PN 131 Comprehensive Final NCLEX Questions
Which description of the four stages of labor is correct for both definition and duration? a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours c. Third stage: active pushing to birth; 20 minutes (multiparous women), 50 minutes (first-timer) d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour
ANS: A Full dilation may occur in less than 1 hour, but in first-time pregnancies it can take up to 20 hours. The second stage extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage extends from birth to expulsion of the placenta and usually takes a few minutes. The fourth stage begins after expulsion of the placenta and lasts until homeostasis is reestablished (about 2 hours).
A nurse is caring for a 17-year-old girl with cystic fibrosis who has been admitted to the hospital to receive antibiotics and respiratory treatment for exacerbation of a lung infection. The girl has a number of questions about her future and the consequences of the disease. Which statements about the course of cystic fibrosis are true? Select all that apply. 1. Breast development is delayed. 2. The client is at risk for developing diabetes. 3. Pregnancy and child-bearing aren't affected. 4. Normal sexual relationships can be expected. 5. Only males carry the gene for the disease. 6. By age 20, the client should be able to decrease the frequency of respiratory treatment.
1. Breast development is delayed. 2. The client is at risk for developing diabetes. 4. Normal sexual relationships can be expected. RATIONALE: Cystic fibrosis delays growth and the onset of puberty. Children with cystic fibrosis tend to be smaller than average size and develop secondary sex characteristics later in life. In addition, clients with cystic fibrosis are at risk for developing diabetes mellitus because the pancreatic duct becomes obstructed as pancreatic tissues are destroyed. Clients with cystic fibrosis can expect to have normal sexual relationships, but fertility becomes difficult because thick secretions obstruct the cervix and block sperm entry. Males and females carry the gene for cystic fibrosis. Pulmonary disease commonly progresses as the client ages, requiring additional respiratory treatment — not less.
A nurse is initiating seizure precautions for a child being admitted to the nursing unit. Which of the following items should the nurse place at the bedside?
1. Oxygen and a tongue depressor 2. A suction apparatus and oxygen 3. An airway and a tracheotomy set 4. An emergency cart and an oxygen mask 2. A suction apparatus and oxygen Rationale: Seizures cause a tightening of all body muscles that is followed by tremors. An obstructed airway and increased oral secretions are the major complications during and after the seizure. Suctioning and oxygen are helpful to prevent choking and cyanosis. Option 1 is incorrect-a tongue depressor is not needed and nothing is placed into the client's mouth during a seizure because of the risk for injury. Option 3 is incorrect, because inserting a tracheostomy is not done. Option 4 is incorrect, because an emergency cart would not be left at the bedside- however, it would be available in the treatment room or on the nursing unit.
A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would do which of the following in order to protect the child from injury? Select all that apply. 1. Keep a padded tongue blade at the bedside for use during a seizure. 2. Remove toys that have bright, blinking lights on them. 3. Keep side rails and other hard objects padded. 4. Turn the client to the side during a seizure. 5. Restrict the client's fluid intake.
2. Remove toys that have bright, blinking lights on them. 3. Keep side rails and other hard objects padded. 4. Turn the client to the side during a seizure. Rationale: Attempting to place something in a child's mouth during a seizure is not helpful even if it is padded. The mouth is usually clenched, and one would have to use force to open the mouth. One must attempt to keep the airway clear and can do that by positioning (option 4). Option 2 may be helpful in preventing a seizure, and option 3 safeguards the client's physical safety. Option 5 is not necessary.
A nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which of the following is the priority nursing action? 1. Increase oral fluids. 2. Document the finding. 3. Notify the registered nurse. 4. Place the infant supine in a side-lying position.
3. Notify the registered nurse Rationale: The anterior fontanel is diamond-shaped and located on the top of the head. It should be soft and flat in a normal infant, and it normally closes by 12 to 18 months of age. A larger-than-normal fontanel may be a sign of increased ICP within the skull. Although the anterior fontanel may bulge slightly when the infant cries, bulging at rest may indicate increased ICP. Options 1 and 4 are inaccurate interventions. Although the nurse would document the finding, the first action is to report the finding to the registered nurse, who will then contact the health care provider.
A 5-year-old child returns to the pediatric unit following a cardiac catheterization using the right femoral vein. The child has a thick elastoplast dressing. Which assessment finding requires immediate intervention? 1. One leg is slightly cooler than the other leg. 2. The leg used for the catheter insertion is slightly paler than the other leg. 3. A small amount of bright red blood is seen on the dressing. 4. The pedal pulse of the right leg isn't detectable.
4. The pedal pulse of the right leg isn't detectable. RATIONALE: Using the femoral vein during catheterization can cause the affected blood vessels to spasm or cause a blood clot to develop, altering circulation in the leg. The inability to detect the pedal pulse in the affected leg is an ominous sign and requires immediate intervention. Small amounts of coolness or pallor are normal. These findings should improve. Although the nurse should continue to monitor a dressing with a small amount of blood on it, this finding isn't the priority in this situation.
A 4-month-old infant is taken to the pediatrician by his parents because they're concerned about his frequent respiratory infections, poor feeding habits, frequent vomiting, and colic. The physician notes that the infant has failed to gain expected weight and recommends that the infant have a sweat test performed to detect possible cystic fibrosis. To prepare the parents for the test, the nurse should explain that: 1. the baby will need to fast before the test. 2. a sample of blood will be necessary. 3. a low-sodium diet is necessary for 24 hours before the test. 4. a low-intensity, painless electrical current is applied to the skin.
4. a low-intensity, painless electrical current is applied to the skin. RATIONALE: Because cystic fibrosis clients have elevated levels of sodium and chloride in their sweat, a sweat test is performed to confirm this disorder. The nurse should explain to the parents that after pilocarpine (a cholinergic medication that induces sweating) is applied to a gauze pad and placed on the arm, a low-intensity, painless electrical current is applied for several minutes. The arm is then washed off, and a filter paper is placed over the site with forceps to collect the sweat. Elevated levels of sodium and chloride are diagnostic of cystic fibrosis. No fasting is necessary before this test and no blood sample is required. A low-sodium diet isn't required before the test.
For what reason is breastfeeding contraindicated? a. Hepatitis B b. Everted nipples c. History of breast cancer 3 years ago d. Human immunodeficiency virus (HIV) positive
ANS: D Women who are HIV positive are discouraged from breastfeeding. Although hepatitis B antigen has not been shown to be transmitted through breast milk, as an added precaution infants born to HBsAg-positive women should receive the hepatitis B vaccine and immune globulin immediately after birth. Everted nipples are functional for breastfeeding. Newly diagnosed breast cancer is a contraindication to breastfeeding.
A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances
3. Exercise intolerance Rationale: The child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but it is not specific to this type of disorder alone. Options 2 and 4 are not related to this disorder.
When assessing a woman in the first stage of labor, the nurse recognizes that the most conclusive sign that uterine contractions are effective is: a. Dilation of the cervix b. Descent of the fetus c. Rupture of the amniotic membranes d. Increase in bloody show
ANS: A The vaginal examination reveals whether the woman is in true labor. Cervical change, especially dilation, in the presence of adequate labor indicates that the woman is in true labor. Descent of the fetus, or engagement, may occur before labor. Rupture of membranes may occur with or without the presence of labor. Bloody show may indicate slow, progressive cervical change (e.g., effacement) in both true and false labor.
The most critical nursing action in caring for the newborn immediately after birth is: a. Keeping the airway clear b. Fostering parent-newborn attachment c. Drying the newborn and wrapping the infant in a blanket d. Administering eye drops and vitamin K
ANS: A The care given immediately after the birth focuses on assessing and stabilizing the newborn. Although fostering parent-newborn attachment is an important task for the nurse, it is not the most critical nursing action in caring for the newborn immediately after birth. The care given immediately after birth focuses on assessing and stabilizing the newborn. The nursing activities are (in order of importance) to maintain a patent airway, support respiratory effort, and prevent cold stress by drying the newborn and covering with a warmed blanket or placing the newborn under a radiant warmer. After the newborn has been stabilized, the nurse assesses the newborn's physical condition, weighs and measures the newborn, administers prophylactic eye ointment and a vitamin K injection, affixes an identification bracelet, wraps the newborn in warm blankets, and then gives the partner or the mother the infant.
A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which of the following on the handout? Select all that apply. 1. It is a disease that causes mucus formation to be abnormally thick. 2. It is a chronic multisystem disorder affecting the exocrine glands. 3. It is transmitted as an autosomal recessive trait. 4. It is a disease that causes dilation of the passageways of all organs. 5. It is a disease that affects males only. 6. It is a disease that affects the lungs only.
1. It is a disease that causes mucus formation to be abnormally thick. 2. It is a chronic multisystem disorder affecting the exocrine glands. 3. It is transmitted as an autosomal recessive trait. Rationale: CF is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait and can affect both males and females.
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply. 1. Call a code blue. 2. Notify the registered nurse. 3. Place the infant in a prone position. 4. Prepare to administer intravenous fluids. 5. Prepare to administer 100% oxygen by face mask.
2. Notify the registered nurse. 5. Prepare to administer intravenous fluids. 6. Prepare to administer 100% oxygen by face mask. Rationale: The child who is cyanotic with oxygen saturations dropping to 60% is having a hypercyanotic episode. Hypercyanotic episodes often occur among infants with tetralogy of Fallot, and they may occur among infants whose heart defect includes the obstruction of pulmonary blood flow and communication between the ventricles. If a hypercyanotic episode occurs, the infant is placed in a knee-chest position immediately. The registered nurse is notified, who will then contact the health care provider. The knee-chest position improves systemic arterial oxygen saturation by decreasing venous return so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to get into this position and relieve chronic hypoxia. There is no reason to call a code blue unless respirations cease. Additional interventions include administering 100% oxygen by face mask, morphine sulfate, and intravenous fluids, as prescribed.
A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse would expect the blood pressure in the child's legs and arms to be: 1. Increased in the arms and the legs 2. Decreased in the arms and the legs 3. Decreased in the legs and increased in the arms 4. Increased in the legs and decreased in the arms
3. Decreased in the legs and increased in the arms Rationale: Coarctation indicates a narrowing in the aorta. This would indicate an increased pressure proximal to the defect and a decreased pressure distal to the defect. This would result in a lower blood pressure in the legs and a higher blood pressure in the arms, which is indicated in option 3.
When planning care for a laboring woman whose membranes have ruptured, the nurse recognizes that the woman's risk for _____ has increased. a. Intrauterine infection b. Hemorrhage c. Precipitous labor d. Supine hypotension
ANS: A When the membranes rupture, microorganisms from the vagina can ascend into the amniotic sac, causing chorioamnionitis and placentitis. Rupture of membranes (ROM) is not associated with fetal or maternal bleeding. Although ROM may increase the intensity of contractions and facilitate active labor, it does not result in precipitous labor. ROM has no correlation with supine hypotension.
The diagnosis of pregnancy is based on which positive signs of pregnancy? Choose all that apply. a. Identification of fetal heartbeat b. Palpation of fetal outline c. Visualization of the fetus d. Verification of fetal movement e. Positive human chorionic gonadotropin (hCG) test
ANS: A, C, D Identification of fetal heartbeat, visualization of the fetus, and verification of fetal movement are all positive, objective signs of pregnancy. Palpation of fetal outline and positive hCG test are probable signs of pregnancy. A tumor also can be palpated. Medication and tumors may lead to false-positive results on pregnancy tests.
The musculoskeletal system adapts to the changes that occur during pregnancy. A woman can expect to experience what change? a. Her center of gravity will shift backward. b. She will have increased lordosis. c. She will have increased abdominal muscle tone. d. She will notice decreased mobility of her pelvic joints.
ANS: B An increase in the normal lumbosacral curve (lordosis) develops, and a compensatory curvature in the cervicodorsal region develops to help her maintain her balance. The center of gravity shifts forward. She will have decreased muscle tone. She will notice increased mobility of her pelvic joints.
The nurse providing care for the laboring woman understands that variable fetal heart rate (FHR) decelerations are caused by: a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Fetal hypoxemia
ANS: B Variable decelerations can occur any time during the uterine contracting phase and are caused by compression of the umbilical cord. Altered fetal cerebral blood flow results in early decelerations in the FHR. Uteroplacental insufficiency results in late decelerations in the FHR. Fetal hypoxemia results in tachycardia initially, then bradycardia if hypoxia continues.
Some pregnant clients may complain of changes in their voice and impaired hearing. The nurse can tell these clients that these are common reactions to: a. A decreased estrogen level b. Displacement of the diaphragm, resulting in thoracic breathing c. Congestion and swelling, which occur because the upper respiratory tract has become more vascular d. Increased blood volume
ANS: C Estrogen levels increase, causing the upper respiratory tract to become more vascular; this produces swelling and congestion in the nose and ears and therefore voice changes and impaired hearing. Estrogen levels increase, not decrease. The diaphragm is displaced. However, the key is that estrogen levels increase, causing the upper respiratory tract to become more vascular; this produces swelling and congestion in the nose and ears and therefore voice changes and impaired hearing. The volume of blood is increased. However, the key here is that estrogen levels increase, causing the upper respiratory tract to become more vascular; this produces swelling and congestion in the nose and ears and therefore voice changes and impaired hearing.
A 27-year-old pregnant woman had a preconceptual body mass index (BMI) of 19. The nurse knows that this woman's total recommended weight gain during pregnancy should be at least: a. 20 kg (44 lb) b. 16 kg (35 lb) c. 12.5 kg (27.5 lb) d. 10 kg (22 lb)
ANS: C This woman has a normal BMI and should gain 11.5 to 16 kg during pregnancy. A weight gain of 20 kg (44 lb) is unhealthy for most women. This woman has a normal BMI and should gain 11.5 to 16 kg during pregnancy. A weight gain of 16 kg (35 lb) is the high end of the range of weight this woman should gain in her pregnancy. A weight gain of 10 kg (22 lb) is appropriate for an obese woman. This woman has a normal BMI, which indicates that her weight is average.
A woman arrives at the clinic for a pregnancy test. Her last menstrual period (LMP) was February 14, 2011. Her expected date of birth (EDB) is: a. September 17, 2011 b. November 7, 2011 c. November 21, 2011 d. December 17, 2011
ANS: C Using Nägele's rule, the EDB is calculated by subtracting 3 months from the month of the LMP and adding 7 days + 1 year to the day of the LMP. Therefore, with an LMP of February 14, 2011, her due date is November 21, 2011. September 17, 2011, is too short a period to complete a normal pregnancy. Using Nägele's rule, an EDB of November 7, 2011 is 2 weeks early. December 17, 2011, is almost a month past the correct EDB.
A woman has come to the clinic for preconception counseling because she wants to start trying to get pregnant in 3 months. She can expect the following advice: a. "Discontinue all contraception now." b. "Lose weight so that you can gain more during pregnancy." c. "You may take any medications you have been taking regularly." d. "Make sure you include adequate folic acid in your diet."
ANS: D A healthy diet before conception is the best way to ensure that adequate nutrients are available for the developing fetus. A woman's folate or folic acid intake is of particular concern in the periconception period. Neural tube defects are more common in infants of women with a poor folic acid intake. Depending on the type of contraception used, it may not be appropriate to discontinue all contraception at this time. Advising the client to lose weight now so that she can gain more during pregnancy is not appropriate advice. Depending on the type of medications the woman is taking, it may not be appropriate for her to continue taking them regularly.
The most basic information a maternity nurse should have concerning conception is: a. Ova are considered fertile 48 to 72 hours after ovulation b. Sperm remain viable in the woman's reproductive system for an average of 12 to 24 hours c. Conception is achieved when a sperm successfully penetrates the membrane surrounding the ovum d. Implantation in the endometrium occurs 6 to 10 days after conception
ANS: D After implantation, the endometrium is called the decidua. Ova are considered fertile for about 24 hours after ovulation. Sperm remain viable in the woman's reproductive system for an average of 2 to 3 days. Penetration of the ovum by the sperm is called fertilization. Conception occurs when the zygote, the first cell of the new individual, is formed.
Human chorionic gonadotropin (hCG) is an important biochemical marker for pregnancy and therefore the basis for many tests. A maternity nurse should be aware that: a. hCG can be detected as early as 2½ weeks after conception b. The hCG level increases gradually and uniformly throughout pregnancy c. Much lower than normal increases in the level of hCG may indicate a postdate pregnancy d. A higher than normal level of hCG may indicate an ectopic pregnancy or Down syndrome
ANS: D Higher levels also could be a sign of multiple gestation. hCG can be detected as early as 7 to 10 days after conception. The hCG level fluctuates during pregnancy, peaking, declining, stabilizing, and then increasing again. Abnormally slow increases may indicate impending miscarriage.
In order to reassure and educate pregnant clients about changes in the cervix, vagina, and position of the fetus, nurses should be aware that: a. Because of a number of changes in the cervix, abnormal Papanicolaou (Pap) tests are much easier to evaluate b. Quickening is a technique of palpating the fetus to engage it in passive movement c. The deepening color of the vaginal mucosa and cervix (Chadwick sign) usually appears in the second trimester or later as the vagina prepares to stretch during labor d. Increased vascularity of the vagina increases sensitivity and may lead to a high degree of arousal, especially in the second trimester
ANS: D Increased sensitivity and an increased interest in sex sometimes go together. This frequently occurs during the second trimester. These cervical changes make evaluation of abnormal Pap tests more difficult. Quickening is the first recognition of fetal movements by the mother. Ballottement is a technique used to palpate the fetus. The Chadwick sign appears from the sixth to eighth weeks.
Which fetal heart rate (FHR) finding concerns the nurse during labor? a. Accelerations with fetal movement b. Early decelerations c. An average FHR of 126 beats/min d. Late decelerations
ANS: D Late decelerations are caused by uteroplacental insufficiency and are associated with fetal hypoxemia. They are considered ominous if persistent and uncorrected. Accelerations in the FHR are an indication of fetal well-being. Early decelerations in the FHR are associated with head compression as the fetus descends into the maternal pelvic outlet; they generally are not a concern during normal labor. An FHR finding of 126 beats/min is normal and not a concern.
A toddler develops acute otitis media and is ordered cefpodoxime proxetil (Vantin) 5 mg/kg P.O. every 12 hours. If the child weighs 22 lb (10 kg), how many milligrams will the nurse administer with each dose? 1. 50 mg 2. 100 mg 3. 110 mg 4. 220 mg
1. 50 mg RATIONALE: The dose is 5 mg/kg and the child weighs 10 kg. To determine the dose, the nurse would calculate: 5 mg/1 kg × 10 kg = 50 mg per dose.
A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle accident for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP? 1. Nausea 2. Papilledema 3. Decerebrate posturing 4. Alterations in pupil size
1. Nausea Rationale: Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.
An infant with congestive heart failure (CHF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output (I&O). Which is the best method for the nurse to use to monitor the urine output? 1. Weighing the diapers 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula
1. Weighing the diapers Rationale: The best method to monitor urine output in an infant on diuretic therapy is to weigh the diapers. The weight of dry diapers is subtracted from the weight of wet diapers to determine the amount of urine excreted: 1 g is equivalent to 1 mL of urine. Comparing intake with output would not provide an accurate measure of urine output. Measuring the amount of water added to formula is unrelated to the amount of output. Although Foley catheter drainage is most accurate in determining output, it is not the best method and places the infant at risk for infection.
A 9-year-old child is admitted to the pediatric unit for treatment of cystic fibrosis. A nurse assessing the child's respiratory status should expect to identify: 1. production of thick, sticky mucus 2. harsh, nonproductive cough 3. stridor 4. unilateral decrease in breath sounds
1. production of thick, sticky mucus RATIONALE: Cystic fibrosis is associated with the production of thick, sticky mucus. Cystic fibrosis isn't associated with harsh, nonproductive coughing or with stridor or unilateral decrease in breath sounds.
A child is being discharged with proventil (Albuterol) nebulizer treatments. The nurse should instruct the parents to watch for: 1. tachycardia. 2. bradypnea. 3. urine retention. 4. constipation.
1. tachycardia. RATIONALE: Proventil is a beta-adrenergic blocker bronchodilator used to relieve bronchospasms associated with acute or chronic asthma or other obstructive airway diseases. Signs and symptoms of proventil toxicity that the nurse should instruct the parents to watch for include tachycardia, restlessness, nausea, vomiting, and dizziness. Unusually slow respirations, urine retention, and constipation aren't associated with proventil toxicity.
An infant who weighs 7.5 kg is to receive ampicillin (Omnipen) 25 mg/kg I.V. every 6 hours. How many milligrams should the nurse administer per dose? Record your answer using one decimal place.
187.5 milligrams RATIONALE: The nurse should calculate the correct dose using the following equation: 25 mg/kg × 7.5 kg = 187.5 mg
A nurse is teaching the mother of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? 1. "I hope my baby will come home from the hospital." 2. "I know that this disease is serious and can lead to asthma." 3. "My baby needs to be cured this time so it won't happen again." 4. "My baby has been sick. A machine will help him breathe."
2. "I know that this disease is serious and can lead to asthma." RATIONALE: By saying bronchiolitis places the child at risk for developing asthma, the mother demonstrates understanding of her infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.
Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur? 1. 1 to 2 years 2. 1 week to 1 year, peaking at 2 to 4 months 3. 6 months to 1 year, peaking at 10 months 4. 6 to 8 weeks
2. 1 week to 1 year, peaking at 2 to 4 months RATIONALE: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.
A nurse is developing a plan to teach a mother how to reduce her infant's risk of developing otitis media. Which direction should the nurse include in the teaching plan? 1. Administer antibiotics whenever the infant has a cold. 2. Place the infant in an upright position when giving a bottle. 3. Avoid getting the infant's ears wet while bathing or swimming. 4. Clean the infant's external ear canal daily.
2. Place the infant in an upright position when giving a bottle. RATIONALE: Feeding an infant a bottle in an upright position reduces the pooling of formula or breast milk in the nasopharynx. Formula, in particular, provides a good medium for the growth of bacteria, which can travel easily through the short, horizontal eustachian tubes. Administering antibiotics whenever the infant has a cold, avoiding getting the ears wet, and cleaning the external ear canal daily don't reduce the risk of an infant developing otitis media.
An 8-month-old infant is admitted with a febrile seizure. The infant weighs 17 lb (7.7 kg). The physician orders ceftriaxone (Rocephin), 270 mg I.M. every 12 hours. (The safe dosage range is 50 to 75 mg/kg daily.) The pharmacy sends a vial containing 500 mg, to which the nurse adds 2 ml of preservative-free normal saline solution. The nurse should administer how many milliliters? 1. None because this isn't a safe dosage 2. 0.08 ml 3. 1.08 ml 4. 1.8 ml
3. 1.08 ml RATIONALE: Because the infant weighs 17 lb (7.7 kg), the safe dosage range is 385 to 578 mg daily. The ordered dosage, 540 mg daily, is safe. To calculate the amount to administer, the nurse may use the following fraction method: 500 mg/2 ml = 270 mg/X ml 500X = 270 × 2 500X = 540 X = 540/500 X = 1.08 ml
A nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for signs of: 1. Failure to thrive 2. Bleeding 3. Congestive heart failure (CHF) 4. Decreased tolerance to stimulation
3. Congestive heart failure (CHF) Rationale: Nursing care for Kawasaki disease initially centers around observing for signs of CHF. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, lung congestion, and abdominal distention. Options 1, 2, and 4 are not findings directly associated with this disorder.
Which of the following represents a primary characteristic of autism? 1. Normal social play 2. Consistent imitation of others' actions 3. Lack of social interaction and awareness 4. Normal verbal and nonverbal communication
3. Lack of social interaction and awareness Rationale: Autism is a severe form of an autism spectrum disorder. A primary characteristic is a lack of social interaction and awareness. Social behaviors in autism include a lack of or an abnormal imitation of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and markedly abnormal nonverbal communication.
An infant is hospitalized for treatment of inorganic failure to thrive. Which nursing action is most appropriate for this child? 1. Encouraging the infant to hold a bottle 2. Keeping the infant on bed rest to conserve energy 3. Rotating caregivers to provide more stimulation 4. Maintaining a consistent, structured environment
4. Maintaining a consistent, structured environment RATIONALE: The nurse caring for an infant with inorganic failure to thrive should strive to maintain a consistent, structured environment because it reinforces a caring feeding environment. Encouraging the infant to hold a bottle would reinforce an uncaring feeding environment. The infant should receive social stimulation rather than be confined to bed rest. The number of caregivers should be minimized to promote consistency of care.
A nurse prepares a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which of the following would be included in the plan? 1. Wear gloves when administering the eardrops. 2. Pull the ear up and back before instilling the eardrops. 3. Pull the earlobe down and back before instilling the ear drops. 4. Hold the child in a sitting position when administering the ear drops.
3. Pull the earlobe down and back before instilling the ear drops. Rationale: When administering eardrops to a child who is less than 3 years old, the ear should be pulled down and back. For children who are more than 3 years old, the ear is pulled up and back. Gloves do not need to be worn by the parents, but handwashing needs to be performed before and after the procedure. The child should be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.
A nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of congestive heart failure (CHF). The nurse looks for which early sign of CHF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing
3. Tachycardia Rationale: The early signs of CHF include tachycardia, tachypnea, profuse scalp sweating, fatigue, irritability, sudden weight gain, and respiratory distress. A cough may occur with CHF as a result of mucosal swelling and irritation, but it is not an early sign. Pallor may be noted in the infant with CHF, but it is also not an early sign.
A nurse is providing home care instructions to the mother of a child with bacterial conjunctivitis. The nurse should tell the mother: 1. That the child may attend school if antibiotics have been started 2. To save any unused eye medication in case a sibling gets the eye infection 3. That the child's towels and washcloths should not be used by other members of the household 4. To wipe any crusted material from the eye with a cotton ball soaked in warm water, starting at the outer aspect of the eye and moving toward the inner aspect
3. That the child's towels and washcloths should not be used by other members of the household Rationale: Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include good handwashing and not sharing towels and washcloths with others. The child should be kept home from school until 24 hours after antibiotics are started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.
An emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). The nurse anticipates that the likely initial treatment will be: 1. Dialysis 2. The administration of vitamin K 3. The administration of activated charcoal 4. The administration of sodium bicarbonate
3. The administration of activated charcoal Rationale: Initial treatment of salicylate overdose includes administration of activated charcoal to decrease absorption of the aspirin. Intravenous (IV) fluids and inducing emesis may be prescribed to enhance excretion but would not be the initial treatment. Dialysis is used in extreme cases if the child is unresponsive to therapy. Vitamin K is the antidote for warfarin (Coumadin) overdose.
When planning care for a 7-year-old boy with Down syndrome, the nurse should: 1. plan interventions at the developmental level of a 7-year-old because that is the child's age. 2. plan interventions at the developmental level of a 5-year-old because the child will have developmental delays. 3. assess the child's current developmental level and plan care accordingly. 4. direct all teaching to the parents because the child can't understand.
3. assess the child's current developmental level and plan care accordingly. RATIONALE: Nursing care should be planned at the developmental age of a child with Down syndrome, not the chronological age. Because children with Down syndrome can vary from mildly to severely mentally challenged, each child should be individually assessed. Directing all teaching to parents isn't appropriate because a child with Down syndrome is capable of learning, especially one with mild limitations.
The mother of an infant newly diagnosed with cystic fibrosis is being taught proper nutritional needs for the infant. The nurse determines that the mother understands nutritional needs when the mother replies: 1. "I know that my infant needs to drink predigested formula until she has her stool pattern developed." 2. "When I begin feeding my infant cereal, I will make sure to warm the cereal and administer the pancreatic enzyme mixed in." 3. "I will make sure that I give my infant fat-free milk as a supplement to her predigested formula, because she is not able to digest fat." 4. "I know I need to monitor my infant's stools and if there are more than four stools a day, I will increase the pancreatic enzyme."
4. "I know I need to monitor my infant's stools and if there are more than four stools a day, I will increase the pancreatic enzyme." Rationale: Cystic fibrosis requires a high-calorie, high-protein diet with pancreatic enzyme replacement therapy. The infant needs to remain on the predigested formula until 1 year of age, when formula can be discontinued and then fat-free milk consumed. The pancreatic enzyme should not be mixed with warmed foods because this inactivates the enzyme. Stools must be monitored, and pancreatic enzymes are administered based on the stool pattern.
A nurse provides home care instructions to the parents of a child with congestive heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "If more than one dose is missed, I will call the health care provider." 3. "I will take my child's pulse before administering the medication." 4. "If my child vomits after medication administration, I will repeat the dose."
4. "If my child vomits after medication administration, I will repeat the dose." Rationale: The parents need to be instructed that, if the child vomits after the digoxin is administered, they are not to repeat the dose. Options 1, 2, and 3 are accurate instructions regarding the administration of this medication. Additionally, the parents should be instructed that if a dose is missed and it is not noticed until 4 hours later, the dose should not be administered.
A nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is appropriate? 1. "Don't worry. It won't hurt." 2. "The test usually takes an hour." 3. "You must sleep the whole time that the test is being done." 4. "The special medicine will feel warm when it's put in the tubing."
4. "The special medicine will feel warm when it's put in the tubing." RATIONALE: To prepare a 4-year-old child without increasing anxiety, the nurse should provide concrete information in small amounts about nonthreatening aspects of the procedure. Therefore, saying the special medicine will feel warm is most appropriate. Saying that it won't hurt may prevent the child from trusting the nurse in the future. Explaining the time needed for the procedure wouldn't provide sufficient information. Stating that the child will need to sleep isn't true and could provoke anxiety.
A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and thus to the need to notify the registered nurse? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure (BP) 4. A weight gain of 1 lb in 1 day
4. A weight gain of 1 lb in 1 day Rationale: A weight gain of 0.5 kg (1 lb) in 1 day is a result of the accumulation of fluid. The nurse should monitor the urine output, monitor for evidence of facial or peripheral edema, check the lung sounds, and report the weight gain. Tachypnea and an increased BP would occur with fluid accumulation. Diaphoresis is a sign of CHF, but it is not specific to fluid accumulation, and it usually occurs with exertional activities.
A mother is discontinuing breast-feeding after 5 months. What should the nurse advise the mother to include in her infant's diet? 1. Iron-rich formula and baby food 2. Whole milk and baby food 3. Skim milk and baby food 4. Iron-rich formula alone
4. Iron-rich formula alone RATIONALE: The American Academy of Pediatrics recommends iron-rich formula for 5-month-old infants and cautions against giving infants solid food — even baby food — until age 6 months. The Academy doesn't recommend whole milk before age 12 months or skim milk before age 2 years.
When administering an oral medication to an infant, the nurse should take which action to minimize the risk of aspiration? 1. Administering the oral medication as quickly as possible 2. Placing the medication in the infant's formula bottle 3. Keeping the infant upright with the nasal passages blocked 4. Using an oral syringe to place the medication beside the tongue.
4. Using an oral syringe to place the medication beside the tongue. RATIONALE: Using an oral syringe is the best way to prevent aspiration because it allows controlled administration of a small amount of medication. Administering the medication too quickly could cause aspiration. Putting the drug in a bottle of formula isn't preferred because the infant may not take the entire dose of medication and because the contents of the bottle could interfere with drug absorption or action. Blocking the nasal passages could cause aspiration.
A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial pulse coupled with a weak femoral pulse, the nurse suspects that the child has: 1. patent ductus arteriosus. 2. coarctation of the aorta. 3. a ventricular septal defect. 4. truncus arteriosus.
2. coarctation of the aorta. RATIONALE: The nurse should suspect coarctation of the aorta because it causes signs of peripheral hypoperfusion, such as a weak femoral pulse and a bounding radial pulse. These signs are rare in patent ductus arteriosus, ventricular septal defect, and truncus arteriosus.
The nurse expects to administer an oxytocic (e.g., Pitocin, Methergine) to a woman after expulsion of her placenta to: a. Relieve pain b. Stimulate uterine contraction c. Prevent infection d. Facilitate rest and relaxation
ANS: B Oxytocics stimulate uterine contractions, which reduce blood loss after the third stage of labor. Oxytocics are not used to treat pain. Oxytocics do not prevent infection. Oxytocics do not facilitate rest and relaxation.
Probable signs of pregnancy are: a. Determined by ultrasound b. Observed by the health care provider c. Reported by the client d. Diagnostic tests
ANS: B Probable signs are those detected through trained examination. Fetal visualization is a positive sign of pregnancy. Presumptive signs are those reported by the client. The term diagnostic tests is open for interpretation. To actually diagnose pregnancy, one would have to see positive signs of pregnancy.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences a cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? 1. Knee-to-chest 2. Fowler's 3. Trendelenburg's 4. Prone
1. Knee-to-chest RATIONALE: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation.
A nurse formulates a nursing diagnosis of Risk for infection for a child with Down syndrome. Which condition typically seen in children with this syndrome supports this nursing diagnosis? 1. Muscular hypotonicity 2. Muscle spasticity 3. Increased mucus viscosity 4. Hypothyroidism
1. Muscular hypotonicity RATIONALE: Several conditions make the child with Down syndrome highly vulnerable to respiratory infections. For example, the hypotonicity of chest muscles in children with Down syndrome leads to diminished respiratory expansion and pooling of secretions, and an underdeveloped nasal bone impairs mucus drainage. Down syndrome isn't associated with muscle spasticity or increased mucus viscosity. Although hypothyroidism is common in children with Down syndrome, it doesn't increase the risk of infection.
A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of: 1. Peripheral hypoxia 2. Chronic hypertension 3. Delayed physical growth 4. Destruction of bone marrow
1. Peripheral hypoxia Rationale: Clubbing, a thickening and flattening of the tips of the fingers and toes, is thought to occur because of a chronic tissue hypoxemia and polycythemia. Options 2, 3, and 4 are not causes of clubbing.
A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child? 1. Nausea 2. Bradycardia 3. Bulging fontanel 4. Dilated scalp veins
2. Bradycardia Rationale: Late signs of increased ICP include a significant decrease in the level of consciousness, bradycardia, and fixed and dilated pupils. Nausea is an early sign of increased ICP. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant rather than in a 5-year-old child.
A nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease? 1. It is an acquired cell-mediated immunodeficiency disorder. 2. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. 3. It is a chronic multi-system autoimmune disease characterized by the inflammation of connective tissue. 4. It is an inflammatory autoimmune disease that affects the connective tissue of the heart, joints, and subcutaneous tissues.
2. It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause. Rationale: Kawasaki disease, also called mucocutaneous lymph node syndrome, is a febrile generalized vasculitis of unknown etiology. Option 1 describes human immunodeficiency virus (HIV) infection. Option 3 describes systemic lupus erythematosus. Option 4 describes rheumatic fever.
For a child who's admitted to the emergency department with an acute asthma attack, nursing assessment is most likely to reveal: 1. apneic periods. 2. expiratory wheezing. 3. inspiratory stridor. 4. fine crackles throughout.
2. expiratory wheezing. RATIONALE: Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma rarely causes apneic periods. Inspiratory stridor more commonly accompanies croup. The child may have some fine crackles but wheezing is much more common in an acute asthma attack.
According to Erikson's psychosocial theory of development, an 8-year-old child would be in which stage? 1. Trust versus mistrust 2. Initiative versus guilt 3. Industry versus inferiority 4. Identity versus role confusion
3. Industry versus inferiority RATIONALE: In middle childhood, the 6- to 12-year-old child is mastering the task of industry versus inferiority. The trust versus mistrust task is in infancy (birth to 1 year). In early childhood, the 1- to 3-year-old child is in the stage of initiative versus guilt. Identity versus role confusion occurs
A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 AM, 12 noon, and at 6:00 PM The nurse tells the mother that the postural drainage should be performed at: 1. 8:00 AM, 2:00 PM, and 6:00 PM 2. 9:00 AM, 1:00 PM and 6:00 PM 3. 8:00 AM, 12:00 noon, and 6:00 PM 4. 10:00 AM, 2:00 PM and 8:00 PM
4. 10:00 AM, 2:00 PM and 8:00 PM Rationale: Respiratory treatments should be performed at least 1 hour before meals or 2 hours after meals to prevent vomiting. In some children with cystic fibrosis, treatments are prescribed every 2 hours, particularly if infection is present. It is also important to perform these treatments before bedtime to clear airways and facilitate rest.
A nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is: 1. An infectious disease of the central nervous system 2. An inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by a difficulty in controlling the muscles
4. A chronic disability characterized by a difficulty in controlling the muscles Rationale: Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe retardation.
A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse would work with the child to meet these goals by: 1. Keeping the child in a special education classroom with other children with similar disabilities 2. Laying the child in the supine position with a 30-degree elevation of the head to facilitate feeding 3. Removing ankle-foot orthoses and braces once the child arrives at school 4. Placing the child on a wheeled scooter board
4. Placing the child on a wheeled scooter board Rationale: Option 4 provides the child with maximum potential in locomotion, self-care, and socialization. The child can move around independently on the abdomen anywhere the child wants to go and can interact with others as desired. Orthoses must be used all the time to aid locomotion (option 3). Option 1 does not provide for maximum socialization and normalization, rather, children with CP need to be mainstreamed as much as cognitively able. Not all children with CP are intellectually challenged. Option 2 does not provide for normalization in self-care. Just as children without CP sit up and use assistive devices when eating, so should children with CP.
During labor a fetus with an average fetal heart rate (FHR) of 135 beats/min over a 10-minute period is considered to have: a. Bradycardia b. A normal baseline heart rate c. Tachycardia d. Hypoxia
ANS: B The baseline heart rate is measured over 10 minutes; a normal range is 110 to 160 beats/min. Bradycardia is a FHR less than 110 beats/min for 10 minutes or longer. Tachycardia is a FHR more than 160 beats/min for 10 minutes or longer. Hypoxia is an inadequate supply of oxygen; no indication of this condition exists with a baseline heart rate in the normal range.
A nurse caring for a woman in labor understands that maternal hypotension can result in: a. Early decelerations b. Fetal arrhythmias c. Uteroplacental insufficiency d. Spontaneous rupture of membranes
ANS: C Low maternal blood pressure reduces placental blood flow during uterine contractions, resulting in fetal hypoxemia. Maternal hypotension does not result in early decelerations. Maternal hypotension is not associated with fetal arrhythmias. Spontaneous rupture of membranes is not a result of maternal hypotension.
A nurse providing care to a pregnant woman should know that all are normal gastrointestinal changes in pregnancy except: a. Ptyalism b. Pyrosis c. Pica d. Decreased peristalsis
ANS: C Pica (a desire to eat nonfood substances) is an indication of iron deficiency and should be evaluated. Ptyalism (excessive salivation) is a normal finding. Pyrosis (heartburn) is a normal finding. Decreased peristalsis is a normal finding.
A child with iron deficiency anemia is ordered ferrous sulfate (Ferralyn), an oral iron supplement. When teaching the child and parent how to administer this preparation, the mother asks why she needs to mix the supplement with citrus juice. Which response by the nurse is best? 1. "The vitamin C in the citrus juice helps with iron absorption." 2. "Having food and juice in the stomach helps with iron absorption." 3. "The citrus juice counteracts the unpleasant taste of the iron." 4. "There isn't a specific reason for it."
1. "The vitamin C in the citrus juice helps with iron absorption." RATIONALE: Administering an oral iron supplement such as ferrous sulfate with citrus juice or another vitamin C source enhances its absorption. Preferably, doses should be administered between meals because gastric acidity and absence of food promote iron absorption. Although citrus juice may improve the taste of an oral iron supplement, this isn't the primary reason for mixing the two together. Telling the mother that there isn't a specific reason for mixing the supplement with citrus juice is inappropriate and inaccurate.
Which action should a nurse include in the care plan for a 2-month-old infant with heart failure? 1. Allow the infant to rest before feeding. 2. Bathe the infant and administer medications before feeding. 3. Weigh and bathe the infant before feeding. 4. Feed the infant when he cries.
1. Allow the infant to rest before feeding. RATIONALE: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends energy when crying
A nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan? 1. Immune globulin 2. Heparin infusion 3. Morphine sulfate 4. Digoxin (Lanoxin)
1. Immune globulin Rationale: Intravenous immune globulin (IVIG) is administered to the child with Kawasaki disease to decrease the incidence of coronary artery lesions and aneurysms and to decrease fever and inflammation. Options 2, 3, and 4 are not components of the treatment plan for this disease.
A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action? 1. Notify the registered nurse of the finding. 2. Assess for other associated anomalies and document carefully. 3. Tell the mother and father that this may indicate spina bifida. 4. Recognize that this is normal in the neonate and continue the bath.
1. Notify the registered nurse of the finding. Rationale: The legal role of the LPN is to practice under the supervision of the registered nurse. In this instance, the tuft of hair may be indicative of a spinal anomaly, and the registered nurse should be notified of the finding. It is inappropriate to discuss abnormal findings with the parents because this is the responsibility of the health care provider, if an anomaly is suspected or diagnosed. The LPN should take the priority intervention of notifying the registered nurse before documenting in the chart.
A nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Choose the interventions that would be included in the plan of care. Select all that apply. 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. 3. Ensure that the infant's head is in a flexed position. 4. Wear a mask at all times when in contact with the infant. 5. Place the child in a tent that delivers warm, humidified air. 6. Position the infant side-lying, with the head lower than the chest.
1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station. Rationale: The infant with RSV should be isolated in a private room or in a room with another child with RSV. The infant should be placed in a room near the nurses' station for close observation. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and to decrease pressure on the diaphragm. Cool, humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea. Contact precautions (wearing gloves and a gown) reduce the nosocomial transmission of RSV.
A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? *Select all that apply. 1. Time the seizure.* 2. Restrain the child. 3. Stay with the child.* 4. Place the child in a prone position. 5. Move furniture away from the child.* 6. Insert a padded tongue blade into the child's mouth.
1. Time the seizure. 3. Stay with the child. 5. Move furniture away from the child. Rationale: During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration, because saliva will drain out of the corner of the child's mouth. The child is not restrained, because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure.
A nurse is preparing to teach a 13-year-old adolescent with asthma to administer his own breathing treatments. Which principle should the nurse keep in mind when planning the teaching session? 1. Adolescents are unable to follow detailed instructions. 2. Adolescents are worried about appearing different from their peers. 3. Adolescents' fine motor coordination isn't sufficiently developed to administer treatments. 4. Adolescents have a well-developed sense of self-identity.
2. Adolescents are worried about appearing different from their peers. RATIONALE: Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. Adolescents are capable of following detailed instructions. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. Fine motor coordination is well developed by adolescence. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity, identity isn't already well-developed.
A nurse is caring for a 2½-year-old child with tetralogy of Fallot (TOF). Which abnormalities are associated with TOF? 1. Aortic stenosis, atrial septal defect, overriding aorta, and left ventricular hypertrophy 2. Pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy 3. Pulmonic stenosis, patent ductus arteriosus, overriding aorta, and right ventricular hypertrophy 4. Transposition of the great vessels, intraventricular septal defect, right ventricular hypertrophy, and patent ductus arteriosus
2. Pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy RATIONALE: TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. The other combinations of defects aren't characteristic of TOF.
A nurse is evaluating the parent's understanding of discharge care regarding the functioning of the infant's ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications? 1. "If my baby has a high-pitched cry, I should call the doctor." 2. "I should position my baby on the side with the shunt when sleeping." 3. "My baby will pass urine more often now that the shunt is in place." 4. "I should call my doctor if my baby refuses purees."
1. "If my baby has a high-pitched cry, I should call the doctor." Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a high-pitched cry in the infant. The baby should not have pressure when on the shunt side. Skin breakdown and possible compression to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. Option 4 is only a concern if the baby becomes malnourished or dehydrated, which could then raise the body temperature. Otherwise, refusal to eat purees has no direct relationship to the shunt functioning.
A toddler with a ventricular septal defect is receiving digoxin (Lanoxin) to treat heart failure. Which assessment finding should be the nurse's priority concern? 1. Bradycardia 2. Tachycardia 3. Hypertension 4. Hyperactivity
1. Bradycardia RATIONALE: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.
When a nurse assesses a 2-year-old child with suspected dehydration, which condition should be reported to the physician immediately? 1. Irritability for the past 12 hours 2. Capillary refill less than 2 seconds 3. Decreased blood pressure 4. Tachycardia, dry skin, and dry mucous membranes
3. Decreased blood pressure RATIONALE: The nurse should immediately report decreased blood pressure because it's a late sign of severe dehydration. This delayed decrease occurs because compensatory mechanisms in children are able to sustain blood pressure in the low-normal range for some time. Irritability, capillary refill less than 2 seconds, tachycardia, dry skin, and dry mucous membranes are all early signs of dehydration.
A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by: 1. Testing the child's urine for specific gravity 2. Asking the child what happens during a seizure 3. Obtaining a family history of psychiatric illness 4. Obtaining a history regarding factors that may occur before the seizure activity
4. Obtaining a history regarding factors that may occur before the seizure activity Rationale: Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test, because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself.
A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is: 1. Taking the apical pulse 2. Taking the blood pressure 3. Testing the urine for protein 4. Palpating the anterior fontanel
4. Palpating the anterior fontanel Rationale: A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.
Which pelvic shape is ideal for a vaginal birth? __________________
ANS: Gynecoid The gynecoid pelvis is the most common; major gynecoid pelvic features are present in 50% of all women. Anthropoid and android features are less common, and platypelloid pelvic features are the least common.
The volume of amniotic fluid is an important factor in assessing fetal well-being. Oligohydramnios (an amniotic fluid volume of less than 300 ml) is associated with what kind of fetal anomalies? a. Renal b. Cardiac c. Gastrointestinal d. Neurologic
ANS: A An amniotic fluid volume of less than 300 ml (oligohydramnios) is associated with fetal renal anomalies. The amniotic fluid volume has no bearing on the fetal cardiovascular system. Gastrointestinal anomalies are associated with hydramnios, or an amniotic fluid volume greater than 2 L. The amniotic fluid volume has no bearing on the fetal neurologic system.
A pregnant woman tells her nurse that she is worried about the blotchy, brownish coloring over her cheeks, nose, and forehead. The nurse can reassure her that this is a normal condition related to hormonal change, commonly called the mask of pregnancy or, scientifically: a. Chloasma b. Linea nigra c. Striae gravidarum d. Palmar erythema
ANS: A Chloasma, the mask of pregnancy, usually fades after birth. Linea nigra is a pigmented line that runs vertically up the abdomen. Striae gravidarum are also known as stretch marks. Palmar erythema is signified by pinkish red blotches on the hands.
The nurse knows that the second stage of labor, the descent phase, has begun when: a. The amniotic membranes rupture b. The cervix cannot be felt during a vaginal examination c. The woman experiences a strong urge to bear down d. The presenting part is below the ischial spines
ANS: C During the descent phase of the second stage of labor, the woman may experience an increase in the urge to bear down. Rupture of membranes (ROM) has no significance in determining the stage of labor. The second stage of labor begins with full cervical dilation. Many women may have an urge to bear down when the presenting part is below the level of the ischial spines. This can occur during the first stage of labor, as early as 5 cm dilation.
A nurse is preparing to administer the first dose of tobramycin (Nebcin) to an adolescent with cystic fibrosis. The order is for 3 mg/kg I.V. daily in three divided doses. The client weighs 95 lb. How many milligrams should the nurse administer per dose? Record your answer using one decimal place.
Answer: 43.2 milligrams RATIONALE: To perform this dosage calculation, the nurse should first convert the client's weight to kilograms using this formula: 1 kg/2.2 lb = X kg/95 lb 2.2X = 95 X = 43.2 kg Then, she should calculate the client's daily dose using this formula: 43.2 kg × 3 mg/kg = 129.6 mg Lastly, the nurse should calculate the divided dose: 129.6 mg ÷3 doses = 43.2 mg/dose
A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which of the following is the appropriate nursing action? 1. Withhold the medication. 2. Administer the medication. 3. Double-check the apical heart rate and administer the medication. 4. Check the blood pressure and respirations and administer the medication.
1. Withhold the medication Rationale: Digoxin is effective within a narrow therapeutic range (0.5 to 2 ng/mL). Safety in dosing is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. If the heart rate is less than 100 beats per minute in an infant, the nurse would withhold the dose and notify the registered nurse and health care provider. Options 2, 3, and 4 are incorrect actions.
A nurse is teaching parents about accident prevention for a toddler. Which guideline is most appropriate? 1. Always make the toddler wear a seat belt when riding in a car. 2. Make sure all medications are kept in containers with childproof safety caps. 3. Never leave a toddler unattended on a bed. 4. Teach rules of the road for bicycle safety.
2. Make sure all medications are kept in containers with childproof safety caps. RATIONALE: Making sure all medications are kept in containers with childproof safety caps is the most appropriate guideline because poisoning accidents are common in toddlers owing to the toddler's curiosity and his increasing mobility and ability to climb. When riding in a car, a toddler should be strapped into a car seat, not a seat belt. A seat belt is an appropriate guideline for a school-age child. Never leaving a child alone on a bed is an appropriate guideline for parents of infants. Toddlers already have the ability to climb on and off of beds and other furniture by themselves. Note, however, that toddlers should never be left unattended on high surfaces, such as an examining table in a physician's office. Teaching the rules of the road for bicycle safety is an appropriate safety measure for a school-age child. Toddlers shouldn't be allowed in the road unsupervised.
A nurse caring for a laboring woman is cognizant that early decelerations are caused by: a. Altered fetal cerebral blood flow b. Umbilical cord compression c. Uteroplacental insufficiency d. Spontaneous rupture of membranes
ANS: A Early decelerations are the fetus's response to fetal head compression. These are considered benign and interventions are not necessary. Variable decelerations are associated with umbilical cord compression. Late decelerations are associated with uteroplacental insufficiency. Spontaneous rupture of membranes has no bearing on the fetal heart rate (FHR) unless the umbilical cord prolapses, which would result in variable or prolonged bradycardia.
The primary goal to be included in the plan of care for a child who has cerebral palsy is to: 1. Eliminate the cause of the disease. 2. Improve muscle control and coordination. 3. Prevent the occurrence of emotional disturbances. 4. Maximize the child's assets and minimize the limitations.
4. Maximize the child's assets and minimize the limitations Rationale: The goal of managing the child with cerebral palsy is early recognition and intervention to maximize the child's abilities. The cause of the disease cannot be eliminated. It is best to minimize emotional disturbances, if possible, but not to prevent them because it is healthy for the child to express emotions. Improvement of muscle control and coordination is a component of the plan, but the primary goal is to maximize the child's assets and minimize the limitations caused by the disease.
A newly married couple plans to use natural family planning. It is important for them to know how long an ovum can live after ovulation. The nurse knows that teaching is effective when the couple responds that an ovum is considered fertile for: a. 6 to 8 hours b. 24 hours c. 2 to 3 days d. 1 week
ANS: B Ova are considered fertile for about 24 hours after ovulation. Ova are considered fertile for much longer than 6 to 8 hours. Most remain fertile for 24 hours. Ova do not remain fertile for 2 to 3 days. If unfertilized by a sperm, the ovum degenerates and is reabsorbed. Ova do not remain viable for 1 week. After 24 hours the ovum degenerates and is reabsorbed.
A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately? 1. Temperature 100.9° F 2. Pulse 78 beats per minute 3. Blood pressure 110/70 mm Hg 4. Respirations 22 breaths per minute
1. Temperature 100.9 F Rationale: Fever may be an indication of an infection of the shunt, which is the primary concern in the postoperative period, related to a shunt insertion. All of the other vital signs are normal findings for this child.
The nurse should implement which of the following in the care of a child who is having a seizure? Select all that apply. 1. Time the seizure. 2. Restrain the child. 3. Stay with the child. 4. Insert an oral airway. 5. Place the child in a supine position. 6. Loosen clothing around the child's neck.
1. Time the seizure 3. Stay with the child 6. Loosen clothing around the child's neck Rationale: During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out of the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.
A nurse is conducting an infant nutrition class for parents. Which foods are appropriate to introduce during the first year of life? Select all that apply. 1. Sliced beef 2. Pureed fruits 3. Whole milk 4. Rice cereal 5. Strained vegetables 6. Fruit juice
2. Pureed fruits 4. Rice cereal 5. Strained vegetables RATIONALE: The first food provided to a neonate is breast milk or formula. Between ages 4 and 6 months, rice cereal can be introduced, followed by pureed or strained fruits and vegetables, then strained, chopped or ground meat. Infants shouldn't be given whole milk until they are at least age 1. Fruit drinks provide no nutritional benefit and shouldn't be encouraged.
Which of the following is the most appropriate location for assessing the pulse of an infant who is less than 1 year old? 1. Radial 2. Carotid 3. Brachial 4. Popliteal
3. Brachial Rationale: To assess a pulse in an infant (i.e., a child <1 year old), the pulse is checked at the brachial artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant.
