404 Exam 3

A pregnant client late in the second trimester comes to the emergency department with a report of painless, bright red vaginal bleeding. The client states, "It started all of a sudden and now it seems to have stopped." Placenta previa is suspected. Which action should the nurse implement immediately for this client? A. Determine fetal heart sounds using an external monitor. B. Prepare the client for an immediate cesarean birth. C. Assist with insertion of internal monitoring to assess uterine pressure. D. Prepare the client for a pelvic examination to assess rupture of membranes.

A. Determine fetal heart sounds using an external monitor. Rationale: For placenta previa, the nurse should attach external monitoring equipment to record fetal heart sounds and uterine contractions. Internal monitoring is contraindicated. A pelvic or rectal examination should never be done with painless bleeding late in pregnancy because any agitation of the cervix when there is a placenta previa might tear the placenta further and initiate massive hemorrhage, which could be fatal to both the pregnant client and fetus. The decision to birth the fetus depends on the point at which a diagnosis of placenta previa is made and the age of the gestation. If labor has begun, bleeding is continuing, or the fetus is being compromised (measured by the response of the fetal heart rate to contractions), birth must be accomplished regardless of gestational age. If the bleeding has stopped, the fetal heart sounds are of good quality, pregnant client vital signs are good, and the fetus is not yet 36 weeks of age, a client is usually managed by expectant watching.

The nurse is evaluating care provided to a client in the third trimester of pregnancy who has been diagnosed with gestational hypertension. Which finding indicates that treatment has been successful for this client? A. urine protein 0 B. increased perspiration C. weight gain of 1 lb/week D. diastolic blood pressure 20 mmHg over normal level

A. urine protein 0 Rationale: Manifestations of gestational hypertension include elevated blood pressure, edema, and proteinuria. Absence of protein in the urine indicates that treatment has been successful. Increased perspiration is not a manifestation of gestational hypertension. A weight gain of 1 lb/week in the client who is in the third trimester of pregnancy is an indication of ongoing edema. A diastolic blood pressure that is 20 mmHg over normal level is an indication of ongoing hypertension.

A client with diabetes who is in the second trimester of pregnancy notes that the usual dose of insulin to maintain blood glucose levels has been increasing over the last few weeks. What should the nurse explain to the client about insulin during pregnancy? A. The fetus is using insulin to maintain blood glucose level in utero. B. Insulin resistance develops because of human placental lactogen hormone and other hormones. C. An increase in circulating blood volume during pregnancy deactivates insulin. D. The change in diet causes an increased need for insulin to maintain blood glucose levels.

B. Insulin resistance develops because of human placental lactogen hormone and other hormones. Rationale: Clients with diabetes who become pregnant develop insulin resistance as the pregnancy progresses or the insulin does not seem as effective during pregnancy. This phenomenon is believed to be caused by the presence of the hormone human placental lactogen and high levels of cortisol, estrogen, progesterone, and catecholamines. The increased need for insulin is not because of the fetus using insulin to maintain blood glucose level in utero. The client's increased circulating blood volume is not deactivating insulin. The client's change in diet might necessitate an adjustment in insulin dosage, but this would vary according to blood glucose level.

The nurse is reviewing the plan of care for a pregnant client experiencing a threatened miscarriage. Which outcome would be appropriate for this client? A. Bed rest is maintained until all bleeding stops. B. Less than one perineal pad is saturated per hour. C. Bleeding spontaneously stops within 24 to 48 hours. D. Normal coitus is resumed 1 week after the episode.

C. Bleeding spontaneously stops within 24 to 48 hours. Rationale: For a threatened miscarriage, an outcome for care would be that all bleeding would spontaneously stop within 24 to 48 hours. Bed rest is not recommended for a threatened miscarriage because blood will pool in the vagina. Vaginal bleeding that saturates a perineal pad in 1 hour is an emergency and could indicate an incomplete or complete miscarriage. Normal coitus should be withheld for 2 weeks after a threatened miscarriage.

A client with heart disease who is 28 weeks pregnant asks the nurse why office appointments have been scheduled every week for the next 4 weeks. What should the nurse respond to the client? A. This is the routine schedule for all pregnant clients. B. This is when most clients have a risk of going into early labor. C. During weeks 28 and 32, blood volume peaks, and heart function can be affected. D. Extra care is needed to make sure the fetus is developing normally during this time period.

C. During weeks 28 and 32, blood volume peaks, and heart function can be affected. Rationale: The danger of pregnancy in a client with heart disease occurs primarily because of this increase in circulatory volume. The most dangerous time for the client is in weeks 28 to 32, just after the blood volume peaks. Weekly appointments are not routine for all pregnant clients at this part of the pregnancy. This is not the time when most clients have a risk of going into early labor. The extra appointments are not needed to make sure the fetus is developing normally during this time period.

A pregnant client is hospitalized because of preeclampsia. Magnesium sulfate is ordered to prevent eclampsia. When preparing to administer the magnesium sulfate, the nurse would ensure that which medication would be readily available? A. hydralazine B. labetalol C. calcium gluconate D. nifedipine

C. calcium gluconate Rationale: When administering magnesium sulfate, the nurse would make sure that calcium gluconate is readily available should the client develop signs and symptoms of magnesium toxicity. Hydralazine, labetalol, and nifedipine are other drugs that may be used to control hypertension instead of magnesium sulfate.

A woman of 16 weeks' gestation telephones the nurse because she has passed some "berry-like" blood clots and now has continued dark brown vaginal bleeding. Which action would the nurse instruct the woman to do? A. "Maintain bed rest, and count the number of perineal pads used." B. "Come to the health care facility if uterine contractions begin." C. "Continue normal activity, but take the pulse every hour." D. "Come to the health facility with any vaginal material passed."

D. "Come to the health facility with any vaginal material passed." Rationale: This is a typical time in pregnancy for gestational trophoblastic disease to present. Asking the woman to bring any material passed vaginally would be important so the material can be assessed for this.

A woman has been diagnosed as having gestational hypertension. Which symptom for this condition is the most typical? A. increased perspiration B. weight loss C. susceptibility to infection D. blood pressure elevation

D. blood pressure elevation Rationale: The symptom of gestational hypertension is blood pressure elevation (140/90 mm Hg) identified after 20 weeks' gestation without proteinuria.

The nurse is identifying nursing diagnoses for a client with gestational hypertension. Which diagnosis would be the most appropriate for this client? A. risk for injury related to fetal distress B. imbalanced nutrition related to decreased sodium levels C. ineffective tissue perfusion related to poor heart contraction D. ineffective tissue perfusion related to vasoconstriction of blood vessels

D. ineffective tissue perfusion related to vasoconstriction of blood vessels Rationale: In gestational hypertension, vasospasm occurs in both small and large arteries during pregnancy. This can lead to ineffective tissue perfusion. There is no evidence to suggest that the fetus is in distress. There is no enough information to support imbalanced nutrition. Gestational hypertension does not affect heart contractions.

Which change in insulin is most likely to occur in a woman during pregnancy? A. enhanced secretion from normal B. not released because of pressure on the pancreas C. unavailable because it is used by the fetus D. less effective than normal

D. less effective than normal Rationale: Somatotropin released by the placenta makes insulin less effective. This is a safeguard against hypoglycemia.

A new mother asks the nurse, "Are there any medicines that I can or cannot take since I'm breastfeeding?" Which response by the nurse would be best? a. "Always check with your provider because almost all drugs are excreted to some extent in breast milk." b. "You can take medicines but stop breastfeeding for 1 week after taking it." c. "It shouldn't be a problem if you take any common over-the-counter medicines." d. "You need to stay away from any opioid pain medicines and sedatives while breastf

a. "Always check with your provider because almost all drugs are excreted to some extent in breast milk." Rationale: Almost any drug may cross into the acinar cells and be secreted in breast milk. As a general rule, the mother should take no drug unless prescribed or approved by her primary care provider while breastfeeding. Halting breastfeeding could impact the mother's ability to continue at a later time.

The nurse is caring for a small-for-gestational-age infant born to a drug dependent client. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? Select all that apply. a. Tremors b. Convulsions c. High-pitched cry d. Constant movement e. Sluggish respiratory rate

a. Tremors b. Convulsions c. High-pitched cry d. Constant movement Rationale: Infants of drug-dependent women tend to be small for gestational age. If the client took a drug close to birth, the infant may show withdrawal symptoms shortly after birth that include tremors, convulsions, high-pitched cry, and constant movement. Respiratory rate would be rapid and not sluggish.

The nurse is concerned that a pregnant client is experiencing abruptio placentae. What did the nurse assess in this client? A. increased blood pressure and oliguria B. pain in a lower quadrant and increased pulse rate C. painless vaginal bleeding and a fall in blood pressure D. sharp fundal pain and discomfort between contractions

D. sharp fundal pain and discomfort between contractions Rationale: Abruptio placentae is characterized by a sharp, stabbing pain high in the uterine fundus as the initial separation occurs. Manifestations of abruptio placentae do not include increased blood pressure, oliguria, pain in the lower quadrant, increased pule rate, painless vaginal bleeding, or a fall in blood pressure.

A nurse is teaching new parents about caring for their newborn's umbilical cord. The nurse determines that the teaching was successful based on which statement made by the parents? a. "It is important that we keep the area dry." b. "We need to keep the area covered with dry gauze." c. "The best thing to do is wash it often with soap and water." d. "Once a day, we apply a small amount of petroleum jelly."

a. "It is important that we keep the area dry." Rationale: It is important to remind the parents to continue to keep the cord dry until it falls off. Until the cord falls off, they should fold diapers below the level of the umbilical cord, so that when the diaper becomes wet, the cord does not become wet also. The nurse should not teach the parents to cover the umbilical cord with dry gauze, wash it with soap and water, or apply petroleum jelly to the site.

The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective? a. The newborn is placed on the back to sleep b. The mother removes a pacifier from the baby's mouth c. The baby is on an every-2-hour formula-feeding schedule d. The parents signed a waiver refusing routine immunizations after birth

a. The newborn is placed on the back to sleep Rationale: Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to 60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding, and having routine immunizations. Removing the pacifier, bottle feeding, and refusing routine immunizations after birth all increase the infant's risk for experiencing SIDS.

Hypoglycemia in a mature infant is defined as a blood glucose level below which amount? a. 100 mg/100 ml whole blood b. 80 mg/100 ml whole blood c. 45 mg/100 ml whole blood d. 30 mg/100 ml whole blood

c. 45 mg/100 ml whole blood Rationale: Because newborns do not manifest symptoms of a reduced glucose level until it decreases well below adult levels, a finding below 45 mg/100 ml whole blood is considered hypoglycemia.

A woman who began breastfeeding develops sore nipples. The nurse bases her response on which of the following? a. She will have to discontinue breastfeeding b. To prevent getting an infection, she will need an antibiotic prescribed c. Exposing her nipples to air after each feeding should help d. Allowing the infant to suck for longer periods during each feeding will toughen her nipples

c. Exposing her nipples to air after each feeding should help Rationale: Longer periods of sucking might irritate nipples; exposing the nipples to air can help.

The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital? a. The baby has a changing area b. The kitchen has a refrigerator c. The windows are covered with screens d. The baby sleeps with the mother in bed

d. The baby sleeps with the mother in bed Rationale: Evidence that an inadequate home environment assessment was performed as the baby is sleeping with the mother. The American Academy of Pediatrics recommends newborns have their own crib as a step toward preventing sudden infant death syndrome. The baby having a changing area, the kitchen having a refrigerator, and the windows covered with screens indicate that the home environment is adequate to support the needs of a newborn.

At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernail extending beyond the fingertips, and poor skin turgor. Based on these findings, how would the nurse would classify this neonate? a. Postterm b. Preterm c. SGA d. LGA

a. Postterm Rationale: These characteristics are consistent with a postterm infant. An SGA infant has some of these same characteristics but does not exhibit long fingernails. A preterm infant has translucent skin, and an LGA infant has excessive subcutaneous fat.

A newborn infant has loose, yellow stools. Although the infant is healthy, his mother is concerned that this means he is allergic to breast milk. The nurse would explain to her that: a. She might try burping the infant more frequently b. The stools of breastfed infants are normally loose c. She might consider changing to a soybean formula d. Her child may need to be investigated for bile duct disease

b. The stools of breastfed infants are normally loose Rationale: Until infants begin to eat solid food, their stools are yellow and slightly loose.

The nurse is talking with a parent of an adolescent who is newly diagnosed with type 2 diabetes and asks, "How could this happen? No one in our family has diabetes." What response would be appropriate? a. "This is caused by the pancreas not making enough insulin." b. "This disorder usually occurs when inadequate calories are ingested on a regular basis." c. "Because this disorder is genetic, someone in the family will eventually develop the illness." d. "This is caused by insulin resistance from

d. "This is caused by insulin resistance from previous pancreatic injury or generalized infection." Rationale: Type 2 diabetes is now seen in overweight adolescents as well as those who eat a diet high in fats and carbohydrates and do not exercise regularly. Pancreatic malfunction is not a cause of type 2 diabetes. This disorder is not linked to inadequate ingestion of daily calories. This disorder may have a genetic link, but environmental factors such as obesity, diet, and exercise can influence its development. Type 2 diabetes is a result of insulin resistance in the metabolism of glucose to maintain normal blood glucose levels, but it is not associated with infection or a previous pancreatic injury.

A 9-year-old is hospitalized for a long-term illness. The best project to give the to help achieve the child's developmental task would be: a. A scrapbook that will take 3 weeks to complete b. A puppet show that will take 2 weeks to plan c. Watching her favorite program on television d. Sewing a purse that will take one afternoon

d. Sewing a purse that will take one afternoon Rationale: Small projects that can be completed quickly offer a sense of reward and are best to help children develop a sense of industry.

A primigravid at 35 weeks' gestation arrives at the emergency department unsure if her membranes have ruptured. The nurse tests the client's fluid from the vagina with nitrazine paper. The paper turns blue. The nonstress test reveals a heart rate of 142 beats/minute and good variability. Occasional contractions are noted. What will the nurse include in the discharge teaching? Select all that apply. A. "Avoid douching until after the birth." B. "You may resume sex as desired." C. "Take a tub bath at least once per day." D. "Return to your normal teaching duties and rest at lunchtime." E. "Measure oral temperature twice per day and report any elevation."

A. "Avoid douching until after the birth." E. "Measure oral temperature twice per day and report any elevation." Rationale: When the nitrazine paper turns blue, it indicates a rupture of membranes. Many times labor will occur shortly afterward. When that does not occur, the client with preterm rupture of membranes is at risk for developing an infection. The nurse should instruct the client to avoid douching and measure oral temperature twice per day. Sex and tub baths should be avoided because these could introduce an infection into the uterus. Activities that require the client to be on her feet for hours at a time, such as classroom teaching, are not suggested.

A nurse is monitoring the serum drug level of a pregnant client with preeclampsia who is receiving a continuous infusion of magnesium sulfate. For which level would the nurse continue the infusion? A. 6.8 mg/100ml B. 8.4 mg/100 ml C. 9.2 mg/100 ml D. 10.6 mg/100 ml

A. 6.8 mg/100ml Rationale: Therapeutic serum blood levels for magnesium sulfate should be maintained at 5-8 mg/100 ml. If blood serum levels rise above this, respiratory depression, cardiac arrhythmias, and cardiac arrest can occur.

A gravida 2 para 1 client in preterm labor was administered terbutaline sulfate to stop the progression of labor and then discharged. What should the nurse teach the client to help prevent the reoccurrence of preterm labor? Select all that apply. A. Drink 8 to 10 glasses of fluid each day. B. Report any signs of ruptured membranes. C. Remain on bed rest except to use the bathroom. D. Lie flat on the back should uterine contractions occur. E. Engage in mild activities of daily living with frequent rest periods.

A. Drink 8 to 10 glasses of fluid each day. B. Report any signs of ruptured membranes. C. Remain on bed rest except to use the bathroom. Rationale: To reduce the onset of preterm labor, the nurse should instruct the client to drink 8 to 10 glasses of fluid each day to remain hydrated. The client should also report any signs of ruptured membranes and remain on bed rest unless using the bathroom. Should uterine contractions begin, the client should be instructed to lie on either the right or left side to increase blood return to the uterus. The client should not engage in any activity other than bed rest with bathroom privileges.

A pregnant client with a history of premature cervical dilatation undergoes cervical cerclage. Which outcome indicates that this procedure has been successful? A. The client delivers a full-term fetus at 39 weeks' gestation. B. The client's membranes spontaneously rupture at week 30 of gestation. C. The client experiences minimal vaginal bleeding throughout the pregnancy. D. The client has reduced shortness of breath and abdominal pain during the pregnancy.

A. The client delivers a full-term fetus at 39 weeks' gestation. Rationale: Premature cervical dilatation is when the cervix dilates prematurely and cannot retain a fetus until term. After the loss of one child because of premature cervical dilatation, a surgical operation termed cervical cerclage can be performed to prevent this from happening in a second pregnancy. This procedure is the use of purse-string sutures placed in the cervix to strengthen the cervix and prevent it from dilating until the end of pregnancy. Evidence that this procedure is effective would be the client delivering a full-term fetus at 39 weeks' gestation. Spontaneous rupture of the membranes could indicate that the procedure was not successful. Vaginal bleeding could indicate another health problem or that the procedure was not successful. This procedure does not impact the client's respirations or amount of abdominal pain while pregnant. These manifestations could indicate another health problem with the pregnancy.

A client is admitted with a diagnosis of ruptured ectopic pregnancy. For what should the nurse anticipate preparing the client? A. immediate surgery B. internal uterine monitoring C. bed rest for the next 4 weeks D. intravenous administration of a tocolytic

A. immediate surgery Rationale: An ectopic pregnancy is one in which implantation occurred outside the uterine cavity, usually within the fallopian tube. As the embryo grows, the fallopian tube can rupture. The therapy for ruptured ectopic pregnancy is laparoscopy to ligate the bleeding vessels and to remove or repair the damaged fallopian tube. There is no reason to begin uterine monitoring. The client does not need to be on bed rest for 4 weeks. A tocolytic is not needed because the client is not in labor.

The nurse is concerned that a pregnant client is developing polyhydramnios. What did the nurse assess in this client? Select all that apply. A. tense uterus B. sudden weight loss C. extreme shortness of breath D. difficulty hearing fetal heart rate E. uterus larger than expected for gestation week

A. tense uterus C. extreme shortness of breath D. difficulty hearing fetal heart rate E. uterus larger than expected for gestation week Rationale: Polyhydramnios is an excessive amount of amniotic fluid. The first sign of this disorder may be a rapid enlargement of the uterus. The uterus becomes tense, and the client experiences shortness of breath because of the uterus pressing on the diaphragm. Auscultating the fetal heart rate can be difficult because of depth of the increased amount of fluid surrounding the fetus. The uterus will be larger than expected for the client's gestational week.

A nurse is assessing for ankle clonus in a pregnant client with preeclampsia who is receiving magnesium sulfate. Which action would be appropriate for the nurse to do? A. Have the client wiggle the toes. B. Dorsiflex the foot three times rapidly. C. Stroke the bottom of the client's foot from heel to toe. D. Ask the client to plantar flex the foot.

B. Dorsiflex the foot three times rapidly. Rationale: To elicit ankle clonus, the nurse will dorsiflex the client's foot three times in rapid succession. When taking the hand away, the nurse observes the foot. If no further motion is present, no ankle clonus is present. If the foot continues to move involuntarily, clonus is present.

A pregnant client is developing HELLP syndrome. During labor, which order should the nurse question? A. Assess urine output every hour. B. Prepare for epidural anesthesia. C. Position on the left side during labor. D. Assess blood pressure every 15 minutes.

B. Prepare for epidural anesthesia. Rationale: In the HELLP syndrome, clients develop low platelet counts. With a low platelet count, injections such as epidural anesthesia are contraindicated. This is the order that the nurse should question. The client's urine output should be assessed every hour because renal failure is a complication of this syndrome. Positioning on the left side during labor will help blood flow to the uterus. Assessing blood pressure every 15 minutes is appropriate for the client with this syndrome.

A woman who is Rh negative asks the nurse how many children she will be able to have before Rh incompatibility causes them to die in utero. The nurse's best response would be that: A. no more than three children is recommended. B. as long as she receives Rho(D) immune globulin, there is no limit. C. only her next child will be affected. D. she will have to ask her primary care provider.

B. as long as she receives Rho(D) immune globulin, there is no limit. Rationale: Because Rho(D) immune globulin supplies passive antibodies, it prevents the woman from forming antibodies. Without antibodies that could affect the fetus, the woman could have as many children as she wants.

What would be the physiologic basis for a placenta previa? A. a loose placental implantation B. low placental implantation C. a placenta with multiple lobes D. a uterus with a midseptum

B. low placental implantation Rationale: The cause of placenta previa is usually unknown, but for some reason the placenta is implanted low instead of high on the uterus.

A newborn is being breastfed. To evaluate nutritional adequacy, you should be aware that breast milk contains an average of how many calories? a. 12 calories per ounce b. 20 calories per ounce c. 24 calories per ounce d. 30 calories per ounce

b. 20 calories per ounce Rationale: Twenty calories per ounce is not only the calorie content of breast milk but also that of commercial formulas.

The nurse encourages a woman with gestational diabetes to maintain an active exercise period during pregnancy. Prior to this exercise period, the nurse would advise her to take which action? A. Inject a bolus of insulin. B. Eat a high-carbohydrate snack. C. Eat a sustaining-carbohydrate snack. D. Add a bolus of long-acting insulin.

C. Eat a sustaining-carbohydrate snack. Rationale: Because exercise uses up glucose, women with diabetes should take a sustaining-carbohydrate snack before hard exercise to prevent hypoglycemia.

A pregnant woman diagnosed with diabetes should be instructed to perform which action? A. Discontinue insulin injections until 15 weeks gestation. B. Ingest a smaller amount of food prior to sleep to prevent nocturnal hyperglycemia. C. Notify the primary care provider if unable to eat because of nausea and vomiting. D. Prepare foods with increased carbohydrates to provide needed calories.

C. Notify the primary care provider if unable to eat because of nausea and vomiting. Rationale: During pregnancy, the insulin levels change in response to the production of HPL. The client needs to alert her provider if she is not able to eat or hold down appropriate amounts of nutrition. The client is at risk for episodes of hypoglycemia during the first trimester. She should never discontinue insulin therapy without her provider's directions. The increase of carbohydrates needs to be balanced with protein, and smaller meals would result in hypoglycemia rather than hyperglycemia.

The nurse is monitoring a pregnant client who is receiving intravenous magnesium sulfate for eclampsia. During the last assessment, the nurse was unable to elicit a patellar reflex. What should the nurse do? A. Check the fetal heart rate. B. Measure blood pressure. C. Stop the current infusion. D. Increase the infusion rate.

C. Stop the current infusion. Rationale: When infusing magnesium sulfate, the nurse should stop the infusion if deep tendon reflexes are absent. Checking the fetal heart rate and measuring blood pressure could waste time and provide the client with more magnesium sulfate. The infusion rate should not be increased because this could lead to cardiac dysrhythmias and respiratory depression.

A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which action would be the priority for this woman on admission? A. performing a vaginal examination to assess the extent of bleeding B. helping the woman remain ambulatory to reduce bleeding C. assessing fetal heart tones by use of an external monitor D. assessing uterine contractions by an internal pressure gauge

C. assessing fetal heart tones by use of an external monitor Rationale: Not disrupting the placenta is a prime responsibility in caring for a patient with placenta previa, so an external fetal monitor would be used. An internal monitor, a vaginal examination, and remaining ambulatory could all disrupt the placenta and thus are contraindicated.

A pregnant client is being admitted for severe preeclampsia. In which room location should the nurse place this client? A. near the nursery B. next to the elevator C. in a darkened room D. across from the nurse's station

C. in a darkened room Rationale: With preeclampsia with severe features, most women are hospitalized so that they can be closely monitored. Visitors are usually restricted to support people such as a partner, father of the child, mother, or older children. Raise bed side rails to help prevent injury if a seizure should occur. The room should be darkened if possible because a bright light can also trigger seizures. However, the room should not be so dark that caregivers need to use a flashlight to make assessments. Sudden noises, such as noises from the nursery, elevator or nurse's station can trigger a seizure in a woman with preeclampsia with severe features.

A client with diabetes is in the first trimester of pregnancy and is currently having difficulty keeping blood glucose levels within normal limits. The client explains that she has been "eating for two" so the baby is healthy. How should the nurse respond to the client? A. "Elevated blood glucose levels cause low birth weights in infants." B. "Elevated blood glucose levels ensure the baby has mature lungs at birth." C. "Elevated blood glucose levels hasten the development of the fetus in utero." D. "Elevated blood glucose levels in the first trimester have been linked to congenital anomalies."

D. "Elevated blood glucose levels in the first trimester have been linked to congenital anomalies." Rationale: The first trimester of pregnancy is the most important time for fetal development. If the client can control hyperglycemia during this time, the chances of a congenital anomaly are greatly reduced. Infants of clients with poorly controlled diabetes tend to be large. At birth, babies born to clients with uncontrolled diabetes are prone to respiratory distress syndrome. Elevated blood glucose levels do not hasten the development of the fetus in utero and can lead to hydramnios.

A nurse is conducting discharge teaching with a pregnant client at 32 weeks' gestation admitted to the facility with preterm labor that has been arrested. The nurse determines that the teaching was successful based on which client statement? A. "I need to remain on strict bed rest when I go home." B. "It's safe for me to do any type of activity at home." C. "My contractions now will be a lot stronger if I go into labor." D. "I need to do a fetal kick count each day while at home."

D. "I need to do a fetal kick count each day while at home." Rationale: Following initial therapy for preterm labor and if contractions have ceased and there is evidence of fetal well-being, clients with arrested preterm labor can be safely cared for at home. The client does not need to be on bed rest but should limit strenuous activities. To help with fetal assessment, a client may be asked to record daily fetal movement (kick) counts or a "count to 10" test. There is no evidence to suggest that the client's contractions will be weaker or stronger when labor begins.

A woman develops gestational diabetes. Which assessment should she make daily? A. Test her urine for protein with a chemical reagent strip. B. Measure her abdominal diameter with a tape measure. C. Measure her uterine height by hand-span distance. D. Measure serum for glucose level by a finger prick.

D. Measure serum for glucose level by a finger prick. Rationale: Assessing serum glucose reveals both hyperglycemia and hypoglycemia.

A client who is 16 weeks' pregnant is passing pieces of body tissue along with blood clots and dark red blood from the vagina. What should the nurse direct the client to do at this time? A. Begin immediate bed rest. B. Count the number of perineal pads that are saturated with blood. C. Continue with normal daily activity and monitor pulse rate every hour. D. Seek immediate medical attention and bring the expressed vaginal material.

D. Seek immediate medical attention and bring the expressed vaginal material. Rationale: Gestational trophoblastic disease is abnormal proliferation and then degeneration of the trophoblastic villi. The embryo fails to develop beyond a primitive start. At approximately week 16 of pregnancy, vaginal bleeding will begin as spotting of dark-brown blood accompanied by discharge of the clear fluid-filled vesicles. The pregnant client who begins to miscarry at home needs to bring any clots or tissue passed to the hospital because the presence of clear fluid-filled cysts identifies gestational trophoblastic disease. The client needs to seek immediate medical attention and not stay at home on bed rest, count perineal pads, or continue with normal activity and count pulse rates every hour.

A client who is in labor in planning to breastfeed the newborn. The client asks the nurse, "I am really excited to breastfeed my newborn. When can I do it?" Which response by the nurse is appropriate? a. "You can breastfeed within 1 hour of your newborn's birth." b. "You can start once the newborn has been allowed to rest." c. "For the first 24 hours, your newborn will get water and then you can breastfeed." d. "Breastfeeding can start after your newborn has had one feeding of formula."

a. "You can breastfeed within 1 hour of your newborn's birth." Rationale: Breastfeeding should begin as soon after birth as possible, within 1 hour of birth, ideally while the parent is still in the birthing room and while the newborn is in the first reactivity period. Breastfeeding should not wait until after the newborn rests. Twenty-four hours is too long to wait to begin breastfeeding. Mixing breastfeeding and formula feeding is not recommended.

The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lb. How much formula should the nurse teach the parents to provide each day? a. 20 to 24 oz b. 30 to 36 oz c. 42 to 54 oz d. 60 to 72 oz

a. 20 to 24 oz Rationale: The total fluid ingested for 24 hours must be sufficient to meet the infant's fluid needs and is calculated by determining 75 to 90 ml or 2.5 to 3.0 oz of fluid per pound of body weight per day. Because the infant weighs 8 lb, the amount of formula would be between 8.0 x 2.5, or 20 oz, and 8.0 x 3.0, or 24 oz. The other choices are inaccurate calculations for the amount of formula to provide to an infant weighing 8 lb.

When teaching a woman about ingesting drugs while breastfeeding, which statement is most accurate? a. Almost all drugs are excreted to some extent in breast milk b. A mother can plan on taking common over-the-counter drugs without difficulty c. A mother has to limit her exposure to opioids and sedatives while breastfeeding d. A mother should halt breastfeeding for 1 week after taking any drug

a. Almost all drugs are excreted to some extent in breast milk Rationale: Almost all drugs are excreted in breast milk, over-the-counter as well as prescription.

The nurse notices that a newborn has a white discharge from his breasts. The nurse would explain to his parents that this is: a. Caused by his mother's hormones b. A suggestion he may need chromosomal studies c. A sign that he has a pituitary tumor d. Caused by exposure to cool air

a. Caused by his mother's hormones Rationale: Both male and female newborns may have a milky breast discharge from being under the influence of female hormones in utero.

A 9-year-old girl tells the nurse about belonging to a girls' social media club. How does belonging to this group support the child's development? a. Fulfills peer group needs b. Teaches the child leadership skills c. Helps the child develop autonomy d. Encourages the child to learn rules

a. Fulfills peer group needs Rationale: Nine-year-old's take the values of their peer group very seriously. This is typically the friend or club age because children form groups. This type of club does not teach the child leadership skills, develop autonomy, or learn rules.

1. While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this client? Select all that apply. a. Grunting b. Nasal flaring c. Intercostal retractions d. Oxygen saturation 96% e. Increasing respiratory rate

a. Grunting b. Nasal flaring c. Intercostal retractions e. Increasing respiratory rate Rationale: A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions, which reflect the degree of difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits and does not indicate respiratory distress.

A new mother asks the nurse how soon she can breastfeed after delivery. Which of the following would be the nurse's best answer (barring unforeseen complications)? a. Immediately after birth b. After the infant is allowed to rest c. Once the infant has a first feeding of formula d. In 24 hours after her infant is given water

a. Immediately after birth Rationale: Newborns are able to feed (and interested in feeding) immediately after birth.

A 12-year-old child is diagnosed with hyperthyroidism. What problem would the nurse anticipate the child may have in school? a. Inability to submit neat handwriting assignments b. Increase in sleepiness by the end of the day c. Non-comprehension of written material d. Inability to fit legs under a school desk

a. Inability to submit neat handwriting assignments Rationale: Children with hyperthyroidism are seen in the health care provider's office with the first reports being sleep problems, poor school performance, and distractibility. These children are easily frustrated, get overheated, and fatigued during physical education classes. The disease causes muscle weakness and the child can develop fine tremors, which leads to poor handwriting. The child tends to have an increased rate of growth but the growth is not abnormal so he or she should not have a problem placing the legs under the desk. The child is tired throughout the entire day, not just at the end of the day. The disease does not cause problems with cognitive delays so the child should not have problems with comprehension.

All infants need to be observed for hypoglycemia during the newborn period. Based on the facts obtained from pregnancy histories, which infant would be most likely to develop hypoglycemia? a. An infant whose labor began with ruptured membranes b. An infant who had difficulty establishing respirations at birth c. An infant who has marked acrocyanosis of his hands and feet d. An infant whose mother craved chocolate during pregnancy

b. An infant who had difficulty establishing respirations at birth Rationale: Newborns use a great many calories in their effort to achieve effective respirations. Infants who had difficulty establishing respirations need to be assessed for hypoglycemia.

A nurse is caring for a newborn born 36 hours ago to a pregnant client participating in a methadone maintenance program. The nurse determines the newborn is experiencing withdrawal based on which assessment finding(s)? Select all that apply. a. Irritability b. Weak, mild crying c. Bradypnea d. Frequent sneezing e. Clonus

a. Irritability d. Frequent sneezing e. Clonus Rationale: Signs and symptoms of withdrawal in the newborn include irritability; disturbed sleep pattern; constant movement, possibly leading to abrasions on the elbows, knees, or nose; tremors; frequent sneezing; shrill, high-pitched cry (not a weak, mild cry); hyperreflexia and clonus (neuromuscular irritability); convulsions; tachypnea/rapid respirations (not bradypnea), possibly so severe that it leads to hyperventilation and alkalosis; and vomiting and diarrhea, leading to large fluid losses and secondary dehydration.

A newborn is diagnosed as having hypocalcemia. A symptom of this is: a. Jitteriness b. Excessive sleepiness c. Constipation d. A distended abdomen

a. Jitteriness Rationale: Hypocalcemia interferes with muscle contractility, producing jitteriness.

When teaching a mother to care for her newborn's umbilical cord, which of the following instructions would you include? a. Keeping it dry b. Washing it with soap and water c. Applying petroleum jelly to it daily d. Covering it with dry gauze

a. Keeping it dry Rationale: Keeping the umbilical cord dry and open to air helps to prevent infection.

A 7-year-old child is diagnosed as having type 1 diabetes. What is one of the first symptoms usually noticed by parents when this illness develops? a. Loss of weight b. Craving for sweets c. Severe itching d. Swelling of soft tissue

a. Loss of weight Rationale: The classic signs of type 1 diabetes are polydipsia, polyuria, and polyphagia. With polyphagia, the child has an increased appetite and increased hunger, and the child eats all the time but is losing weight. This occurs because the lack of energy sugar supplies causes the muscle tissues and the fat stores to shrink. The lack of insulin also reduces the ability of the body's cells to use glucose. This leads to starvation of the cells. Loss of weight is an early symptom parents see first. They tend to equate the increased appetite as normal with growing, but become concerned when the child starts losing weight even though the child is eating. Itching and swelling are not signs of diabetes. A craving for sweets is normal for a child, especially one who is growing rapidly.

The nurse is evaluating a new mother's ability to breastfeed her infant. Which criteria indicate that the mother is able to breastfeed independently? Select all that apply. a. Nipples are everted b. Breasts are soft and non-tender c. Mother holds the nipple in the baby's mouth d. Baby swallows spontaneously and frequently e. Nurse places pillows under the baby for support

a. Nipples are everted b. Breasts are soft and non-tender d. Baby swallows spontaneously and frequently Rationale: The LATCH breastfeeding charting system is used to measure a mother's ability to breastfeed independently. Criteria that indicate the mother can breastfeed independently include everted nipples, breasts are soft and nontender, and the baby swallows spontaneously and frequently. The mother having to hold the nipple in the baby's mouth and the nurse assisting with positioning indicate the mother is not independent in breastfeeding.

The nurse is caring for a newborn that weighed 7 lb 3 oz (3220 g) at birth. What action should the nurse take first based on this weight? a. Plot the weight on a gestational age graph b. Ask for a physician to examine the newborn c. Draw additional blood work for cholesterol level d. Turn off the radiant heat warmer for physical assessment

a. Plot the weight on a gestational age graph Rationale: A newborn's weight is important because it helps to determine maturity as well as establish a baseline against which all other weights can be compared. The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. The weight in relation to the gestational age should be plotted on a standard neonatal graph. The nurse does not need to ask a physician to examine the newborn. There is no evidence to suggest that the infant needs a cholesterol level drawn. The weight does not influence if the newborn needs to be placed in a radiant heat warmer.

A nurse is planning the care for a newborn delivered vaginally about 90 minutes ago. The medical record of the pregnant client and newborn reveals the following: Pregnant client: type 1 diabetes Fetus: cephalic presentation Vaginal delivery at 38.4 weeks' gestation Rupture of membranes at 35 weeks' gestation Newborn's Apgar score 5 at 1 minute, 6 at 5 minutes Amniotic fluid: positive for meconium The nurse determines that the newborn is at risk for respiratory problems based on which finding i

a. Pregnant client's history of diabetes d. Timing of membrane rupture e. Apgar score f. Amniotic fluid appearance Rationale: For this newborn, predisposing factors include the pregnant client's history of diabetes, premature rupture of membranes (roughly 3 weeks prior to birth), the newborn's Apgar score, and meconium in the amniotic fluid. Other factors include low birth weight, intrauterine growth restriction, pregnant client's use of barbiturates or opioids close to birth, irregularities detected by fetal heart monitor during labor, cord prolapse, postmaturity (postterm), small for gestational age, breech birth, multiple birth, and anomalies of the chest, heart, or respiratory tract.

A 10-year-old child spends 2 hours alone every afternoon before the parents arrive home from work. Which safety measure should the nurse suggest the parents teach the child? a. Preparing a no-cook snack after school b. Lighting candles in case there is a power failure c. Wearing the house key prominently around the neck d. Telling people at school about being home alone for added safety

a. Preparing a no-cook snack after school Rationale: Parents should plan after-school snacks for the child who does not require cooking to prevent burns. Lighting candles could be a fire hazard if they are left unattended. Wearing the house key around the neck could indicate that the child will be home alone. Telling people at school about being home alone could encourage a break-in or other action against the child.

A newborn is prescribed to receive vitamin K (Aqua-Mephyton) 0.5 mg intramuscularly. What should the nurse do when providing this medication to the newborn? a. Administer the medication in the deltoid muscle b. Administer the medication into the anterolateral muscle c. Provide the medication immediately before breastfeeding d. Notify the physician of swelling and irritation at the injection site

b. Administer the medication into the anterolateral muscle Rationale: Vitamin K should be administered into a large muscle such as the anterolateral muscle of the newborn's thigh. The deltoid muscle is not used for intramuscular injections in the newborn. The medication should be given so as not to interrupt breastfeeding. Swelling and irritation at the injection site is a possible adverse reaction and does not necessarily need to be reported to the physician.

The nurse is planning care for a school-age child diagnosed with growth hormone deficiency. Which diagnosis should the nurse select to help the child with this health problem? a. Risk for situational low self-esteem related to short stature b. Ineffective tissue perfusion related to infantile blood vessels c. Impaired skin integrity related to overproduction of melanin d. Risk for self-directed violence related to oversecretion of epinephrine

a. Risk for situational low self-esteem related to short stature Rationale: Children with short stature tend to report feeling of lower quality of life largely related to discrimination. The nurse may need to remind parents to assign duties and responsibilities to children that match their chronologic age, not their physical size, in order to promote children's feelings of maturity and self-esteem. A child that differs in any way from peers may be the victim of bullying. The nurse should alert the parent to this possibility and assess for this at well-child visits to help protect the child's quality of life. Tissue perfusion is not affected by this disorder. This disorder does not cause impaired skin integrity. There is no overproduction of epinephrine with this disorder.

After completing a physical assessment of a newborn, the nurse notifies the health care provider about which finding? a. Scaphoid abdomen b. Absence of bleeding at the base of the umbilical cord c. Bowel sounds present at two-to-three per minute d. Liver palpable 2 cm under the right costal margin

a. Scaphoid abdomen Rationale: The contour of a newborn abdomen looks slightly protuberant. A scaphoid or sunken appearance suggests missing abdominal contents or a diaphragmatic hernia (bowel or other abdominal organs positioned in the chest instead of the abdomen). Bowel sounds show the bowel is beginning peristalsis and should be present within 1 hour after birth. On the right side, the edge of the liver is usually palpable 1 to 2 cm below the costal margin. There should be no bleeding at the base of the cord and it should not appear wet.

During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother? a. This is a normal finding b. This is most likely a symptom of diarrhea c. The baby may be developing an allergy to breast milk d. The child will need to be isolated until the stool can be cultured

a. This is a normal finding Rationale: After meconium stools, the newborn's stool changes in color and consistency. This is a transitional stool and is green. It might look like diarrhea. This does not indicate that the baby is developing an allergy to breast milk or that the child needs to be isolated until the stool can be cultured.

The nurse is preparing teaching materials for a family whose child is prescribed somatropin for a growth hormone deficiency. What should the nurse instruct the parents about the administration of this medication? a. This medication must be given by injection b. This medication must be given in the morning before school c. Hip or knee pain is an expected adverse effect of this medication d. This medication does not interact with any other types of medication

a. This medication must be given by injection Rationale: Somatropin is administered by injection. It is best given at the hour of sleep because that is when growth hormone is released. Hip or knee pain could indicate a slipped capital epiphysis and should be reported to the health care provider. The nurse should urge the parents to inform all health care providers that the child is receiving this medication to avoid medication interactions.

The nurse is caring for a large-for-gestational-age infant born to a client with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant? a. To detect rebound hypoglycemia b. To determine insulin dosage to administer c. To explain the effects of maternal hyperglycemia on the baby d. To estimate the amount of calories to provide the infant through formula

a. To detect rebound hypoglycemia Rationale: Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled, the infant would have had an increased blood glucose level in utero to match the mother's glucose level; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age infants is not done to determine insulin dosage, to explain the effects of maternal hyperglycemia on the baby, or to estimate the amount of calories to provide the infant through formula.

The nurse is interviewing the parents of a 3-year-old child brought to the emergency department for fever and fussiness. Which question is the best example to use when completing a health history about pain? a. "Your child doesn't have any pain, does she?" b. "Does your child have pain?" c. "So, your child has been fussy?" d. "Tell me about your child's temperament."

b. "Does your child have pain?" Rationale: When conducting a health history, the nurse should use therapeutic communication techniques such as active listening and eliminate any barriers to communication. Open-ended and close-ended questions can both be effective when used during a health history. Close-ended questions ask directly for a fact and are limited in scope. They require no further explanation. Asking "Does your child have pain?" is a closed-ended question and only requires a yes or no answer. The nurse can then explore the issue of pain with the parents. Asking about temperament does not address the issue of pain. Compound, expansive, and leading questions such as "Your child doesn't have pain does she?" should be avoided. Compound questions elicit information that is often inaccurate and requires follow-up. Asking "So, your child has been fussy?" is not a therapeutic question. The parents could only respond yes or no and this would give the nurse no further information as

The nurse is discussing home safety with the parents of a 10-year-old client. Which statement by the client's parents most concerns the nurse? a. "Our child is home alone for an hour each day." b. "Our child swims alone before we get home from work." c. "Our child refuses to eat any green vegetables." d. "We do our best to keep no-cook snacks in the home."

b. "Our child swims alone before we get home from work." Rationale: Latchkey children need to learn to be independent but safe. The nurse would be most concerned about the child swimming while no one else is at the home. If the child becomes endangered while swimming, there is no one there to assist. It is common for children at this age to be home alone between arriving home from school and when the parents arrive home from work. This is not an issue, as long as the child knows and follows safety rules. There are other ways the child can gain nutrition beyond green vegetables. No-cook snacks should be kept in the home as this ensures the child does not use the oven or stove to prepare a meal when hungry. This statement requires follow-up, but is not more concerning than swimming alone.

Which of the following statements is true about breastfeeding? a. Breastfeeding increases the risk of breast cancer b. Breastfeeding offers a good chance for bonding with the infant c. Uterine involution is slowed by breastfeeding d. Breastfeeding mothers have a decreased risk of developing thrombophlebitis

b. Breastfeeding offers a good chance for bonding with the infant Rationale: Breastfeeding reduces the risk of breast cancer and enhances uterine involution. It provides the opportunity for mother-infant bonding.

The nurse is teaching a child with type 1 diabetes mellitus to administer insulin. The child is receiving a combination of short-acting and long-acting insulin. The nurse knows that the child has appropriately learned the technique when the child: a. Administers the insulin into a doll at a 30-degree angle b. Draws up the short-acting insulin into the syringe first c. Wipes off the needle with an alcohol swab d. Administers the insulin intramuscularly into rotating sites

b. Draws up the short-acting insulin into the syringe first Rationale: Drawing up the short-acting insulin first prevents mixing a long-acting form into the vial of short-acting insulin. This maintains the short-acting insulin for an emergency. Insulin is given subcutaneously not intramuscularly. A SQ injection is administered at a 90-degree angle if the person can grasp 2 in (5 cm) of skin. If only 1 in (2.5 cm) of skin can be grasped, then the injection should be given at a 45 degree angle. The needle is sterile. It should not be wiped with an alcohol swab. Only the top of the insulin vial should be wiped with an alcohol swab.

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is: a. Inspiratory stridor b. Expiratory grunting c. Expiratory wheezing d. Inspiratory "crowing"

b. Expiratory grunting Rationale: Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

On an Apgar evaluation, how is reflex irritability tested? a. Raising the infant's head and letting it fall back b. Flicking the soles of the feet and observing the response c. Dorsiflexing a foot against pressure resistance d. Tightly flexing the infant's trunk and then releasing it

b. Flicking the soles of the feet and observing the response Rationale: Reflex irritability means the ability to respond to stimuli. It can be tested by flicking the foot or evaluating the response to a catheter passed into the nose.

The nurse is explaining the process of breast milk production with a client pregnant with her first child. What should the nurse include when providing this teaching? Select all that apply. a. Breast milk is thin, yellow, and watery b. For the first 3 to 4 days, the breast milk is colostrum c. Uterine cramping is a contraindication to breastfeeding d. True breast milk comes in by the 10th day after giving birth e. Most mothers have breast milk by the first day after giving birth

b. For the first 3 to 4 days, the breast milk is colostrum d. True breast milk comes in by the 10th day after giving birth Rationale: For the first 3 to 4 days after delivery, the breast milk is colostrum. The consistency changes to true breast milk by the 10th postpartum day. Colostrum is thin, yellow, and watery. Uterine cramping occurs as a result of oxytocin released during breastfeeding and is not a contraindication to breastfeeding but an expected occurrence. Most mothers do not have breast milk by the first day after giving birth.

After hospital discharge, the parent of a child newly diagnosed with type 1 diabetes mellitus telephones the nurse because the child is acting confused and very sleepy. Which emergency measure would the nurse suggest the parent carry out before bringing the child to see the health care provider? a. Give the child one unit of regular insulin b. Give the child a glass of orange juice c. Give the child nothing by mouth so that a blood sugar can be drawn at the health care provider's office d. Give

b. Give the child a glass of orange juice Rationale: The child is experiencing symptoms of hypoglycemia. Administering a form of glucose would help relieve them. This can be glucose tablets or a rapidly absorbable carbohydrate such as orange juice. This should be followed by a snack of complex carbohydrates and protein within 30 to 60 minutes. Insulin cannot be absorbed when taken orally and administering insulin would make the hypoglycemia worse. Withholding treatment waiting to get to the health care provider's office may cause the hypoglycemia to worsen and be a risk to the child's life. Children with diabetes and their parents need to be taught to recognize and treat the symptoms of hypoglycemia.

A nurse is providing care to a 3-day-old newborn who is receiving phototherapy to treat hyperbilirubinemia. The nurse determines that the treatment is effective based on assessment of the newborn's stools appearing as which color? a. Brownish-black b. Green c. Mustard yellow d. Reddish-brown

b. Green Rationale: The stools of a newborn under bilirubin lights are often green because of the excessive bilirubin being excreted as a result of the therapy. The stools are also frequently loose and may be irritating to the skin. Urine may be dark-colored from urobilinogen formation.

A client who has just given birth to her first baby asks the nurse for help with breastfeeding. Which nursing diagnosis would be the most appropriate for the client at this time? a. Powerlessness b. Health-seeking behaviors c. Readiness for enhanced coping Anxiety related to breastfeeding

b. Health-seeking behaviors Rationale: The new mother is asking the nurse for help with breastfeeding, which supports the nursing diagnosis of health-seeking behaviors. The client requesting help with breastfeeding does not indicate powerlessness, readiness for enhanced coping, or anxiety related to breastfeeding.

While reviewing a newborn's hospital record, which of the following would be most important for you to locate? a. How he was positioned in utero (posterior or anterior) b. If he breathed spontaneously at birth c. If his mother used prepared childbirth If he was a planned pregnancy

b. If he breathed spontaneously at birth Rationale: Although all of these are important, inability to breathe spontaneously at birth has the potential to have the most long-term consequences.

The developmental task of the school-aged period, according to Erikson, is gaining a sense of: a. Autonomy versus shame b. Independence versus dependence c. Industry versus inferiority d. Identity versus failure

c. Industry versus inferiority Rationale: The school-age years, according to Erickson, are the stage of industry versus inferiority. The developmental stage helps increase the child's sense of self worth. Industry is associated with the child's increased interest in knowledge and the development of social skills. Autonomy versus shame is the developmental tasks of 1 to 3 year old children. Erickson's stages do not include the developmental tasks of independence versus dependence nor identity versus failure.

The nurse is caring for a 10-year-old child with growth hormone (GH) deficiency. Which therapy would you anticipate will be prescribed for the child? a. Short-term aldosterone provocation b. Injections of GH c. Oral administration of somatotropin d. Long-term blocking of beta cells

b. Injections of GH Rationale: Growth hormone (GH) deficiency occurs when the anterior pituitary is unable to produce enough hormone for usual growth. Somatotropin is the name of the growth hormone administered. Administering subcutaneous GH to the child helps correct this deficiency. The GH dosage is 0.2 to 0.3 mg/kg given daily. It is not administered orally. Aldosterone causes sodium to be retained and a provocation would be the administration of diuretics to reduce the sodium. Beta cells are found in the heart muscles, smooth muscles, airways, and arteries. They are also found in the pancreas to secrete insulin. None of these cell actions are related to the anterior pituitary.

The mother of a school-age child is distraught because the child has been diagnosed with obesity. What actions should the nurse suggest to the mother to help the child with this problem? Select all that apply. a. Explain that obesity will lead to an early death b. Maintain a balanced eating approach in the home c. Purchase books explaining the latest ways to lose weight d. Seek out a preteen weight loss group for the child to participate in e. Encourage increased activity such as walking the dog

b. Maintain a balanced eating approach in the home d. Seek out a preteen weight loss group for the child to participate in e. Encourage increased activity such as walking the dog after school Rationale: Strategies to help the school-age child with obesity include maintaining a healthy eating approach in the home, seeking a weight loss group with other preteens for the child to attend, and encouraging increased activity. Explaining that obesity will lead to an early death could cause the child to become obsessed with dieting and create an eating disorder. The child should not be encouraged to use fad diets to lose weight.

While making a visit to the home of a family with a school-age child, the nurse observes a hunting rifle leaning against the wall in the dining room. Which nursing diagnosis should the nurse use to guide interventions for the family at this time? a. Anxiety b. Risk for injury c. Health-seeking behaviors d. Readiness for enhanced parenting

b. Risk for injury Rationale: The nursing diagnosis appropriate for this situation is risk for injury because the firearm is in the dining room. The parents need instruction about safety precautions with firearms and school-age children. There is no evidence of anxiety. The parents are not asking for health-related information. The parents are not demonstrating readiness to learn more about parenting.

A preterm infant is transferred to a distant hospital for care. When her parents visit her, which action would be most important for the nurse to urge them to do? a. Call the baby by her name b. Touch and, if possible, hold her c. Stand so the baby can see them d. Bring a piece of clothing for her

b. Touch and, if possible, hold her Rationale: Preterm infants may be hospitalized for an extended time, so parents need to be encouraged to touch and interact with the infant to begin bonding.

A mother asks you how she can judge that her infant is receiving sufficient breast milk. What would be the most appropriate response? a. "You need to weigh the infant before and after each feeding." b. "The infant should sleep at least 3 hours between feedings." c. "The infant should gain weight and have six wet diapers daily." d. "The infant should not become constipated."

c. "The infant should gain weight and have six wet diapers daily." Rationale: An infant who is voiding adequately is undoubtedly receiving adequate fluid.

Typical development for the school-aged child includes playing games with friends. At what age are children typically ready for games that include playing on a team that has a winner or loser? a. 5 years b. 7 years c. 10 years d. 13 years

c. 10 years Rationale: Consider growth and development when advising. Erikson's stages can be helpful in determining. Before about 10 years, children are unable to lose a game and still maintain the self-concept that they are good people.

A preterm infant is receiving oxygen to maintain respiratory status. The nurse closely monitors the infant's Po2 levels to prevent retinopathy of prematurity. Which level is a significant cause for concern? a. 90 mm Hg b. 95 mm Hg c. 100 mm Hg d. 110 mm Hg

c. 100 mm Hg Rationale: When blood Po2 levels rise to higher than 100 mm Hg, the risk of retinopathy of prematurity increases. All preterm infants who receive oxygen must have blood oxygen levels monitored by pulse oximeter, transcutaneous oxygen saturation, or blood gas monitoring so the blood Po2 level can be kept within normal limits.

A nurse is reviewing the blood sugar test results of a child diagnosed with type 1 diabetes: Before meal: 84 mg/dL (4.66 mmol/l) 1 hour after meal: 160 mg/dL (8.88 mmol/l) 2 hours after meal: 180 mg/dL (9.99 mmol/l) Middle of the night: 92 mg/dL (5.11 mmol/l) Which result would lead the nurse to notify the health care provider? a. Before meal b. 1 hour after meal c. 2 hours after meal d. Middle of the night

c. 2 hours after meal Rationale: Acceptable blood glucose levels for a child 2 hours after a meal would range from 80 to 150 mg/dL (4.44 to 8.32 mmol/l). This child's level is above the range at 180 mg/dL (9.99 mmol/l). The other levels are within the acceptable ranges (before meal—70 to 110 mg/dL (3.89 to 6.11 mmol/l); 1 hour after meal— 90 to 180 mg/dL (5.0 to 10.0 mmol/l); and middle of night—70 to 120 mg/dL (3.89 to 6.66 mmol/l).

The nurse records a newborn's Apgar score at birth. A normal 1-minute Apgar score is: a. 1 to 2 b. 5 to 9 c. 7 to 10 d. 12 to 15

c. 7 to 10 Rationale: An Apgar score of 7 to 10 implies the infant is breathing well and cardiovascular adaptation is occurring.

The nurse assesses a newborn's Apgar score at birth and documents that it is normal. Which score did the nurse most likely record? a. 1 b. 4 c. 8 d. 13

c. 8 Rationale: An Apgar score between 7 and 10 indicates that the infant scored as high as 70% to 90% of all infants at 1 and 5 minutes after birth and is adjusting well to extrauterine life. A score of 4 to 6 indicates a guarded condition, and the newborn may need clearing of the airway and supplementary oxygen. A score <4 indicates serious danger of respiratory or cardiovascular failure, and the newborn needs resuscitation. Ten is the maximum number on the Apgar scoring system.

A newborn was diagnosed as having hypothyroidism at birth. The parent asks the nurse how the disease could be discovered this early. Which is the nurse's best answer? a. Hypothyroidism is usually detected at birth by the newborn's physical appearance b. A newborn has a typical rash at birth that suggests the diagnosis c. A simple blood test to diagnose hypothyroidism is required in most states d. The newborn is already severely impaired at birth, and this suggests the diagnosis

c. A simple blood test to diagnose hypothyroidism is required in most states Rationale: With hypothyroidism there is insufficient production of the thyroid hormones required to meet the body's metabolic as well as growth and developmental needs. Without these hormones, cognitive impairment occurs. Hypothyroidism is diagnosed by a newborn screening procedure. This screening procedure is required by most states. With early diagnosis the condition can be treated by replacing the missing hormones. The later the diagnosis is made, the more irreversible cognitive impairment becomes. At birth, a newborn with hypothyroidism will be a poor feeder. Other symptoms, such as lethargy and hypotonicity, become evident after the first month of life. There are no other outward manifestations, such as rashes or appearances, that can be seen. These are not part of the condition.

A parent tells the nurse that the 6-year-old child has been biting his fingernails since beginning first grade. After analysis, the cause is determined to be increased stress. What advice would the nurse give the parent regarding this behavior? a. Encourage the child to drink more milk for stronger nails b. Distract the child by teaching a new skill, such as whistling c. Allow some time every day for the child to talk about new experiences d. Allow the child to choose a reward for not biting the

c. Allow some time every day for the child to talk about new experiences Rationale: The developmental task of the school-age child is industry. They are busy learning, achieving, and exploring. With school comes separation from the parents, new people, new activities. Beginning school can be a time of extreme stress for children. Biting the nails can be a symptom that something is concerning the child. Spending time with the child and allowing the child time to discuss these new experiences of school helps the child to put experiences in perspective and begin to deal with them. Allowing the child a reward for not biting the nails does not address the underlying issue of why the child is biting the nails in the first place. The underlying issue is emotionally based, so adding milk or providing a distraction will not correct the problem.

At an amniocentesis just prior to birth, the lecithin/sphingomyelin ratio (L/S) of a fetus was determined to be 1:1. Based on this, she is prone to which type of respiratory problem following birth? a. Wheezing from excess fluid accumulation b. Bronchial constriction from room air c. Alveolar collapse on expiration d. Inspiratory constricture from air contaminants

c. Alveolar collapse on expiration Rationale: Without adequate surfactant, infants are unable to sustain respiratory function and, thus, develop respiratory distress syndrome with alveolar collapse on expiration.

A new mother does not want the baby to return to the nursery because of the fear of someone taking the baby without her permission. What should the nurse explain to the mother to allay her fears? a. Only people who are known to the staff are permitted in the nursery b. Keeping the baby in the mother's room at all times is the best approach c. Both the mother and infant have identification bands that need to match d. Security questions everyone before permitting them access to the hospital

c. Both the mother and infant have identification bands that need to match Rationale: Hospitals have an identification banding system where the mother's and the infant's identification bands are to match. Only people with proper hospital identification should be permitted into the nursery. Keeping the baby in the mother's room at all times could be dangerous because the baby could be left unattended, permitting someone an opportunity to abduct the infant. Security does not routinely question everyone before permitting them access to the hospital.

A pediatric client has just been diagnosed with diabetes. What would the nurse do first? a. Educate the client on stress management b. Regulate nutrition c. Check blood glucose levels d. Administer insulin

c. Check blood glucose levels Rationale: The nurse must check the insulin level before it can be administered. Once a need is established, then insulin administration becomes the priority intervention. Stress management, glucose checks, and nutritional consultation can all be implemented once therapy with insulin begins.

On the fourth day postpartum, a woman develops breast engorgement. Which measure would be best to recommend to her as a means of alleviating this problem? a. Discontinuing breastfeeding for 24 hours b. Decreasing her fluid intake to below 500 ml per 24 hours c. Encouraging her to continue regular breastfeeding d. Having her apply lanolin cream to each breast

c. Encouraging her to continue regular breastfeeding Rationale: Engorgement (a feeling of fullness in the breasts) can be alleviated by the infant breastfeeding.

During a home visit, the nurse learns that a new mother is experiencing breast engorgement. What should the nurse recommend to help alleviate this problem? a. Discontinuing breastfeeding for 24 hours b. Having her apply lanolin cream to each breast c. Encouraging her to wear a firm-fitting bra d. Decreasing her fluid intake to below 500 ml per 24 hours

c. Encouraging her to wear a firm-fitting bra Rationale: A mild analgesic for pain relief and breast support from a firm-fitting bra may provide relief from engorgement. Also, a common suggestion to relieve breast engorgement is to empty the breasts of milk by having the infant suck more often or at least continue to suck as much as before. Breastfeeding should not be discontinued. Applying cream to the breasts will not help with engorgement. The mother does not need to be placed on a fluid restriction.

During a home visit, a new mother tells the nurse that her nipples are sore from breastfeeding. What should the nurse instruct the mother at this time? Select all that apply. a. Insert plastic liners into the nursing bra b. Apply petroleum jelly to the nipples before feeding c. Expose the nipples to air so the nipple dries d. Position the baby differently for each feeding e. Massage a few drops of breast milk to the areola

c. Expose the nipples to air so the nipple dries d. Position the baby differently for each feeding e. Massage a few drops of breast milk to the areola Rationale: To help with sore nipples from breastfeeding, the nurse should instruct the mother to expose the nipples to air so the nipple dries, position the baby differently for each feeding, and massage a few drops of breast milk to the areola. The mother should be discouraged from applying petroleum jelly to the nipples or inserting plastic liners into the nursing bra because these prevent air from circulating around the breast.

When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate? a. 12 to 16 breaths/min b. 16 to 20 breaths/min c. 20 to 30 breaths/min d. 30 to 60 breaths/min

d. 30 to 60 breaths/min Rationale: The respiratory rate of a newborn in the first few minutes of life may be as high as 80 breaths/min. Because respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths/min. Respiration rates less than 30 breaths/min should be reported to the health care provider for evaluation.

Which of the following is an advantage of breastfeeding for the infant? a. Breast milk is more difficult to digest, so it makes the infant feel fuller longer b. Breast milk contains antibodies and thus decreases the possibility of gastrointestinal illnesses c. It takes less effort for an infant to suck at a breast than from a bottle d. Breast milk leads to firmer stools, increasing bowel tone

d. Breast milk leads to firmer stools, increasing bowel tone Rationale: Breast milk contains antibodies that are instrumental in reducing gastrointestinal infections.

On the first day postpartum, a new mother is concerned that her milk has not yet "come in." The nurse would explain to her that: a. Most mothers do have milk by 1 day postpartum b. She will not have breast milk until 7 days postpartum c. Her infant must not be sucking well or she would have milk by now d. Breast milk normally comes in on the third or fourth postpartum day

d. Breast milk normally comes in on the third or fourth postpartum day Rationale: Colostrum has been forming since the fourth month of pregnancy; milk forms on the third or fourth postpartum day.