the staff that the client will be transported immediately.

2. Place the client in Trendelenburg's position. Rationale: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The client would be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse would push the call light to summon help, and other staff members need to call the PHCP and notify the delivery room. If the cord is protruding from the vagina, no attempt would be made to replace it because that could traumatize it and further reduce blood flow. Oxygen at 8 to 10 L/min by face mask is administered to the client to increase fetal oxygenation.

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome? 1. Stimulate the labor process. 2. Prevent dehydration and hypoxemia. 3. Avoid the necessity of a cesarean section. 4. Eliminate the need for analgesic administration.

2. Prevent dehydration and hypoxemia. Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during the intrapartum period. Maintaining adequate intravenous fluid intake and the administration of oxygen via face mask will help to ensure a safe environment for maternal and fetal health during labor. These measures will not stimulate the labor process, avoid the necessity of a cesarean section, or eliminate the need for analgesic administration.

The nurse is assigned to care for a hospitalized toddler. The nurse plans care, knowing that what would be the highest priority? 1. Providing a consistent caregiver 2. Protecting the toddler from injury 3. Adapting the toddler to the hospital routine 4. Allowing the toddler to participate in play and diversional activities

2. Protecting the toddler from injury Rationale: The toddler is at high risk for injury as a result of developmental abilities and an unfamiliar environment. Although consistency, adaptation, and diversion are important, protection from injury is the highest priority.

The nurse has been working with a laboring client and notes that she has been pushing effectively for 1 hour. What is the client's primary physiological need at this time? 1. Ambulation 2. Rest between contractions 3. Change positions frequently 4. Consume oral food and fluids

2. Rest between contractions Rationale: The birth process expends a great deal of energy, particularly during the transition stage. Encouraging rest between contractions conserves maternal energy, facilitating voluntary pushing efforts with contractions. Uteroplacental perfusion also is enhanced, which promotes fetal tolerance of the stress of labor. Ambulation is encouraged during early labor. Ice chips would be provided. Changing positions frequently is not the primary physiological need. Food and fluids are likely to be withheld at this time.

The nurse is preparing to perform a pediatric physical examination. The child refuses to sit on the examining table, screams when the nurse attempts to perform the assessment, and does not make eye contact. What is the most appropriate initial nursing action? 1. Refrain from complimenting the child. 2. Talk to the parent while ignoring the child. 3. Offer a prolonged explanation about the assessment. 4. Use a demanding approach when discussing expected behavior.

2. Talk to the parent while ignoring the child. Rationale: When performing a pediatric physical examination, if signs of readiness (i.e., sitting on the examining table rather than the parent's lap, allowing physical touch, and making eye contact) are not observed, the nurse would talk to the parent while essentially ignoring the child, then gradually focus on the child or favorite object, such as a doll, and make complimentary remarks about the child, such as about appearance, dress, or a favorite object. If the child refuses to cooperate, the nurse would use a direct approach regarding expected behavior and avoid prolonged explanations about the examining procedure.

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse would monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out. 3. The child has a low-grade fever and complains of a sore throat. 4. The child is leaning backward, supporting self with the hands and arms.

2. The child is leaning forward, with the chin thrust out.

The nurse is caring for a 2-year-old child with acute otitis media who requires the administration of antibiotic eardrops. The nurse observes the parent administering the eardrops to the child. Which observation by the nurse indicates that the parent is performing the procedure correctly? 1. The parent pulls the earlobe up and back. 2. The parent pulls the earlobe down and back. 3. The parent holds the child in a sitting position. 4. The parent must wear gloves to administer the medication.

2. The parent pulls the earlobe down and back. Rationale: To administer eardrops to a child younger than 3 years, the earlobe would be pulled down and back. In the older child, the earlobe is pulled up and back to obtain a straight canal. Gloves do not need to be worn by the parents, but hands must be washed before and after the procedure. The child needs to be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.

The nurse is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which finding would alert the nurse to a compromise? 1. Maternal fatigue 2. The passage of meconium 3. Coordinated uterine contractions 4. Progressive changes in the cervix

2. The passage of meconium Rationale: Signs of fetal or maternal compromise include a persistent, nonreassuring fetal heart rate; fetal acidosis; and the passage of meconium. Maternal fatigue can occur if the labor is prolonged but do not indicate fetal or maternal compromise. Progressive changes in the cervix and coordinated uterine contractions are a reassuring pattern in labor.

The nurse is administering an intravenous analgesic to a laboring client. The client inquires as to why the nurse is waiting for a contraction to begin before infusing the medication into the intravenous line. Which is the nurse's most appropriate response? 1. "The medication will affect you and your pain level only when given during a contraction." 2. "The medication will provide optimal relief when it is given while your pain level is highest." 3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." 4. "You will experience a lower incidence of adverse effects from the medication when administered during a contraction."

3. "Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication." Rationale:Intravenous medication would be administered slowly in small doses starting at the beginning of a contraction and carrying over for three to five contractions. This intervention minimizes the amount of the medication that crosses the placenta and enters the fetal circulation, thus minimizing its effects on the fetus. Although this method of administration may decrease the amount of medication reaching the fetus, it does not totally eliminate effects of the medication on the fetus. The statements in the remaining options are incorrect information about the medication effects.

A 6-month-old infant is admitted to the hospital. The nurse weighs the infant and notes that the infant's weight is 14 pounds. Which statement by the parent indicates that further teaching is needed? 1. "The weight for age is just right." 2. "I am so glad the baby is gaining the correct amount of weight for this age." 3. "I will have to increase milk intake because the baby is not gaining enough weight." 4. "The baby weighed 7 pounds when born so they are at the correct weight for this age."

3. "I will have to increase milk intake because the baby is not gaining enough weight." Rationale: Newborns double their birth weight at 5 to 6 months of age and triple it by 1 year. Therefore, options 1, 2, and 4 are correct statements. Option 3 indicates the need for further teaching.

The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which statement by the student indicates an understanding of the ductus venosus? 1. "It connects the pulmonary artery to the aorta." 2. "It is an opening between the right and left atria." 3. "It connects the umbilical vein to the inferior vena cava." 4. "It connects the umbilical artery to the inferior vena cava."

3. "It connects the umbilical vein to the inferior vena cava." Rationale: The ductus venosus connects the umbilical vein to the inferior vena cava. The foramen ovale is a temporary opening between the right and left atria. The ductus arteriosus joins the aorta and the pulmonary artery.

The nurse explains the purpose of effleurage to a client in early labor. Which statement would the nurse include in the explanation? 1. "It is the application of pressure to the sacrum to relieve a backache." 2. "It is a form of biofeedback to enhance bearing-down efforts during delivery." 3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." 4. "It is performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest."

3. "It is light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus." Rationale:Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage also provides tactile stimulation to the fetus. Options 1, 2, and 4 are inaccurate descriptions of effleurage.

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How would the nurse interpret this finding? 1. Extreme fatigue 2. The presence of pain 3. An airway obstruction 4. The presence of dehydration

3. An airway obstruction Rationale:Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat. The remaining options are inaccurate interpretations of the child's position.

The nurse is providing instructions to a pregnant client who is scheduled for an amniocentesis. What instruction would the nurse provide? 1. Strict bed rest is required after the procedure. 2. Hospitalization is necessary for 24 hours after the procedure. 3. An informed consent needs to be signed before the procedure. 4. A fever is expected after the procedure because of the trauma to the abdomen.

3. An informed consent needs to be signed before the procedure. Rationale: Because amniocentesis is an invasive procedure, informed consent needs to be obtained before the procedure. After the procedure, the client is instructed to rest but may resume light activity after the cramping subsides. The client is instructed to keep the puncture site clean and to report any complications, such as chills, fever, bleeding, leakage of fluid at the needle insertion site, decreased fetal movement, uterine contractions, or cramping. Amniocentesis is an outpatient procedure and may be done in the primary health care provider's office or in a special prenatal testing unit. Hospitalization is not necessary after the procedure.

The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. Which assessment finding supports the presence of Chadwick's sign? 1. Darkening of the areola 2. Softening of the uterine isthmus 3. Bluish discoloration of cervix and vagina 4. Palpation of the uterus above the level of the symphysis pubis

3. Bluish discoloration of cervix and vagina Rationale: The cervix undergoes significant changes after conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick's sign, is one of the earliest signs of pregnancy. Darkening of the areola occurs during pregnancy but is not related to Chadwick's sign. Softening of the uterine isthmus is known as Hegar's sign. The presence of the uterus (fundal height) just above the symphysis pubis dates the pregnancy to be about 13 weeks' gestation.

The nurse is preparing to administer an analgesic to a client in labor. Which analgesic is contraindicated for a client who has a history of opioid dependency? 1. Fentanyl 2. Morphine sulfate 3. Butorphanol tartrate 4. Meperidine hydrochloride

3. Butorphanol tartrate (Agonist-antagonist) Rationale: Butorphanol tartrate is an opioid analgesic that can precipitate withdrawal symptoms in an opioid-dependent client. Therefore, it is contraindicated if the client has a history of opioid dependency. Fentanyl, morphine sulfate, and meperidine are opioid analgesics but do not tend to precipitate withdrawal symptoms in opioid-dependent clients.

A pregnant gravida 1, para 0 client at 39 weeks' gestation arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that the client has had a positive group B streptococcus (GBS) laboratory report during the prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which would be the nurse's first action? 1. Provide the client with instructions on how to push. 2. Prepare the labor room and the client for an imminent delivery. 3. Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). 4. Call the PHCP to the labor and delivery unit to perform a delivery.

3. Call the primary health care provider (PHCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP). Rationale: The client evidences progression toward delivery because the cervix is dilated 6 cm and the signs and symptoms of active labor are present. Because the client has had a positive GBS result during pregnancy, the neonate is at risk for becoming infected with GBS via vertical transmission during birth. GBS poses a significant risk for infant morbidity and mortality. To decrease this risk, it is recommended that IAP be administered during labor. Providing the client with instructions on pushing is not appropriate at a time when the client does not need to use this information; thus, this is not a priority. The client is not close to complete dilation; therefore, the PHCP is not required for delivery at this time.

The nurse is preparing to care for a client in labor. The obstetrician has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion? 1. An IV infusion of antibiotics 2. Placing the client on complete bed rest 3. Continuous electronic fetal monitoring 4. Placing a code cart at the client's bedside

3. Continuous electronic fetal monitoring Rationale: Oxytocin is a uterine stimulant used to induce labor. Continuous electronic fetal monitoring would be implemented during an IV infusion of oxytocin. There are no data in the question to indicate the need for complete bed rest or the need for antibiotics. Placing a code cart at the bedside of a client receiving an oxytocin infusion is not necessary.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations? 1. Prepare the client for a cesarean delivery. 2. Monitor the FHR every 30 minutes. 3. Encourage an upright or side-lying maternal position. 4. Increase the rate of the oxytocin infusion every 10 minutes.

3. Encourage an upright or side-lying maternal position. Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. Many nursing actions are available to prevent FHR decelerations without necessitating surgical intervention. Monitoring the FHR every 30 minutes will not prevent FHR decelerations. The nurse should discontinue an oxytocin infusion in the presence of FHR decelerations, thereby reducing uterine activity and increasing uteroplacental perfusion.

The nurse is developing a plan of care for a 4-year-old child scheduled for a renal biopsy. What developmental characteristic of this child would the nurse consider? 1. Masturbation is common in this age-group. 2. Body image may be a concern for the child. 3. Fears of mutilation may be present in the child. 4. The urination pattern will cause embarrassment for the child.

3. Fears of mutilation may be present in the child. Rationale:During the preschool years, a child's fears of separation and mutilation are great because the child is facing the developmental task of trusting others. As the child gets older, fears about virility and reproductive ability may surface. Masturbation is most common in the toddler age-group as children discover their genital organs. Body image and embarrassment is a concern for the adolescent.

Which assessment following an amniotomy would be conducted first? 1. Cervical dilation 2. Bladder distention 3. Fetal heart rate pattern 4. Maternal blood pressure

3. Fetal heart rate pattern Rationale: Fetal heart rate is assessed immediately after amniotomy to detect any changes that may indicate cord compression or prolapse. When the membranes are ruptured, minimal vaginal examinations would be done because of the risk of infection. Bladder distention or maternal blood pressure would not be the first thing to check after an amniotomy.

A prenatal client with severe abdominal pain is admitted to the maternity unit. The nurse is monitoring the client closely because concealed bleeding is suspected. Which assessment findings indicate the presence of concealed bleeding? Select all that apply. 1. Back pain 2. Heavy vaginal bleeding 3. Increase in fundal height 4. Hard, board-like abdomen 5. Persistent abdominal pain 6. Early deceleration on the fetal heart monitor

3. Increase in fundal height 4. Hard, board-like abdomen 5. Persistent abdominal pain Rationale: The signs of concealed abdominal bleeding in a pregnant client include an increase in fundal height; a hard, board-like abdomen; persistent abdominal pain; late decelerations in fetal heart rate; and decreasing baseline variability. Back pain, heavy vaginal bleeding, and early deceleration on the fetal heart monitor are not specific signs of concealed bleeding.

A client arrives at a birthing center in active labor. Following examination, it is determined that the client membranes are still intact and the client is at a -2 station. The primary health care provider prepares to perform an amniotomy. What will the nurse relay to the client as the most likely outcomes of the amniotomy? Select all that apply. 1. Less pressure on the cervix 2. Decreased number of contractions 3. Increased efficiency of contractions 4. The need for increased blood pressure monitoring 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord

3. Increased efficiency of contractions 5. The need for frequent fetal heart rate monitoring to detect the presence of a prolapsed cord Rationale: Amniotomy (artificial rupture of the membranes) can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the progress begins to slow. Rupturing of the membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions. Increased monitoring of maternal blood pressure is unnecessary following this procedure. The fetal heart rate needs to be monitored frequently, as there is an increased likelihood of a prolapsed cord with ruptured membranes and a high presenting part.

Which purposes of placental functioning would the nurse include in a prenatal class? Select all that apply. 1. It cushions and protects the baby. 2. It maintains the temperature of the baby. 3. It is the way the baby gets food and oxygen. 4. It prevents all antibodies and viruses from passing to the baby. 5. It provides an exchange of nutrients and waste products between the parent and developing fetus.

3. It is the way the baby gets food and oxygen. 5. It provides an exchange of nutrients and waste products between the parent and developing fetus. Rationale: The placenta provides an exchange of oxygen, nutrients, and waste products between the parent and the fetus. The amniotic fluid surrounds, cushions, and protects the fetus and maintains the body temperature of the fetus. Nutrients, medications, antibodies, and viruses can pass through the placenta.

A child is hospitalized because of persistent vomiting. The nurse would monitor the child closely for which priority problem? 1. Diarrhea 2. Metabolic acidosis 3. Metabolic alkalosis 4. Hyperactive bowel sounds

3. Metabolic alkalosis Rationale: Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action would the nurse take to determine fetal heart sounds accurately? 1. Noting whether the heart rate is greater than 140 beats/minute 2. Placing the diaphragm of the Doppler on the client's abdomen 3. Palpating the maternal radial pulse while listening to the FHR 4. Performing Leopold's maneuvers first to determine the location of the fetal heart

3. Palpating the maternal radial pulse while listening to the FHR Rationale: The nurse would simultaneously palpate the maternal radial or carotid pulse and auscultate the FHR to differentiate between the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the FHR. Noting whether the heart rate is more than 140 beats/minute or placing the diaphragm of the Doppler on the client's abdomen will not ensure accuracy in obtaining the FHR. Leopold's maneuvers may help the examiner to locate the position of the fetus but will not ensure a distinction between the two heart rates.

The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription would the nurse question? 1. Monitor fetal heart rate continuously. 2. Monitor maternal vital signs frequently. 3. Perform a vaginal examination every shift. 4. Administer an antibiotic per PHCP prescription and per agency protocol.

3. Perform a vaginal examination every shift. Rationale: Vaginal examinations would not be done routinely on a client with premature rupture of the membranes because of the risk of infection. The nurse would expect to monitor fetal heart rate, monitor maternal vital signs, and administer an antibiotic.

Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction would the nurse include in the client's teaching plan? 1. Schedule the procedures so that they are 4 hours apart. 2. Perform the breathing exercises and then the postural drainage. 3. Perform the postural drainage first and then the breathing exercises. 4. Perform postural drainage in the morning and breathing exercises in the evening.

3. Perform the postural drainage first and then the breathing exercises. Rationale: Breathing exercises are recommended for a majority of children with cystic fibrosis (CF), even those with minimal pulmonary involvement. The exercises usually are performed twice daily, and they are preceded by postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist in assuming correct postures and in maximizing thoracic mobility, such as swinging the arms and bending and twisting the trunk, are included. The ultimate aim of these exercises is to establish a good habitual breathing pattern.

The emergency department nurse is caring for a child with suspected epiglottitis and has ensured that the child has a patent airway. Which action is the next priority in the care of this child? 1. Prepare the child for tracheotomy. 2. Prepare to administer epinephrine. 3. Prepare the child for a chest radiograph. 4. Assist the primary health care provider with intubation.

3. Prepare the child for a chest radiograph. Rationale: If epiglottitis is suspected, the priorities are to maintain a patent airway and obtain a chest radiograph to confirm the diagnosis. If epiglottitis is present, the child is taken promptly to the operating room for tracheal intubation or immediate placement of a surgical airway. Epinephrine is not used in the treatment of epiglottitis.

An infant is being seen in the pediatrician's office for a 2-month-old well-child visit. The nurse encourages the parent to allow the infant to suck on a pacifier during a routine immunization. The nurse explains to the parent that the child is at which stage of Piaget's cognitive development? 1. Trust development 2. Autonomy development 3. Sensorimotor development 4. Preconceptual development

3. Sensorimotor development Rationale: Piaget's first stage of cognitive development is referred to as the sensorimotor stage. In this stage, infants and young toddlers use mainly senses and movement to begin to understand and control their environment. Preconceptual is the second stage after sensorimotor development. Development of trust and autonomy identify Erikson's stages of psychosocial, not cognitive, development.

A sweat test is performed on an infant with a suspected diagnosis of cystic fibrosis (CF). The nurse reviews the results of the test and notes that the chloride level is 40 mEq/L (40 mmol/L). How would the nurse interpret this finding? 1. A negative test 2. A positive test 3. Suggestive of CF 4. An unrelated finding

3. Suggestive of CF Rationale: In a sweat test, sweating on the infant's forearm is stimulated with pilocarpine, the sample is collected on absorbent material, and the amount of sweat chloride is measured. A chloride level higher than 60 mEq/L (60 mmol/L) is considered to be a positive test result. A sweat chloride level lower than 40 mEq/L (40 mmol/L) is considered normal. A sweat chloride level higher than or equal to 40 mEq/L (40 mmol/L) is suggestive of CF and requires a repeat test. Options 1, 2, and 4 are incorrect interpretations of the test results.

The nurse is caring for a client in labor and notes that minimal variability is present on a fetal heart rate (FHR) monitor strip. Which conditions are most likely associated with minimal variability? Select all that apply. 1. Early labor 2. Amniotomy 3. Tachycardia 4. Fetal hypoxia 5. Metabolic acidemia 6. Congenital anomalies

3. Tachycardia 4. Fetal hypoxia 5. Metabolic acidemia 6. Congenital anomalies Rationale: The fluctuations in the baseline FHR are the definition of variability. Variability can be classified into four different categories: absent, minimal, moderate, and marked. Minimal variability is defined as fluctuations that are fewer than six beats/minute. Tachycardia, fetal hypoxia, metabolic acidemia, and congenital anomalies are all associated with possible minimal variability. Rupturing membranes and early labor are not correlated to this condition.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The Ferguson reflex is initiated from perineal pressure.

3. The cervix is dilated completely. 5. The Ferguson reflex is initiated from perineal pressure. Rationale: The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The client has a strong urge to push in stage 2 when the Ferguson reflex is activated. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply. 1. The contractions are regular. 2. The membranes have ruptured. 3. The cervix is dilated completely. 4. The client begins to expel clear vaginal fluid. 5. The spontaneous urge to push is initiated from perineal pressure.

3. The cervix is dilated completely. 5. The spontaneous urge to push is initiated from perineal pressure. Rationale:The second stage of labor begins when the cervix is dilated completely and ends with birth of the neonate. The woman has a strong urge to push in stage 2 from perineal pressure. Options 1, 2, and 4 are not specific assessment findings of the second stage of labor and occur in stage 1.

A child with croup is being discharged from the hospital. The nurse provides instructions to the parent and advises the parent to bring the child to the emergency department if which occurs? 1. The child is irritable. 2. The child appears tired. 3. The child develops stridor. 4. The child takes fluids poorly.

3. The child develops stridor. Rationale: The parent needs to be instructed to bring the child to the emergency department if the child develops stridor at rest, cyanosis, severe agitation or fatigue, or moderate to severe retractions or is unable to take oral fluids.

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse measures the fundal height in centimeters and notes that the fundal height is 30 cm. How would the nurse interpret this finding? 1. The client is measuring large for gestational age. 2. The client is measuring small for gestational age. 3. The client is measuring normal for gestational age. 4. More evidence is needed to determine size for gestational age.

3. The client is measuring normal for gestational age. Rationale: During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus's age in weeks ± 2 cm. Therefore, if the client is at 28 weeks gestation, a fundal height of 30 cm would indicate that the client is measuring normal for gestational age. At 16 weeks, the fundus can be located halfway between the symphysis pubis and the umbilicus. At 20 to 22 weeks, the fundus is at the umbilicus. At 36 weeks, the fundus is at the xiphoid process.

During a clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about CF? 1. CF causes mucus that is formed to be abnormally thick. 2. It is a condition transmitted as an autosomal recessive trait. 3. This disease causes dilation of the passageways of many organs. 4. It is a chronic multisystem disorder affecting the exocrine glands.

3. This disease causes dilation of the passageways of many organs.

The nurse is assessing a client who is at 6 weeks' gestation. The client's prepregnancy body mass index (BMI) was 30.5 kg/m2. The nurse determines that the client has a need for further teaching if the client makes which statement? 1. "Restrictive or extreme diets are not recommended during pregnancy." 2. "It is okay to indulge in my cravings occasionally, but I will eat nutrient-dense foods most of the time." 3. "The recommended weight gain for me during my pregnancy is a total of 11 to 20 pounds (5 to 9.1 kilograms)." 4. "Due to my weight, it would be healthy for me and the baby if I maintained my current weight and did not gain weight."

4. "Due to my weight, it would be healthy for me and the baby if I maintained my current weight and did not gain weight." Rationale: Energy and nutrient needs vary for each pregnant individual. Weight gain recommendations depend on the client's prepregnancy body mass index (BMI). A BMI equal to or greater than 30 kg/m2 is considered obese. Options 1 and 2 indicate client understanding as it is unnecessary for the client to avoid all cravings and it is not recommended to engage in an extreme or restrictive diet during pregnancy in an attempt to lose weight. Option 3 indicates client understanding, as the recommended weight gain for the obese pregnant client is from 11 to 20 pounds (5 to 9.1 kilograms). Therefore, option 4 is the client statement that would require a need for further teaching from the nurse, as overweight and obese clients need to at least gain enough weight to equal the weight of the products of conception (fetus, placenta, and amniotic fluid). Therefore, option 4 is correct.

A parent calls the primary health care provider's office, requesting an appointment for an 8-year-old child. The parent states that the child has asthma and that the child reports having trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the parent? 1. "Is your child crying and irritable?" 2. "Does your child have a productive cough?" 3. "Did your child have a temperature last night of greater than 100° F (37.8° C)?" 4. "Is your child telling you at this time about having trouble breathing?"

4. "Is your child telling you at this time about having trouble breathing?" Rationale:Airway is always the most important indicator to determine whether the child can be seen in the primary health care provider's office or needs to be taken to the emergency department. Although all the assessment questions address manifestations of asthma, asking the child about difficulty breathing specifically addresses airway.

The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if the client makes which statement? 1. "I won't be in labor until my baby drops." 2. "My contractions will be felt in my abdominal area." 3. "My contractions will not be as painful if I walk around." 4. "My contractions will increase in duration and intensity."

4. "My contractions will increase in duration and intensity." Rationale: True labor is present when contractions increase in duration and intensity. Lightening or dropping leads to engagement (presenting part reaches the level of the ischial spine) and occurs when the fetus descends into the pelvis about 2 weeks before delivery. Contractions felt in the abdominal area and contractions that ease with walking are signs of false labor.

The clinic nurse is providing instructions to the parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the parent? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines." 3. "The child will receive all of the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." Rationale: Cystic fibrosis is a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza immunization is recommended for children with cystic fibrosis. Options 1, 2, and 3 are incorrect.

The nurse has provided instructions to the parent of a child with cystic fibrosis about appropriate dietary measures. Which statement by the parent indicates an understanding of these dietary measures? 1. "The diet needs to be low in fat." 2. "The diet needs to be low in protein." 3. "The diet needs to be low in calories." 4. "The diet needs to be high in calories."

4. "The diet needs to be high in calories." Rationale: Children with cystic fibrosis are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and water-soluble vitamin supplements (A, D, E, and K) are administered. If nutritional problems are severe, supplemental tube feedings or parenteral nutrition is administered. Fats are not restricted unless steatorrhea cannot be controlled by administration of increased pancreatic enzymes.

The parent of a child with chronic otitis media who has undergone a myringotomy, with insertion of tympanoplasty tubes, telephones and tells the nurse that the tubes have fallen out. Which is the appropriate response to the parent? 1. "Bring the child to the nearest emergency department." 2. "Replace the tubes immediately so that the opening does not close." 3. "Place the tubes in hydrogen peroxide for 1 hour before replacing them in the child's ears." 4. "This is not an emergency. I will speak to the primary health care provider and call you right back."

4. "This is not an emergency. I will speak to the primary health care provider and call you right back." Rationale: A myringotomy is the insertion of tympanoplasty tubes into the middle ear to equalize pressure and keep the ear aerated. The parent needs to be reassured that if the tubes fall out, it is not an emergency, but the primary health care provider needs to be notified. The size and appearance of the tympanostomy tubes needs to be described to the parents after surgery. The tubes are not soaked in hydrogen peroxide or replaced by the parents.

A nulliparous client asks the nurse when fetal movements will be felt. The nurse responds by telling the client that the first recognition of fetal movement will occur at approximately how many weeks of gestation? 1. 5 weeks 2. 9 weeks 3. 13 weeks 4. 18 weeks

4. 18 weeks Rationale: The first recognition of fetal movements, or feeling life, by the multiparous person may occur as early as 14 to 16 weeks' gestation. The nulliparous person may not notice these sensations until 18 weeks' gestation or later, as the person has no prior experience and the uterus has not been previously stretched during pregnancy adaptation. The first recognition of fetal movement is called quickening.

The nurse is caring for a hospitalized child who is receiving a continuous infusion of intravenous potassium for the treatment of dehydration. Which assessment finding requires the need to notify the primary health care provider? 1. Weight increase of 0.5 kg 2. Temperature of 100.8° F (38.2° C) rectally 3. Blood pressure unchanged from baseline 4. A decrease in urine output to 0.5 mL/kg/hr

4. A decrease in urine output to 0.5 mL/kg/hr Rationale: The priority assessment is to assess the status of urine output. Potassium would never be administered in the presence of oliguria or anuria. If urine output is less than 1 to 2 mL/kg/hr, potassium would not be administered. A slight elevation in temperature would be expected in a child with dehydration. A weight increase of 0.5 kg is relatively insignificant. A blood pressure that is unchanged is a positive indicator unless the baseline was abnormal. However, there is no information in the question to support such data.

Fetal distress is occurring with a client in labor. As the nurse prepares the client for a cesarean birth, what other intervention would the nurse implement? 1. Continue the oxytocin drip. 2. Slow the intravenous (IV) rate. 3. Place the client in a high-Fowler's position. 4. Administer oxygen at 8 to 10 L/min via face mask.

4. Administer oxygen at 8 to 10 L/min via face mask. Rationale: Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood volume. Oxytocin stimulates the uterus and is discontinued if fetal heart rate patterns change for any reason. The IV infusion would be increased, not decreased, so as to increase the maternal blood volume. The client's position needs to be lateral and with legs raised to increase maternal blood volume and improve the maternal vascular system.

A 16-year-old client is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? 1. Encourage the client to rest and read. 2. Encourage the parents to room in with the client. 3. Allow the family to bring in the client's favorite computer games. 4. Allow the client to interact with others in the same (adolescent) age-group.

4. Allow the client to interact with others in the same (adolescent) age-group. Rationale: Adolescents often are not sure whether they want their parents with them when they are hospitalized. Because of the importance of their peer group, separation from friends is a source of anxiety. Ideally, the members of the peer group will support their ill friend. Options 1, 2, and 3 isolate the client from the peer group.

A primary health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

4. Checks the amount of urine output Rationale:In hypotonic dehydration, electrolyte loss exceeds water loss. The priority assessment before administering potassium chloride intravenously would be to assess the status of the urine output. Potassium chloride would never be administered in the presence of oliguria or anuria. If the urine output is less than 1 to 2 mL/kg/hour, potassium chloride would not be administered. Although options 1, 2, and 3 are appropriate assessments for a child with dehydration, these assessments are not related specifically to the IV administration of potassium chloride.

The nurse in the labor room is caring for a client who is in the first stage of labor. On assessing the fetal patterns, the nurse notes an early deceleration of the fetal heart rate (FHR) on the monitor strip. Based on this finding, which is the appropriate nursing action? 1. Place the client in Trendelenburg's position. 2. Administer oxygen to the client by face mask. 3. Contact the primary health care provider (PHCP). 4. Document the findings and continue to monitor fetal patterns.

4. Document the findings and continue to monitor fetal patterns. Rationale: Early deceleration of the FHR refers to a gradual decrease in the heart rate followed by a return to baseline in response to compression of the fetal head. It is a normal and benign finding. Because early decelerations are considered benign, interventions are unnecessary. Therefore, contacting the PHCP, changing the client's position, or administering oxygen is not necessary.

The nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which action is most appropriate? 1. Notify the primary health care provider of the findings. 2. Reposition the client and check the monitor for changes in the fetal tracing. 3. Take the client's vital signs and tell the client that bed rest is required to conserve oxygen. 4. Document the findings and tell the client that the pattern on the monitor indicates fetal well-being.

4. Document the findings and tell the client that the pattern on the monitor indicates fetal well-being. Rationale: Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal well-being and adequate oxygen reserve. Options 1, 2, and 3 are inaccurate nursing actions and are unnecessary.

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes, and cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior? 1. Exhaustion 2. Valsalva maneuver 3. Involuntary grunting 4. Fear of losing control

4. Fear of losing control Rationale: Pain, helplessness, panic, and fear of losing control are possible behaviors in the transition phase of the first stage of labor. Options 1, 2, and 3 are not indicative of the description provided in the question.

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The parents become concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the parents that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the primary health care provider and obtain a prescription for a mild sedative. 4. Let one parent hold the child and direct the cool mist over the child's face.

4. Let one parent hold the child and direct the cool mist over the child's face. Rationale:Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by a parent and the cool mist is directed toward the child's face (blow-by). A mild sedative would not be administered to the child. Crying would increase hypoxia and aggravate laryngospasm, which may cause airway obstruction. Options 1 and 2 would not alleviate the child's fear.

A child admitted to the hospital with a diagnosis of gastroenteritis and dehydration weighs 17 lb 2 oz (7.8 kg). The parents state that his preadmission weight was 18 lb 4 oz (8.3 kg). Based on weight alone, what type of dehydration does the nurse expect? 1. Mild dehydration 2. Acute dehydration 3. Severe dehydration 4. Moderate dehydration

4. Moderate dehydration Rationale: Mild dehydration is a weight loss less than 5%; moderate dehydration is 5% to 10%; severe dehydration is greater than 10% weight loss. All types of dehydration are acute situations. The answer can be determined by calculating the percent of weight loss in dehydration. Because the math calculation determines more than a 5% weight loss but less than 10% weight loss, the correct answer is moderate dehydration. By calculating the percent of weight loss, the correct answer can be determined.

The labor room nurse assists with the administration of a lumbar epidural block. How would the nurse check for the major side effect associated with this type of regional anesthesia? 1. Assessing the client's reflexes 2. Taking the client's temperature 3. Taking the client's apical pulse 4. Monitoring the client's blood pressure

4. Monitoring the client's blood pressure Rationale: A major side effect of regional anesthesia is hypotension, which results from vasodilation in the lower body and a reduction in venous return. After regional anesthesia, the blood pressure is taken every 5 minutes during the first 15 minutes and then at 30 minutes and 1 hour. Reflexes, temperature, and apical pulse are not specifically related to this type of anesthesia.

The nurse is performing an assessment on a client who is at 38 weeks' gestation and notes that the fetal heart rate (FHR) is 184 beats/minute. On the basis of this finding, what is the priority nursing action? 1. Document the finding. 2. Check the client's heart rate. 3. Tell the client that the fetal heart rate is normal. 4. Notify the primary health care provider (PHCP).

4. Notify the primary health care provider (PHCP). Rationale: The FHR depends on gestational age and ranges from 160 to 170 beats/minute in the first trimester but slows with fetal growth to 110 to 160 beats/minute near or at term. At or near term, if the FHR is less than 110 beats/minute or more than 160 beats/minute with the uterus at rest, the fetus may be in distress. Because the FHR is increased from the reference range, the nurse would notify the PHCP. Options 2 and 3 are inappropriate actions based on the information in the question. Although the nurse documents the findings, based on the information in the question, the PHCP needs to be notified.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse would identify which findings as normal? 1. Light green, with no odor 2. Clear and dark amber in color 3. Thick and white, with no odor 4. Pale straw in color, with flecks of vernix

4. Pale straw in color, with flecks of vernix Rationale: Amniotic fluid normally is pale straw in color and may contain flecks of vernix caseosa. Greenish fluid may indicate the presence of meconium and suggests fetal distress. Amber-colored fluid suggests the presence of bilirubin. The fluid would not be thick and white; this could be an indication of infection.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen. The nurse documents these observations as signs of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation

4. Placental separation As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. Options 1, 2, and 3 are incorrect interpretations.

The nurse assists in the vaginal delivery of a newborn. Following the delivery, the nurse observes a spurt of blood from the vagina. The nurse would document this observation as a sign of which condition? 1. Hematoma 2. Uterine atony 3. Placenta previa 4. Placental separation

4. Placental separation Rationale: As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears. The other options are not characterized by these findings.

The pediatric nurse is caring for a hospitalized toddler. What does the nurse determine is the most appropriate play activity for the toddler? 1. Listening to music 2. Playing peek-a-boo 3. Hand sewing a picture 4. Playing with a push-pull toy

4. Playing with a push-pull toy Rationale: The toddler has increased use of motor skills and enjoys manipulating small objects such as toy people, cars, and animals. Push-pull toys are appropriate for this age. Listening to music is most appropriate for an adolescent. Playing peek-a-boo is most appropriate for an infant. Hand sewing a picture is most appropriate for a school-age child.

The nurse is admitting a 10-month-old infant who is being hospitalized for a respiratory infection. The nurse develops a plan of care for the infant and includes which most appropriate intervention? 1. Keeping the infant as quiet as possible 2. Restraining the infant to prevent dislodging of tubes 3. Placing small toys in the crib to provide stimulation for the infant 4. Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization

4. Providing a consistent routine with touching, rocking, and cuddling throughout hospitalization Rationale: A 10-month-old is in the Trust versus Mistrust stage of psychosocial development according to Erikson. The infant is developing a sense of self, and the nurse would appropriately provide a consistent routine for the child. Hospitalization may have an adverse effect, and the nurse would touch, rock, and cuddle the infant to promote a sense of trust and provide sensory stimulation. Keeping the infant as quiet as possible will not provide sensory stimulation. The infant would not be restrained. Placing small toys in the crib is an unsafe action.

The parents bring their child to the emergency department. Based on the child's sitting position, drooling, and apparent respiratory distress, a diagnosis of epiglottitis is suspected. The nurse would plan for which priority intervention? 1. Obtaining a chest x-ray 2. Asking the parents about the precipitating events 3. Obtaining weight for correct antibiotic dose infusion 4. Providing assisted ventilation and obtaining the necessary equipment

4. Providing assisted ventilation and obtaining the necessary equipment Rationale: The highest priority with epiglottitis is to have assisted ventilation available because the highest risk with this child is complete airway obstruction. Therefore, interventions related to airway are the priority. Physiological interventions continue to have the highest priority, with assessment of breath and heart sounds and then obtaining pulse oximetry being priorities. Once the airway is stabilized, the temperature, weight, and a chest x-ray can be obtained. The last priority is to ask about precipitating events, which is done once physiological needs are met.

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse would tell the parent that which factor motivates good and bad actions for the child at the preconventional level? 1. Peer pressure 2. Social pressure 3. Parents' behavior 4. Punishment and reward

4. Punishment and reward Rationale: In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated factors for this stage of moral development.

The nurse is caring for a 25-year-old client who is pregnant with the first child. The client has a history of smoking half a pack of cigarettes per day for 1 year. The client does not drink alcohol. The client states that a crib is set up in the bedroom with "plenty of soft, stuffed animals to keep the baby comfortable." The client has been receiving prenatal care since the client was 6 weeks pregnant. Which factors increase the risk of sudden infant death syndrome (SIDS) for this infant? Select all that apply. 1. First pregnancy 2. No alcohol use 3. The client's age 4. Smoking half a pack of cigarettes per day 5. Prenatal care that began at 6 weeks' gestation 6. The planned sleeping arrangements for the baby

4. Smoking half a pack of cigarettes per day 6. The planned sleeping arrangements for the baby Rationale: Sudden infant death syndrome (SIDS) is defined as the unexplained death of an infant 1 year of age or younger that remains unexplained after autopsy, death scene examination, and clinical history review. Certain factors increase the risk of SIDS, including but not limited to maternal age younger than 20 years, maternal smoking and alcohol use, blankets or stuffed animals or toys in the crib, co-sleeping, late or no prenatal care, and low birth weight or premature infant. First pregnancy, no alcohol use, being 25 years old, and receiving prenatal care starting at 6 weeks' gestation are not known risk factors for SIDS. Therefore, options 4 and 6 are correct because they are risk factors.

Which action by the parent of an infant with respiratory syncytial virus infection who is receiving ribavirin would indicate a need for further instruction regarding the management of the disease process? 1. Wearing protective garb when visiting the infant 2. Washing the hands before leaving the infant's room 3. Telling a family member who has asthma that they should not visit the infant 4. Telling a family member, who is pregnant, that it is acceptable to visit the infant

4. Telling a family member, who is pregnant, that it is acceptable to visit the infant Rationale: When an infant is receiving ribavirin, exposure precautions need to be observed. Anyone entering the infant's room needs to wear a gown, mask, gloves, and hair covering. Anyone who is pregnant or considering pregnancy and anyone with a history of respiratory problems or airway disease would not care for or visit the infant who is receiving ribavirin. Handwashing is

The nurse at a well-baby clinic is assessing the motor development of a 24-month-old child. On the basis of the age of the child, the nurse expects to note what as the highest-level developmental milestone? 1. The child snaps large snaps. 2. The child builds a tower of 2 blocks. 3. The child puts on simple clothes independently. 4. The child opens a door by turning the doorknob.

4. The child opens a door by turning the doorknob. Rationale: A 24-month-old child would be able to open a door using the doorknob. At age 15 months, the nurse would expect that the child could build a tower of 2 blocks. At age 30 months, the child needs to be able to snap large snaps and put on simple clothes independently.

Shortly after receiving epidural anesthesia, a laboring client's blood pressure drops to 95/43 mm Hg. Which immediate actions would the nurse take? Select all that apply. Your Answers: 1. Prepare for delivery. 2. Administer a tocolytic. 3. Administer an opioid antagonist. 4. Turn the client to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute.

4. Turn the client to a lateral position. 5. Increase the rate of the intravenous infusion. 6. Administer oxygen by face mask at 10 L/minute. Rationale: Hypotension results in decreased placental perfusion, so the focus of nursing care would be to initiate interventions that increase oxygen perfusion to the fetus. Turning the client to left lateral position assists in deflecting the uterus off the vena cava, thus improving circulation. Increasing the rate of the intravenous infusion will increase blood volume, which will increase the blood pressure. An increase in blood pressure would increase placental perfusion. Administering a high flow rate of oxygen will increase the oxygen levels in the circulation and increase oxygen delivery to the fetus. The client is not revealing any signs or symptoms of imminent delivery, as the client just received an epidural which is typically administered at 6 cm or earlier dilation, so option 1 can be eliminated. Administering a tocolytic can be eliminated because the decrease in placental perfusion is the result of hypotension, not uterine hyperstimulation. Administering an opioid antagonist can be eliminated because the client is not experiencing an ineffective breathing pattern caused by opioid administration.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction? 1. Variability 2. Accelerations 3. Early decelerations 4. Variable decelerations

4. Variable decelerations Rationale: Variable decelerations occur if the umbilical cord becomes compressed, reducing blood flow between the placenta and the fetus. Variability refers to fluctuations in the baseline fetal heart rate. Accelerations are a reassuring sign and usually occur with fetal movement. Early decelerations result from pressure on the fetal head during a contraction.

Which would be the highest expected growth and development occurrence at 12 months of age for an infant who has had appropriate growth assessed at each well-child visit? 1. Imitates sounds 2. Smiles spontaneously 3. Sits steadily unsupported 4. Walks holding on to someone's hand

4. Walks holding on to someone's hand Rationale: Growth and development are sequential and predictable. One task builds on another. Mastery of a lower-level task must occur before higher-level tasks are completed. At 12 months a child can walk holding on to someone's hand. Smiling, imitating sounds, and sitting steadily unsupported begin at 6 months of age.

Which would be the highest expected growth and development occurrences at 10 months of age for an infant who has had appropriate growth assessed at each well-child visit? Select all that apply. 1. Will smile spontaneously 2. Rolls over in both directions 3. Able to sit steadily unsupported 4. Would be able to say "mama" and "dada" 5. Will pull up and stand for several seconds holding on to furniture 6. Will be able to pick up small pieces of food when placed in a high chair

4. Would be able to say "mama" and "dada" 5. Will pull up and stand for several seconds holding on to furniture 6. Will be able to pick up small pieces of food when placed in a high chair Rationale: Growth and development are sequential and predictable. One task builds on another. Mastery of a lower-level task must occur before higher-level tasks are completed. A child must be able to roll over before sitting alone and before beginning to creep and crawl. After mastering crawling, the infant (10 months of age) will pull up and hold on to furniture. Sitting steadily unsupported begins soon after 6 months. The pincer grasp is mastered by 12 months but begins refinement at 10 months. Once this is accomplished, the infant will begin grasping a spoon. Language development begins at 6 months with imitating sounds and smiling spontaneously, progressing to saying "mama" and "dada" at 10 months of age.