419 exam 2
The nurse has just finished administering the DTaP vaccine to a 2-month-old and is educating the parent about immunization. Which statement is accurate? "There are no side effects from this vaccine." "You need to renew this immunization every 10 years." "Bring her back for the second dose when she is 4 months old." "The 'T' stands for tuberculosis."
"Bring her back for the second dose when she is 4 months old."
The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss? Placental abruption Genetic abnormality Premature rupture of membranes Preeclampsia
Placental abruption
A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor? decrease in circulation and perfusion to the fetus decrease in arterial carbon dioxide pressure increase in fetal breathing movements increase in fetal oxygen pressure
decrease in circulation and perfusion to the fetus
A 12-hour-old infant is receiving IV fluids for polycythemia. For which complication should a nurse monitor this client? hypotension tachycardia fluid overload decreased level of consciousness
fluid overload
The nurse assesses a client in labor and finds that the fetal long axis is longitudinal to the maternal long axis. How should the nurse document this finding? a.position b. presentation c. attitude d. lie
lie
A nurse is describing the many changes a newborn will go through during his or her first couple of weeks after birth. The nurse explains how the functions of the placenta are taken over by which organ? cardiovascular system liver intestine kidneys
liver
A woman is experiencing dystocia that appears related to psyche problems. Which intervention would be most appropriate for the nurse initiate? administering oxytocin preparing the woman for an amniotomy encouraging the women to change positions frequently providing a comfortable environment with dim lighting
providing a comfortable environment with dim lighting
A nurse is assessing a newborn with the parents. The nurse explains that which aspect of newborn behavior is an important indication of neurologic development and function? a. orientation to surroundings b. crying response c. reflex d. voluntary movements
reflex
Which client statement is anticipated after immediately receiving an intrathecal injection of pain medication? a. "I feel a dull achiness around my abdomen." b. "I have no pain now." c. "I feel cramping but no sharp pain." d. "I still have intense pain. The medication is not working."
"I have no pain now."
When providing care for a child with herpes zoster (shingles), the parents ask the nurse how the child contracted this infectious disorder. Which response by the nurse is most appropriate? "Herpes zoster is a reactivation of a previous varicella zoster infection." "Handwashing is an effective way to prevent the spread of infectious disorders." "Your child must have been exposed to someone with herpes zoster." "Children who are immunocompromised are more likely to contact shingles."
"Herpes zoster is a reactivation of a previous varicella zoster infection."
A woman who is about to be discharged after a vaginal birth notices a flea-like rash on her newborn's chest that consists of tiny red lesions all across the nipple line. What is the best response from the nurse when explaining this to the woman? "It is a self-limiting virus that does not require treatment." "It is a normal skin finding in a newborn." "It is an indication that the woman has mistreated her newborn." "It is a sign of a group beta streptococcus skin infection. "
"It is a normal skin finding in a newborn."
A student observes during an initial prenatal visit. The student states, "I heard the primary care provider say that the client has a gynecoid pelvis. What does that mean?" The best response by the nurse is: "It is elongated, the width is roomy, but the length is narrow." "It is a typical male pelvis. With this type of pelvis, large neonates must be born by cesarean birth although some small neonates are able to be born vaginally." "It is rounded in shape and allows ample room for the neonate to fit through the passageway." "It is flat and narrow, making it extremely difficult for the neonate to pass through."
"It is rounded in shape and allows ample room for the neonate to fit through the passageway."
A woman has been in labor for the past 8 hours, and she has progressed to the second stage of labor. However, after 2 hours with no further descent, the provider diagnoses an "arrested descent." The woman asks, "Why is this happening?" Which response is the best answer to this question? "It is likely that your body has not secreted enough hormones to soften the ligaments so your pelvic bones can shift to allow birth of the baby." "More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal." "Maybe your baby has developed hydrocephaly and the head is too swollen." "Maybe your uterus is just tired and needs a rest."
"More than likely you have cephalopelvic disproportion (CPD) where baby's head cannot make it through the canal."
The nurse is preparing discharge instructions for a client at 32 weeks' gestation who was admitted for PROM. What is the best response from the nurse when the client asks when she can have intercourse with her husband again? "The need to keep the infant safe should be of more concern than when to have sex." "That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor." "You will not be able to have intercourse again until 6 weeks after you give birth." "Intercourse has nothing to do with preterm labor; you can have sex with your husband."
"That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."
The parents of a 12-month-old child tell the nurse the child has stopped walking and is now only crawling or sitting with support. How should the nurse respond? "If you continue to notice these changes, we should follow up within the next 3 months." "This is a concern. Let's be sure the physician is aware of this change." "Children often regress in their developmental stages...no need to worry." "Every child develops at different rates. Don't be alarmed. Just enjoy your child!"
"This is a concern. Let's be sure the physician is aware of this change."
The mother and father of a 5-year-old boy are discussing bicycle safety with the nurse. What comment indicates further teaching is needed? a."Our son always wears a helmet." b. "He is able to ride without training wheels." c."He never rides in the street." d."We just got him a new bike he can grow into."
"We just got him a new bike he can grow into."
The nurse is mentoring a newly licensed nurse in the health clinic, talking with the single mother of an infant. The mother was 10 minutes late to the appointment and is concerned the clinic will not allow the health visit to be conducted today. Which statement by the newly licensed nurse would alert the nurse to provide additional teaching to the newly licensed nurse? "Why don't you plan to have your retired neighbor bring the baby next time since having the parent with the baby isn't necessary?" "It is important to be current with your baby's progress, so we will see her today." "I know work schedules can make getting to appointment on time difficult and I am glad you are here now." "Follow me into the private exam room so we can discuss any concerns you have about your baby."
"Why don't you plan to have your retired neighbor bring the baby next time since having the parent with the baby isn't necessary?"
The father of a 4-year-old is concerned his child is not telling the truth and blaming others for things that have happened. Which response should the nurse prioritize after the father shares that the child is blaming someone named "Andrew" for a broken tool, and they have no idea who this is? "You should punish your son because no child should be telling lies at this age." "You should watch this type of behavior closely since most children this age tell the truth." "Your son may have a friend named Andrew, but it could be an imaginary friend." "You need to show your child the broken tool since at this age they must see something in order to understand."
"Your son may have a friend named Andrew, but it could be an imaginary friend."
A student nurse is reviewing newborn physical measurements and asks the charge nurse if her client's weight of 2800 g and length of 51 cm falls within normal parameters. The charge nurse would respond to the student nurse in which manner? A birth weight between 2200 and 3000 g is considered small for gestational age. Normal birth length is usually 52 cm or above for a full-term newborn. A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn. A length between 48 and 50 cm plots out at the 95th percentile for length.
A birth weight of 2800 g falls within the normal weight parameters for a full-term newborn.
A client's membranes have just ruptured. Her fetus is presenting breech. Which action should the nurse do immediately to rule out prolapse of the umbilical cord in this client? Place the woman in Trendelenburg position. Assess fetal heart sounds. Administer amnioinfusion. Administer oxygen at 10 L/min by face mask.
Assess fetal heart sounds.
During which time is the nurse correct to document the end of the third stage of labor? a. At the time of placental delivery b. When pushing begins c. Following fetal birth d. When the mother is moved to the postpartum unit
At the time of placental delivery
When developing the plan of care for a 5-year-old boy with Rocky Mountain spotted fever, the nurse knows the cause of the illness is: Animal bite Infection with group A streptococcus Contact with contaminated sports equipment Bite of a tick
Bite of a tick
The nurse plays a major role in assessing the progress of labor. The nurse integrates understanding of the typical rule for monitoring labor progress. Which finding would the nurse correlate with this rule? Cervix dilates 1 cm per hour. Cervix dilates 2 cm per hour. Fetus descends 2 cm per hour. Fetus descends 1 cm per hour.
Cervix dilates 1 cm per hour.
Which primary symptom does the nurse identify as a potentially fatal complication of epidural or intrathecal anesthesia? a. Intense pain b. Difficulty breathing c. Staggering gait d. Decreased level of consciousness
Difficulty breathing
A group of nursing students are reviewing the functions of white blood cells. The students demonstrate an understanding of the information when they identify which white blood cell as responsible for combating allergic disorders? Monocytes Eosinophils Lymphocytes Neutrophils
Eosinophils
Which nursing action is a priority when the fetus is at the +4 station? a. Have a blue bulb suction and an infant warmer ready b. Prepare for an immediate cesarean section c. Have a tocometer and a patient gown ready d. Provide lubricating jelly and an internal monitor
Have a blue bulb suction and an infant warmer ready
Parents report that their neonate received intravenous antibiotics while in the newborn nursery. The nurse recognizes this as a potential risk factor for which health problem? Articulation difficulties Visual disorder Hearing impairment Difficulty with fine motor skills
Hearing impairment
The nurse is caring for a preschool-aged child who needs a CT scan. Which action would the nurse use to best prepare the child for this diagnostic test? Tell the child that the CT scan is a picture of the dark parts inside the body. Explain that the child must behave because the technician is busy. Tell the child to follow directions to avoid being hurt. Help the child to pretend that the CT scan machine is a camera.
Help the child to pretend that the CT scan machine is a camera.
A woman in labor is having very intense contractions with a resting uterine tone >20 mm Hg. The woman is screaming out every time she has a contraction. What is the highest priority fetal assessment the health care provider should focus on at this time? Look for late decelerations on monitor, which is associated with fetal anoxia. Monitor fetal blood pressure for signs of shock (low BP, high FHR). Monitor heart rate for tachycardia. Monitor fetal movements to ensure they are neurologically intact.
Look for late decelerations on monitor, which is associated with fetal anoxia.
A preschool-age child tells the nurse about an imaginary friend. The parents are concerned because the child refuses to do anything without the friend's help. Which nursing diagnosis is most applicable for the family? Compromised family coping related to abnormal behavior of child Parental anxiety related to lack of understanding of childhood development Disturbed thought processes related to deep-set psychological need Social isolation related to unwillingness to relate except through imaginary friend
Parental anxiety related to lack of understanding of childhood development
A client is admitted to the health care facility. The fetus has a gestational age of 42 weeks and is suspected to have cephalopelvic disproportion. Which should the nurse do next? Prepare the client for a cesarean birth. Place the client in lithotomy position for birth. Perform artificial rupture of membranes. Administer oxytocin intravenously at 4 mU/minute.
Prepare the client for a cesarean birth.
The nursing instructor is teaching a session on how labor starts.The instructor determines the session is successful when the class correctly chooses which causative factor that initiates labor? Progesterone levels rise at term to initiate contractions. Prostaglandins may be the causative factor of labor. The ovary releases additional estrogen at term. Oxytocin blood levels increase with contractions.
Prostaglandins may be the causative factor of labor.
The nurse at an outpatient facility is obtaining a blood specimen from a 9-year-old girl. Which technique would most likely be used? Accessing an indwelling venous access device Puncturing a vein on the dorsal side of the hand Using an automatic lancet device on the heel Administering sucrose prior to beginning
Puncturing a vein on the dorsal side of the hand
A nurse is coaching a woman during the second stage of labor. Which action should the nurse encourage the client to do at this time? Hold the breath while pushing during contractions. Pant while pushing. Push with contractions and rest between them. Begin pushing as soon as the cervix has dilated to 8 cm.
Push with contractions and rest between them.
The nurse is interacting with several families with children during their health visits. Which child would the nurse prioritize to receive a hearing screening? The 6-month-old who attempts to mimic sounds the parents make The 3-week-old infant who was discharged without a hearing screening The 3-month-old whose mother reports the child turns their head to noises The 8-week-old who had an initial hearing screening reported as negative
The 3-week-old infant who was discharged without a hearing screening
The nurse is observing the parents and child during a health supervision visit. Which observation would alert the nurse to inquire and observe further? The father of the child states, "He didn't get first at the spelling bee, but he did well in his class." The infant, in a car seat, is placed on the exam table so the baby is facing the parents as they talk with the nurse The mother asks the father to hold the toddler when the nurse asks the mother to sign paperwork at the front desk. The mother says, "Wait until we are finished with this doctor's visit and then I will take you to the bathroom."
The mother says, "Wait until we are finished with this doctor's visit and then I will take you to the bathroom."
What physical change does not contribute to the impetus for a full-term newborn to begin breathing following birth? a. The environment surrounding the newborn is colder than in utero. b. The respiratory center in the brain is stimulated by the noise around the newborn. c. The newborn is touched for the first time by human hands. d. The infant experiences a drastic decrease in his oxygen level after the cord is cut.
The respiratory center in the brain is stimulated by the noise around the newborn.
The student nurse is preparing to administer an immunization to an 18-month-old child under the direction of a registered nurse. Which actions by the student nurse indicate the need for the registered nurse to intervene? Select all that apply. The student nurse reports that IM injections are to be avoided for children under the age of 2 years. The student nurse obtains a 23G needle to use for the injection. The student nurse prepares the triceps muscle for the IM injection. The student selects a needle that is 5/8 inches to perform a IM injection into the deltoid muscle. The student nurse reports plans to use a 20G needle for an IM deltoid injection.
The student nurse prepares the triceps muscle for the IM injection. The student nurse reports that IM injections are to be avoided for children under the age of 2 years. The student nurse reports plans to use a 20G needle for an IM deltoid injection.
Question 16 of 20 The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging? Attempt to push in one of the fetus's shoulders. Use McRoberts maneuver. Apply pressure to the fundus. Use Zavanelli maneuver.
Use McRoberts maneuver.
A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication? Placenta previa Hypertonic uterus Umbilical cord compression Uterine rupture
Uterine rupture
At what time is the laboring client encouraged to push? a. When the fetal head can be seen b. When the cervix is fully dilated c. When she feels the urge to push d. When the health care provider has arrived
When the cervix is fully dilated
A nursing instructor is teaching students about fetal presentations during birth. The most common cause for increased incidence of shoulder dystocia is: increased number of overall pregnancies. poor quality of prenatal care. longer lengths of labor. increasing birth weight.
increasing birth weight.
A 2-month-old infant is admitted to a local health care facility with an axillary temperature of 96.8° F (36° C). Which observed manifestation would confirm the occurrence of cold stress in this client? lethargy and hypotonia increase in the body temperature increased appetite hyperglycemia
lethargy and hypotonia
A child is diagnosed with group A streptococcal pharyngitis. The nurse would teach the parents to be alert for signs and symptoms of: scarlet fever. pneumonia. impetigo. osteomyelitis.
scarlet fever.
Assessment of a woman in labor reveals that the scapula of the fetus is the presenting part. The nurse interprets this finding as indicating which fetal presentation? shoulder vertex cephalic breech
shoulder
The nurse is caring for a child admitted to the hospital for sepsis. Which assessment finding is the most concerning? oral temperature 102.3°F (39°C) apical heart rate 120 beats per minute urine output of 10 ml over 3 hours white blood cell count 18,000 mm3
urine output of 10 ml over 3 hours
