206 Final
A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation?
By positioning the neonate so that the head remains still
A client is being treated for facial burns caused by a house fire. Which assessment should the nurse make a priority
Checking for airway patency
To assess a client's cranial nerve function a nurse should assess
Gag reflex
Which statement would be appropriate for a nurse documenting a stage 1 pressure ulcer found on a client who is immobilized?
The client's skin is intact with non-blanchable redness of a localized area over a bony prominence.
The nurse is caring for an adolescent on a burn unit who has sustained third-degree burns over 40% of the body. A family member asks why the client is not reporting more pain. How should the nurse respond?
The server burns have damaged nerves that sense pain
Which client is most appropriate for the registered nurse to assign to the licensed practical nurse (LPN)?
multiparous woman with Klebsiella pneumoniae cystitis
During the fourth stage of labor
the client should be assessed carefully for , uterine atony.
What is the priority nursing intervention in the postictal phase of a seizure?
Assess the client's breathing pattern
A client is undergoing fertility testing and it has been determined that she is oligo-ovulatory. Which drug would be used to stimulate ovulation in this type of menstrual cycle?
clomiphene
As part of the respiratory assessment a nurse observes the neonate's nares for patency and mucus. The information obtained from this assessment is important because
neonates are obligate nose breathers.
The nurse is assisting a client who just received an epidural during the first stage of labor. Which medication does the nurse know may be needed at this time?
oxytocin
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing
raccoon's eyes and Battle's sign.
When caring for a client with preeclampsia during labor the nurse should:
restrict the amount of fluid administered.
The nurse is performing a routine assessment of a 37-week pregnant client. What should the nurse implement during this prenatal visit?
screening for group B strep and STIs
A client is concerned that her 2-day-old breast-feeding neonate isn't getting enough to eat. The nurse should teach the client that breast-feeding is effective if:
the neonate latches onto the areola and swallows audibly.
A nurse is caring for a client who underwent a lumbar laminectomy 2 days ago. Which finding requires immediate intervention?
urine retention or incontinence
A nurse is caring for a client after evacuation of a hydatidiform mole. The nurse should tell the client to:
use birth control for at least 1 year.
During routine preconception counseling a client asks how early a pregnancy can be diagnosed. What is the nurse's best response?
"8 days after conception."
The prenatal client tells the nurse that she has been eating ginger cookies to treat her nausea and vomiting. Which response by the nurse is best?
"When consumed as a spice in foods, ginger is generally considered safe in pregnancy."
A client is using the rhythm (calendar-basal body temperature) method of family planning. In this method the unsafe period for sexual intercourse is indicated by
3 full days of elevated basal body temperature and clear, thin cervical mucus.
A client who is 5 weeks' pregnant reports nausea and vomiting. The nurse reassures the client that these symptoms probably will subside by:
9 to 12 weeks' gestation.
A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention should be included in the plan of care before a hydrotherapy treatment is initiated?
Administer pain medication 30 minutes before therapy to help manage pain.
The nurse is developing a plan of care for a client with a stage 3 heel ulcer. Which intervention should the nurse include?
Apply a hydrocolloidal dressing.
A newly postpartum client is asking to go to the bathroom 45 minutes after birth. She had an epidural for labor and birth and has an IV infusing and every 15 minutes assessments are in progress. What should the nurse do to provide the safest care for this client?
Assess the client's ability to stand and bear weight before going to the bathroom.
When auscultating the heart sounds of a client who's 34 weeks pregnant the nurse detects a systolic ejection murmur. Which action should the nurse take?
Document the finding, which is normal during pregnancy.
A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates
Dysfunction in the brain stem
A pregnant client arrives in the emergency department and states "My baby is coming." The nurse sees a portion of the umbilical cord protruding from the vagina. What should the nurse do first?
Hold pressure on the fetal head.
A client is admitted to an acute care facility with a suspected dysfunction of the lower brain stem. The nurse should monitor this client closely for
Hypoxia
A nurse is assessing the left lower extremity of a client with type 2 insulin-requiring diabetes and cellulitis. What should the nurse do
Instruct the client to elevate the left leg when sitting in the chair.
A 10-week pregnant client tells the nurse she is worried about the fatigue that is causing difficulty with functioning at work. How can the nurse best instruct this client about the relief of fatigue?
Instruct the client to take at least two rest breaks during the workday.
Which statement about a fetal biophysical profile would be incorporated into the teaching plan for a primigravid client with insulin-dependent diabetes?
It is noninvasive using real-time ultrasound.
A client is being treated for acute low back pain. The nurse should report which of these clinical manifestations to the health care provider (HCP) immediately?
New onset of foot drop
A client with hydrocephalus reports having had a headache in the morning on arising for the last 3 days but it disappears later in the day. What should the nurse do next?
Notify the health care provider (HCP).
A newborn who is 20 hours old has a respiratory rate of 66 breaths/min is grunting when exhaling and has occasional nasal flaring. The newborn's temperature is 98°F (36.6°C); he is breathing room air and is pink with acrocyanosis. The mother had membranes that were ruptured 26 hours before birth. What nursing actions are most indicated?
Place a pulse oximeter, and contact the health care provider (HCP) for a prescription to draw blood cultures.
A nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client?
The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment.
In the fourth stage of labor
a full bladder increases the risk of what postpartum complication? , hemorrhage
In an industrial accident a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of their body. The client is in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
a urine output consistently above 40 ml/hour (40 mL/hour)
A nurse is assessing a client who is 6 weeks pregnant. Which findings best support a suspicion of ectopic pregnancy?
amenorrhea and adnexal fullness and tenderness
The most effective health-promotion measure related to glaucoma that the nurse could teach clients is:
annual intraocular pressure measurements for people older than 40 years.
The nurse is caring for an expectant mother who asks how decisions are made if complications place both the mother and fetus at risk. What ethical principle will the nurse cite when responding to the client's question?
autonomy
A neonate born several hours ago shows signs of a tracheoesophageal fistula (TEF). During the initial assessment what does the nurse expect to find?
continuous drooling
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include
diminished responsiveness.
A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in a row the nurse should instruct the client to
discard the pack, use an alternative contraceptive method until her period begins , and start a new pack on the regular schedule:
The nurse is assessing a client with retinal detachment. The nurse should assess the client for:
flashing lights and visual field loss.
A nurse recognizes that labor is divided into how many stages?
four
Which is the correct order
from first to last, for proper placement of a urinary catheter? All options must be used. , Prepare a sterile field Lubricate the catheter adequately with a water-soluble lubricant Insert the catheter far enough into the bladder to prevent trauma to the urethral tissue Ensure free flow of urine.
When magnesium sulfate is administered to a client in labor its action occurs at which site?
neural-muscular junctions
A client who is 14 weeks pregnant states "Ever since I've been pregnant, I've had a hard time moving my bowels." Increased levels of what hormone are responsible for this common discomfort of pregnancy?
progesterone
A nurse is preparing a neonate for circumcision. Which behavior is the best example of nursing advocacy?
recommending the use of analgesia for circumcision
Which statement describes the term fetal position?
relationship of the fetus's presenting part to the mother's pelvis
Which finding is the most serious adverse effect associated with oxytocin administration during labor?
tetanic contractions
A client received burns to the entire back and left arm. Using the Rule of Nines
the nurse can calculate that the client has sustained burns on what percentage of the body? , 27%
A client with psoriasis visits the dermatology clinic. When inspecting the affected areas
the nurse expects to see which type of secondary lesion? , Scale
While caring for a client who has just given vaginal birth to a neonate the nurse is monitoring for signs of placental separation. What signs indicate that the placenta has separated? Select all that apply
sudden gush of vaginal blood change in shape of the uterus , lengthening of the umbilical cord
The obstetric nurse is performing a nonstress test on a 30 week primigravida client sent from a healthcare provider's office. The client reports a decrease in fetal movement over the past 24 hours. The nurse documents the above nursing note. Which nursing statement is appropriate at this time?
"I will check with the healthcare provider to see if further tests are needed."
A client with type 1 diabetes has just learned she's pregnant. The nurse is teaching her about insulin requirements during pregnancy. Which guideline should the nurse provide?
"Insulin requirements usually decrease during the first trimester."
A primigravid client is 8 weeks' pregnant and has had her first examination. The healthcare provider stated the client has a positive Hegar's sign. The client is concerned that this sign means something is wrong. How should the nurse respond to this client's concerns?
"This is a good sign. It means the uterus is softened."
A nurse is assessing a pregnant client in the second trimester. The nurse weighs the client then compares the current and previous weights. During the second trimester how much weight should the client gain per week?
1 lb (0.45 kg)
A client comes to the office for a routine prenatal visit at 26 weeks gestation The urine dipstick is negative for protein but 2+ for glucose The nurse would teach the client about what testing that needs to be performed?
1-hour glucose tolerance test
A primigravid client with severe preeclampsia exhibits hyperactive very brisk patellar reflexes with two beats of ankle clonus present. How does the nurse document the patellar reflexes?
4+
During neonatal resuscitation immediately after delivery chest compressions should be initiated when the heart rate falls below
60 beats/minute.
A client preparing to undergo a lumbar puncture states they don't think they will be able to get comfortable with their knees drawn up to the abdomen and the chin touching their chest. The client asks if they can lie on their left side. Which statement is the best response by the nurse?
Although the required position may not be comfortable, it will make the procedure safer and easier to perform."
Which hospitalized client is at highest risk for catheter associated urinary tract infection (CAUTI)?
Client with Diabetus Mellitus
A client is admitted with a diagnosis of chronic hydronephrosis. Which assessment finding requires immediate action or will assist the nurse in planning care?
Client's blood urea nitrogen (BUN) is 32 mg/dL.
A primigravid client who was successfully treated for preterm labor at 30 weeks' gestation had a history of mild hyperthyroidism before becoming pregnant. What instructions should the nurse include in the plan of care?
Continue taking low-dose oral propylthiouracil as ordered.
A client at 37 weeks' gestation is scheduled for an ultrasound. What should the nurse instruct the client to do before the test?
Drink 1 to 2 L of fluid.
The nurse is assessing a client with dark skin for the presence of a stage I pressure ulcer. Which is the best approach to making this assessment?
Look for skin color that is darker than the surrounding tissue.
A client at 36 weeks gestation has been admitted to the hospital for gestational hypertension. The client's blood pressure is 188/98 mm Hg and the client has no proteinuria. What is the priority nursing action at this time?
Notify the physician immediately.
At the 28th week visit the prenatal client's hemoglobin is 13 g/dL( 130 g/L). What is the best intervention?
Reinforce that the client should continue taking her prenatal vitamins for her entire pregnancy.
The nurse notes that the dialysate drainage of a client receiving peritoneal dialysis is cloudy. Which action should the nurse take?
Report the finding to the healthcare provider.
A client with chronic renal failure is receiving hemodialysis three times a week. What should the nurse do to protect the fistula?
Report the loss of a thrill or bruit on the arm with the fistula.
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1 inch × 1 inch (3 cm x 3 cm) area on the sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the medical record?
Stage II pressure ulcer
The nurse is performing Leopold's maneuver on a woman who is at 37 weeks gestation and finds the fetus in the following position. Which action by the nurse is anticipated?
Support the client while the healthcare provider performs external cephalic version.
A client is Rh(D)-negative and D-negative and hasn't formed Rh antibodies. When should the client receive RHO(D) immune globulin (RhoGAM) to prevent isoimmunization?
at about 28 weeks' gestation and again within 72 hours after birth
During the admission assessment of a female neonate a nurse notes a large lump on the neonate's head. Concerned about making the correct assessment the nurse differentiates between caput succedaneum and a cephalohematoma based on the knowledge that
a cephalohematoma doesn't cross the suture lines.
The nurse conducts the health assessment of a client who is a primigravida in the prenatal clinic. Which presumptive signs of pregnancy should the nurse expect to assess?
amenorrhea and quickening
After developing severe hydramnios a primigravid client exhibits dyspnea along with edema of the legs and vulva Which procedure should the nurse expect the client to undergo and why?
amniocentesis to temporarily relieve discomfort
A client has had a cerebrovascular accident which has affected the left side of the client's brain. The nurse should assess the client for which symptom?
aphasia
The nurse is assessing a client who is immobile and notes that an area of sacral skin is reddened
but not broken. The reddened area continues to blanch and refill with fingertip pressure. What should the nurse do next? , Reposition the client off the reddened skin and reassess in a few hours.
During the sixth month of pregnancy a client reports intermittent earaches and a constant feeling of fullness in the ears. What is the most likely cause of these symptoms?
eustachian tube vascularization
During each prenatal checkup a nurse obtains a client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup?
evaluating the client for edema
A 37-year-old client of Native American/First Nations/Aboriginal descent visits the clinic for the first time. She is about 12 weeks pregnant and this is her first pregnancy. Which test does the nurse anticipate will be prescribed?
glycosylated hemoglobin
A client with human immunodeficiency virus (HIV) infection gives birth to a neonate. When assessing the neonate the nurse is most likely to detect
hepatosplenomegaly.
While caring for a pregnant adolescent client the nurse should develop a care plan that incorporates the adolescent's:
level of emotional maturity.
The nurse should assess an older adult with macular degeneration for:
loss of central vision.
Which finding will the nurse observe in the client in the ictal phase of a generalized tonic-clonic seizure?
loss of consciousness, body stiffening, and violent muscle contractions
A multigravid client at 32 weeks' gestation has experienced hemolytic disease of the newborn in a previous pregnancy. The nurse should prepare the client for frequent antibody titer evaluations obtained from which source?
maternal blood
A nurse is assessing a client who's 29 weeks pregnant. What is the most cost-effective method for assessing fetal well-being?
maternal fetal activity count
During labor a primigravid client receives an epidural anesthetic and the nurse assists in monitoring maternal and fetal status. Which finding suggests an adverse reaction to the anesthesia?
maternal hypotension
The nurse is evaluating the client's risk for having a pressure sore. Which is the best indicator of risk for the client's developing a pressure sore?
mobility status
A multipara is admitted to the birthing room after her initial examination reveals her cervix to be at 8 cm completely effaced (100%), and at 0 station. Based on these findings, the nurse should recognize that the client is in which phase of labor?
transitional phase
The nurse is assessing a client with a cervical injury for autonomic dysreflexia. The nurse should assess the client for:
sudden, severe hypertension
The nurse instructs a primigravid client to increase her intake of foods high in magnesium. This nutrient plays a role in which process?
synthesis of proteins, nucleic acids, and fats
When assessing the fetal heart rate tracing a nurse assesses the fetal heart rate at 170 beats/minute. This rate is considered fetal tachycardia if
the fetal heart rate remains at greater than 160 beats/minute for 10 minutes.
A client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit
the nurse checks the client's oculocephalic (doll's eye) response by , turning the client's head suddenly while holding the eyelids open.
When a client is recovering as expected from spinal anesthesia
the nurse should assess: , degree of response to pinpricks in the legs and toes.
A nurse is conducting an assessment of a neonate born 3 hours ago. Which finding makes the nurse suspect a congenital hip dislocation?
unequal gluteal folds
A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor?
unequal pupil size
A nurse is preparing to perform a physical examination on a postpartum client. The client asks the nurse why gloves are necessary for the examination. What is the nurse's best response?
"Gloves are required for standard precautions.
The nurse is teaching pain management to a prenatal class. The nurse knows that the instruction has been effective when a participant says
"I will feel most of my pain in my pelvis during early labor."
A nurse is using Doppler ultrasound to assess a pregnant client. When should the nurse expect to begin hearing fetal heart tones?
11 weeks' gestation
A client is being admitted to the labor and childbirth unit. Her GTPAL classification is 5-2-1-1-2. When providing shift report which information would the nurse include? Select all that apply.
The client has had four previous pregnancies The client has had two full-term children, one premature child, and one abortion The client has two living children and is pregnant again.
When assessing the client with Parkinson's disease the nurse should observe the client for:
a stiff, masklike facial expression.
An appropriate for gestational age neonate should weigh
between the 10th and the 90th percentiles for age.
At a preconception visit a 24-year-old client is found to have malformation of the uterus. The nurse uses the accompanying figure to explain which type of uterine malformation?
bicornuate uterus
The nurse is assessing a client with increasing intracranial pressure (ICP). The nurse should notify the health care provider (HCP) about which early change in the client's condition?
decrease in level of consciousness (LOC)
The end of the third stage of labor is marked by what event?
delivery of the placenta
After determining that a pregnant client is Rh-negative a physician orders an indirect Coombs' test. The purpose of performing this test with a pregnant client is to:
detect maternal antibodies against fetal Rh-positive factor.
When developing a series of parent classes on fetal development the nurse should include which feature as being developed by the end of the third month (9 to 12 weeks)?
external genitalia
"During an annual checkup a client tells the nurse that she and her partner have decided to start a family. Ideally, when should the nurse plan for childbirth education to begin and end?
It should begin before conception and end 3 months after childbirth.
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
Lactated ringers solution
A nurse is caring for a client who has limited mobility and requires a wheelchair. The nurse has concern for circulation problems when which device is used?
Ring or donut
When caring for a client in the first stage of labor the nurse documents cervical dilation of 9 cm and intense contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should recognize that the client is in which phase of labor?
transitional phase
Which nursing goal is realistic to establish with a client who has multiple sclerosis (MS)
improved muscle strength
A client asks the nurse if it is safe to have sex during the third trimester. How should the nurse respond?
"Sex is safe in any trimester."
While assessing a male neonate whose mother desires him to be circumcised the nurse observes that the neonate's urinary meatus appears to be located on the ventral surface of the penis. The nurse notifies the healthcare provider because the nurse suspects which disorder?
hypospadias
The prenatal client wants to know why the nurse is asking about her use of herbal supplements. What is the nurse's best response?
"Understanding the full picture of what herbal supplements you use to manage your health will help us better provide coordinated and safe care."
The nurse is assessing a client's motor response after brain surgery. The nurse pinches the client's skin to elicit a response and observes the client's arms and legs moving straight out and the feet and toes bend downward. How should the nurse document this response?
Extension posturing
A client with gestational hypertension is likely to exhibit
sudden weight gain headaches and double vision.
A client has stress incontinence. Which data from the client's history contributes to the client's incontinence?
the client's history of three full-term pregnancies
A client who had transurethral resection of the prostate has dribbling urine after his Foley catheter is removed on the second postoperative day. The nurse notes that the client had 200 mL of urine output in the last 8 hours with a 1000-mL intake. What should the nurse do first?
Assess for bladder distention.
A woman with preeclampsia is receiving magnesium sulfate via infusion pump at 1 g/h. The nurse's assessment includes temperature 36.7°C; pulse 78; respirations 12/minute; blood pressure 128/82 mm Hg; urinary output 90 mL in last 4 hours via urinary catheter; patellar-tendon reflex absent; ankle clonus absent; fetal heart rate 120 beats/min; cervix 4 cm dilated 80% effaced station -1. Which is the most appropriate action for the nurse to take?
Discontinue the magnesium sulfate infusion and notify the health care provider (HCP).
A primigravida at 8 weeks' gestation tells the nurse that she wants an amniocentesis because there is a history of hemophilia A in her family. The nurse informs the client that she will need to wait until she is at 15 weeks' gestation for the amniocentesis. Which is the most appropriate rationale for the nurse's statement regarding amniocentesis at 15 weeks' gestation?
The volume of amniotic fluid needed for testing will be available by 15 weeks.
Which is an initial sign of Parkinson's disease?
Tremor
The nurse is assessing a client recovering from a hemorrhagic cerebral vascular accident (CVA) that occurred 7 days ago. Which assessment finding should be reported to the healthcare provider?
Worsening headache
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out the IV line. What should the nurse do to protect the client without increasing the intracranial pressure (ICP)?
Wrap the hands in soft "mitten" restraints.
A client had a cystoscopy to remove a renal stone. Which laboratory data warrants immediate intervention by the nurse
a white blood cell count of 14,000 mm/dL (14.00 x 109/L)
A 29-week gestation client arrives in the labor and birth suite for an emergency cesarean section. The neonate is born and artificial surfactant is administered. Which action best explains the main function and goal of surfactant use?
helps lungs remain expanded after the initiation of breathing improving oxygenation
A teenage client is admitted to the burn unit with burns over 49% of the body surface area
including the face and neck. Carbon particles are noted around the nose and mouth. The client is slightly confused and reports minor pain. When assessing the client, which is an immediate priority for the nurse to evaluate? , Patency of airway
The topic of physiologic changes that occur during pregnancy is to be included in a parenting class for primigravid clients who are in their first half of pregnancy. Which of the following topics would be important for the nurse to include in the teaching plan?
increased risk for urinary tract infections
A nurse is monitoring the contractions of a client in the first stage of labor. Order the phases of a uterine contraction from the beginning of contraction to its conclusion. All options must be used.
increment acme decrement relaxation
A pregnant client's hepatitis B report reads "HBsAg = positive." Which correctly describes the client's hepatitis B status?
infected
After giving birth to an 8-lb (3.6-kg) girl a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate the first feeding usually consists of
iron-fortified infant formula.
A nurse is preparing to auscultate fetal heart tones in a pregnant client Abdominal palpation reveals a hard round mass under the left side of the rib cage a softer round mass just above the symphysis pubis small irregular shapes in the right side of the abdomen and a long firm mass on the left side of the abdomen. Based on these findings where is the best place to auscultate fetal heart tones?
left upper abdominal quadrant
A client is 41 weeks gestation and is admitted to the hospital in true labor. She has an external fetal monitor in place. What does the nurse recognize as a reassuring fetal heart rate (FHR) pattern?
spontaneous accelerations; FHR increases by 15 beats per minute (bpm) lasting at least 15 seconds
The nurse observes that when a client with Parkinson's disease unbuttons the shirt
the upper arm tremors disappear. Which statement best guides the nurse's analysis of this observation about the client's tremors? , The tremors sometimes disappear with purposeful and voluntary movements.
The nurse is performing Leopold's maneuvers on a woman who is in her eighth month of pregnancy. The nurse is palpating the uterus as shown. Which maneuver is the nurse performing?
third maneuver