Nursing 1205 Final Review
A nurse is preparing to administer acetaminophen to a child for fever. The order states to administer 10 mg/kg/dose. The child weighs 28 pounds. The label on the bottle reads 120 mg/5 ml. How many milliliters should the nurse administer.
,,,,
A nurse is calculating the output of an infant admitted with dehydration. When weighing the diaper, the nurse knows that 1g of wet diaper weight is equal to what amount of urine?
1 ml
A nurse is admitting a 6-month-old infant who has dehydration. When she tracks the clients urinary output, what amount should indicate to the nurse that the treatment has corrected the fluid imbalance?
2 ml/kg/hr
A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed 1/2 cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 ml gingerale with medications. How many mL should the nurse chart as the child's intake
260 ML
A nurse is caring for a client who is in labor. When monitoring the uterine contractions, the nurse is aware that relaxation between contractions should be greater than
30 seconds
A nurse is assessing a newborn 1 hour after delivery. What respiratory rate is within the expected reference range for a newborn?
48
What child should the nurse identify as a potential victim of abuse?
A child whose parents answer questions for the child
A nurse is reviewing contraception options for four clients. For which client would oral contraceptives be indicated?
A client who has a blood pressure of 140/90
A nurse is assessing a postpartum client who was prescribed Methylergonovine (Methergine). The nurse should know that the medication was effective when the client has
A firm fundus
A nurse is providing health promotion teaching to the parents of a toddler. What condition should the nurse identify as the leading cause of death among this age group?
Accidents
A nurse is preparing to administer an IM injection to a preschooler. Which action is appropriate for the nurse to take?
Allow the preschooler to hold a cartoon sticker or another toy
A nurse is teaching a client who is starting a new prescription for an oral contraceptive. What medications are contraindicated for this client?
Anticonvulsants
A nurse is planning care for an infant. What would be the most appropriate site to assess a pulse?
Apex of the heart
A nurse is caring for a client who is 2 days postpartum, is breastfeeding, and reports nipple soreness. What measures should the nurse suggest to help lessen discomfort during breastfeeding?
Apply breast milk to her nipples before each feeding, alternate breasts at the beginning of each feeding, start breastfeeding with the nipple that is less sore, and change the infants position on the nipples
A charge nurse, following hospital policy, reports an incident of suspected child abuse. The parent of the child becomes upset and demands to know the reason for the nurse's action. What should the appropriate nursing response be?
As a nurse, I am required by law to report incidents of suspected child abuse
A nurse is bathing a toddler and notices that she has several bruises. What action should the nurse take first?
Ask the parents what caused the bruises
A nurse is caring for a client who is to undergo an amniotomy. Which is the priority nursing action following the procedure?
Assess the fetal heart rate pattern
A nurse is providing home safety information to the parents of an 11-month-old infant. What should be included?
Avoid grapes and popcorn, position the crib away from windows.
Your patient has been prescribed azithromycin 1 gram or doxycycline 100 mg BID for 7 days. What is she being treated for?
Chlamydia
A nurse is admitting a client who is at 38 weeks of gestation and is in the first stage of labor. Which assessment finding should the nurse report to the provider immediately.
Continuous contractions lasting 2 minutes
During a postpartum assessment 1 hour following delivery, a nurse finds a large amount of lochia rubra on a client's perineal pad with several small clots. The fundus is midline and firm at the umbilicus. What action should the nurse take?
Document the findings and continue to monitor the client
A nurse assessing a newborn finds an apical heart rate of 130. What is the appropriate nursing action?
Document this as an expected finding.
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. What finding in the client's history should the nurse view to be consistent with a diagnosis of endometriosis?
Dysmenorrhea with menses that has worsened over time
A client who is 7 days postpartum calls the clinic to report pain and redness of her left calf. Besides seeing her provider, which intervention should the nurse suggest?
Elevate her leg
A client who is postpartum asks the nurse to feed her newborn. What is an appropriate nursing response?
Feeding an infant can feel a little intimidating at first, but I'll stay with you to help.
A nurse is assessing an infant. Which of the following developmental skills is a 1-month-old infant able to do?
Follows movement with eyes
A nurse at the pediatric hotline receives a call from a mother who plans to administer children's aspirin to a toddler for a fever and wants to know the dosage. Which statement by the nurse is an appropriate response?
Give her acetaminophen, not aspirin
Your patient has been provided the following education. Which STI is the nurse providing counseling for? Educate and prepare for pelvic exam for vaginal swab, obtain history of sexual exposure, abstain from sexual intercourse or use a condom, Educate regarding risk factors, if left untreated, it can lead to systemic problems (joints, heart, brain)
Gonorrhea
A nurse is assessing a client who is in her third trimester of pregnancy. Which finding should the nurse recognize as an effective physiologic change during pregnancy?
Gradual lordosis
A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should plan which intervention?
Have the client ambulate frequently in the hallway
A nurse is teaching a group of teenage clients about prevention of sexually transmitted infections (STI's). Which of the following practices is the most important preventative measure to include in the teaching?
Having one partner
Name the infection...The nurse provided the following patient education... This infection can still be transmitted when the lesions are gone. Abstaining from sex and using condoms can reduce transmission of this disease. The doctor has prescribed antiviral medications to reduce the severity, increase healing, and reduce occurrence of outbreaks.
Herpes Simplex
A client delivered a 34-week, 1550 gram newborn who has nasal flaring, intercostal retractions, expiratory grunting, and mild cyanosis. The nurse should place the newborn in an incubator that will create a neutral thermal environment because
His temperature control mechanism is immature
A nurse is caring for a toddler, admitted to a pediatric unit. What statement should the nurse use when preparing to check the child's vital signs?
I am going to listen to your heart
A nurse is caring for a client who is postpartum. The nurse should recognize what statement by the client as a possible indication of inhibition of parental attachment?
I just wish he had more hair. I'm going to have to keep a hat on his head till he grows some.
A nurse is teaching a parent of a toddler about dealing with temper tantrums. What statement by the parent indicates understanding of the teaching?
I should ignore the temper tantrums
A woman in her third trimester of pregnancy describes the action she took when she experienced a mild headache. What client action should be of greatest concern to the nurse?
I took 200 mg of motrin and drank a full glass of water
A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse understands that further teaching is necessary when the mother states what?
I will give my son the enzymes between meals
A nurse is caring for a child who has cystic fibrosis and is being discharged after initial diagnosis and treatment. The nurse should recognize that the parent understands the child's nutritional needs when she states...
I will make certain that pancreatic enzymes are taken with all of my child's snacks and meals.
A home health care nurse visiting a client who is postpartum and is breastfeeding her newborn determines that she has breast engorgement. Which client statement indicates to the nurse that she understands the teaching about managing this problem?
I'll feed my baby every 2 hours.
What is the most reliable method of contraception for those who are sexually active
IUD
A nurse is discussing the reporting of child abuse with a newly licensed nurse. What statement indicates an understanding by the newly licensed nurse?
If suspicion of abuse exists then reporting is mandatory
What is the patient education for missed birth control pills?
If you missed on take the missed dose now then continue taking the medication as ordered. If you miss 2 pill take 2 the day your remember and 2 the next day. If you miss more than 2 call your doctor. Anytime you miss use a back up method of birth control.
The parent of a toddler asks a nurse at a well-child clinic how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent
Ignore the temper tantrums
The patient has been given the following education. What common disorder in pregnancy is she having? Eat more red meat and organ meat, when taking your medication take with orange juice to help with absorption.
Iron deficiency anemia
A nurse is reinforcing teaching with a client who is pregnant about expected changes related to pregnancy. Which statement by the client indicates understanding of the teaching?
It is normal to have a white vaginal discharge
The parent of a 4-year old tells a nurse that the child believes there are monsters hiding in the closet at bedtime. What nursing response is most appropriate?
Keep a night-light on in your child's room.
A nurse is caring for a client in the 36th week of pregnancy with a suspected placenta previa. What should the nurse expect clinical findings to include?
Large amounts of bright red vaginal bleeding without pain
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. What toy should the nurse suggest in order to meet the developmental needs of the client?
Large building blocks
A client who is postpartum after giving birth to her third child tells the nurse she does not want any more children and asks what method of birth control she would recommend. What is the appropriate nursing response?
Let's talk about available options and go from there.
On a client's first postpartum day, she says to the nurse "The baby has been breathing funny, fast and slow, off and on." What is the appropriate nursing response?
Lets work together to observe his breathing carefully. I'll sit here while you finish feeding him.
A nurse is assessing a client during a prenatal visit. What skin changes should the nurse expect?
Linea Nigra Chloasma Striae Gravidarum
A nurse is caring for a client 4 hours postpartum following a vaginal birth. The client has saturated a perineal pad within 10 minutes. What is the nurse's first action?
Massage the client's fundus
A nurse is assessing the psychosocial development of a toddler. The nurse is aware that this stage is characterized by what?
Negative behaviors characterized by the need for autonomy
A nurse is preparing to assess a toddler who is hospitalized for dehydration and gastroenteritis. Identify the sequence the nurse should follow.
Observe the child's skin coloring and appearance, auscultate the chest and abdomen, palpate the abdomen, obtain the client's tympanic temperature
A nurse is assessing a child and noted many bruises. What is the appropriate action that the nurse should take?
Obtain a detailed history
A nurse in a clinic is discussing effective techniques for counseling clients about sexually transmitted infections (STIs) with a new graduate nurse during orientation to the clinic. What statement is appropriate to include in this discussion?
Obtain a reproductive health history from clients
A nurse in a clinic is caring for a female client who has gonorrhea. What action should the nurse perform?
Obtain information about the client's recent sexual partners
A nurse is caring for a child who has acute gastroenteritis but is able to retain oral fluids. The nurse should anticipate providing which type of fluid?
Oral rehydration solution
A nurse is assessing a client for postpartum infection. Which finding should indicate to the nurse that the client requires further evaluation for endometriosis?
Pelvic Pain
A nurse is caring for a newborn and assessing newborn reflexes. To elicit the Moro reflex, the nurse uses which action?
Perform a sharp hand clap near the infant.
A nurse in labor and delivery is caring for a client on an external electronic fetal monitor. The nurse observes the fetal heart rate begins to decelerate after the contraction has started and the lowest point of the deceleration occurs after the peak of the contraction. What is the priority action by the nurse?
Place the client in the lateral position
A nurse caring for a client in active labor notes late decelerations on the fetal monitor. What is the priority nursing action?
Position the client on her side
A nurse in a well-child clinic is assessing a 6-month-old infant. What assessment should the nurse expect to make?
Posterior fontanel is closed
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse notes late decelerations and interprets them as indicating what?
Potential for fetal distress
A nurse is presenting educational materials for a group of young clients on estrogen hormone replacement therapy following total hysterectomy. What information should the nurse include about estrogen hormone replacement therapy?
Protects against coronary heart disease
A client who is one day postpartum is having a sitz bath. To determine the client's tolerance of the procedure, which assessment should the nurse perform?
Pulse rate
A nurse is reinforcing teaching about car safety with the parents of a toddler who weighs 10.9 kg. What describes the correct placement of the car seat?
Rear facing in the middle of the back seat
A nurse is reinforcing car seat safety with the parent of an infant who weighs 4.5 kg. What car seat position should be included in the teaching?
Rear-facing in the middle of the back seat
A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that what reflex will initiate sucking?
Rooting
A nurse is preparing to palpate the uterine fundus of a client who is at 22 weeks of gestation to measure fundal height. At which location should the nurse expect to find the fundus?
Slightly above the umbilicus
A nurse is caring for a client who has HIV. What infection control precaution should the nurse use while caring for this client?
Standard
A nurse at a family practice clinic receives a call from a client who is taking oral contraceptives but forgot to take one oral contraceptive pill. What instructions should the nurse give her?
Take the missed dose along with the next dose
A nurse in labor and delivery is caring for a client following a vaginal examination by the provider which is documented as 3cm, 30%, and -1. The nurse evaluates this documentation as which of the following?
The cervix is dilated 3cm, it is effaced 30%, and the presenting part is 1cm above the ischial spines.
A nurse is teaching an assistive personnel to count respiration rate on a newborn. What statement indicates understanding of why the respiratory rate should be counted for a complete minute?
The rate and rhythm are irregular in newborns
A nurse is preparing to discharge a child with a new prescription for an oral antibiotic. What should be included in the discharge instructions?
The reason the child is taking the medication Written information about the medication Adverse effects of the medication
A nurse is speaking with the mother of a 6-year-old child. What statement by the mother should concern the nurse?
The teacher says my child has to squint to see the board
A nurse is caring for an 8-month-old infant in the hospital. When the parent leaves the room, the child begins to scream. The parent begins to cry and says, "I don't understand why my child is so upset. I've never seen my child act this way around others before." How should the nurse respond?
This is a normal, expected reaction for a child of this age.
A nurse is caring for a new mother who is concerned that her newborn's eyes cross. Which of the following statements is a therapeutic response by the nurse?
This is expected because newborns lack the muscle control necessary to regulate eye movement.
When administering ear drops to a toddler, the nurse pulls the auricle down and back. The mother asks, "why are you pulling the ear that way?" What is an appropriate response by the nurse?
This opens the ear canal allowing medication to reach the inner ear region
A nurse is teaching a parent of a toddler about nutrition. What should be included in the teaching?
Toddlers have a decrease in nutritional needs and will tend to eat less
A nurse is caring for a hospitalized 2-year old child who throws a tantrum when his parent leaves. Which toy should the nurse provide to help alleviate the child's stress?
Toy hammer and a pounding board
A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate. It is noted that the client's respiratory rate is 10 breaths/min, and deep tendon reflexes are 0. Which nursing interventions is appropriate at this time?
Turn off the magnesium sulfate drip
A nurse is caring for a client who is postpartum. Following delivery of the placenta, the nurse examines the umbilical cord. What vessel should the nurse expect to observe in the newborn's umbilical cord?
Two arteries and one vein
A nurse is caring for a 3-year old child admitted with acute diarrhea and dehydration. What client finding indicates that oral rehydration therapy has been effective?
Urine specific gravity 1.015
A patient has the following: breast tenderness, fatigue, nausea and a missed period the nurse knows that these are what types of signs of pregnancy?
What are presumptive signs of pregnancy. Probable signs include positive urine pregnancy test Positive signs are fetal heart tones, fetal movement by trained practioner, visualizing fetus on U/S
During the vaginal examination the nurse notes that the presenting part is at the level of the ischial spines.
What is 0 station See page 465 Information on Identifying Fetal station. There will be at least 3 questions dealing with this.
Priority action following amniotomy.
What is Assess fetal heart rate/cervical examination.
The most common method of prenatal testing. Provides an indirect measurement of uteroplacental function.
What is Nonstress Test. A reactive NST includes at least 2 fetal heart rate accelerations from baseline of at least 15 bpm for at least 15 seconds within 20 minutes. Non reactive if this is not reached after 40 minutes. Non reactive NST=absence of 2 fetal heart rate accelerations using 15 X 15 criteria in a 20 minute timeframe
An 8 month old cries when parents leave the room and the nurse is unable to comfort the child. The parents ask if this is normal. is this Normal yes or no. Why
What is Yes the child this age has stranger anxiety as well as separation anxiety Erickson's Psychosocial theory is the only one you need to know. Review for infant-school age.
This test evaluates fetal breathing, fetal motion, amniotic fluid, fetal tone and a NST
What is a biophysical profile. The BPP is a U/S exam. Each of the five areas receive a score from 0-2. 8-10 is normal. 6 or below needs investigated
When looking at a fetal monitoring strip the nurse notes decelerations to the fetal heart rate that occur during the peak of the contraction and continue after the uterus is at rest. What type of deceleration is this? What does it signify?
What is a late deceleration a sign of uteroplacental insufficiency. These are always an emergency and need to be treated. First change position to left lateral, administer oxygen, stop Pitocin, call MD for orders Review Determining FHR Patterns page 494 Table 14.1 page 495-498 At least 2-3 questions.
What parameters in pulse rate could indicate a postpartum complication?
What is a pulse rate over 100 bpm Review postpartum vitals page: 559 Box 16.2 Postpartum Danger Signs
Of all signs of true labor which would be the best indication the patient is in active labor?
What is change in the cervical dilation True vs. false labor 458 See pages 475 Be able to identify different stages of labor 473-479 At least 2-3 questions.
1 hour after delivery the nurse notes the fundus is midline and firm at the umbilicus. There is a moderate to large amount of lochia rubra. Name the priority nursing action.
What is document the findings these are expected for this stage and continue to monitor. At least 2-3 questions will deal with lochia and fundus assessment after delivery. Uterus page 560 Lochia page 562
A patient calls the doctors office and states she has erythema and pain on her left breast. This is an indicator of which condition?
What is mastitis Know the difference between mastitis and engorgement. See page 580
The nurse is completing an assessment of a 1 week old. The nurse claps her hand near the infant and hold the infant vertically allowing one foot to touch the table surface. What 2 things is the nurse assessing?
What is moro reflex and stepping reflex Review infant reflexes pages 643-644
A nurse notes contractions occurring 3-5 minutes lasting 90 seconds. They are strong in intensity and she complains of pain in the lower back. Name one priority nursing action.
What is notify the physician of contractions lasting longer than 90 seconds these are prolonged and could indicate the uterus is not relaxing enough.
List a strategy to enhance a 4-year old with taking medications.
What is offer a choice of taking with juice or water. Review how to give medications to pediatrics. Page 1259-1271
The parents of a newborn ask why their newborn has dry cracked skin. What generally causes this condition?
What is post-term Review Newborn Physical Exam for s/s of normal Table 18.3 page 645
A patient has a negative rubella titer what does this mean should she be immunized? If so when?
What is she is not immune to rubella and should be given a rubella immunization following delivery of the baby
A 6 month old infant has been treated for dehydration. What would be the expected urine output and specific gravity if rehydration has been effective?
What is urine output of 2 ml/kg/hour, specific gravity of 1.010 to 1.025. Greater than 1.025 indicated dehydration
A nurse is caring for a child with a suspected diagnosis of cystic fibrosis. What diagnostic test will the nurse prepare the child for to confirm the diagnosis?
a sweat chloride test
A nurse is caring for a client who asks which of the several contraception methods she is considering is most reliable. What is the correct response from the nurse?
an IUD
A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, and nurse observes the toddler sitting quietly in the corner of the crib, sucking a thumb. When the nurse approaches the crib, the toddler shyly turns away from the nurse. The nurse should know that these behaviors indicate
an anxiety reaction to the stress of hospitalization
A nurse is planning care for a child that has severe diarrhea. What is the priority nursing action?
assess the fluid balance
A nurse is assessing a client who had a spontaneous vaginal delivery nearly 12 hours ago. The nurse should expect to find the uterine fundus at what position on the client's abdomen?
at the
A nurse is assessing a 7-month-old infant. What would indicate the need for further evaluation?
babbles one-syllable sounds
A nurse is caring for a toddler with a 2-day history of vomiting and elevated temperature. What should the nurse recognize as the most reliable indicator of fluid loss?
body weight
A nurse is assessing a newborn the day after delivery. The nurse notes a raised bruised area on the left side of the scalp that does not cross the suture line. The nurse should document this finding as
cephalhematoma
A nurse is caring for a client who is a primigravida, at term, and having contractions but is stating that she is "not really sure if she is in labor or not." The nurse should recognize that what is an indication of true labor?
changes in the cervix
A nurse is caring for a client who has a history of genital herpes. What finding should the nurse expect during data collection?
dysuria
A nurse is assessing a client who is 8 hours postpartum and multiparous. What findings should alert the nurse to the client's need to urinate
fundus three fingerbreaths above the umbilicus
A nurse is assessing a client who is 3 days postpartum and is breastfeeding. Her fundus is three fingerbreadths below the umbilicus, and her lochia rubra is moderate. Her breasts feel hard and warm. The nurse should identify that the client...
has expected findings at this time
A nurse is caring for an antepartum client whose laboratory work reveals a negative rubella titer. The nurse should know this result means that the client
is not immune to rubella and will need an immunization following delivery
A nurse is caring for a client who is gravida 3, para 2, and is in active labor. After a vaginal examination, the nurse determines that the fetal head is at station +3. The appropriate nursing action is to
prepare for delivery of the newborn
A client who is at 18 weeks of gestation tells the nurse that she felt light fluttering in her stomach the previous day. The nurse should document that this is
quickening
A nurse is caring for a client who has severs preeclampsia and is receiving magnesium sulfate IV at 2g/hour. What finding indicates that it is safe for the nurse to continue the infusion?
respiratory rate of 16/min
Making negative statements about newborn or refusing to care for newborn.
signs of poor attachment
A nurse is performing a vaginal examination of a client who is in active labor, with the fetus in vertical lie. When the nurse determines that the fetal head is at station 0, it means that
the lowermost portion of the head is at the level of the ischial spines.
A nurse is educating a client who was diagnosed with genital herpes. What statement indicates that the client needs further information?
transmission of the disease does not occur when my symptoms are gone.
A nurse is caring for a child who is diagnosed with otitis media. What assessment findings should the nurse expect?
tugging on the affected ear lobe
A nurse is monitoring a client who is in the first stage of labor, with an external fetal monitor in place and IV fluids infusing. The nurse notes variable decelerations in the fetal heart rate on the monitoring strip. The nurse knows that the probable cause of this pattern is
umbilical cord compression
Uterine overdistention can cause this postpartum complication.
uterine atony
A nurse in a community clinic is counseling a client who has just received a positive result from chlamydia testing. What is an appropriate statement for the nurse to make?
we'll treat this infection with one dose of azithromycin