304 Final Review

A nurse is assessing a client who has pertussis. Which of the following findings should the nurse expect? (Select all that apply.) A. Runny nose B. Mild fever C. Cough with whooping sound D. Swollen salivary glands E. Red rash

A. & B. because, a client who has pertussis has coldlike manifestations, including runny nose, congestion, and mild fever. C. because, a client who has pertussis will experience coughing fits and a whooping sound.

A nurse is caring for a client who is in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? (Select all that apply.) A. Gonorrhea B. Chlamydia C. HIV D. Group B streptococcus E. TORCH infection

A. and B. because, erythromycin is administered to the infant immediately following delivery to prevent Neisseria gonorrhoeae and Chlamydia trachomatis. C. because, Retrovir is prescribed to a client in labor who is HIV-positive. D. because, Penicillin G or ampicillin may be prescribed to treat positive GBS.

A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse anticipate the provider will prescribe? A. Ceftriaxone B. Fluconazole C. Metronidazole D. Zidovudine

A. because, Ceftriaxone IM or doxycycline orally for 7 days is prescribed for the treatment of gonorrhea.

A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? A. Koplik spots B. Parotitis C. Strawberry tongue D. Paroxysmal cough

A. because, Koplik spots are small, irregular oral lesions with a bluish-white center and are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash appears and are accompanied by manifestations of fever, malaise, conjunctivitis, and other cold manifestations.

A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following findings should the nurse expect? (Select all that apply.) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein

A. because, Rheumatic fever is caused by Group A Beta-hemolytic streptococcus. An erythema marginatum (rash) is a manifestation. E. because, Rheumatic fever is caused by Group A beta-hemolytic streptococcus. An increase in C-reactive protein is a manifestation.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate 125/min C. Soft, flat fontanel D. Systemic murmur

A. because, a 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.

A nurse is caring for a child who has short stature. Which of the following diagnostic tests should be completed to confirm growth (GH) deficiency? (Select all that apply.) A. CT scan of the head B. Bone age scan C. GH stimulation test D. Serum IGF-1 E. DNA testing

A. because, a CT scan of the head is conducted to determine whether there is a structural component to the short stature. B. because, a bone age scan is conducted to determine the development of the bones. C. because, a GH stimulation test is conducted to confirm diagnosis of GH deficiency. D. because, a serum IGF-1 is obtained as a preliminary test to determine GH deficiency.

A nurse is reviewing sick-day management with a parent of a child who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? (Select all the apply.) A. Monitor blood glucose levels every 3 hr. B. Discontinue taking insulin until feeling better. C. Drink 8 oz of fruit juice every hour. D. Test urine for ketones. E. Call the provider if blood glucose is greater than 240 mg/dL.

A. because, a client who is experiencing illness can have waning blood glucose levels. Frequently monitoring of blood glucose levels is done to identify hyperglycemic or hypoglycemic episodes. D. because, a client who is experiencing an illness should test her urine for ketones to assist in early detection of ketoacidosis. E. because, a client who is experiencing illness should notify the provider of blood glucose levels greater than 240 mg/dL to obtain further instructions in caring for the hyperglycemia.

A nurse is teaching the parent of a child who has a growth hormone deficiency. Which of the following are complications of untreated growth hormone deficiency? (Select all that apply.) A. Delayed sexual development B. Premature aging C. Advanced bone age D. Short stature E. Increased epiphyseal closure

A. because, a complication of untreated growth hormone deficiency includes delayed sexual development. B. because, a complication of untreated growth hormone deficiency includes premature aging. D. because, a complication of untreated growth hormone deficiency includes short stature.

A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility. B. Inform the child he will be put to sleep during the procedure. C. Read the child a story about a cartoon character having a similar operation. D. Tell the child the appointment is to have his throat checked.

A. because, a preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure.

A nurse us administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? (Select all that apply.) A. Respirations less than 12/min B. Urinary output less than 30 mL/hr C. Hyperreflexic deep-tendon reflexes D. Decreased level of consciousness E. Flushing and sweating

A. because, a respiratory rate less than 12/min is a sign of magnesium sulfate toxicity. B. because, urinary output less than 30 mL/hr is a sign of magnesium sulfate toxicity. D. because, decreased level of consciousness is a sign of magnesium sulfate toxicity.

A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? (Select all that apply.) A. Fetal distress B. Preterm labor C. Vaginal bleeding D. Cervical dilation greater than 6 cm E. Severe gestational hypertension

A. because, acute fetal distress is a complication that is a contraindication for use of magnesium sulfate therapy. C. because, vaginal bleeding is a complication that is a contraindication for magnesium sulfate therapy. D. because, cervical dilation greater than 6 cm is a complication that is a contraindication for magnesium sulfate therapy.

A school nurse is assessing an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints

A. because, an adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen.

A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? (Select all that apply.) A. Episiotomy B. Oxytocin infusion C. Forceps D. Cesarean birth E. Internal fetal monitoring

A. because, an episiotomy should be avoided for a client who is HIV-positive due to the risk of maternal blood exposure. C. because, the use of forceps during delivery should be avoided due to the risk of fetal bleeding. E. because, internal fetal monitoring should be avoided due to the risk of fetal bleeding.

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A. "The infant may be dehydrated." B. "The infant might be anemic." C. "The infant might have received too much fluid." D. "The infant might have leukemia."

A. because, an increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration.

A nurse is caring for a group of infants who have congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of great arteries B. Ventricular-septal defect C. Coarctation of the aorta D. Patent-ductus arteriosus

A. because, an infant who has transposition of great arteries will have severe cyanosis because reversal of the anatomic position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation.

A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client us actively bleeding. Which of the following types of. medications should the nurse anticipate the provider will prescribe? A. Betamethasone B. Indomethacin C. Nifedipine D. Methylergonovine

A. because, betamethasone is given to promote lung maturity if delivery is anticipated.

A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) C. Haemophilus influenza type B (Hib) D. Hepatitis B (Hep B)

A. because, children should receive booster doses of the DTaP immunization between the ages of 4 and 6. It is around this age that blood titers drop due to decreasing antibodies.

A nurse is assessing a child who has short stature. Which of the following findings would indicate a growth hormone deficiency? A. Proportional height to weight B. Height proportionally greater than weight C. Weight proportionally greater than height D. BMI greater than height/weight ratio

A. because, children who have growth hormone deficiency present with short stature with proportional height and weight.

A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when in my child's room." D. "I will apply lotion to my child's peeling hands."

A. because, children who have rheumatic fever might take salicylates (aspirin) to control the inflammatory process that occurs in the joints.

A nurse is providing teaching for an adolescent client who has mononucleosis. The client has a fever, fatigue, swollen lymph nodes, sore throat, and a sore upper abdomen. Which of the following instructions should the nurse include in the teaching? (Select all that apply). A. Take antibiotics until symptoms subside. B. Drink plenty of fluids. C. Avoid participating in strenuous activities. D. Allow for periods of rest. E. Take aspirin as needed for fever and discomfort. F. Gargle with saltwater every 2 to 3 hr.

A. because, clients who have pertussis or streptococcal pharyngitis can benefit from antibiotic therapy. B. because, fluids are encouraged to prevent dehydration with illness. C. because, the spleen could rupture as a result of injury. Strenuous activities should be avoided. D. because, fatigue is common in clients who have mononucleosis. Allowing for periods of rest facilitates healing. F. because, saltwater can soothe discomfort associated with a sore throat.

A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring in the child's stuffed animal. B. Give the child choices when planning daily activities. C. Administer phenytoin three times per day. D. Provide a shared room with another child his age.

A. because, encouraging parents to bring in a child's favorite stuffed animal helps lessen the disruptiveness of hospitalization.

A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." B. "I will give my child 2 units of regular insulin." C. "I will insist that my child lies down to rest for 30 minutes." D. "I will check my child's urine for glucose twice daily."

A. because, giving a child 10 to 15 g of simple carbohydrates, such as 240 mL (8 oz) of milk, will elevate the blood glucose level and alleviate the hypoglycemia.

A nurse is providing discharge teaching to a client following the removal of a hydatidiform mole. Which of the following statements should the nurse include in the teaching? A. "Do not become pregnant for at least 1 year." B. "Seek genetic counseling for yourself and your partner prior to getting pregnant again." C. "You should have an hCG level drawn in 6 weeks." D. "Have your blood pressure checked weekly for the next month."

A. because, hydatidiform moles are uncontrolled growths in the uterus arising from placental or fetal tissue in early pregnancy. These is an increased incidence of choriocarcinoma associated with molar pregnancies. Pregnancy must be avoided for 1 year so the client can be closely monitored for manifestations of this condition.

A nurse is assessing a newborn 1 hr after birth. Which of the following assessment findings should the nurse report to the provider? A. Jaundice of the sclera B. Respiratory rate 50/min C. Acrocyanosis D. Blood glucose 60 mg/dL

A. because, if the newborn has jaundice within the first 24 hr of life, this can indicate a potential pathological process such as hemolytic disease. Pathological jaundice can result in high levels of bilirubin that can cause damage to the neonatal brain.

A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia C. Otitis media D. Osteomyelitis

A. because, in the surgical repair of the myelomeningocele, the pathway for the CSF is altered; therefore, the infant is at risk for hydrocephalus and the nurse should monitor the infant for this condition.

A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference. B. Position the infant supine. C. Place the infant under a radiant warmer. D. Tape a piece of plastic over the protruding membranes.

A. because, infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference helps to determine any increase.

A nurse is caring for child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make? A. "An abdominal ultrasound will confirm the pocket in the intestine." B. "Genotyping will be done to identify this condition." C. "A biopsy will be done on a small amount of tissue from the colon." D. "An upper GI series should identify the area involved."

A. because, intussusception is the invasion of one part of the intestine into the other, resting a pocket. The presence of an intussusception is confirmed by an abdominal x-ray, ultrasound, or CT scan.

A nurse is caring for four newborns. Which of the following newborns is at greatest risk for hypoglycemia? A. A newborn who is large for gestational age B. A newborn who has an Rh incompatibility C. A newborn who has pathologic jaundice D. A newborn who has fetal alcohol syndrome

A. because, large for gestational age (LGA) newborns are those newborns whose weight is at or above the 90th percentile. One of the most common etiologies of LGA newborns is a mother who is diabetic. LGA newborns, especially those born to mothers who have diabetes, are at increased risk for hypoglycemia. Other newborns at risk for hypoglycemia are small for gestational age (SGA) newborns (those below the 10th percentile), premature newborns, and newborns who have perinatal hypoxia.

A nurse is caring for a client whose membranes have ruptured and is in active labor. The fetal monitor tracing reveals late decelerations. Which of the following actions should the nurse take first? A. Turn the client onto her left side. B. Palpate the client's uterus. C. Administer oxygen to the client. D. Increase the client's IV fluids.

A. because, late decelerations indicate that the client is experiencing uteroplacental insufficiency. The client might be experiencing pressure on the inferior vena cava, which decreases the oxygen to the placenta and thus to the fetus. Turning the client onto her left side will relieve the pressure and facilitate better blood flow to the placenta, thereby increasing the fetal oxygen supply.

A nurse is caring for a newborn whose mother received magnesium sulfate to treat preterm labor. Which of the following clinical manifestations in the newborn indicates toxicity due to the magnesium sulfate therapy? A. Respiratory depression B. Hypothermia C. Hypoglycemia D. Jaundice

A. because, magnesium sulfate can cause respiratory and neuromuscular depression in the newborn. The nurse should monitor the newborn for clinical manifestations of respiratory depression.

A nurse is caring for a client who is pregnant and reports nausea and vomiting. Which of the following instructions should the nurse provide the client? A. "You should eat some crackers before rising from bed in the morning." B. "You should eat foods served at warm temperatures." C. "You should sip whole milk with breakfast." D. "You should brush your teeth immediately after meals."

A. because, morning sickness is caused by the buildup of human chorionic gonadotropin (hCG) in the mother's system. Dry foods eaten before rising in the morning tend to reduce the risk of nausea in clients who are pregnant.

A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (Select all that apply.) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Heart Failure

A. because, narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in weak or absent femoral pulses. B. because, narrowing of the lumen of the aorta results in obstruction of blood flow from the ventricle, resulting in cool skin of the lower extremities. E. because, heart failure occurs when the heart is unable to meet the body's demands, and is a manifestation of coarctation of the aorta.

A nurse is caring for a newborn who is premature at 30 weeks of gestation. Which of the following findings should the nurse expect? A. Abundant lanugo B. Good flexion C. Heel creases covering the bottom of feet D. Dry, parchment-like skin

A. because, newborns who are premature have abundant lanugo, fine hair, especially over their back. A full-term newborn typically has minimal lanugo present only on the shoulders, pines, and forehead.

A nurse is caring for a 10-year-old child who has nephrotic syndrome. Which of the following findings should the nurse report to the provider? A. Serum protein 5.0 g/dL B. Hgb 14.5 g/dL C. Hct 40% D. Platelet 200,000 mm3

A. because, serum protein 5.0 g/dL is out of the expected reference range for a 10-year-old child and should be reported to the provider.

A nurse is caring for a 2-year-old child who has frequent highlight urinary tract infections. When educating the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include in the teaching? A. Teach the child to wipe from front to back. B. Give the child frequent bubble baths C. Urge the child to urinate every 6 hr. D. Administer oxybutynin daily.

A. because, the child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra.

A nurse is caring for a client who is at 16 weeks of gestation and has severe iron-deficiency anemia. The provider prescribes an injection of iron dextran IM. Which of the following methods should the nurse use to administer the medication? A. Use a 20-gauge needle, and administer the medication using the Z-track method. B. Use a 22-gauge needle, and administer the medication deep into the thigh. C. Use a 25-gauge needle, and administer the medication into the deltoid muscle. D. Use an 18-gauge needle, and administer the medication into the rectus femoris muscle.

A. because, the nurse should administer iron using the Z-track method to prevent staining of tissue. A 20-gauge needle is the correct size.

A nurse is preparing to administer naloxone to a newborn. Which of the following conditions can require administration of this medication? A. IV narcotics administered to the mother during labor. B. Maternal drug use. C. Hyaline membrane disease. D. Meconium aspiration.

A. because, the nurse should administer naloxone to reverse respiratory depression due to acute narcotic toxicity, which can result from IV narcotics administration during labor.

A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering. B. Insert a dull knitting needle into the cast to rub itchy skin. C. Exercise every 8 hr for the first 24 hr. D. Draw on the cast using magic markers.

A. because, the nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Although water will not damage the fiberglass cast, water can enter the openings of the cast and result in maceration of the skin.

A nurse is teaching the parents of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give my child a dose of albendazole today and again in 2 weeks." B. "I will collect specimens immediately after my child has a bowel movement." C. "I will give my child a tub bath twice each day." D. "I will place my child's bed linens in a seal plastic bag for 7 days."

A. because, the nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to completely eradicate the parasite and prevent reinfection.

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake. B. Decrease the child's calorie intake. C. Increase the child's fiber intake. D. Decrease the child's salt intake.

A. because, the nurse should recommend an increase in protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowances to meet their nutritional needs.

A nurse is teaching the parents of a 4-month-old who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." B. "I will place my baby on her side when sleeping." C. "I will decrease the number of feedings my baby receives per day." D. "I will give my baby loperamide with each feeding."

A. because, the parents can give the infant thickened feedings with rice cereal to help decrease the reflux. In addition, the added calories can help those infants who are underweight due to the gastroesophageal reflux.

A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Abdomen 5 cm (2 in) from the umbilicus

A. because, the vests lateralis is a large, developed muscle, even in an infant. The muscle can tolerate the volume of the injection, and there are no important nerves or blood vessels in the muscle.

A nurse in an antepartum clinic answers a phone call from a client who is at 37 weeks of gestation and reports, "I became very dizzy while lying in bed this morning, but the feeling went away when I turned on my side." Which of the following actions should the nurse take? A. Instruct the client about vena cava syndrome and measures to prevent it. B. Arrange for the client to come to the clinic for an assessment. C. Check the client's chart for gestational diabetes mellitus. D. Schedule a non stress test for the client.

A. because, this is the typical finding of vena cava syndrome, or hypotension that occurs in clients who are pregnant upon assuming a supine position. It is caused by compression of the inferior vena cava by the gravid uterus with a consequent reduction in venous return. A side lying position promotes uterine perfusion and fetoplacental oxygenation

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parents indicates an understanding of the teaching? A. "My child should consume 1,000 calories per day." B. "My child should have 4 ounces of protein per day." C. "I should give my child 32 ounces (4 cups) of milk per day." D. "I should feed my child 4 ounces (1/2 cup) of vegetables per day."

A. because, toddlers who are 2 years old should consume 1,000 calories daily.

A nurse is caring for a client who reports intestinal gas pain following a cesarean section. Which of the following actions should the nurse take? A. Assist the client to ambulate in the hallway. B. Instruct the client to splint the incision with a pillow. C. Have the client drink fluids through a straw. D. Encourage the client to drink carbonated beverages.

A. because, walking can help stimulate peristalsis, which will promote expulsion of gas.

A nurse is reviewing the medical record of a client who is at 33 weeks of gestation and has placenta previa and bleeding. Which if the following prescriptions should the nurse clarify with the provider? A. Perform a vaginal examination B. Perform continuous external fetal monitoring C. Insert a large-bore IV catheter D. Obtain a blood sample for laboratory testing

A. because, what a client has a placenta previa, the placenta implants in the lower part of the uterus and obstructs the cervical os (the opening to the vagina). The nurse should clarify this prescription because any manipulation can cause tearing of the placenta and increased bleeding.

A nurse is caring for a client who is receiving oxytocin for induction of labor. Which of the following actions should the nurse take? A. Perform continuous fetal heart rate monitoring. B. Measure maternal temperature every hour. C. Evaluate maternal contraction pattern every hour. D. Check blood pressure every 5 min.

A. because, when oxytocin is administered to an antepartum client, the fetal monitor must be used to continuously monitor the fetal heart rate and maternal contractions.

A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250 mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. B. Give potassium as a rapid IV bolus. C. Administer 3 units of ultralente insulin subcutaneously. D. Obtain an HbA1c level stat.

A. because, when the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% to 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur.

A nurse is teaching a client who has active genital herpes simplex virus, type 2. Which of the following statements should the nurse include in the teaching? A. "You will have a cesarean birth prior to the onset of labor." B. "Your baby will receive erythromycin eye ointment after birth to treat the infection." C. "You should take oral metronidazole for 7 days prior to 37 weeks of gestation." D. "You should schedule a cesarean birth after your water breaks."

A. because, whenever possible, the cesarean birth should be scheduled prior to the onset of labor or rupture of membranes to reduce the risk of neonatal transmission of herpes.

A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? (Select all that apply.) A. Obesity B. Multifetal pregnancy C. Maternal age greater than 40 D. Migraine headache E. Oligohydramnios

A., B., & D.

A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? (Select all that apply.) A. Joint pain B. Malaise C. Rash D. Urinary frequency E. Tender lymph nodes

A., B., C., & E. because, TORCH infections are flu-like in presentation.

A nurse is caring for a client who reports indications of preterm labor. Which of the following findings are risk factors of this condition? (Select all that apply.) A. Urinary tract infection B. Multifetal pregnancy C. Oligohydramnios D. Diabetes Mellitus E. Uterine abnormalities

A., B., D., & E.

A nurse is preparing to administer diphenhydramine 5mg/kg/day PO to divide equally every 8 hr to a school-age child who weighs 50 lb. Available is diphenhydramine oral solution 12.5 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer: 15 mL. STEP 1: What is the unit of measurement the nurse should calculate? kg STEP 2: Set up an equation and solve for X. 2.2 lb/1 kg = Client's weight in lb/X kg 2.2 lb/1 kg = 50 lb/X kg X = 22.7272 STEP 3: Round if necessary. 22.7272 = 22.7 STEP 4: Reassess to determine whether the conversion to kg makes sense. If 1 kg = 2.2 lb, it makes sense that 50 lb = 22.7 kg. STEP 5: What is the unit of measurement the nurse should calculate? mg STEP 6: Set up an equation and solve for X. mg x kg/day = X 5 mg x 22.7 kg = 113.5 STEP 7: Round if necessary. STEP 8: Reassess to determine whether the amount makes sense. If the prescription reads 5 mg/kg/day to divide equally every 8 hr and the school-age child weights 22.7 kg, it makes sense to give 113.5 mg/day or 37.883 mg every 8 hr. STEP 9: What is the unit of measurement to calculate? mL STEP 10: What is the quantity of the dose available? 5 ml STEP 11: What is the dose available? Dose available = Have 12.5 mg STEP 12: What is the dose the nurse should administer? Dose to administer = Desired 37.8333 mg STEP 13: Should the nurse convert the units of measurement? NO. STEP 14: Set up the equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired X mL = 5 mL/12.5 mg x 37.8333 mg X = 15.1332 mL STEP 15: Round if necessary. STEP 16: Reassess to determine whether the amount to give makes sense. If there is 12.5 mg/5 mL and the prescription reads 37.5 mg, it makes sense to give 15 mL. The nurse should administer diphenhydramine oral solution 15 mL PO every 8 hr.

A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005

B. because, 1.035 is a concentrated specific gravity, which is an unexpected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hr.

A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should the nurse plan to administer? A. Digoxin immune fab B. Acetylcysteine C. Naloxone D. Vitamin K

B. because, Acetylcysteine is the antidote for acetaminophen overdose or poisoning.

A nurse administers betamethasone to a client who is a 33 weeks of gestation to stimulate fetal lung maturity. When planning care for the newborn, which of the following conditions should the nurse identify as an adverse effect of this medication? A. Hyperthermia B. Decreased blood glucose C. Rapid pulse rate D. Irritability

B. because, Betamethasone causes hyperglycemia in the client, which predisposes the newborn to hypoglycemia in the first hours after delivery. It is important to assess the newborn's blood glucose level within the first hour following birth and frequently thereafter until blood glucose levels are stable.

A nurse is caring for a client who has oligohydramnios. Which of the following fetal anomalies should the nurse expect? A. Atrial septal defect B. Renal agenesis C. Spina bifida D. Hydrocephalus

B. because, Oligohydramnios is a volume of amniotic fluid less than 300 mL during the third trimester of pregnancy and occurs when there is a renal system dysfunction or obstructive uropathy. Absence of fetal kidneys will cause oligohydramnios.

A nurse is caring for a client who has trichomoniasis and a prescription for metronidazole. Which of the following instructions should the nurse provide to the client about the treatment plan? A. "Your partner needs to be cultured and be treated with metronidazole only if his cultures are positive." B. "You and your partner need to take the medication and use a condom during intercourse until cultures are negative." C. "If both you and your partner are treated simultaneously, you may continue to engage in sexual intercourse." D. "Only you will need to take the metronidazole, but you should not have intercourse until your culture is negative."

B. because, Trichomonas vaginalis is the organism that causes the sexually transmitted infection trichomoniasis. Both men and women can be infected with trichomoniasis. Clinical findings include yellowish to greenish, frothy, mucopurulent, copious discharge with an unpleasant odor, as well as itching, burning, or redness of the vulva and vagina. Trichomoniasis can be treated easily with metronidazole. However, for the treatment to work, it is important to make sure both sexual partners receive treatment to prevent reinfection. Instruct the client to use condoms during sexual intercourse while being treated.

A nurse is caring for a 10-year-old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A. A hot dog on a whole wheat bun B. 3 oz of baked chicken on a whole wheat roll C. 1/2 cup diced potatoes with scrambled eggs D. A medium blueberry muffin

B. because, a baked chicken on a whole wheat roll bun has the lowest fat content at 6.2 g.

A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. When planning for the nutritional needs of the child, which of the following actions should the nurse plan to take? A. Administer pancrelipase to the child prior to each meal. B. Supplement the child's feedings with enteral feedings. C. Provide the child with a low-protein meal. D. Perform dressing changes 10 min prior to the child's meals.

B. because, a child who has burns in excess of 25% of total body surface area requires enteral supplementation to consume enough calories to heal.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactive and thumb sucking C. Shows interest in toys around him D. Attempts to escape and find parent

B. because, a child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.

A nurse is caring for a child who has poststreptococcal glomerulonephritis (APSGN). Which of the following manifestations should the nurse expect? (Select all that apply.) A. Frothy urine B. Periorbital edema C. Ill appearance D. Decreased creatinine E. Hypertension

B. because, a client who has APSGN will exhibit periorbital edema due to decrease in plasma filtration. C. because, a client who has APSGN will exhibit an ill appearance due to the manifestations experienced from the inadequate functioning of the kidneys. E. because, a client who has APSGN will exhibit hypertension due to inadequate function of the kidneys and possibly edema.

A nurse is assessing an infant who has heart failure. Which of the following findings should the nurse expect? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring

B. because, a client who has heart failure will exhibit cool extremities as the heart is unable to adequately circulate oxygenated blood. C. because, a client who has heart failure will exhibit peripheral edema as the heart muscle is unable to adequately circulate blood through the body and back to the heart. E. because, a client who has heart failure will exhibit nasal flaring due to inadequate oxygenation of blood.

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? (Select all that apply.) A. Dipstick protein of 1 + B. Edema in the ankles C. Hyperlipidemia D. Weight loss E. Anorexia

B. because, a client who has nephrotic syndrome will exhibit edema in the ankles due to decreasing colloidal osmotic pressure in the capillaries. C. because, a client who has nephrotic syndrome will exhibit hyperlipidemia due to the increased hepatic synthesis of proteins and lipids. E. because, a client who has nephrotic syndrome will exhibit anorexia due to the edema of the intestinal mucosa.

A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor

B. because, a common gastrointestinal response to excessive histamine release in nausea. D. because, a common skin manifestation of excessive histamine release is hives, also known as urticaria. E. because, a serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor.

A nurse receives report on a client who is in labor and is experiencing contractions 4 min apart. Which of the following patterns should the nurse expect on the fetal monitoring tracing? A. Contractions that last for 60 seconds each with a 4-min rest between contractions B. Contractions that last for 60 seconds each with a 3-min rest between contractions C. A contraction that lasts 4 min followed by a period of relaxation D. Contractions that last 45 seconds each with a 3-min rest between contractions

B. because, a contraction is how often a uterine contraction occurs. The nurse will measure the interval from the beginning of one contraction to the beginning of the next contraction. A contraction lasting 60 seconds with a relaxation period of 3 min is equivalent to contractions every 4 min.

A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? A. Hit 40% B. Potassium 2.5 mEq/L C. Serum creatinine 0.4 mg/dL D. BUN 6 mg/dL

B. because, a potassium level of 2.5 mEq/L indicates hypokalemia, which can cause arrhythmias or even cardiac arrest; therefore, the nurse should report this finding to the provider.

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure

B. because, a ventricular septal defect, a hole in the septal wall between the ventricles, is an acyanotic heart defect. A systolic murmur can be best heard at the lower left sternal border. Sound is transmitted in the direction of blood flow, so any back flow of blood from the left to right ventricle through the septal defect is best heard in this area.

A nurse is caring for a client who desires an intrauterine device (IUD) for contraception. Which of the following findings is a contraindication for the use of this device? A. Hypertension B. Menorrhagia C. History of multiple gestations D. History of thromboembolic disease

B. because, an IUD is a small plastic or copper device placed inside the uterus that changes the uterine environment to prevent pregnancy. An IUD is contraindicated for women who have menorrhagia, severe dysmenorrhea, or history of ectopic pregnancy.

A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelet count 500,000 mm3 B. RBC 2.5 million/uL C. WBC 4,000/mm3 D. Hct 60%

B. because, an RBC of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC.

A nurse is teaching a group of parents about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? (Select all that apply). A. Rubella (German measles) B. Rubeola (Measles) C. Pertussis (whooping cough) D. Varicella (chickenpox) E. Mumps

B. because, complications of rubeola include ear infections, pneumonia, diarrhea, encephalitis, and death. C. because, complications of pertussis include pneumonia, convulsions, apnea, encephalopathy, and death in infants and children; and weight loss, loss of bladder control, syncope, and rib fractures in teens and adults. D. because, complications of varicella include dehydration, pneumonia, bleeding problems, bacterial infection of the skin, sepsis, toxic shock syndrome, bone or joint infections, and death.

A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? A. Blood-tinged sputum B. Dizziness C. Pallor D. Somnolence

B. because, dizziness and lightheadedness are associated with orthostatic hypotension, which occurs when taking nifedipine.

A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? A. Bottle formula with added protein B. Small, frequent bottle feedings of electrolyte solution C. Continuous nasoduodenal tube feedings D. Bolus feedings via gastrostomy tube

B. because, feedings begin 4 to 6 hr after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water.

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L

B. because, having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood.

A nurse is teaching an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following findings should the nurse include in the teaching? (Select all that apply.) A. Increased urination B. Hunger C. Signs of dehydration D. Irritability E. Sweating and pallor F. Kussmaul respirations

B. because, hunger is a manifestation of hypoglycemia because of the increased adrenergic nervous system activity. D. because, irritability is a manifestation of hypoglycemia because of the depleted glucose in the CNS. E. because, sweating and pallor is a manifestation of hypoglycemia because of the increased adrenergic nervous system activity.

A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Your child's immunizations today will be half-doses." B. "The pneumococcal and influenza vaccines are recommended for your child." C. "Immunizations will be delayed until your child tests HIV negative." D. "Your child will need to start the immunization schedule over once his laboratory values are within reference range."

B. because, immunization against common childhood illnesses, including the influenza and pneumococcal disease, is recommended for all children exposed to and infected with HIV.

A nurse is caring for a 2-year-old child who has a heart defect and is scheduled for cardiac catheterization. Which of the following actions should the nurse take? A. Place on NPO status for 12 hr prior to the procedure. B. Check for iodine or shellfish allergies prior to the procedure. C. Elevate the affected extremity following the procedure. D. Limit fluids intake following the procedure.

B. because, iodine-based dyes can be used in this procedure, so the child is assessed for allergies to iodine or shellfish which could lead to anaphylaxis.

A nurse is assessing a newborn who is 12 hr old and notes mild jaundice of the face and trunk. Which of the following actions should the nurse take? A. Administer phytonadione IM. B. Obtain a stat prescription for a bilirubin level. C. Obtain a bagged urine specimen. D. Perform a gestational age assessment.

B. because, jaundice in the first 24 hr of life is pathologic. The nurse should notify the provider and obtain a stat prescription for a bilirubin level.

A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest. B. Monitor the child for increased temperature. C. Administer oxygen to the child. D. Monitor the child for bleeding.

B. because, leukopenia places the child at risk for infection; therefore, the nurse should monitor the child for a fever.

A nurse in the emergency department is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an intrauterine device. The nurse should suspect which of the following? A. Missed abortion B. Ectopic pregnancy C. Severe preeclampsia D. Hydatidiform mole

B. because, manifestations of an ectopic pregnancy include unilateral lower quadrant pain with or without bleeding. Use of an IUD is a risk factor associated with this condition.

A nurse is caring for a preterm newborn who is receiving oxygen therapy. Which of the following findings should the nurse identify as a potential complication from the oxygen therapy? A. Atelectasis B. Retinopathy C. Interstitial emphysema D. Necrotizing enterocolitis

B. because, oxygen therapy can cause retinopathy of prematurity, especially in preterm newborns. It is a disorder of retinal blood vessel development in the premature newborn. In newborns who develop retinopathy of prematurity, the vessels grow abnormally from the retina into the clear gel fills the back of the eye. It can reduce vision or result in complete blindness.

A nurse is teaching the parents of a 3-year-old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching? A. "My child should not play around others who have ear infections." B. "We should not smoke around our child." C. "My child should not swim this summer." D. "I will encourage my child to blow his nose forcefully when he has a cold."

B. because, preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract.

A nurse is caring for a 10-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider? A. Serum BUN 8 mg/dL B. Serum creatinine 1.3 mg/dL C. Blood pressure 100/74 mm Hg D. Urine output of 550 mL in 24 hr

B. because, serum creatinine 1.3 mg/dL is out of the expected reference range for a 10-year-old child, and should be reported to the provider.

A nurse is caring for a preschool-age who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions. B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. C. Encourage the child to mouth rinse with hydrogen peroxide every 2 to 4 hr. D. Give the child lemon glycerin swabs to use after each meal.

B. because, the child should use a soft sponge toothbrush when brushing her teeth because a regular toothbrush might cause further irritation to the mucosal ulcers.

A nurse is speaking with an expectant father who says that he feels resentful of the added attention others are giving his wife since the pregnancy was announced several weeks ago. Which of the following responses should the nurse make? A. "Has your wife sensed your anger toward her and the baby?" B. "These feelings are common to expectant fathers in early pregnancy." C. "I'm sure that it's really hard to accept this when it's your baby, too." D. "It would be wise for you to speak to a therapist about these feelings."

B. because, the father needs reassurance that these feelings are expected. The nurse should reassure him that when the pregnancy becomes obvious he will feel more involved. This therapeutic response addresses the client's feelings by providing information.

A nurse is caring for a newborn immediately following delivery. Which of the following actions should the nurse take first? A. Perform a detailed physical assessment. B. Place the newborn directly on the client's chest. C. Give the newborn vitamin K IM. D. Administer erythromycin ophthalmic ointment.

B. because, the greatest risk to the newborn is cold stress, which increases the need for oxygen and glucose. Placing the newborn directly on the client's chest will help maintain the newborn's temperature.

A nurse is teaching parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."

B. because, the intake of citrus juices with the iron will increase the iron's absorption.

A nurse is caring for a client who is at 26 weeks of gestation and reports constipation. Which of the following responses by the nurse is appropriate? A. "You should drink 1 ounce of mineral oil every morning." B. "You should walk for at least 30 minutes every day." C. "You should eat at least 3 ounces of red meat per day." D. "You should stop taking your prenatal vitamin."

B. because, the nurse should encourage the client to participate in moderate physical activity, such as walking or swimming, every day. This activity increases intestinal peristalsis, which will help alleviate constipation.

A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? A. Keep the infant's mouth open by using a tongue blade for 4 hr following surgery. B. Suction the infant gently with a bulb syringe PRN. C. Place the infant in prone position. D. Clean the infant's incision with chlorhexidine.

B. because, the nurse should gently suction the infant's mouth with a bulb syringe to maintain a patent airway.

A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I can take my brace off to sleep every night at bedtime." B. "I can take my brace off for about an hour daily to shower." C. "I should loosen the straps on my brace if it is rubbing my skin." D. "I should place the pads of brace against my skin with a t-shirt over them."

B. because, the nurse should instruct the child to wear the brace 23 hr each day and to only remove it for showering or participating in physical therapy.

A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan? A. Administer low-dose aspirin for pain. B. Inspect the toddler's toys for sharp edges. C. Perform passive range-of-motion to the affected joint during a bleeding episode. D. Avoid contact with people who have respiratory infections.

B. because, the nurse should instruct the parents to inspect the toddler's toys for sharp edges or parts because this could increase the toddler's risk of bleeding.

A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? A. Chill the medication prior to administration. B. Massage the anterior area of the infant's ear following administration. C. Hyperextend the infant's neck during administration. D. Pull the auricle up and back during medication administration.

B. because, the nurse should instruct the parents to massage the anterior area of the ear following administration of eardrums to facilitate instillation of the medication.

A nurse is admitting a client who is in labor and experiencing moderate bright red vaginal bleeding. Which of the following actions should the nurse take? A. Perform a vaginal examination to determine cervical dilation. B. Obtain blood samples for baseline laboratory values. C. Place a spiral electrode on the fetal presenting part. D. Prepare the client for a transvaginal ultrasound.

B. because, the nurse should obtain samples of the client's blood for baseline testing of hemoglobin and hematocrit levels.

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest. B. Check the child's blood pressure every 4 hr. C. Administer albumin to the child every 8 hr. D. Provide the child with a low-carbohydrate diet.

B. because, the nurse should the child's blood pressure every 4 to 6 hr to monitor for hypertension.

A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's laboratory reports. Which of the following findings is a manifestation of this condition? A. Hgb 12.2 g/dL B. Urine ketones present C. Alanine aminotransferase D. Serum glucose 114 mg/dL

B. because, the presence of ketones in the urine is associated with the breakdown of proteins and fats that occurs in a client who has hyperemesis gravidarum.

A nurse is caring for a client who is 2 hr postpartum. The nurse notes the client's perineal pad has a large amount of lochia rubra with several clots. Which of the following actions should the nurse take first? A. Check for a full bladder. B. Massage the fundus. C. Measure vital signs. D. Administer carboprost IM.

B. because, the primary cause of early postpartum bleeding is uterine atony manifested by a relaxed, boggy uterus. Thus, the greatest risk for the client is hemorrhage. The nurse should massage the client's fundus first.

A nurse is caring for a client who is at 8 weeks of gestation with twins and primigravida. The client states that even though she and her husband planned this pregnancy, she is experiencing many ambivalent feelings about it. Which of the following responses should the nurse make? A. "Have you told your husband about these feelings?" B. "These feelings are quite normal at the beginning of pregnancy." C. "Perhaps you should see a counselor to discuss these feelings." D. "I am quite concerned about these feelings. Could you explain more?"

B. because, this client needs reassurance that these feelings are normal and there is no reason for concern.

A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm3 B. Hgb 6 g/dL C. WBC 6,000/mm3 D. Potassium 4.5 mEq/L

B. because, this hemoglobin level is below the expected reference range and is indicative of anemia; therefore, the nurse should report this finding to the provider.

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain. B. Check for pulses in the affected leg every 4 hr. C. Cleanse the pins every 12 hr. D. Inform parents to discourage visitors for the child.

B. because, traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hr.

A nurse is assessing a client who is receiving magnesium sulfate as treatment for pre-eclampsia. Which of the following clinical findings is the nurse's priority? A. Respirations 16/min B. Urinary output 40 mL in 2 hr C. Reflexes +2 D. Fetal heart rate 158/min

B. because, urinary output is critical to the excretion of magnesium from the body. The nurse should discontinue the magnesium sulfate if the hourly output is less than 30 mL/hr.

A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine. B. Give the medication at the side of the infant's mouth. C. Add the medication to a full bottle of the infant's formula. D. Administer the medication slowly while holding the nares closed.

B. because, when administering medications to an infant, a needleless oral syringe or medicine doppler is placed in the side of the mouth (buccal cavity alongside the tongue) to prevent gagging and aspiration.

A nurse is providing care for a client who is diagnosed with a marginal abruption placentae. The nurse is aware that which of the following findings are risk factors for developing the condition? (Select all that apply.) A. Fetal position B. Blunt abdominal trauma C. Cocaine use D. Maternal age E. Cigarette smoking

B., C., and E.

A nurse is caring for a client who is in labor. A vaginal examination reveals the following informations: 2 cm, 50%, +1, right occiput anterior (ROA). Based on this information, which of the following fetal positions should the nurse document in the medical record? A. Transverse B. Breech C. Vertex D. Mentum

C. because, ROA describes the relationship of the presenting part of the fetus to the client's pelvis. In this case, the occipital bone is the presenting part and is located anteriorly in the client's right side. Based on the presentation of the fetus, the position is vertex.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature of 37.5° C (99.5° F) B. Apical pulse rate 140/min C. BP 86/40 mm Hg D. Respiratory rate of 32/min

C. because, a BP of 86/40 mm Hg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3° C (101° F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen

C. because, a child who has acute otitis media should take an antibiotic to help alleviate the infection.

A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on the urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a finger stick glucose of 110 mg/dL

C. because, a child who has sickle cell anemia must maintain adequate hydration because dehydration might cause sickle cell crisis that can occlude the child's circulation.

A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and committing and scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse expect? A. Hyperemesis gravidarum B. Threatened abortion C. Hydatidiform mole D. Preterm labor

C. because, a client who has a hydatidiform mole exhibits increased fundal height that is consistent with the week of gestation, and excessive nausea and vomiting due to elevated hCG levels. Scant, dark discharge occurs in the second trimester.

A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? A. "I will take this pill with my breakfast." B. "I will take this medication with a glass of milk." C. "I plan to drink more orange juice while taking this pill." D. "I plan to add more calcium-rich foods to my diet while taking this medication."

C. because, a diet with increased vitamin C improves the absorption of ferrous sulfate.

A nurse is caring for a client who is at 36 weeks of gestation and has pre-eclampsia. Which of the following findings should the nurse identify as the priority? A. 1+ proteinuria B. Blood pressure 140/98 mm Hg C. Nonreactive non stress test D. Fundal height 33 cm

C. because, a nonstress test measures fetal heart rate (FHR) accelerations with normal movement. A fetal acceleration is a positive sign present when the FHR increases 15/min and lasts 15 seconds. In a nonreactive nonstress test, there are no accelerations. Absence of FHR accelerations suggests that the fetus might be going into distress.

A nurse is teaching a child who has type 1 diabetes mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching? A. "I should skip breakfast when I am not hungry." B. "I should increase my insulin when I exercise." C. "I should drink a glass of milk when I am feeling irritable." D. "I should draw up the NPH insulin into the syringe before the regular insulin."

C. because, an early manifestation of hypoglycemia is irritability. Drinking a glass of milk, which is approximately 15 g of carbohydrates, indicates understanding of the teaching.

A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria

C. because, an infant who has moderate dehydration will have a slight tachypnea.

A nurse is caring for a client who has a prescription for naloxone. Which of the following is the intended action of the medication in relation to the central nervous system (CNS)? A. Accentuate effects of narcotics on the CNS B. Depress activity of the CNS C. Block effects of narcotics on the CNS D. Stimulate activity of the CNS

C. because, by blocking the effects of narcotics on the CNS, naloxone prevents CNS and respiratory depression in the newborn following delivery.

A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to help with muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."

C. because, children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which aid in reducing the spasticity.

A nurse is caring for a child who has type 1 diabetes mellitus. Which of the following are manifestations of diabetic ketoacidosis? (Select all that apply.) A. Blood glucose 58 mg/dL B. Weight gain C. Dehydration D. Mental confusion E. Fruity breath

C. because, clients who have diabetic ketoacidosis experience osmotic diuresis because of the electrolyte shift. D. because, clients who have diabetic ketoacidosis experience mental confusion because of the electrolyte shift. E. because, clients who have diabetic ketoacidosis experience fruity breath because of the body's attempt to eliminate ketones.

A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness

C. because, epiglottitis is a disorder caused by inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is common finding due to the toddler's inability to swallow saliva.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? A. Nausea B. Hoarse voice C. Frequent swallowing D. Sore throat

C. because, frequent swallowing can be an indication of bleeding, therefore is the nursing priority finding to address.

A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting

C. because, infants who have tracheomalacia have a weakened trachea, which leads to collapse. Clinical manifestations of tracheomalacia include barking cough, stridor, wheezing cyanosis, and apnea.

A parent of a school-age child will need to take injections for growth delay. Which of the following responses should the nurse make? A. "Injections are usually continued until age 10 for girls and age 12 for boys." B. "Injections continue until your child reaches the fifth percentile on the growth chart." C. "Injections should be continued until there is evidence of epiphyseal closure." D. "The injections will need to be administered throughout your child's entire life."

C. because, injections are continued until there is evidence of epiphyseal closure on radiographic tests.

A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area. B. Initiate contact isolation precautions. C. Give the child flavored popsicles. D. Administer phytonadione.

C. because, maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children accept flavored popsicles as a source of fluid.

A nurse is caring for a client who is in labor and has an epidural for pain relief. Which of the following is a complication from the epidural block? A. Nausea and vomiting B. Tachycardia C. Hypotension D. Respiratory depression

C. because, maternal hypotension is an adverse effect of epidural anesthesia. The nurse should administer an IV fluid bolus prior to the placement of epidural anesthesia in order to decrease the likelihood of this complication.

A nurse is planning care for a newborn who requires phototherapy for hyperbilirubinemia. Which of the following actions should the nurse include in the plan of care? A. Swaddle the newborn in a receiving blanket during the treatment. B. Maintain NPO status until the newborn's bilirubin is within the expected reference range. C. Ensure the newborn's eyes are closed before applying the eye shield. D. Apply lotion to the newborn's skin twice per day.

C. because, overexposure to the lights during treatment can cause damage to the newborn's corneas. Therefore the nurse should gently close the newborn's eyes prior to applying the eye shield.

A nurse is teaching about poisoning prevention to a group of parents who have toddlers. Which of the following statements should the nurse make? A. "Keep medications on a counter that is out of reach of the toddler." B. "Do not allow live plants in the house." C. "Put all cleaning supplies in a locked cabinet." D. "Allow your child to eat from his favorite ceramic bowls."

C. because, parents should lock up cleaning supplies to provide for the safety of toddlers. Toddlers are very inquisitive and are able to open most cabinet doors without difficulty. The toddler cannot open the door of a locked cabinet.

A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy. B. Give the child a thorough explanation before providing care. C. Encourage rooming-in. D. Tell the child you will help fix her.

C. because, rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope in an unfamiliar environment.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." B. "You will need to decrease your insulin dosage when you become a teenager." C. "You can use a vial of insulin for up to 30 days." D. "Stop taking your insulin if you are vomiting."

C. because, the child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator.

A nurse is caring for a school-age child who has glomerulonephritis. The child has decreased urinary output, a blood pressure of 160/78 mm Hg, and is receiving hydralazine. Which of the following lunch choices should the nurse recommend? A. 1 hot dog, 22 potato chips, and 120 mL (4 oz) of orange juice B. 1 sandwich with lettuce, tomato, and 4 slices bacon, a small apple, and 240 mL (8 oz) of milk C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice D. 1 cup of cottage cheese, a small banana, and 240 mL (8 oz) of soda

C. because, the child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet is the lowest option and consists of 571 g of potassium and 268 g of sodium.

A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? A. Plain flour pastry B. Wheat cereal C. Scrambled eggs D. Rye toast

C. because, the client who has celiac disease should be on a low-gluten diet and should avoid foods containing barley, oat, rye, and wheat; therefore, scrambled eggs are an appropriate breakfast item for the nurse to recommend to the client.

A nurse is providing teaching to the mother of an infant who has a prescription for digoxin. Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C. "Give the correct dose of medication at regularly scheduled times." D. "If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."

C. because, the correct amount of digoxin should be administered at regularly scheduled times to maintain therapeutic blood levels.

A nurse is discussing diaphragm use with a client. Which of the following statements by the client indicates an understanding of the teaching? A. "I should clean my diaphragm with alcohol each time I use it." B. "I should leave the diaphragm in place 4 hours after intercourse." C. "I should replace my diaphragm every 2 years." D. "I should use a vaginal lubricant to insert my diaphragm."

C. because, the diaphragm is a flexible rubber cup that is filled with spermicide and is inserted over the cervix prior to intercourse. The diaphragm is a prescribed device fitted by the provider. It should be replaced every 2 years.

A nurse is assessing a client on the first postpartum day. Findings include fundus firm and one finger breadth above and to the right of the umbilicus, moderate lochia rubra with small clots, temperature 37.7° C (99.2° F), and pulse rate 52/min. Which of the following actions should the nurse take? A. Report the vital signs to the provider. B. Massage the fundus. C. Ask the client when she last voided. D. Administer an oxytocic agent.

C. because, the muscles supporting the uterus have been stretched during pregnancy, the fundus is easily displaced when the bladder is full. The fundus should be found firm at midline. A deviated, firm fundus indicates a full bladder. The nurse should assist the client to void.

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Apply a warm cloth to the bridge of the child's nose. B. Tilt the child's head back. C. Apply continuous pressure to the child's nose for at least 10 min. D. Administer aspirin for the child's pain.

C. because, the nurse needs to apply continuous pressure for at least 10 minutes to help stop bleeding.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities. B. Administer meperidine every 4 hr until the crisis has resolved. C. Maintain the child on bed rest. D. Decrease the child's fluid intake for 8 hr.

C. because, the nurse should maintain bed rest for the child who is experiencing a vast-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.

A nurse is planning care for a client who is at 35 weeks of gestation. Which of the following laboratory tests should the nurse obtain? A. Rubella titer B. Blood type C. Group B streptococcus B-hemolytic D. 1-hour glucose tolerance test

C. because, the nurse should obtain a vaginal/anal group B streptococcus B-hemolytic (GBS) culture at 35 to 37 weeks of gestation to screen for infection. Prophylactic antibiotics should be given during labor to the client who is positive for GBS.

A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? A. Initiate contact precautions for the child. B. Explain to the parents that chemotherapy will start 3 months following surgery. C. Put a "no abdominal palpation" sign over the child's bed. D. Prepare the child for a spinal tap.

C. because, the nurse should place a sign over the child's bed reading "no abdominal palpation" because palpitation is not necessary to confirm diagnosis and could aid in metastasis.

A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in one-piece outfits." B. "I need to buy diapers that are tighter than my infant usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."

C. because, the parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma, to act as a sealant to prevent skin breakdown.

A nurse is caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids. B. Give the child magnesium hydroxide PO. C. Prepare the child for a barium enema. D. Educate the parents that the child will need a colostomy.

C. because, the pressure created by a barium enema might force the bowel to resume a normal configuration. Some children are treated with the barium enema and do not require surgical intervention.

A nurse is teaching a client about a nonstress test. Which of the following statements by the client indicates an understanding of the teaching? A. "I know not to eat anything after midnight." B. "I will have medication given to me to cause contractions." C. "I should press the button on the handheld marker when my baby moves." D. "I will have to stimulate my breast to cause contractions."

C. because, the purpose of the test is to assess fetal well-being. The client should press the button on the handheld marker when she feels fetal movement.

A nurse is caring for a newborn who has irregular respirations of 52/min with several periods of apnea lasting approximately 5 seconds. The newborn is pink with acrocyanosis. Which of the following actions should the nurse take? A. Administer oxygen. B. Place the newborn in an isolette. C. Continue to routinely monitor the newborn. D. Assess the newborn's blood glucose.

C. because, this newborn is exhibiting a normal respiratory rate and rhythm. No additional measures are needed at this time.

A nurse is providing postoperative teaching for the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? A."I will expect the site to bulge when my baby cries." B. "I will place a belly band around my child's abdomen." C. "I will fold my baby's diaper away from the incision." D. "I will bathe my child in the bath tub daily."

C. because, to prevent infection, the parent should be able to verbalize and demonstrate proper folding of the diaper to protect the surgical incision from contamination.

A nurse manager is reviewing ways to prevent a TORCH infection during pregnancy with a group of newly licensed nurse. Which of the following statements by a nurse indicates understanding of the teaching? A. "Obtain an immunization against rubella early in pregnancy." B. "Seek prophylactic treatment if cytomegalovirus is detected during pregnancy." C. "A women should avoid crowded places during pregnancy." D. "A women should avoid consuming undercooked meat while pregnant."

D. because, Toxoplasmosis, a TORCH infection, is contracted by consuming undercooked meat.

A nurse is caring for a child who has Tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm3 B. WBC 4,000/mm3 C. Thyroid stimulating hormone 7.0 micro units/mL D. RBC 6.8 million/uL

D. because, a child who has Tetralogy of Fallot causes cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.

A nurse is administering a rubella immunization to a client who is 2 days postpartum. Which of the following statements indicates to the nurse the client needs further instruction? A. "I can continue to breastfeed." B. "I will still need to have my provider perform a rubella titer check with my next pregnancy." C. "I cannot receive the rubella immunization during my pregnancy." D. "I can conceive any time I want after 20 days.

D. because, a client who receives a rubella immunization should not conceive for at least 1 month after receiving the rubella immunization to prevent injury to the fetus.

A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition? A. No alteration in menses B. Transvaginal ultrasound indicating a fetus in the uterus C. Serum progesterone greater than the expected reference range D. Report of severe shoulder pain

D. because, a client's report of severe shoulder pain is a finding associated with a ruptured ectopic pregnancy due to the presence of blood in the abdominal cavity, which irritates the diaphragm and phrenic nerve.

A nurse is caring for a newborn who has neonatal abstinence syndrome. Which of the following clinical findings should the nurse expect? A. Extended periods of sleep B. Poor muscle tone C. Respiratory rate 50/min D. Exaggerated reflexes

D. because, a newborn who has neonatal abstinence syndrome usually exhibits clinical findings of hyperactivity within the central nervous system (CNS). Exaggerated reflexes are indicative of CNS irritability.

A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron. B. Avoid people who have infections. C. Administer PRN oxygen. D. Encourage quiet play.

D. because, a platelet count of 20,000/mm3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk for injury, thereby reducing the chance of hemorrhage.

A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelet count 120,000/mm3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL

D. because, a serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids.

A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. Sudden decrease in wheezing

D. because, a sudden decrease in wheezing can be an indication that the child is experiencing decreased air movement and should be reported to the provider. A sudden decrease in wheezing (silent chest) indicates ventilator failure and an imminent respiratory arrest.

A nurse in a prenatal clinic is caring for a client who is within the recommended guideline for weight. The client asks the nurse how much weight is safe for her to gain during her pregnancy. Which of the following responses should the nurse make? A. "Your provider can discuss an appropriate amount of weight gain with you." B. "A weight gain of about 14 pounds each trimester is suggested." C. "If you eat nutritious foods when you feel hungry, the amount of weight gain is insignificant." D. "A weight gain of about 25 to 35 pounds is good."

D. because, a weight gain of 25 to 35 lb is associated with good fetal outcome. A gain of 4 lb in the first trimester and 12 lb each for the second and third trimester is recommended.

A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. "My child has frequent mood swings." B. "My child has a very messy bedroom." C. "My child takes 1 to 2 showers per day." D. "My child spends 4 hours per day in internet chat rooms."

D. because, adolescents might spend time using a computer, but parents should know what they are doing, who they are communicating with, and limit the time. The American Academy of Pediatrics guidelines recommend 2 hr of screen time daily.

A nurse is providing teaching to the parents of a newborn about how to care for his circumcision at home. Which of the following instructions should the nurse include in the teaching? A. Apply the diaper tightly over the circumcision area. B. Remove the yellow exudate with each diaper change. C. Use prepackage commercial wipes to clean the circumcision site. D. Encourage nonnutritive sucking for pain relief.

D. because, allowing the newborn to suck on a pacifier is an effective form of nonpharmacological pain management.

A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? A. "The test determines the level of antibiotics in your child's blood." B. "The test tells us if your child ever has the measles." C. "The test verifies the amount of albumin in your child's blood." D. "The test shows us if your child had a recent strep infection."

D. because, an ASO titer indicates that the child has had a recent strep infection. In determining a definitive diagnosis for acute glomerulonephritis, this must be documented as it is usually the result of this type of infection.

A nurse is caring for a client who has clinical manifestations of an ectopic pregnancy. Which of the following findings is a risk factor for an ectopic pregnancy? A. Anemia B. Frequent urinary tract infections C. Previous cesarean birth D. Pelvic inflammatory disease (PID)

D. because, an ectopic pregnancy occurs when the fertilized egg implants in tissue outside of the uterus and the placenta and fetus beings to develop there. The most common site is within a Fallopian tube, but ectopic pregnancies can occasionally occur in the ovary or the abdomen. Most cases are a result of scarring caused by a previous tubal infection or tubal surgery/ Therefore, PID places the client at risk for an ectopic pregnancy.

A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure."

D. because, applying a pressure dressing over the area following the procedure helps to prevent bleeding from the site.

A nurse is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? A. Nifedipine B. Pyridoxine C. Ferrous sulfate D. Calcium gluconate

D. because, calcium gluconate is the antidote to magnesium sulfate.

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake. B. Administer acetaminophen to the child twice daily. C. Weight the child once each week. D. Keep the child away from people who have an infection.

D. because, children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.

A nurse is caring for a child who has a vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expect that the child has which of the following condition? A. Measles B. Fifth disease C. Tetanus D. Varicella

D. because, children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over.

A nurse is discussing epidural anesthesia with a client who is receiving oxytocin for induction of labor. Which of the following statements should the nurse make? A. "An epidural given too early during labor can cause maternal hypertension." B. "An epidural given too early during labor will not be effective in active labor." C. "An epidural given too early can cause fetal depression." D. "An epidural given too early can prolong labor."

D. because, clients who receive anesthesia before the active phase of labor usually find the progression of their labor to slow. The medication depresses the central nervous system. Therefore, it will take longer for the cervix to dilate and efface.

A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? A. Allow a parent to administer an injection to the nurse. B. Have the child teach the injection technique to the parents. C. Have a parent administer the insulin to the child. D. Demonstrate the injection technique on an orange.

D. because, demonstrating the injection technique on an orange poses no risk to the client and is therefore the first action the nurse should take.

A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? A. Cover the child's wounds with a clean, dry cloth. B. Establish IV access for the child with a large-bore catheter. C. Provide reassurance to the child's parents. D. Determine the child's breathing pattern.

D. because, determining the child's breathing pattern is the first action the nurse should take.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints. B. Apply a pressure-reducing overlay to the child's mattress. C. Increase the child's fluid intake. D. Encourage the child to use an incentive spirometer.

D. because, encouraging the child to use an incentive spirometer will assist the child in adequate oxygenation and is the priority nursing action.

A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following statements should the nurse make? A. "Your child will need to take estrogen daily when she reaches puberty." B. "Your child will need monthly blood coagulation studies." C. "Your child will need surgery to remove the diseased thyroid." D. "Your child will need to take thyroid hormone replacement for her entire life."

D. because, in congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require life-long thyroid hormonal replacement for normal growth and development.

A nurse is reaching a group of parents about communicable diseases. The nurse should include which of the following is the best method to prevent a communicable disease? A. Hand washing B. Avoiding persons who active disease C. Covering your cough D. Obtaining immunizations

D. because, obtaining immunizations has decreased the rate of communicable diseases and is the best method to prevent further spread of illness.

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale." B. "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 second interval." D. "I will record the highest reading of three attempts."

D. because, once the client establishes a personal best, she should routinely check the PEFM by performing three attempts and recording the highest reading of the three.

A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices as having the highest protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices

D. because, peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which helps with the healing process.

A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? A. Hypotension B. Stomatitis C. Bloody diarrhea D. Periorbital edema

D. because, periorbital edema is an expected finding in a child who has glomerulonephritis.

A nurse is caring for a client who is at 39 weeks of gestation and is in active labor. Which of the following actions should the nurse include in the plan of care? A. Keep four side rails up while the client is in bed. B. Monitor fetal heart rate every hour. C. Insert an indwelling urinary catheter. D. Check the cervix prior to analgesic administration.

D. because, prior to administering an analgesic during active labor, the nurse must know how many centimeters the cervix is dilated. If administered too close to the time of delivery, the analgesic could cause respiratory depression in the newborn.

A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following statements should the nurse make? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."

D. because, the abdominal muscles are immature and not well developed at this stage. Therefore, it is common for a toddler to have a "potbellied" appearance.

A nurse is caring for a client who is in labor. The client questions the application of an internal fetal scalp monitor. Which of the following responses should the nurse make? A. "Don't worry. Your baby is fine." B. "You will need to ask your provider." C. "Your provider feels it would be best." D. "We need to observe your baby more closely."

D. because, the client has asked information-seeking question. This therapeutic response provides information to the client in an honest, nonthreatening manner. The use of an internal fetal scalp monitor, or an internal spiral electrode, provides a more accurate assessment of fetal well-being during labor.

A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? A. Use a condom with sexual intercourse. B. Avoid bubble bath solution when taking a tub bath. C. Wipe from the back to front when performing perineal hygiene. D. Keep a daily record of fetal kick counts.

D. because, the client should record daily fetal kick counts.

A nurse is caring for a child who has cystic fibrosis and a pulmonary infection. Which of the following findings is the nurse's priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions

D. because, the inability to clear secretions is the priority-finding because the child has a compromised airway and the nurse must act in a manner that ensures transportation of oxygen to the body's cells.

A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? A. Spoon B. Straw C. Firm nipple D. Cup

D. because, the infant should be fed clear liquids using a cup for 7 to 10 days following a cleft palate repair to prevent trauma and injury to the suture line.

A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will give the lansoprazole 30 min after my baby's feedings." B. "I will lay my baby on her side after feedings." C. "I will give my baby a bottle just before bedtime." D. "I will add rice cereal to my baby's feedings."

D. because, the mother should add 1 tsp to 1 tbsp of rice cereal per ounce of formula or expressed breast milk to thicken the feedings because this will decrease the number of vomiting episodes.

A nurse is planning care for a client who is pregnant and is Rh-negative. In which of the following situations should the nurse administer Rh (D) Immune Globulin? A. While the client is in labor B. Following an episode of influenza during pregnancy C. Prior to a blood transfusion D. At 28 weeks of gestation

D. because, the nurse should administer Rh(D) Immune Globulin to a client who is pregnant and has Rh-negative blood at 28 weeks of gestation. Rh(D) Immune Globulin consists of passive antibodies against the Rh factor, which will destroy any fetal RBCs in the maternal circulation and block maternal antibody production.

A nurse is assessing a child who has chronic renal failure. Which of the following findings should the nurse expect? A. Flushed face B. Hyperactivity C. Weight gain D. Delayed growth

D. because, the nurse should expect the child to exhibit delayed growth.

A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen. B. Elevate the adolescent's leg on pillows. C. Place an ice pack on the cast. D. Assess for manifestations of circulatory impairment.

D. because, the nurse should first assess for circulatory impairment to ensure there is no vascular compromise.

A nurse is teaching a school-age child who has diabetes mellitus about insulin administration. Which of the following should the nurse include in the teaching? A. "You should inject the needle at a 30-degree angle." B. "You should combine your glargine and regular insulin in the same syringe." C. "You should aspirate for blood before injecting the insulin." D. "You should give four or five injections in one area before switching sites."

D. because, the nurse should instruct the client to administer four to five injections about 2.5 cm (1 in) apart before switching to another site.

A nurse is assessing pain in a 3-year-old following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? A. Word-Graphic Rating Scale B. Color Tool C. Poker Chip Tool D. FACES Rating Scale

D. because, the nurse should use the FACES rating scale to assess this child's pain level. This scale is appropriate for a 3 year old and provides a series of facial expressions representing amounts of pain.

A nurse is caring for a client who is at 34 weeks of gestation and has a prescription for terbutaline for preterm labor. Which of the following statements by the client is the priority? A. "My ankles are swollen at the end of the day." B. "I can feel the baby kicking my ribs, and it is very uncomfortable." C. "I'm growing more and more worried every day." D. "My heart feels as if it is racing."

D. because, the primary action of terbutaline is to cause bronchodilation and relax smooth muscles. However, an adverse effect is tachycardia. If the pulse is greater than 130/min, the terbutaline needs to be held until the provider is notified.

A nurse is planning care for a client who has a prescription for oxytocin. Which of the following is a contraindication for the use of this medication? A. Prolonged rupture of membranes at 38 weeks of gestation B. Intrauterine growth restriction C. Postterm pregnancy D. Active genital herpes

D. because, the use of oxytocin is contraindicated for clients who have an active genital herpes infection. The newborn can acquire the infection as they pass through the birth canal. Therefore, a cesarean birth is recommended for clients who have an active genital herpes infection.

A nurse is caring for a newborn who was born to a client who has a narcotic use disorder. Which of the following nursing actions should the nurse identify as a contraindication for the care of the newborn? A. Promoting maternal-newborn bonding B. Tight swaddling of the newborn C. Small frequent feedings D. Frequent stimulation

D. because, this newborn needs a quiet, calm environment with minimal stimulation to promote rest and reduce stress. A stimulating environment can trigger irritability and hyperactive behaviors.

What does TORCH infections stand for?

Toxoplasmosis, other infections (e.g., hepatitis), rubella virus, cytomegalovirus, and herpes simplex virus are known collectively as TORCH.

A nurse is providing discharge teaching to the parents of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily." B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores." D. "I will allow my child to ride his bicycle tomorrow."

c. because, a child who has leukemia is at an increased risk for mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations.

A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. "The PICC line will last several weeks with proper care." B. "The public health nurse will rotate the insertion site every 3 days." C. "You will need to make certain the arm board is in place at all times." D. "Your child will go to the operating room to have the line placed."

A. because, PICC lines are the preferred venous access device for short to moderate IV therapy. They can remain in place for long periods with proper care.

A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min C. Blood pressure 88/40 mm Hg D. Temperature 37.6° C (99.7° F)

A. because, a heart rate of 175/min is above the expected reference range for a 12-month-old infant; therefore, the nurse should report this finding to the provider.

A nurse is caring for a client who is at 39 weeks of gestation and is in the active phase of labor. The nurse observes late decelerations in the fetal heart rate (FHR). Which of the following findings should the nurse identify as the cause of late decelerations? A. Uteroplacental insufficiency B. Fetal head compression C. Fetal ventricular septal defect D. Umbilical cord compression

A. because, a late deceleration in the FHR is a non reassuring FHR pattern resulting from fetal hypoxemia due to insufficient placental perfusion. The nurse should reposition the client, initiate oxygen, and increase the infusion rate of IV fluid to enhance placental perfusion.

A nurse is assessing a newborn who was born at 39 weeks of gestation. Which of the following findings should the nurse expect? A. Symmetric rib cage B. Dry, wrinkled skin C. Vernix over the entire body D. Lanugo abundant on the back

A. because, a newborn is born at 39 weeks of gestation is full-term and should have a symmetric rib cage.

A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children? A. Cow's milk B. Wheat bread C. Corn syrup D. Eggs

A. because, according to evidence-based practice, the nurse should instruct the parent that cow's milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow's milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow's milk.

A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Head lags when pulled from a lying to a sitting position B. Absence of startle and crawl reflexes C. Inability to pick up a rattle after dropping it D. Rolls from back to side

A. because, at the age of 5 months, the infant should have no head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.

A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply). A. Observe the parents' actions when feeding the child B. Maintain a detailed record of food and fluid intake is correct C. Follow the child's cues as to when food and fluids are provided D. Sit beside the child's high chair when feeding the child E. Play music videos during scheduled meal times

A. because, inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. B. because, a nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.

A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I lock my medications in the medicine cabinet." B. "I keep my child's crib mattress at the highest level." C. "I turn pot handles to the side of my stove while cooking." D. "I will give my child syrup of ipecac if she swallows something poisonous."

A. because, locking up medications and other potential poisons prevent access. Toddlers have improved gross and fine motor skills that allow for further exploration of the environment and possible access to hazardous substances.

A nurse is caring for a postpartum client 8 hr after delivery. Which of the following factors places the client at risk for uterine atony? (Select all that apply.) A. Magnesium sulfate infusion B. Distended bladder C. Oxytocin infusion D. Prolonged labor E. Small for gestational age newborn

A. because, magnesium sulfate is a smooth muscle relaxant and can prevent adequate contraction of the uterus. B. because, after birth, clients can experience a decreased urge to void due to birth-induced trauma, increased bladder capacity, and anesthetics which can result in a distended bladder. The distended bladder displaces the uterus and can prevent adequate contraction of the uterus. D. because, prolonged labor can stretch out the musculature of the uterus and cause fatigue, which prevents the uterus from contracting.

A nurse is caring for a client who believes she may be pregnant. Which of the following findings should the nurse identify as a positive sign of pregnancy? A. Palpable fetal movement B. Chadwick's sign C. Positive pregnancy test D. Amenorrhea

A. because, palpable fetal movements are a positive sign of pregnancy. Quickening, the client's report of fetal movement, is a presumptive sign of pregnancy.

A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to his body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.

A. because, preschool-age children might make this comparison. D. because, preschool-age children believe that their thoughts and wishes can make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age. E. because, preschool-age children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought.

A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? A. Follow a nightly routine and established bedtime. B. Encourage active play prior to bedtime. C. Let the child remain awake until tired enough to go to sleep. D. Reward the child with a food treat just prior to sleep if the child goes to bed on time.

A. because, preschool-age children test limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.

A nurse is caring for a client who is at 38 weeks of gestation and reports no fetal movement for 24 hr. Which of the following actions should the nurse take? A. Auscultate for a fetal heart rate. B. Have the client drink orange juice. C. Reassure the client that a term fetus is less active. D. Palpate the uterus for fetal movement.

A. because, presence of a fetal heart rate is a reassuring manifestation of fetal well-being. The nurse should auscultate for the fetal heart rate using a Doppler device or an external fetal monitor. This is the priority nursing action.

A nurse is assessing a 6-year-old at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length related to height D. Presence of a loose, central incisor

A. because, the development of sexual characteristics prior to the age of 9 years in boys, and 9 years in girls, is an indication of precocious puberty and requires further evaluation.

A nurse is providing teaching to the parents of a newborn about home safety. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will place my baby on his back when it is time for him to sleep." B. "I will keep my baby's crib close to the heat vents to keep him warm." C. "I will use an infant carrier when I drive to places close to my house." D. "I will tie my baby's pacifier around his neck with a piece of yarn."

A. because, the newborn should always sleep on his back to prevent sudden infant death syndrome.

A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? A. Copies a circle B. Cuts foods using a table knife C. Begins writing in cursive D. Prints first and last name clearly

A. because, the nurse should explain that copying a circle is a skill achieved by the age of 4 years.

A nurse is teaching a client who is at 12 weeks of gestation about manifestations of potential complications that she should report to her provider. Which of the following information should the nurse include in the teaching? A. Swelling of the face B. Urinary frequency C. White vaginal discharge D. Intermittent nausea

A. because, the nurse should instruct the client to report swelling of the face because this can indicate hypertensive disorder or preeclampsia.

A nurse is caring for a client who is at 32 weeks of gestation and is experiencing preterm labor. Which of the following medications should the nurse plan to administer? A. Betamethasone B. Misoprostol C. Methylergonovine D. Poractant alfa

A. because, the nurse should plan to administer Betamethasone IM, a glucocorticoid, to stimulate fetal lung maturity and thereby prevent respiratory depression.

A nurse is caring for a client who is at 37 weeks of gestation and is undergoing a non stress test. The fetal heart rate (FHR) is 130/min without accelerations for the past 10 min. Which of the following actions should the nurse take? A. Use vibroacoustic stimulation on the client's abdomen for 3 seconds B. Report the nonreactive test result to the provider immediately. C. Request a prescription for an internal fetal scalp electrode D. Auscultate the FHR with a Doppler transducer

A. because, the nurse should use a vibroacoustic stimulator on the client's abdomen to elicit fetal activity because the fetus us most likely sleeping. Fetal movement should cause accelerations in the FHR.

A nurse is assessing a 2-day-old newborn and notes an egg-shaped, edematous bluish discoloration that does not cross the suture line. Which of the following pieces of information should the nurse provide to the mother when she inquires about the finding? A. "This will resolve within 3 to 6 weeks without treatment." B. "This will resolve on its own within 3 to 4 days." C. "The provider might drain this area with a syringe." D. "This is expected at birth so you don't need to worry about it."

A. because, this discoloration is a cephalhematoma, resulting from a collection of blood between the skull and periosteum, that will resolve within 2 to 6 weeks.

A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area C. Avoid placing the scrotum inside the collection bag D. Wait several hours after positioning the device before checking it

A. because, this is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device.

A nurse is assessing a client who is at 35 weeks of gestation and has preeclampsia without severe features. Which of the following findings should the nurse identify as the priority? A. 480 mL urine output in 24 hr. B. Blood pressure 144/92 mm Hg C. +2 edema of the feet D. 1+ protein in the urine

A. because, when using the urgent vs. non urgent approach to client care, the nurse should determine that the priority finding is 480 mL or urine in 24 hr. because the minimum acceptable urine output in an adult client is 30 mL/hr. This can indicate progression of preeclampsia to preeclampsia with severe features, which requires immediate intervention. Therefore, this is the priority finding.

A nurse is assessing a client who is at 12 weeks of gestation and has a hydatidiform mole. Which of the following findings should the nurse expect? A. Hypothermia B. Dark brown vaginal discharge C. Decreased urinary output D. Fetal heart tones

B. because, a hydatidiform mole, or a molar pregnancy, is a benign proliferative growth of the chorionic villi, which gives rise to multiple cysts. The products of conception transform into a large number of edematous fluid-filled vesicles. As cells slough off the uterine wall, vaginal discharge is usually dark brown and can contain grape like clusters.

A nurse is caring for a newborn directly after birth. Which of the following medications should the nurse administer to the newborn within 1 to 2 hr of delivery? A. Naloxone B. Erythromycin ophthalmic ointment C. Poractant alpha D. Rotavirus immunization

B. because, every newborn born in the United States should receive erythromycin ophthalmic ointment to prevent gonorrheal or chlamydial infections that the newborn can contract during birth.

A nurse is assisting a client who is 4 hr postpartum to get out of bed for the first time. The client becomes frightened when she has a gush of dark red blood from her vagina. Which of the following statements should the nurse make? A. "You may have retained placental fragments in your uterus." B. "Blood pools in the vagina when you are lying in bed." C. "You might have a damaged blood vessel." D. "The amount of blood flow will increase during the first few days after giving birth."

B. because, in the early postpartum period, lochia will pool in the vagina when the client is lying in bed and will flow out of the vagina when the client stands up. After the initial gush, the bleeding will slow down to a trickle of bright red lochia.

A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents B. Uses the FACES scale C. Use the numeric rating scale D. Check the child's temperature

B. because, pain is a subjective experience even for a 3-year-old child. The FACES scale can be used to accurately determine the presence of pain in children as young as 3 years of age.

A nurse is caring for a newborn who is premature in the neonatal intensive care unit. Which of the following actions should the nurse take to promote development? A. Rapidly advance oral feedings. B. Position the naked newborn on the parent's bare chest. C. Provide frequent periods of visual and auditory stimulation. D. Discourage the use of pacifiers.

B. because, positioning the naked newborn on the parent's bare chest can decrease stress in the parents and the newborn. This action can help maintain thermal stability, raise oxygen saturations, increase feeding strength, and promote breastfeeding.

A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small piece jigsaw puzzle D. A book of short stories

B. because, preschool play centers on imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.

A nurse is performing a physical assessment on a 6-month-old infant. Which of the following highlight reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro

B. because, the Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.

A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeps on hands and knees B. Inability to vocalize vowel sounds C. Uses crude pincer grasp D. Stands by holding onto support

B. because, the infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word.

A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster

B. because, the meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia, which affects the blood. Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.

A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child B. Explain sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child

B. because, the noises in a facility can be frightening to a child who is experiencing a sensory loss. It is important to explain these noises to allay the child's fears.

A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing. B. Check the child's respiratory status. C. Administer an antidote to the child. D. Establish IV access for the child.

B. because, the nurse observes that the child's lips are edematous and inflamed and that he is drooling. These findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway.

A nurse is assessing a client who is at 37 weeks of gestation and has a suspected pelvic fracture due to blunt abdominal trauma. Which of the following findings should the nurse expect? A. Bradycardia B. Uterine contractions C. Seizures D. Bradypnea

B. because, the nurse should expect the client to be experiencing uterine contractions due to abdominal trauma.

A nurse is caring for a client who is receiving magnesium sulfate by continuous IV infusion. Which of the following medications should the nurse have available at the client's bedside? A. Naloxone B. Calcium gluconate C. Protamine sulfate D. Atropine

B. because, the nurse should have calcium gluconate available to give to client who is receiving magnesium sulfate by continuous IV infusion in case of magnesium sulfate toxicity. The nurse should monitor the client for a respiratory rate less than or equal to 12/min, muscle weakness, and depressed deep-tendon reflexes.

A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head to toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical technology D. Stop the assessment if the child becomes uncooperative

B. because, the nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.

A nurse is providing teaching to a client who is postpartum and does not plan to breastfeed her newborn. Which of the following instructions should the nurse include in the teaching? A. Stand under a hot shower with your breasts exposed. B. Place ice packs on your breasts. C. Wear a loose-fitting, comfortable bra. D. Limit fluid intake to 1 L per day.

B. because, the nurse should instruct the client to place ice packs on her breasts using a 15 min on and 45 min off schedule, to decrease swelling of the breast tissue as the body produces milk.

A nurse is teaching a client who is at 10 weeks of gestation about an abdominal ultrasound in the first trimester. Which of the following information should the nurse include in the teaching. A. "You will have a nonstress test prior to the ultrasound." B. "You will need to have a full bladder during the ultrasound." C. "The ultrasound will determine the length of your cervix." D. "You will experience uterine cramping during the ultrasound."

B. because, the nurse should tell the client that a full bladder helps to lift the gravid uterus out of the pelvis during the examination. Therefore, it is important to ensure that the client has a full bladder to obtain the most accurate image of the fetus.

A nurse is teaching a client who has pre-eclampsia and is to receive magnesium sulfate via continuous IV infusion about expected adverse effects. Which of the following adverse effects should the nurse include in the teaching? A. Elevated blood pressure B. Feeling of warmth C. Hyperactivity D. Generalized pruritus

B. because, the nurse should tell the client to expect the feeling of warmth all over her body while the magnesium sulfate is infusing.

A nurse is teaching a client who is at 8 weeks of gestation and has a uterine fibroid about potential effects of the fibroid during pregnancy. Which of the following information should the nurse include in the teaching? A. "The fibroid will shrink during the pregnancy." B. "The fibroid can increase the risk for postpartum hemorrhage. C. "You will receive an injection of medroxyprogesterone acetate to shrink the fibroid." D. "You will have to undergo a cesarean birth because of the fibroid."

B. because, uterine fibroids can increase the risk for postpartum hemorrhage due to the increase in blood supply to the uterus, which supports the fibroid.

A nurse is assessing a client who is 14 hr postpartum and has a third-degree perineal laceration. The client's temperature is 37.8° C (100° F), and her fundus is firm and slightly deviated to the right. The client reports a gush of blood when she ambulates and no bowel movement since delivery. Which of the following actions should the nurse take? A. Notify the provider about the elevated temperature. B. Assist the client to empty her bladder. C. Administer a bisacodyl suppository. D. Massage the client's fundus.

B. because, when the client's fundus is deviated to the right or left it can indicate that her bladder is full. The nurse should assist the client to empty her bladder to prevent uterine atony and excessive lochia.

A nurse is reviewing laboratory results for a client who is at 37 weeks of gestation. The nurse notes that the client is rubella non-immune, positive for group A beta-hemolytic streptococci, and has a blood type of O negative. Which of the following actions should the nurse take? A. Administer a dose of Rh0(D) immune globulin. B. Request a prescription for an antibiotic until delivery. C. Instruct the client to obtain a rubella immunization after delivery. D. Inform the client that she will need to deliver via cesarean birth.

C. Instruct the client to obtain a rubella immunization after delivery.

A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk B. Go to an emergency department C. Call the poison control center D. Induce vomiting

C. because, according to evidence-based practice, the nurse should instruct the parents to first call poison control center, which will then identify further actions the parents should take.

A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."

C. because, the coating action of liquids permits larger areas of contact with tissues and results in more extensive damage.

A nurse is teaching a client who is at 13 weeks of gestation about the treatment of incompetent cervix with cervical cerclage. Which of the following statements by the client indicates an understanding of the teaching? A. "I am sad that I won't be able to get pregnant again." B. "I can resume having sex as soon as I feel up to it." C. "I should go to the hospital if I think I may be in labor." D. "I should expect bright red bleeding while the cerclage is in place."

C. because, cervical cerclage prevents premature opening of the cervix during pregnancy. The client should immediately go to a facility for evaluation if she experiences any manifestations of labor while the cerclage is in place. If the client experiences preterm uterine contractions she might require tocolytic therapy.

A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.

C. because, complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children in this stage want to learn and master new concepts. If the child complains daily about going to school, it warrants further evaluation.

A nurse is caring for a client who is at 35 weeks of gestation and has severe pre-eclampsia, Which of the following assessments provides the most accurate information regarding the client's fluid and electrolyte status? A. Blood pressure B. Intake and output C. Daily weight D. Severity of edema

C. because, evidence-based practice indicates that daily weight is the most accurate assessment to determine a client's fluid and electrolyte status.

A nurse is assessing a 4-hour-old newborn who is to breastfeed and notes hands and feet are cool and slightly blue. Which of the following actions should the nurse take? A. Apply an oxygen hood over the newborn's head and neck. B. Check the newborn's temperature using a temporal thermometer. C. Place the naked newborn on the mother's bare chest and cover both with a blanket. D. Give the newborn glucose water between feedings.

C. because, exposure to a cool environment causes vasoconstriction, which results in cool extremities with a bluish discoloration. Placing the newborn skin-to-skin with his mother helps stabilize his temperature and promotes bonding.

A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker B. Place soft pillows around the edge of the infant's crib C. Position the car seat so it is rear-facing D. Secure a safety gate at the top and bottom of the stairs E. Maintain the water heater temperature at 49° C (120° F)

C. because, infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. D. because, as the infant begins to crawl and becomes more mobile, the risk of falls increases. E. To prevent a burn injury, the temperature of the water heater should not exceed 49° C (120° F).

A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? A. Grabs feet and pulls them to her mouth B. Posterior fontanel is closed C. Legs remain crossed and extended when supine D. Birth weight has doubled

C. because, legs crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the legs flex at the knees when the infant is supine. Crossed and extended legs when supine is a finding associated with cerebral palsy.

A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 B. First hospitalization C. Male gender D. Calm, quiet demeanor

C. because, male clients are at increased risk for hospitalization-related stress compared to female clients.

A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism

C. because, object permanence refers to the cognitive skill of knowing an object skill exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.

A nurse is caring for a client who is to receive a continuous IV infusion of oxytocin following a vaginal birth. Which of the following assessment findings should the nurse monitor to evaluate the effectiveness of the medication? A. Urinary output B. Blood pressure C. Fundal consistency D. Pulse rate

C. because, oxytocin is a smooth muscle relaxant that causes contraction of the uterus. The nurse should palpate the uterine fundus to determine consistency or tone to determine if the medication is effective.

A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps, rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "I am not going to let my child play with other children for 2 days." B. "I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I can give my child acetaminophen for discomfort associated with the immunization." D. "My child might have some discharge from the injection site."

C. because, parents can give acetaminophen for minor discomforts such as low-grade fever and local tenderness resulting from the administration of the immunization.

A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete B. Unable to hop on one foot C. Birth weight is tripled D. Able to state first and last name

C. because, the birth weight should be triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.

A nurse is assessing a 12-hour-old newborn and notes a respiratory rate of 44/min with shallow respirations and periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take? A. Perform chest percussion. B. Place the newborn in a prone position. C. Continue routine monitoring. D. Request a prescription for supplemental oxygen.

C. because, the nurse should continue routine monitoring because the newborn's assessment findings indicate he is adapting to extrauterine life.

A nurse is caring for a client who is in the latent phase of labor and is receiving oxytocin every 2 min which last 100 to 110 seconds and that the fetal heart rate (FHR) is reassuring. Which of the following actions should the nurse take? A. Decrease the infusion rate of the maintenance IV fluid. B. Administer oxygen via nonrebreather mask. C. Decrease the dose of oxytocin by half. D. Administer terbutaline 0.25 mg subcutaneously.

C. because, the nurse should decrease the dose of oxytocin by half because the client is experiencing uterine tachysystole.

A nurse is caring for a client who is in active labor and has meconium staining of the amniotic fluid. The nurse notes a reassuring fetal heart rate (FHR) tracing from the external fetal monitor. Which of the following actions should the nurse take? A. Prepare the client for an ultrasound examination. B. Prepare the client for an emergency cesarean birth. C. Prepare equipment needed for newborn resuscitation. D. Perform endotracheal suctioning as soon as the fetal head is delivered.

C. because, the nurse should ensure that all supplies and equipment needed for resuscitation of the newborn are readily available for every delivery. Endotracheal suctioning is recommended in cases of meconium staining only if the newborn has poor respiratory effort, decreased muscle tone, and bradycardia after delivery.

A nurse is assessing a client who is postpartum following a vacuum-assisted birth. For which of the following findings should the nurse monitor to identify a cervical laceration? A. Continuous lochia flow and a flaccid uterus B. Report of increasing pain and pressure in the peritoneal area C. A slow trickle of bright vaginal bleeding and a firm fundus D. A gush of rubra lochia when the nurse massages the uterus

C. because, the nurse should monitor for bright red bleeding as a slow trickle, oozing or outright bleeding, and a firm fundus to identify a cervical laceration.

A nurse is assessing a client who is at 35 weeks of gestation and is receiving magnesium sulfate via continuous IV infusion for severe pre-eclampsia. Which of the following findings should the nurse report to the provider. A. Deep tendon reflexes 2+ B. Blood pressure 150/96 mm Hg C. Urinary output 20 mL/hr D. Respiratory rate 16/min

C. because, the nurse should report a urinary output of 20 mL/hr because this can indicate inadequate renal perfusion, increasing the risk of magnesium sulfate toxicity. A decrease in urinary output can also indicate a decrease in renal perfusion secondary to a worsening of the client's pre-eclampsia.

A nurse is assessing a newborn 1 min after birth and notes a heart rate of 136/min, respiratory rate of 36/min, well flexed extremities, responding to stimuli with a cry, and blue hands and feet. Which of the following is the Apgar score the nurse should assign to the newborn? A. 7 B. 8 C. 9 D. 10

C. because, the nurse should use the Apgar scoring system to perform a quick assessment of the newborn at 1 min and 5 min after birth. The nurse should assign a score of 0, 1, or 2 to each of five categories. The nurse should assign a score of 2 for a heart rate greater than 100/min; a score of 2 for a good, strong cry, which shows normal respiratory effort; a score of 2 for well flexed extremities, which shows expected normal muscle tone; a score of 2 for responding to stimulation with a cry, cough, or sneeze; and a sore of 1 for blue hands and feet, known as acrocyanosis.

A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take? A. Have the toddler wear a disposable gown when in the unit's playroom B. Wear sterile gloves when changing the toddler's diapers C. Wear a mask when assisting the toddler with meals D. Ask visitors to wear an N-95 mask when entering the room

C. because, the nurse should wear a mask when within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large droplet particles expelled in the air.

A nurse is planning care for a client who is postpartum and has cardiac disease. For which of the following prescriptions should the nurse seek clarification? A. Monitor the client's intake and output. B. Initiate a high-fiber diet for the client. C. Monitor the client's weight weekly. D. Initiate bedrest with the head of the bed elevated

C. because, the nurse should weigh the client daily to monitor for fluid overload.

A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papilloma virus (HPV) and hepatitis A B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) C. Haemophilus influenza type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)

C. because, the recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization at the ages of 2 months, 4 months, and 12 to 15 months. The IPV immunization series consists of 4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.

A nurse is testing the reflexes of a newborn to assess neurologic maturity. Which of the following reflexes is the nurse assessing when she quickly and gently turns the newborn's head to one side? A. Rooting B. Moro C. Tonic neck D. Babinski

C. because, to elicit the tonic neck reflex, the nurse should quickly and gently turn the newborn's head to one side when he is sleeping or falling asleep. The newborn's arm and leg should extend outward to the same side that the nurse turned his head while the opposite arm and leg flex. This reflex persists for about 3 to 4 months.

A nurse is teaching a client who is at 30 weeks of gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour

C. because, vaginal bleeding can be an abnormal finding during pregnancy that might indicate a complication such a placental abruption, placenta previa, or preterm labor.

A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine B. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)

D. because, Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age.

A nurse in a pediatric clinic for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following is appropriate for the nurse to include in the teaching? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero. B. Administer a folic acid supplement to the child each day. C. Give pancreatic enzymes to the child with meals and snacks. D. Ensure the child's dietary intake of calcium and iron is adequate.

D. because, a child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.

A nurse is providing teaching to a client who is at 8 weeks of gestation about manifestations to report to the provider during pregnancy. Which of the following should the nurse include in the teaching? A. Nausea upon awakening B. Leg cramps when sleeping C. Increase in white vaginal discharge D. Blurred or double vision

D. because, a client who is pregnant should report experiencing blurred or double vision as these could be a manifestation of gestation hypertension or pre-eclampsia.

A nurse is assessing a newborn for congenital hip dysplasia. Which of the following findings should the nurse expect? A. Legs that are shorter than the arms. B. Temperature of one leg differing from that of the other. C. Symmetrical gluteal folds D. Limited abduction of one hip

D. because, a newborn who has congenital hip dysplasia can have limited abduction because the head of the femur might have slipped out of the acetabulum.

A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4 ounces of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 quarts of skim milk each day."

D. because, as the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids which are needed for growth and development.

A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers of blocks

D. because, building towers of blocks is an appropriate activity for a 2-year-old child. It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization.

A nurse is providing teaching to a client who is planning to breastfeed her newborn. Which of the following statements by the client indicates an understanding of teaching? A. "I must drink milk every day in order to assure good quality breast milk." B. "Drinking lots of fluids will increase my breast milk production." C. "After the first few weeks, my nipples will toughen up and breastfeeding won't hurt anymore." D. "It is normal for my baby to sometimes feed every hour for several hours in a row."

D. because, cluster feeding is an expected finding for newborns who are breastfeeding. The mother should follow her newborn's cues and feed her 8 to 12 times per day.

A nurse at a prenatal clinic is caring fir a client who suspects she may be pregnant and asks the nurse how the provider will confirm her pregnancy. The nurse should inform the client that which of the following laboratory tests will be used to confirm her pregnancy? A. A blood test for the presence of estrogen B. A blood test for the amount of circulating progesterone C. A urine test for the presence of human chorionic somatomammotropin D. A urine test for the presence of human chorionic gonadotropin

D. because, human chorionic gonadotropin is excreted by the placenta and promotes the excretion of progesterone and estrogen. This hormone is the basis for pregnancy testing.

A nurse is reviewing the medical record of a client who is at 39 weeks of gestation and has polyhydramnios. Which of the following findings should the nurse expect? A. Fundal height of 34 cm (13.4 in) B. Total pregnancy weight gain of 3.6 kg (8 lb) C. Gestational hypertension D. Fetal gastrointestinal anomaly

D. because, polyhydramnios is the presence of excessive amniotic fluid surrounding the unborn fetus. Gastrointestinal malformations and neurologic disorders are expected findings for a fetus experiencing the effects of polyhydramnios.

A nurse is caring for an adolescent who is receiving pain medication via PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medications B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10 D. Reinforce teaching with the client about how to push the button to deliver the medication

D. because, the appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively.

A nurse is assisting a provider during a venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine

D. because, the client is placed in the supine position, with the client's legs in a frog position.

A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold his breath and then blow it out slowly B. Ask the child to describe a pleasurable event C. Bounce the child gently while holding him upright D. Rock the child in long rhythmic movements

D. because, the nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements.

A nurse is caring for a client who has a soft uterus and increased lochial flow. Which of the following medications should the nurse plan to administer to promote uterine contractions? A. Terbutaline B. Nifedipine C. Magnesium Sulfate D. Methylergonovine

D. because, the nurse should administer methylergonovine, an ergot alkaloid, which promotes uterine contractions.

A nurse is assessing a client who is at 34 weeks of gestation and has a mild placental abruption. Which of the following findings should the nurse expect? A. Increased platelet count B. Fetal distress C. Decreased urinary output D. Dark red vaginal bleeding

D. because, the nurse should expect the client who has a mild placental abruption to have minimal dark red vaginal bleeding.

A nurse is teaching a client who is at 12 weeks of gestation and has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Breastfeed your newborn to provide passive immunity." B. "Abstain from sexual intercourse throughout the pregnancy." C. "You will be in isolation after delivery." D. "You should continue to take zidovudine throughout the pregnancy."

D. because, the nurse should inform the client that taking prescription antiviral medication every day decreases the risk of transmission of HIV to her newborn.

A nurse is planning care for a newborn who is receiving phototherapy for an elevated bilirubin level. Which of the following actions should the nurse take? A. Offer the newborn glucose water between feedings. B. Keep the newborn's eye patches on during feedings. C. Apply barrier ointment to the newborn's perianal region. D. Use a photometer to monitor the lamp's energy.

D. because, the nurse should monitor the lamp's energy throughout the therapy to ensure the newborn is receiving the appropriate amount to be effective.

A nurse is caring for a client who is in the latent phase of labor and is experiencing low back pain. Which of the following actions should the nurse take? A. Instruct the client to pant during contractions B. Position the client supine with legs elevated C. Encourage the client to soak in a warm bath D. Apply pressure to the client's sacral area during contractions

D. because, the nurse should provide counter pressure to the sacral area with a palm or a firm object, such as a tennis ball, during contractions. Counter pressure lifts the fetal head away from the sacral nerves, which decreases pain.

A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." B. "A toddler's interest in looking at pictures occurs at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." D. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months."

D. because, the nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively.

A nurse is providing teaching to the parents of a newborn about bottle feeding. Which of the following instructions should the nurse include in the teaching? A. Dilute ready-to-feed formula if the newborn is gaining weight too quickly. B. Prop the bottle with a blanket for the last feeding of the day. C. Discard unused refrigerate formula after 72 hr. D. Boil water for powdered formula for 1 to 2 min.

D. because, the parents should run tap water for 2 min and then boil it for 1 to 2 min before mixing it with the formula to decrease the risk of contamination.

A nurse is caring for a client whose last menstrual period (LMP) began July 8. Using Nagele's rule, the nurse should identify the client's estimated date of birth (EDB) as which of the following? A. October 1 B. April 1 C. October 15 D. April 15

D. because, using Nagele's rule, the nurse determines the EDB by counting back 3 months from the first day of LMP and adding 7 days.

A nurse is preparing to administer morphine oral solution 0.04 mg/kg to a newborn who weighs 2.5 kg. The amount available is morphine oral solution 0.4 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest hundredth. Use a leading zero if it applies. Do not use a trailing zero.)

Dimensional Analysis STEP 1: What is the unit of measurement the nurse should calculate? mg STEP 2: Set up an equation and solve for X: mg x kg = X 0.04 mg x 2.5 kg = 0.1 mg STEP 3: What is the unit of measurement the nurse should calculate? mL STEP 4: What is the quantity of the dose available? 1 mL STEP 5: What is the dose available? 0.4 mg STEP 6: What is the dose the nurse should administer? 0.1 mg STEP 7: Should the nurse convert the units? No. STEP 8: Set up the equation and solve for X. X = Quantity/Have x Conversion (Have)/Conversion (Desired) x Desired 0.4 mg/1 mL x 0.1 mg = 0.25 ml X = 0.25 mL STEP 9: Reassess to determine whether the amount to administer makes sense. If there are 0.4 mg/mL and the prescription reads 0.1 mg, it makes sense to administer 0.25 mL. The nurse should administer morphine oral solution 0.25 mL.

A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Dimensional Analysis STEP 1: What is the unit of measurement to calculate? gtt/min STEP 2: What is the volume needed? 100 mL STEP 3: What is the total infusion time? 4 hr STEP 4: Should the nurse convert the units of measurement? Yes (min does not equal hr) STEP 5: Set up an equation and solve for X. X = Quantity / 1 mL x Conversion (hr) / Conversion (min) x Volume (mL) / Time (hr) X gtt/min = 60 gtt/1 mL x 1 hr/60 min x 100 mL/4 hr X = 25 gtt/min STEP 6: Round if necessary. STEP 7: Reassess to determine whether the amount to administer makes sense. If the prescription reads 100 mL of 0.9% sodium chloride IV to infuse over 4 hr, it makes sense to administer 25 gtt/min. The nurse should set the manual IV infusion to deliver 0.9% sodium chloride IV at 25 gtt/min.

A nurse is caring for a newborn who weighs 4 lb. How many kilograms does the newborn weigh? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

STEP 1: What is the unit of measurement to calculate? kg STEP 2: Set up an equation and solve for X. 2.2 lb/1 kg = client weight in lb/ X kg 2.2 lb/1 kg = 4lb/X kg X = 1.8181 STEP 3: Round if necessary. 1.8181 = 1.8 STEP 4: Reassess to determine whether the conversion to kg makes sense. If 1 kg = 2.2 lb, it makes sense that 4 lb = 1.8 kg.