OB HESI/FINAL

What is the therapeutic level of theophylline?

10-20 mcg/dL

A mother is concerned because she has counted only 8 kicks from her baby in two, 2-hour intervals; what intervention is necessary?

CALL THE HCP

To assess the effectiveness of an analgesic administered to a 4-yr old, what intervention is best for the nurse to implement? A. Use a happy-face/sad-face pain scale B. Ask the mother if she thinks the analgesic is working C. Assess for changes in vital signs D. Teach the child to point to a numeric pain scale

Correct Answer: A A 4-year-old can readily identify with simple pictures to show how he/she is feeling

A 6-year-old is admitted to the pediatric unit after falling off of a bicycle. Which intervention should the RN implement to help the child adjust to the unit. A. Explain hospital schedules, including mealtime B. Use terms such as "honey" and "dear" so show caring C. Provide a list of rules restricting visitation of siblings D. Orient the parents to the hospital unit and refreshment areas

Correct Answer: A A disrupted schedule is very difficult for a child, active sensitivity can minimize the negative effects of hospitalization

Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as A. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks B. a subarachnoid hematoma, which requires immediate drainage to prevent complications C. molding, caused by pressure during labor and will disappear within 2 to 3 days D. a subdural hematoma which can result in lifelong damage

Correct Answer: A A slight abnormal variation of the newborn, usually arises within first 24 hours after delivery. Trauma from delivery causes capillary bleeding between the periosteum and the skull (B) a cranial distortion lasting 5-7 days, caused by pressure on the cranium (C&D) involves cranial bleeding; cannot be detected on physical exam alone

The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake.

Correct Answer: A An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D.

As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider? A. A 6-month old with failure to thrive that has a closed anterior fontanel B. A 24-month old with gastroenteritis that has a closed posterior fontanel C. A 2-month old with chickenpox that has an open posterior fontanel D. A 28-month old with hydrocephalus that has an open anterior fontanel

Correct Answer: A At 6-months of age the anterior fontanel should be open and it should not be closed until approximately 18-months of age. (B&C) are normal findings. (D) A child with hydrocephalus may have delayed closing

Which menu selection by a child w/ celiac disease indicates to the nurse that the child understands necessary dietary considerations? A. Oven-baked potato chips and cola B. Peanut butter and banana sandwhich C. Oat-meal raisin cookies and milk D. Graham crackers and fruit juice

Correct Answer: A Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat and barley (eating foods with this can cause diarrhea).

A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting

Correct Answer: A Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly. Options B, C, and D are not recognized as common complications of trisomy 21.

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? A. "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period." B. "Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk." C. "I can start smoking cigarettes while breastfeeding because it will not affect my breast milk." D. "When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings."

Correct Answer: A Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method. Option B is incorrect because alcohol can immediately enter the breast milk. Nicotine is transferred to the infant in breast milk. Taking a warm shower will stimulate the production of milk, which will be more painful after breastfeedings. A

A woman with Type 2 diabetes mellitus becomes pregnant, and her oral hypoglycemic agents are discontinued. Which intervention is most important for the nurse to implement? A. Describe diet changes that can improve the management of her diabetes B. Inform the client that oral hypoglycemic agents are teratogenic during pregnancy C. Demonstrate how to administer insulin D. Evaluate the client's ability to do glucose monitoring

Correct Answer: A Diet modifications are effective in managing this type of diabetes during pregnancy. The other answers should be implemented but are not a PRIORITY

The nurse is giving a liquid iron preparation to a 3-year-old, which technique should the RN implement to encourage active engagement? A. Use a colorful straw B. Mix the medication in water C. Administer the medication using an oral syringe D. Ask pharmacy to provide an enteric tablet

Correct Answer: A Drinking from a colorful straw can be seen as fun.

When discussing discipline with the mother of a 4 year-old, the nurse should include which guideline? A. Parental control should be constant B. Children aged 4 rarely require reprimand C. Withdrawal of approval is effective D. Parents should enforce rules without question

Correct Answer: A Duh.

A woman who thinks she could be pregnant calls her neighbor, who is a nurse, to ask when she should use a home pregnancy test. Which response is appropriate? A. "A home pregnancy test can be used right after your first missed period." B. "These tests are most accurate after you missed your second period." C "Home pregnancy tests often give false positives and should not be trusted." D. "The test can provide accurate information when used right after ovulation."

Correct Answer: A Home urine test are based on the chemical detection of human chorionic gonadotrophin, which begins to increase 6-8 days after conception. Best detected at 2 weeks gestation or immediately after first missed period.

A nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing? A. Hypotonic B. Precipitate C. Hypertonic D. Preterm labor

Correct Answer: A Hypotonic labor contractions are short, irregular, weak, and usually occur during the active phase of labor. Precipitate labor is that which lasts in its entirety for 3 hours or less. Hypertonic dysfunction usually occurs during the latent phase of labor. Preterm labor is the onset of labor after 20 weeks of gestation and before the beginning of the 38th week of gestation.

A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.

Correct Answer: A Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition. Option B is not necessary because this is not a public health hazard. Option C slows the healing process and can contribute to spread of the infection. The lesions should be washed with soap and water, topical ointment applied, and left open to the air to dry. This will occur at the child's home.

A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? A. Choking, coughing, and cyanosis B. Projectile vomiting and cyanosis C. Apneic spells and grunting D. Scaphoid abdomen and anorexia

Correct Answer: A Includes the 3 "C's" of esophageal atresia caused by the overflow of secretions into the trachea. (B) is characteristic of pyloric stenosis. (C) could be due to prematurity or sepsis, and grunting indicates respiratory distress. (D) characteristic of diaphragmatic hernia

The nurse is reviewing the record of a pregnant client seen in the health care clinic for the first prenatal visit. Which data if noted on the client's record would alert the nurse that the client is at risk for developing gestational diabetes during this pregnancy? A. The client's last baby weighed 10 pounds at birth. B. The client's previous deliveries were by cesarean birth. C. The client has a family history of cardiovascular disease. D. The client is 5 feet 3 inches in height and weighs 165 pounds.

Correct Answer: A Known risk factors that increase the risk of developing gestational diabetes include obesity (more than approximately 198 pounds, depending on height), chronic hypertension, family history of diabetes mellitus, previous birth of a large infant (greater than 4000 g), and gestational diabetes in a previous pregnancy. Options 2, 3, and 4 are not risk factors associated with the development of gestational diabetes.

A nurse is caring for a client in the active stage of labor. The nurse notes that the fetal pattern shows a late deceleration on the monitor strip. Based on this finding the nurse should prepare for which appropriate nursing action? A. Administering oxygen via face mask B. Placing the mother in a supine position C. Increasing the rate of the intravenous (IV) oxytocin (Pitocin) infusion D. Documenting the findings and continuing to monitor the fetal patterns

Correct Answer: A Late decelerations are caused by uteroplacental insufficiency as a result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena cava. An IV oxytocin infusion is discontinued when a late deceleration is noted; otherwise the oxytocin would cause further hypoxemia because of increased uteroplacental insufficiency caused by stimulation of contractions caused by the oxytocin. Option 4 would delay necessary treatment.

A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is prescribed. Which instruction should the nurse provide to this client? A. Breastfeed the infant, ensuring that both breasts are completely emptied. B. Feed expressed breast milk to avoid the pain of the infant latching onto the infected breast. C. Breastfeed on the unaffected breast only until the mastitis subsides. D. Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the infant.

Correct Answer: A Mastitis, caused by plugged milk ducts, is related to breast engorgement, and breastfeeding during mastitis facilitates the complete emptying of engorged breasts, eliminating the pressure on the inflamed breast tissue. Option B is less painful but does not facilitate complete emptying of the breast tissue. Option C will not relieve the engorgement on the affected side. Option D will not decrease antibiotic effects on the infant.

Which finding in a 19 yr old female client should trigger further assessment by the nurse? A. Menstruation has not occurred B. Reports no tetanus immunization since childhood C. Denies having any wisdom teeth D. History of painful, inwards growth on bottom of foot

Correct Answer: A Menstruation is a secondary sex-characteristic that should occur before age 18. (B) A tetanus booster is generally given at age 16.

A 3-month-old develops oral thrush. Which pharmacological agent should the RN administer? A. Nystatin B. Nitrofurantoin C. Norfloxacin D. Neomycin sulfate

Correct Answer: A Nystatin is an oral antiifungal. Duh.

A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? A. Bone pain, pallor B. Weakness, tremors C. Nystagmus, anorexia D. Fever, abdominal distention

Correct Answer: A Option A lists the most common presenting symptoms of leukemia. Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor. Options B and C could be associated with central nervous system disorders. Option D commonly occurs in children but is not specific for leukemia.

When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastroesophageal reflux disease, which intervention is most important for the nurse to implement? A. Record weight daily B. Assess for signs of anemia C. Document sleeping patterns D. Teach parenting skills

Correct Answer: A Patients with GERD have a fear of eating so there is a risk for imbalanced nutrition.

When assessing a child with asthma, the nurse should expect intercostal retractions during A. Inspiration B. Coughing C. Apneic episodes D. Exhalation

Correct Answer: A Result of respiratory effort to inhale through restricted airways.

Which action should the nurse implement when preparing to measure the fundal height of a pregnant client? A. Have the client empty the bladder B. Request the client lie on her left side C. Perform Leopold's maneuvers first D. Give the client some juice

Correct Answer: A The bladder must be completely empty to accurately measure the fundal height.

A 2-year-old child with Downs Syndrome is brought to the clinic for his regular physical exam. The nurse knows which problem is frequently associated with DS A. Congenital heart disease B. Fragile X chromosome C. Trisomy 13 D. Pyloric Stenosis

Correct Answer: A The most common associated condition associated with DS. (B&C) involve abnormalities with chromosomes but are not associated with DS

A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line.

Correct Answer: A The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.

The nurse is teaching a 12-year-old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse S/S are commonly associated with this therapy? A. Polyuria and polydipsia B. Lethargy and fatigue C. Increased facial hair D. Facial bone structure changes

Correct Answer: A These are S/S of diabetes or hyperglycemia. Those receiving growth hormone should have their blood glucose monitored to detect elevations and intolerance.

The nurse is collecting data from a client during the first prenatal visit. The client is anxious to know the gender of the fetus and asks the nurse when she will be able to know. The nurse should respond to the client knowing that the gender of the fetus is determined by which weeks? A. 6 to 8 B. 8 to 10 C. 13 to 16 D. 20 to 22

Correct Answer: C By the end of the twelfth week of gestation, the fetal gender can be determined by the appearance of the external genitalia on ultrasound; therefore the other options are incorrect.

A client at 28-weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. Which instruction should the nurse provide? A. Come to the clinic today for an ultrasound B. Go immediately to the emergency room C. Lie on your left side for about one hour and see if the bleeding stops D. Bring a urine sample to the lab tomorrow to determine if you have a UTI

Correct Answer: A Third trimester painless bleeding is characteristic of a placental previa. Bright red bleeding may be intermittent, occur in gushes, or be continuous **Bleeding that is sudden and accompanied by intense uterine pain indicates placental abruption, which IS life threatening

A 3-week-old newborn is brought to a clinic for follow-up after a home birth. The child bottle feeds for 5 minutes only then falls asleep. A loud murmur characteristic of ventricular septal defect (VSD), and finds the newborn acyanotic with a RR of 64 bpm. What instruction should be provided to ensure the newborn gets adequate fluid intake? (Select all that apply). A. Monitor the infant's weight and number of wet diapers per day B. Increase the infant's intake per feeding by 1-2 ounces per week C. Mix the dose of prophylactic antibiotic with formula in whole bottle D. Allow the infant to rest and refeed on demand or every 2 hours E. Use a softer nipple or increase the size of the nipple opening

Correct Answer: A, B, D & E Infants with VSD fatigue quickly and ingest inadequate amounts. A one-month old infant should ingest 2-4 ounces of formula per feeding to about 30 ounces per day for a 4-month old. The infant should eat every 2 hours to allow for adequate rest in between meals. A larger nipple/nipple size helps to reduce the effort of sucking

Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion

Correct Answer: A,C,D & E Options A, C, D, and E are all common assessment findings in the client with cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis.

A child diagnosed with scarlet fever is being cared for at home. The home health nurse performs an assessment on the child and checks for which clinical manifestations of this disease? Select all that apply. A. Pastia's sign B. Koplik's spots C. White strawberry tongue D. Edematous and beefy-red pharynx E. Petechial red, pinpoint spots on the soft palate F. Small red spots with a bluish-white center and a red base located on the buccal mucosa

Correct Answer: A,C,D &E Pastia's sign describes a rash seen in scarlet fever that will blanch with pressure except in areas of deep creases and the folds of joints. The tongue initially is coated with a white furry covering, with red projecting papillae (white strawberry tongue). By the fourth to fifth day, the white strawberry tongue sloughs off, leaving a red swollen tongue (strawberry tongue). The pharynx is edematous and beefy red. Koplik's spots are associated with rubeola (measles). These are small red spots with a bluish-white center and a red base located on the buccal mucosa. Petechial red, pinpoint spots occurring on the soft palate are characteristic of rubella (German measles).

The nurse caring for a laboring client encourages her to void at least q2h, and records each time the client empties her bladder. What is the primary reason for implementing this nursing intervention? A. Emptying the bladder during delivery is difficult because of the position of the presenting fetal part B. An over-distended bladder could be traumatized during labor, as well as prolong the progress of labor C. Urine specimens for glucose and protein must be obtained at certain intervals throughout labor D. Frequent voiding minimizes the need for catheterization which increases the chance of bladder infection

Correct Answer: B A full bladder can impair the efficacy of the uterine contractions and impede descent of the fetus during labor

The nurse in the gynecology clinic is reviewing the record of a pregnant client after the first prenatal visit. The nurse notes that the health care provider has documented that the woman has a platypelloid pelvis. On the basis of this documentation, the nurse plans care, knowing that this type of pelvis has which characteristic? A. Is heart-shaped B. Has a flat C. Is oval-shaped D. Is normal

Correct Answer: B A platypelloid pelvis has a flat shape. An anthropoid pelvis has an oval shape, and an android pelvis is heart-shaped. A gynecoid pelvis is a normal female pelvis.

A 3-year-old client with sickle cell anemia is admitted to the Emergency Department with abdominal pain. The nurse palpates an enlarged liver, an x-ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis? A. Aplastic. B. Sequestration. C. Hyperhemolytic. D. Vaso-occlusive.

Correct Answer: B A sequestration crisis involves blood pooling in the spleen; S/S include abdominal pain and anemia

When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement? A. Use a blanket as a mummy restraint. B. Monitor the infant's heart rate. C. Lubricate the catheter with saline. D. Explain the procedure to the parents.

Correct Answer: B All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B.

The nurse should explain to a 30-year-old gravid client that alpha fetoprotein testing is recommended for which purpose? A. Detect cardiovascular disorders B. Screen for neural tube defects C. Monitor the placental functioning D. Assess for maternal pre-ecplamsia

Correct Answer: B Alpha-fetoprotein (AFP) is a screening test used in pregnancy. Elevation may indicate neural tube defect

A 3-year-old boy is brought to the emergency room after swallowing an entire bottle of multi-vitamins. Which intervention should RN implement first? A. Inert NG tube for gastric lavage B. Determine the child's pulse and respirations C. Assess the child's level of consciousness D. Administer IV D5NS as prescribed

Correct Answer: B Assessing the airway is the first intervention (respirations)

A 6-month-old boy and his mother are at the health clinic for a well-baby checkup and routine immunization. The HP recommends an influenza vaccine. What medications should the RN plan to administer? A. The routine immunizations and schedule another apt. for the influenza. B. All the immunizations with the influenza being administered in a different site C. The influenza vaccine and schedule another apt. for all other routine immunizations D. The influenza and polio vaccines, then schedule another apt. for the remaining vaccines

Correct Answer: B At 6-months of age, routine vaccinations include TDAP, Hep B, HIB, PVC, IPV, and influenza

Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips C. Her arms and hands receive the infant and she then cuddles the infant to her own body D. She eagerly reaches for the infant and then holds the infant to her own body

Correct Answer: B Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B)

Which class of antiinfective drugs is contraindicated for use in children under 8 yrs of age? A. Aminoglycosides B. Teteracyclines C. Penicillins D. Quinolones

Correct Answer: B Cause enamel hypoplasia and tooth discoloration

A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? A. Ask if she takes a daily calcium tablet B. Extend the leg and dorsiflex the foot C. Lower the leg off the side of the bed D. Elevate the leg above the heart

Correct Answer: B Dorsiflexinfg the foot by pushing the sole of the foot forward or by standing is the best means of relieving leg cramps

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 expects which finding? A. 22 cm B. 30 cm C. 36 cm D.40 cm

Correct Answer: B During the second and third trimesters (weeks 18 to 30), fundal height in centimeters approximately equals the fetus' age in weeks ± 2 cm. 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.

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention? A. Cover the bladder with petroleum jelly gauze. B. Cover the bladder with a nonadhering plastic wrap. C. Apply sterile distilled water dressings over the bladder mucosa. D. Keep the bladder tissue dry by covering it with dry sterile gauze.

Correct Answer: B In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.

A child with sickle cell anemia who is in vaso-occlusive crisis is admitted to the hospital. Which health care provider prescription would assist in reversing the vaso-occlusive crisis? A. Monitor pulse oximetry B. Begin intravenous fluids C. Monitor vital signs and respiratory status D. Check the O2 saturation to ensure it is greater than 95%

Correct Answer: B Increased fluid volume reduces the viscosity of the blood, preventing further vascular occlusion and further sickling caused by dehydration. Options 1, 3, and 4 may be components of care, but they are actions that relate to monitoring the client. The intravenous fluids, however, will treat the condition.

Which growth and development characteristic should the nurse consider when monitoring the effects of a topical medication for an infant? A. A lower sensitivity reactions to skin irritants. B. A thin stratum corneum that increases topical absorption. C. A smaller percentage of muscle mass. D. A greater body surface area that requires larger dosages.

Correct Answer: B Infants have a smaller outer layer of skin. The nurse should monitor the onset and any reactions to the medications.

A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery. In developing a plan of care, the nurse should give the highest priority to which finding? A. Cyanosis of the hands and feet B. Skin color that is slightly jaundiced C. Tiny white papules on the nose or chin D. Red patches on the cheeks and trunk

Correct Answer: B Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin, which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of the hands and feet) is a common finding in newborns; it occurs because the capillary system is immature. Milia are small white papules present on the nose and chin that are caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on the cheeks and trunk are called erythema toxicum neonatorum, a common finding in newborns.

A primigravida, when returning for the results of her multiple marker screening (triple screen), asks the nurse how problems with her baby can be detected by the test. What information will the nurse give to the client to describe best how the test is interpreted? A. If MSAFP (maternal serum alpha-fetoprotein) and estriol levels are high and the human chorionic gonadotropin (hCG) level is low, results are positive for a possible chromosomal defect. B. If MSAFP and estriol levels are low and the hCG level is high, results are positive for a possible chromosomal defect. C. If MSAFP and estriol levels are within normal limits, there is a guarantee that the baby is free of all structural anomalies. D. If MSAFP, estriol, and hCG are absent in the blood, the results are interpreted as normal findings.

Correct Answer: B Low levels of MSAFP and estriol and elevated levels of hCG found in the maternal blood sample are indications of possible chromosomal defects. High levels of MSAFP and estriol in the blood sample after 15 weeks of gestation can indicate a neural tube defect, such as spina bifida and anencephaly, not chromosomal defects. One of the limitations of the multiple marker screening is that any defects covered by skin will not be evident in the blood sampling. After 15 weeks of gestation, there will be traces of MSAFP, estriol, and hCG in the blood sample.

The health care provider prescribes patching for a child with strabismus of the right eye, and the nurse instructs the mother regarding this procedure. What should the nurse include in the instructions? A. Place the patch on both eyes. B. Place the patch on the left eye. C. Place the patch on the right eye. D. Alternate the patch from the right to the left eye hourly.

Correct Answer: B Patching may be used in the treatment of strabismus ( AKA lazy eye) to strengthen the weak eye. In this treatment, the better functioning eye is patched. This encourages the child to use the weaker eye. It is most successful when done during the preschool years. The schedule for patching is individualized and is prescribed by the ophthalmologist.

The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question? A. If the child's tongue darkens, discontinue immediately B. Do not give if the child has chickenpox, flu, or any other viral illnesses C. Avoid the use of Pepto Bismol until the child is 16 D. Pepto Bismol may cause a rebound hyperacidity, worsening the "tummy ache"

Correct Answer: B Pepto contains aspirin, and there is a potential for Reye's syndrome. Other illnesses can worsen the condition.

Which action by the nurse is most helpful in communicating with a preschool-aged child? A. Speak clearly and directly to the child B. Use a doll to play and communicate C. Approach when parent is not present D. Play a board game with the child

Correct Answer: B Playing with the child using a doll or another toy helps them feel more comfortable with a stranger.

A six month old returns from surgery with elbow restraints. What nursing care should be included when caring for a child in restraints? A. Keep restraints on at all times B. Remove restraints one at a time and provide ROM exercises C. Remove all restraints simultaneously and provide play activities D. Renew the HP's order for restraints every 72 hours

Correct Answer: B Removing restraints one at a time is safer than removing them all at once.

An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab stat.

Correct Answer: B Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D is indicated for a serious, life-threatening overdose with digoxin.

What intervention is required for a teenager experiencing acute glomerulonephritis with a BP of 170/88 (previously 210/110)? A. Give the patient their oral diuretic early B. Administer PRN nifedipine (Procardia) sublingually C. Notify the HP and the charge nurse of the patient's condition D. Attempt to calm the patient and retake the BP in 30 min

Correct Answer: B Sublingual Procardia administered sublingual lowers BP quickly and should be done first. (A) Oral diuretics do not work as quickly, but may also be done.

The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. Sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C. Is not completely toilet-trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime

Correct Answer: B Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure. Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common; 2-year-olds are not expected to be toilet-trained. Option D is normal.

The vital signs of 4 yr old child w/ polyuria are: BP 80/40, pulse, 118, and Resp. 24. The child's pedal pulses are present w/ a volume of +1, and no edema is observed. What action should the nurse implement first? A. Insert an indwelling catheter B. Start an IV infusion of normal saline C. Send a specimen to the lab for urinalysis D. Document the child's vital signs and pulses

Correct Answer: B The child is experiencing fluid volume deficit as evidenced by the VS and decreased pulse pressures. **Priority is to restore fluids

The nurse in a health care clinic is instructing a pregnant client how to perform "kick counts." Which statement by the client indicates a need for further instructions? A. " I will record the number of movements or kicks" B. "I need to lie flat on my back to perform the kick count" C. "If I count fewer than 10 kicks in a 2-hour period I should count the kicks again over the next 2 hours." D. "I should place my hands on the largest part of my abdomen and concentrate on the fetal movements to count the kicks."

Correct Answer: B The client should sit or lie quietly on her side to perform kick counts. Lying flat on the back is not necessary to perform this procedure, can cause discomfort, and presents a risk of vena cava (supine hypotensive) syndrome. The client is instructed to place her hands on the largest part of the abdomen and concentrate on the fetal movements. The client records the number of movements felt during a specified time period. The client needs to notify her health care provider if she feels fewer than 10 kicks over two, 2-hour intervals or as instructed by her HCP.

An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child's lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site.

Correct Answer: B The extremity should be extended to prevent trauma to the femoral catheterization site. Options A and D increase the risk for complications and are contraindicated. Option C is not necessary. Only the extremity that was catheterized requires immobilization.

During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing? A. Hearing tests B. Eye exams C. Chest X-rays D. Fasting blood glucose test

Correct Answer: B Visuals changes resulting in blindness can occur in children with JRA.

A 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? A. Gently push the cord into the vagina. B. Place the client in Trendelenburg's position. C. Find the closest telephone and page the health care provider stat. D. Call the delivery room to notify the staff that the client will be transported immediately.

Correct Answer: B When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with her hips higher than her head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the health care provider and notify the delivery room. If the cord is protruding from the vagina, no attempt should 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 mother to increase fetal oxygenation. Test-Taking Strategy: Note the strategic word initial and the words umbilical cord protruding from the vagina. Options 3 and 4 can be eliminated first because these actions delay necessary and immediate treatment. Knowledge that the cord should not be pushed back into the vagina will easily direct you to the correct option

A client with severe preeclampsia is admitted to the maternity department. Which room assignment would be most appropriate for this client? A. A private room across from the elevator B. A semiprivate room across from the nurses' station C. A private room two doors away from the nurses' station D. A semiprivate room with another client who enjoys watching television

Correct Answer: C

The nurse must prevent a 2-year old with severe eczema on the face, neck and scalp from scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the pruritis? A. obtain gloves for the child's hands B. apply finger cots on the child's fingers C. place elbow restraints on the child's arms D. apply soft restraints to the child's wrists

Correct Answer: C (A&B) are too easy to remove. (C) Will prevent the child from reaching the surgical site, but will still allow for playing.

Which behavior would the nurse expect a 2-year-old to exhibit? A. Build a house with blocks B. Ride a tricycle C. Display possessiveness of toys D. Look at a picture book for 15 minutes

Correct Answer: C 2-year-olds are egocentric and unable to share with others

The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse consider normal for this child? A. Has a temper tantrum when told he must share toys B. Plays by himself most of the day C. Demonstrates aggressiveness by boasting when telling a story D. Begins to cry and is tearful when separated from parents

Correct Answer: C 4 year old children are aggressive in their play and enjoy "tale-telling".

A client who delivered an infant an hour ago tells the nurse the she feels wet underneath her buttock. The nurse notes that the perineal pad is saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement first? A. Cleanse the perineum B. Obtain a blood pressure C. Palpate the firmness of the fundus D. Inspect the perineum for lacerations

Correct Answer: C A firm uterus is needed to control bleeding from the placental site of attachment on the uterine wall. The nurse should FIRST assess for firmness and massage the fundus as indicated.

A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by which behavior? A. Ability to communicate verbally B. Response to separation from family C. Concerns for body integrity D. Socialization with other children

Correct Answer: C A preschooler fears that his "insides will leak out". (A) a preschooler is quite verbal (B) mainly for toddlers; (D) not a primary concern.

A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first? A. Slowly pour hydrogen peroxide over the open wound B. Apply ice to the area before rinsing with cold water C. Wash the wound gently with mild soap and water D. Gently cleanse with a sterile pad using povidone-iodine

Correct Answer: C A small superficial laceration should be cleansed thoroughly. (A&D) can be traumatic/painful when cleaning fresh, open wounds

The nurse is assessing a 2-year-old. Which behavior indicates that the child's language development is within normal limits. A. Is able to name four colors B. Can count five blocks C. Is capable of making a three word sentence D. Half of child's speech is understandable

Correct Answer: C A toddler aged 1-3 years is capable of making 2-3 word sentences

Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate. A. A trial of adrenocorticotrophic hormone therapy B. Frequent stimulation of the cremasteric reflex C. A trial of chorionic gonadotrophic hormone D. Frequent warm baths to gently dilate the scrotal area

Correct Answer: C A trial of HCG will aid in testicular descent but does not replace surgery for true undesceneded testes.

A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need? A. 400 calories/day B. 500 calories/day C. 600 calories/day D. 700 calories/day

Correct Answer: C An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54, and 540 + 54 = 594. This infant will require approximately 600 calories/day. Options A, B, and D are incorrect.

The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child's head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.

Correct Answer: C Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium. Options A and B are incorrect positions and may hinder the child's condition. Option D may cause chest pain or a vasovagal response, with resulting hypotension.

A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own blood pressure and gave her parameters to judge a significant increase in blood pressure. When the client calls the clinic complaining of indigestion, which instruction should the nurse provide? A. Lie on your left side and call 911 for emergency assistance. B. Take an antacid and call back if the pain has not subsided. C. Take your blood pressure now, and if it is seriously elevated, go to the hospital. D. See your health care provider to obtain a prescription for a histamine blocking agent.

Correct Answer: C Checking the blood pressure for an elevation is the best instruction to give at this time. A blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of an impending seizure (eclampsia), a life-threatening complication of gestational hypertension. Additional data are needed to confirm an emergency situation as described in option A. Options B and D ignore the threat to client safety posed by a significant increase in blood pressure.

The parents of a child with a cleft lip are concerned and ask the nurse when the lip will be repaired. With which statement should the nurse respond? A. Cleft lip cannot be repaired. B. Cleft-lip repair is usually performed by 6 months of age. C. Cleft-lip repair is usually performed during the first weeks of life. D. Cleft-lip repair is usually performed between 6 months and 2 years.

Correct Answer: C Cleft-lip repair is usually performed during the first few weeks of life. Early repair may improve bonding and makes feeding much easier. Revisions may be required at a later age. All other options are incorrect. P.S. options B & D can be eliminated because they are alike

In developing a teaching plan for a 5-year-old child with diabetes, which component of diabetic management should the nurse plan for the child to manage first. A. Food planning and selection B. Administering insulin injection C. Process of glucose testing D. Drawing up the correct

Correct Answer: C Developmentally, a 5-year-old has the cognitive and psychomotor skills to use a glucometer. (A,B &D) require a more cognitive/psychomotor advance

The nurse in the newborn nursery is preparing to complete an initial assessment on a newborn infant who was just admitted to the nursery. The nurse should place a warm blanket on the examining table to prevent heat loss in the infant caused by which method? A. Radiation B. Convection C. Conduction D. Evaporation

Correct Answer: C Heat loss occurs by four different mechanisms. In conduction, heat loss occurs when the infant is on a cold surface, such as a table. Radiation occurs when heat from the body surface radiates to the surrounding environment. In convection, air moving across the infant's skin transfers heat to the air. Evaporation of moisture from a wet body surface dissipates heat along with the moisture.

An adolescent with diabetes receives 30 units of Humulin N insulin at 7:00 am. In accordance with the peak insulin action time, the nurse would monitor for a hypoglycemic episode at what time? A. At bedtime B. At midmorning C. Before supper D. After breakfast

Correct Answer: C Humulin N insulin is an intermediate-acting insulin that peaks in approximately 6 to 12 hours. It would peak before supper if given at 7:00 am. Short-acting insulin would peak after breakfast or midmorning. Long-acting insulins would peak at bedtime.

The nurse has provided instructions about measures to clean the penis to a mother of a male newborn who is not circumcised. Which statement, if made by the mother, indicates an understanding of how to clean the newborn's penis? A. "I should retract the foreskin and clean the penis every time I change the diaper." B. "I need to retract the foreskin and clean the penis every time I give my infant a bath." C. "I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions." D. "I should gently retract the foreskin as far as it will go on the penis and then pull the skin back over the penis after cleaning."

Correct Answer: C In male newborn infants, the prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, this may cause adhesions to develop. The mother should be told to allow separation to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning. Options that identify actions that address retraction of the foreskin are therefore incorrect.

A client at 32-weeks gestation is hospitalized with severe pregnancy-induced hypertension (PIH), and magnesium sulfate is prescribed to control the symptoms. Which assessment finding indicates the therapeutic drug level has been achieved? A. 4+ reflexes B. Urinary output of 50 ml/hr C. A decrease in RR from 24 to 16 D. A decreased body temp

Correct Answer: C Magnesium sulfate, a CNS depressant, helps prevent seizures.** RR <12 indicate toxicity, Urine output should be at least 30 ml/hr

The nurse is counseling a woman who wants to become pregnant. The woman tells the nurse that she has a 36-day menstrual cycle and the first day of her last menstrual period was January 8. The nurse correctly calculates that the woman's next fertile period is A. January 14-15 B. January 22-23 C. January 30-31 D. February 6-7

Correct Answer: C Ovulation occurs 14 days before the first day of the menstrual period.

Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites

Correct Answer: C Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage. Of the choices listed, only urinary catheterization is an invasive procedure. Options A, B, and D are not invasive and do not require administration of prophylactic antibiotics.

The nurse should encourage the laboring patient to begin pushing when A. there is only an anterior or posterior lip of cervix left B. the client describes the need to have a BM C. the cervix is completely dilated C. the cervix is completely effaced

Correct Answer: C Pushing begins with the second stage of labor (i.e. when the cervix is completely dilated at 10 cm). Pushing before this point could case the cervix to become edematous = operative delivery.

Prior to discharge, what instructions should the nurse give to parents regarding the newborn's umbilical cord care at home? A. Wash the cord frequently with mild soap and water. B. Cover the cord with a sterile dressing. C. Allow the cord to air-dry as much as possible. D. Apply baby lotion after the baby's daily bath.

Correct Answer: C Recent studies have indicated that air drying or plain water application may be equal to or more effective than alcohol in the cord healing process. Options A, B, and D are incorrect because they promote moisture and increase the potential for infection.

A pregnant client at 10 weeks' gestation calls the prenatal clinic to report a recent exposure to a child with rubella. The nurse reviews the client's chart. What is the nurse's best response to the client? A. "You should avoid all school-age children during pregnancy." B. "There is no need to be concerned if you don't have a fever or rash within the next 2 days." C. "You were wise to call. Your rubella titer indicates that you are immune and your baby is not at risk." D. "Be sure to tell the health care provider in 2 weeks as additional screening will be prescribed during your second trimester."

Correct Answer: C Rubella virus is spread by aerosol droplet transmission through the upper respiratory tract and has an incubation period of 14 to 21 days. The risks of maternal and subsequent fetal infection during the second trimester include hearing loss and congenital anomalies; these risks decrease after the first 12 weeks of pregnancy. Rubella titer determination is a standard antenatal test for pregnant women during their initial screening and entry into the health care delivery system. As noted in this client's chart, she is immune to rubella. The correct option is the only option that helps clarify maternal concerns with accurate information.

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign? A. 3 B. 4 C. 5 D. 8

Correct Answer: C The Silverman-Anderson index is an assessment scale that scores a newborn's respiratory status as grade 0, 1, or 2 for each component; it includes synchrony of the chest and abdomen, retractions, nasal flaring, and expiratory grunt. No respiratory distress is graded 0, and a total of 10 indicates maximum respiratory distress. This infant is demonstrating respiratory distress with maximal effort, so a grade 2 is assigned for marked nasal flaring, grade 2 for an audible expiratory grunting, plus grade 1 for just visible retractions, which is a total score of 5. Options A, B, and D are not accurate.

A 12-month-old is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority? A. Give small frequent feedings of fluids B. Accurately chart assessed breath sounds C. Have a bulb syringe readily available to remove secretions D. Encourage older siblings to visit

Correct Answer: C The child already has a respiratory infection and pneumonia, his airway could become compromised with the secretions.

Several children have contracted rubeola (measles) in a local school, and the school nurse conducts a teaching session for the parents of the schoolchildren. Which statement made by a parent indicates a need for further teaching regarding this communicable disease? A. "Small blue-white spots with a red base may appear in the mouth." B. "The rash usually begins on the face and spreads downward toward the feet." C. "The disease can be spread to others 10 days before any sign of the disease appears to 15 days after the rash appears." D. "Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash."

Correct Answer: C The communicable period for rubeola ranges from 4 days before to 5 days after the rash appears, mainly during the prodromal stage. All other options are accurate descriptions of rubeola, so they would not indicate a need for further teaching. The small blue-white spots found in this communicable disease are called Koplik's spots. The incorrect option describes the incubation period for rubella, not rubeola.

Six hours after an oxytocin (Pitocin) induction was begun and 2 hours after spontaneous rupture of the membranes, the nurse notes several sudden decreases in the fetal heart rate with quick return to baseline, with and without contractions. Based on this fetal heart rate pattern, which intervention is best for the nurse to implement? A. Turn the client to her side. B. Begin oxygen by nasal cannula at 2 L/min. C. Place the client in a slight Trendelenburg position. D. Assess for cervical dilation.

Correct Answer: C The goal is to relieve pressure on the umbilical cord, and placing the client in a slight Trendelenburg position is most likely to relieve that pressure. The FHR pattern is indicative of a variable fetal heart rate deceleration, which is typically caused by cord compression and can occur with or without contractions. Option A may be helpful but is not as likely to relieve the pressure as the Trendelenburg position. Option B is not helpful with cord compression. Option D is not the priority intervention at this time. After repositioning the client, a vaginal examination is indicated to rule out cord prolapse and assess for cervical change.

A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide formula for the infant until he becomes calm, and then offer the breast again.

Correct Answer: C The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful. Options A and D would cause nipple confusion. Option B would only cause the infant to be more resistant, resulting in the mother and infant becoming more frustrated.

When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority? A. Administering oxygen therapy continuously B. Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin levels

Correct Answer: C The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. Options A and D are nursing interventions for the cardiac client but do not treat polycythemia. Fluid intake should be increased, not restricted.

The nurse is developing a plan of care for a preterm newborn infant. The nurse develops measures to provide skin care, knowing that the preterm newborn infant's skin appears in what way? A. Thin and gelatinous, with increased subcutaneous fat B. Thin and gelatinous, with increased amounts of brown fat C. Reddened, translucent, and gelatinous, with decreased amounts of subcutaneous fat D. With fine downy hair on thin epidermal and dermal layers, with increased amount of brown fat

Correct Answer: C The skin of a newborn infant plays a significant role in thermoregulation and as a barrier against infection. The skin of a preterm newborn infant is immature in comparison with that of a term newborn infant. The skin of a preterm newborn is thin and gelatinous, with decreased amounts of subcutaneous fat, brown fat, and glycogen stores. In addition, preterm newborn infants lose heat because of their large body surface area in relation to their weight and because their posture is more relaxed, with less flexion. Therefore preterm newborn infants are less able to generate heat, which places them at risk for increased heat loss and increased fluid requirements.

A 16-year old boy is brought to the E.D. with a crushed leg after falling off a horse. His last tetanus toxoid booster was received at 8-years old. Which action should the nurse take? A. Dispense a tetanus antitoxin B. Prepare human tetanus immune globulin C. Administer tetanus toxoid booster D. Delay the tetanus toxoid booster

Correct Answer: C Toxoid booster should be administered every 10 years or with traumatic injury that is contaminated with dirt, feces, soil, or saliva

The nurse is reviewing the health care provider's (HCP'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 should the nurse question? A. Monitor fetal heart rate continuously. B. Monitor maternal vital signs frequently. C. Perform a vaginal examination every shift. D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours.

Correct Answer: C Vaginal examinations should 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.

A 14-year-old female client tells the nurse that she is concerned about the acne she has recently developed. Which recommendation should the nurse provide? A. Remove all blackheads and follow with an alcohol scrub B. Use medical cosmetics only to help hide the blemishes C. Wash the hair and skin frequently with soap and hot water D. Encourage her to see a dermatologist as soon as possible

Correct Answer: C Washing the hair and skin frequently removes oils and debris from the skin, which help prevent and treat acne.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? A. Hold the next dose of insulin. B. Come to the clinic immediately. C. Encourage the child to drink liquids. D. Administer an additional dose of regular insulin.

Correct Answer: C When the child is sick, the mother should test for urinary ketones with each voiding. If ketones are present, liquids are essential to aid in clearing the ketones. The child should be encouraged to drink liquids. Bringing the child to the clinic immediately is unnecessary. Insulin doses should not be adjusted or changed. Test-Taking Strategy: Use general medication guidelines. Eliminate options 1 and 4, noting that they are comparable or alike. Recall that insulin doses should not be adjusted or changed. From the remaining options, note the words positive for ketones. Recalling that liquids are essential to aid in clearing the ketones will direct you to the correct option.

A 2-year-old with gastroesophageal reflux disease has developed a fear of eating. What instruction should the RN include in the parent's teaching plan? A. Invite other children home to share meals B. Accept that he will eat when he is hungry C. Reward the child with a nap after eating D. Consistently follow a set meal-time routine

Correct Answer: D A 2-year-old is comforted by consistency.

What preoperative nursing intervention should be included in the plan of care for an infant w/ pyloric stenosis? A. Monitor for signs of metabolic acidosis B. Estimate the quantity of diarrhea stools C. Place in supine position after feeding D. Observe for projectile vomiting

Correct Answer: D A classic sign of pyloric stenosis, which contributes to metabolic alkalosis

A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate? A. "The child probably has an infection." B. "Have the child gargle with mouthwash every 4 hours." C. "You need to contact the health care provider immediately." D. "Bad mouth odor is normal and may be relieved by drinking more liquids."

Correct Answer: D A tonsillectomy is the surgical removal of the tonsils. Bad mouth odor is normal after tonsillectomy and may be relieved by drinking more liquids. There is no more information that would indicate an infection. Mouthwash gargles will irritate the throat. There is no need to contact the health care provider immediately because bad mouth odor is common and expected after tonsillectomy.

A child is seen in the health care clinic for complaints of fever. On data collection, the nurse notes that the child is pale, tachycardic, and has petechiae. Aplastic anemia is suspected. The nurse understands that which diagnostic test will confirm the diagnosis of aplastic anemia? A. Platelet count B. Granulocyte count C. Red blood cell count D. Bone marrow Biopsy

Correct Answer: D Although the diagnosis of aplastic anemia may be suspected from the child's history and the results of a complete blood count (CBC), a bone marrow biopsy must be performed to confirm the diagnosis.

The nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of which condition? A. Hematoma B. Uterine atony C. Placenta previa D. Placental separation

Correct Answer: D 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.

An infant is born to a mother with hepatitis B. Which prophylactic measure would be indicated for the infant? A. Hepatitis B vaccine given within 24 hours after birth B. Immune globulin (IG) given as soon as possible after delivery C. Hepatitis B immune globulin (HBIG) given within 14 days after birth D. Hepatitis B immune globulin (HBIG) and hepatitis B vaccine given within 12 hours after birth

Correct Answer: D Both HBIG and the vaccine are given to infants with perinatal exposure to prevent hepatitis and achieve lifelong prophylaxis; they are administered within 12 hours after birth. IG is given to prevent hepatitis A.

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicate that further teaching is necessary? A. "I'll check his temperature." B. "I'll give him medication so he'll be comfortable." C. "I'll check his voiding to be sure there's no problem." D. "I'll let him decide when to return to his play activities."

Correct Answer: D Cryptorchidism is a condition in which one or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output.

In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses

Correct Answer: D Diminished femoral pulses could indicate coarctation of the aorta. In the normal transition period, options A and B occur during the 4 to 6 hours after birth (second period of reactivity). Option C is a normal finding in the newborn.

A child with cystic fibrosis is having stools that float and are foul smelling. Which descriptive term should the nurse use to document the finding? A. Diarrhea B. Rhinorrhea C. Galactorrhea D. Steatorrhea

Correct Answer: D Fatty stools float and smell odorous (foul).

What bowel habits are seen in children with Hirschsprung's disease? A. Foul-smelling and fatty B. Bile-colored and watery C. Semi-solid and yellow D. Ribbon-like and brown

Correct Answer: D HD is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results as a failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis causes constipation and a small diameter, brown-colored stools.

In developing a teaching plan for expectant parents, the nurse decides to include information about when the parents can expect the infant's fontanels to close. Which statement is accurate regarding the timing of closure of an infant's fontanels that should be included in this teaching plan? A. The anterior fontanel closes at 2 to 4 months and the posterior fontanel by the end of the first week. B. The anterior fontanel closes at 5 to 7 months and the posterior fontanel by the end of the second week. C. The anterior fontanel closes at 8 to 11 months and the posterior fontanel by the end of the first month. D. The anterior fontanel closes at 12 to 18 months and the posterior fontanel by the end of the second month.

Correct Answer: D In the normal infant, the anterior fontanel closes at 12 to 18 months of age and the posterior fontanel closes by the end of the second month. These growth and development milestones are frequently included in questions on the licensure examination. Options A, B, and C are incorrect.

A mother discovers a bug has flown into her child's ear and can hear the buzzing; what intervention is priority? A. Irrigate the ear. B. Report to the clinic immediately. C. Use a tweezers to try to remove the insect. D. Use a flashlight to coax the insect out of the ear.

Correct Answer: D Insects that make their way into an ear often can be coaxed out using a flashlight or a humming noise. The mother should be instructed not to irrigate the ear or attempt to remove the insect by using tweezers because this could damage the ear. If the mother is unsuccessful in coaxing the insect out of the ear, she should be instructed to report to the clinic or the hospital emergency department.

One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. HR is 84 bpm, BP 156/96. The M.D. prescribe Methergine 0.2 mg IM x 1. Which action should the nurse take immediately? A. Give the medication as prescribed and monitor for efficacy B. Encourage the client to breastfeed rather than bottle feed C. Have the client empty her bladder and massage her fundus D. Call the HP to question the prescription

Correct Answer: D Methergine is contraindicated for clients with elevated BP, so the nurse should contact the HP and question the prescription.

A new mother is afraid to touch her baby's head for fear of hurting the "large soft spot." Which explanation should the nurse give to this anxious client? A. "Some care is required when touching the large soft spot area on top of your baby's head until the bones fuse together" B. "That's just an 'old wives' tale' so don't worry" C. "The soft spot will disappear within 6 weeks and if very unlikely to cause any problems for your baby" D. "There's a strong, tough membrane there to protect the baby so you need not be afraid to wash or comb their hair"

Correct Answer: D Provides correct information and relieves any anxiety

An off-duty nurse finds a woman in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which intervention has the highest priority? A. Use a thread to tie off the umbilical cord B. Provide as much privacy as possible C. Reassure the husband and try to keep him calm D. Put the newborn to breast

Correct Answer: D Putting the newborn to breast will help contract the uterus and prevent a postpartum hemorrhage. Preventing hemorrhage is the highest priority.

The nurse caring for a client with a diagnosis of subinvolution should understand that which is a primary cause of this diagnosis? A. Afterpains B. Increased estrogen levels C. Increased progesterone levels D. Retained placental fragments from delivery

Correct Answer: D Retained placental fragments and infections are the primary causes of subinvolution. When either of these processes is present, the uterus has difficulty contracting. The presence of afterpains is an expected finding following delivery. Options 2 and 3 are not causes of subinvolution

A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child's fluid intake. D. Tell the parent to take the child to the emergency department.

Correct Answer: D The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation. Options A, B, and C are all valuable interventions after the client is assessed and diagnosed.

A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the-counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough.

Correct Answer: D The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production. Option B delays evaluation too long. Although giving fluids is advisable, cough suppressants might mask symptoms of a serious condition.

The nurse assesses a client admitted to the labor and delivery unit and obtains the following data: dark red vaginal bleeding, uterus slightly tense between contractions, BP 110/68, FHR 110 beats/minute, cervix 1 cm dilated and uneffaced. Based on these assessment findings, what intervention should the nurse implement? A. Insert an internal fetal monitor B. Assess for cervical changes q1h C. Monitor bleeding from IV sites D. Perform Leopold's maneuvers

Correct Answer: D The client is presenting with signs of placental abruption so monitoring bleeding from peripheral IV sites is priority. WHY? Disseminated intravascular coagulation (DIC) is a complication of PA characterized by abnormal bleeding

A nulliparous woman asks the nurse when she will begin to feel fetal movements. The nurse responds by telling the woman that the first recognition of fetal movement will occur at approximately how many weeks of gestation? A. 5 weeks B. 9 weeks C. 13 weeks D. 18 weeks

Correct Answer: D The first recognition of fetal movements, or feeling life, by the multiparous woman may occur as early as 14 to 16 weeks' gestation. The nulliparous woman may not notice these sensations until the 18 weeks' gestation or later. The first recognition of fetal movement is called quickening

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement? A. Place a wedge under the client's left side. B. Determine cervical dilation and effacement. C. Administer 10 L of oxygen via facemask. D. Increase the rate of the oxytocin (Pitocin) infusion.

Correct Answer: D The goal of labor augmentation is to produce firm contractions that occur every 2 to 3 minutes, with a duration of 60 to 70 seconds, and without evidence of fetal stress. FHR accelerations are a normal response to contractions, so the oxytocin (Pitocin) infusion should be increased per protocol to stimulate the frequency and intensity of contractions. Options A and C are indicated for fetal stress. A sterile vaginal examination places the client at risk for infection and should be performed when the client exhibits signs of progressing labor, which is not indicated at this time.

A couple has been trying to conceive for nine months without success. Which information obtained from the clients is most likely to have an impact on the couple's ability to conceive a child? A. Exercise regimen of both partners includes running four miles each morning B. History of having sexual intercourse 2-3 times per week C. The woman's menstrual period occurs every 35 days D. They use lubricants with each sexual encounter to decrease friction

Correct Answer: D The use of lubricants has the potential to affect fertility because some lubricants interfere with sperm motility

An expectant father tells the nurse he fears that his wife "is losing her mind." He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? A. Reassure him that these are normal reactions to pregnancy and suggest that he discuss his concerns with the childbirth education nurse B. Help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed C. Ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse D. Let him know that these are normal maternal/fetal bonding behaviors which occur once the mother feels fetal movement

Correct Answer: D These behaviors are positive maternal/fetal bonding

One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking, and when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? A. Stimulate the infant to cry. B. Wrap the infant in warm blankets. C. Feed the infant formula. D. Obtain a serum glucose level.

Correct Answer: D This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level. Option A is an intervention for a lethargic infant. Option B should be done based on the temperature, but first the glucose level should be obtained. Option C helps raise the blood sugar, but first the nurse should determine the glucose level.

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? A. Variability B. Accelerations C. Early decelerations D. Variable decelerations

Correct Answer: D 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 findings are most critical for the nurse to report to the primary health care provider when caring for the client during the last trimester of her pregnancy? (Select all that apply.) A. Increased heartburn that is not relieved with doses of antacids B. Increase of the fetal heart rate from 126 to 156 beats/min from the last visit C. Shoes and rings that are too tight because of peripheral edema in extremities D. Decrease in ability for the client to sleep for more than 2 hours at a time E. Chronic headache that has been lingering for a week behind the client's eyes

Correct Answers: A & E Options A and E are possible signs of preeclampsia or eclampsia but can also be normal signs of pregnancy. These signs should be reported to the health care provider for further evaluation for the safety of the client and the fetus. Options B, C, and D are all normal signs during the last trimester of pregnancy.

Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply A. Providing a low-fat, well-balanced diet. B. Teaching the child effective hand-washing techniques. C. Scheduling playtime in the playroom with other children. D. Notifying the health care provider (HCP) if jaundice is present. E. Instructing the parents to avoid administering medications unless prescribed. F. Arranging for indefinite home schooling because the child will not be able to return to school.

Correct Answers: A,B & E Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand-washing is the most effective measure for control of hepatitis in any setting, and effective hand-washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply) A. Mood swings B. Panic attacks C. Tearfulness D. Decreased need for sleep E. Disinterest in the infant

Correct Answers: A,C "Postpartum blues" is a common emotional response related to the rapid decrease in placental hormones after delivery and include mood swings, teaefulness, feeling low, emotional, and fatigued. B,D, and E indicate "Postpartum Depression"

Which findings are of most concern to the nurse when caring for a woman in the first trimester of pregnancy? (Select all that apply.) A. Cramping with bright red spotting B. Extreme tenderness of the breast C. Lack of tenderness of the breast D. Increased amounts of discharge E. Increased right-side flank pain

Correct Answers: A,C & E Options A and C are signs of a possible miscarriage. Cramping with bright red bleeding is a sign that the client's menstrual cycle is about to begin. A decrease of tenderness in the breast is a sign that hormone levels have declined and that a miscarriage is imminent. Option E could be a sign of an ectopic pregnancy, which could be fatal if not discovered in time before rupture. Options B and D are normal signs during the first trimester of a pregnancy.

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply. A. Presence of Aschoff's bodies B. Absence of C-reactive protein C. Elevated antistreptolysin O titer D. Presence of Reed-Sternberg cell E. Elevated erythrocyte sedimentation rate

Correct Answers: A,C & E Rheumatic fever usually develops after a group A beta-hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated C-reactive protein level; an elevated antistreptolysin O titer; and an elevated erythrocyte sedimentation rate. Reed-Sternberg cells are found in Hodgkin's disease.

Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. B. Administer mineral oil daily. C. Decrease the daily fluids. D. Eliminate dairy products. E. Initiate consistent toileting routine.

Correct Answers: B, D & E Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis.

A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. In performing an assessment on the child, which findings are characteristic of this disorder? Select all that apply. A. Red throat B. Cracking lips C. Conjunctival hyperemia D. Desquamation of the skin E. Enlargement of the cervical lymph nodes

Correct Answers: B,C, & D Kawasaki disease is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory disease. Assessment findings in the acute stage include fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. Desquamation of the skin, cracking lips, joint pain, cardiac manifestations, and thrombocytosis are characteristics of the subacute stage. P.S. the incorrect choices are the same Desquamation = skin peeling

What does a brace do for scoliosis?

Halts the progression of most curvatures. DOES NOT FIX CURVATURE.