ATI Maternal Newborn A&B

A nurse is performing a physical assessment of a newborn. Which of the following clinical finding should the nurse expect?

-Heart Rate 154/ min -Respiratory rate 58/ min -Weight 2,600 g (5lb 12 oz)

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply)

-ankle clonus -exaggerated stretch reflexes -contractures

A nurse is calculating a client expected date of birth using Nägeles rule the client tells the nurse that her last menstrual period started on November 27 which of the following dates as the clients expected date of birth

September 3

A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

Withhold the measles, mumps, and rubella (MMR) vaccine

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?

avoid palpating the abdomen when bathing the child before surgery

A nurse is reviewing the laboratory results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication?

erythrocyte sedimentation rate 18mm/hr

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

place the child in a side-laying position

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?

playing dress-up

A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is priority for the nurse to report to the provider?

substernal retractions

A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?

"Give the infant a pacifier at bedtime."

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?

"I should wear sandals as much as possible."

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make?

"Let's talk about some of the ways you have handled previous stressors in your life."

A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching

"award your child with a sticker when they sit on the potty chair."

A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?

"choose a waterproof sunscreen with a minimum SPF of 15."

A nurse is preparing to perform Leopold's Maneuvers for a client identify the sequence the nurse should follow

-Palpate the funds to identify the fetal part -Determine the location of the fetal back -Palpate for the fetal part presenting at the inlet -Identify the altitude of the head

A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (place in order of performance)

-Turn off the IV pump -occlude the IV tubing -remove the tape securing the catheter -apply pressure over the catheter insertion site

A nurse is demonstrating to a client how to bathe their newborn. In which order should the nurse perform the following actions?

-Wipe eyes -Wash Neck -Cleanse skin around umbilical cord stump -Wash legs and feet -Clean diaper area

A nurse is an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (select all that apply.)

-increased temperature -xerophthalmia -cervical lymphadenopathy

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero

1

A nurse is performing a newborn assessment which of the following images should the nurse identify as an indication of spina bifida occulta

Caucasian baby with small bruise-like/birthmark at the base of the back above buttocks

A nurse is assessing a newborn following circumcision which of the following findings should the nurse identify as an indication of the newborn is experiencing pain

Chin quivering

A nurse is reviewing the laboratory results for a client who is at 10 weeks gestation which of the following laboratory findings should the nurse report to the provider

Hemoglobin 10 g/dL

A nurse is reviewing the prenatal laboratory value for a client who is at 12 weeks of gestation following an initial prenatal visit. Which of the following laboratory findings should the nurse report to the provider

Hemoglobin 10 g/dL

A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy which of the following statements by the client indicated understanding of the teaching

I will continue taking my insulin if I experience nausea and vomiting

A nurse is teaching a client who is in preterm labor about terbutaline which of the following statements by the client indicates an understanding of the teaching

I will have blood tests because my potassium might decrease

A nurse is teaching a client who is Rh negative about Rh0(D) immune globulin which of the following statements by the client indicated understanding of the teaching

I will need this medication if I have an amniocentesis

A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa which of the following actions should the nurse take

Initiate continuous external fetal monitoring

A nurse is developing a plan of care for a client who has preeclampsia and is receiving magnesium sulfate via a continuous IV infusion. Which of the following interventions should the nurse include in the plan?

Monitor the FHR continously

A nurse is providing discharge teaching to a client who has postpartum for which of the following manifestation should the nurse instruct the client to monitor and report to the provider

Unilateral breast pain

A nurse and a prenatal clinic is caring for a client who reports that her menstrual period is two weeks late client appears anxious and asked the nurse if she's pregnant which of the following responses to the nurse make

You can miss your period for several other reasons describe your typical menstrual cycle

A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first?

a toddler who has a concussion and an episode of forceful vomiting

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

a unilateral rib hump

A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?

administer an analgesic to the child

A nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

administer epinephrine IM to the child

A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take?

administer the immunization using a 24 gauge needle

A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain?

allow the mother to breastfeed while the sample is being obtained

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?

an 8 month old infant who is not yet making babbling sounds

A nurse in an emergency department is caring for a school age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take?

apply an antimicrobial ointment to the affected area

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

apply topical analgesic cream to the site 1hr prior to the procedure

A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take?

assess peripheral pulses once every 4 hours

A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first?

check the child's respiratory rate

A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take?

cleanse the affected area with mild soap and water

A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?

cuts an outlined shape using scissors

A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective?

decreased edema

A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?

deep respirations of 32/min

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse?

denies discomfort during assessment of injuries

A nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?

difficulty concentrating

A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority?

disease process

A nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree C (104 degrees F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature?

dress the toddler in minimal clothing

A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?

dry, hacking cough

A nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include?

ensure the oxygen source is functioning in the child's room

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?

epinephrine

A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?

explore the parents feelings and wishes regarding organ donation

A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?

expresses likes and dislikes

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

flank pain

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?

for 24 hrs following initiation of antimicrobial therapy

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take?

give morphine 0.05mg/kg IV

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?

hgb 8.5g/dL

nurse is providing dietary teaching on client who has hyperemesis gravidarum. which statement indicates and understanding by the client

i will eat foods that appeal to my taste instead of trying to balance my meals

A nurse is creating a plan of care for an infant who has an epidural hematoma form a head injury. Which of the following interventions should the nurse include in the plan?

implement seizure precautions for the infant

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?

increase fat content in the child's diet to 40% of total calories.

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis?

increased protein concentration

A nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next?

initiate IV access

A nurse is creating a plan of care for a child who has varicella. which of the following interventions should the nurse include?

initiate airborne precautions for the child

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?

initiate droplet precautions for the child

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the nurse include in the plan?

initiate seizure precautions for the child

A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

mental confusion

A nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take?

monitor the child's oxygen saturation

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider?

nasal flaring

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?

petechiae on the lower extremities

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?

place the infant in a knee-chest position

A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should a nurse identify as a potential indication of physical neglect?

poor personal hygiene

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider?

potassium chloride

A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?

presence of strabismus

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?

provide small, frequent meals for the child

A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take?

provide the child with a book about adventure

A nurse is providing discharge teaching to the parent of a child who is 1 week postop following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?

speech therapist

A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?

sunken anterior fontanel

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?

symmetric burns of the lower extremities

A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?

the toddler received tobramycin during a hospitalization 2 weeks ago

A nurse is caring for a client following an amniocentesis at 18 weeks of gestation which of the following findings should the nurse report to the provider is a potential complication

Leakage of fluid from the vagina

A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

RR 45

A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe?

Recombinant growth hormone

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?

tachypnea

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?

tachypnea

A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?

the child should be able to stand on the balls of their feet when sitting on the bike

A nurse is providing teaching for a client who have birth 2 hr ago about the facility policy for newborn safety. Which of the following client statements indicates an understanding of the teaching?

the person who comes to take my baby's pictures will be wearing a photo identification badge

A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?

absence of peristalsis

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant?

great toe

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for a infection control?

have a designated stethoscope in the infant's room.

A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?

have the adolescent sign a consent form for treatment

A nurse is providing teaching to a client who is at 40 weeks of gestation and has a new prescription for misoprostol. Which of the following instructions should the nurse include in the teaching?

"I can administer oxytocin 4 hours after the insertion of the medication"

A nurse is teaching a newly licensed nurse about collecting a specimen for the universal newborn screening. Which of the following statements should the nurse include in the teaching?

"Ensure that the newborn has been receiving feeding for 24 hours prior to obtaining the specimen"

A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?

"I should keep my child indoors when I mow the yard."

A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?

"I should secure the car seat using lower anchors and tethers instead of the seat belt."

A nurse is teaching a client who is at 10 weeks of gestation about nutrition during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?

"I should take 600 micrograms of folic acid every day"

A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching?

"I will give myself a shot of regular insulin 30 minutes before I eat breakfast."

A nurse is providing teaching to a client about the physiological changes that occur during pregnancy. The client is at 10 weeks of gestation and has a BMI within the expected reference range. Which of the following client statements indicates an understanding of the teaching?

"I will likely need to use alternative positions for sexual intercourse".

A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?

"I will monitor my child's number of wet diapers."

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching?

"Mononucleosis is caused by an infection with the Epstein-Barr virus."

A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching?

"My child will receive antibiotics for several weeks."

A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching?

"I will notify the doctor if I notice that my child is swallowing frequently."

A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?

"I will place my infant's diaper under the harness straps."

A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?

"I will teach challenging academic subjects to students who have ADHD in the morning."

A nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include?

"Shake the medication prior to administration."

A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?

"When you child's lesions are crusted, usually 6 days after they appear."

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?

oral rehydration solution

A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make?

"You can sign the consent form because you are married"

A nurse is providing discharge teaching to a client who had a cesarean birth 3 days ago. Which of the following instructions should the nurse include?

"You can still become pregnant if you are breastfeeding"

A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make?

"You should offer your child high protein meals and snacks throughout the day."

A nurse is teaching a client who is at 37 weeks of gestation and has a prescription for a non-stress test. Which of the following instructions should the nurse include?

"You should press the handheld button when you feel your baby move."

A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching?

"encourage the child to perform independent self-care."

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?

"Your daddy will be back after you eat."

A nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching?

"allow the stent to drain directly into your infant's diaper."

A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include?

"apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include?

"pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy."

A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?

"wait 3 days before taking a tub bath."

A nurse is teaching the guardian of a 6 month old infant about teething. Which of the following statements should the nurse make?

"your baby might pull at their ears when they are teething."

A nurse is performing a physical assessment of a newborn upon admission to the nursery. Which of the following manifestations should the nurse expect?

-Acrocyanosis -Positive Babinski reflex -Two umbilical arteries visible

A nurse is preparing to administer oxytocin to a client who is post partum which of the following findings as an indication for the administration of the medication select all that apply

-Flaccid uterus -Excess vaginal bleeding

A nurse is admitting an infant who has intussesception. Which of the following findings should the nurse expect? (select all that apply)

-vomiting -lethargy

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?

1/2 cup raisins

A nurse is preparing to administer ibuprofen 5mg/kg every 6 hours prn for temperatures above 38.0 C (100.5 F) to an infant that weighs 17.6 Lb. The infant has a temperate of 38.4 C (101.2 F). Available is ibuprofen liquid 100mg/5mL. How many mL should the nurse administer to the infant per dose? round to the nearest whole number. Use a leading 0 if it applies.

2

A nurse is preparing to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture the prescription states administer is it from ice in 1 g Orly now available is 250 mg tablets how many tablets for the nurse administer round the answer to the nearest whole number using leading zero if it applies do not use a trailing zero

4 tablets

A nurse is preparing to administer magnesium sulfate 2g/hr IV to a client who is in preterm labor. Available is 20 g magnesium sulfate in 500 mL of dextrose 5% in water (D5W). The nurse should set the IV infusion pump to administer how many mL/hr?

50 ml/hr

A nurse in a prenatal clinic is assessing a group of clients. Which of the following clients should the nurse see first?

A client who is at 11 weeks of gestation and reports abdominal cramping

A nurse on a antepartum unit is caring for four clients which of the following client to the nurse identify as a priority

A client who is at 34 weeks of gestation and reports epigastric pain

A nurse is assessing four newborns. Which of the following findings should the nurse report to the provider?

A newborn who is 18 hr old and has an axillary temperature of 99.9° F

A nurse is caring for a client who is anemic at 32 weeks of gestation and is in preterm labor. The provider prescribed bethamethasone 12 mg IM. Which of the following outcomes should the nurse expect?

A reduction in respiratory distress in the newborn

A nurse is planning care for a client who is two hours postpartum which of the following intervention should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment

Demonstrate to the client how to perform a newborn bath

A nurse is admitting a client who is in labor. The client admits to recent cocaine use. For which of the following complications should the nurse assess?

Abruptio placenta

A nurse is caring for a client who is at 26 weeks of gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client head to the side, which of the following actions should the nurse take immediately after the seizure?

Administer oxygen via a nonrebreather mask

A nurse is reviewing the medical record at 1800 for client who is at 34 weeks of gestation based on the chart findings and documentation the nursing plan of care should include which of the following actions

Administer terbutaline

A nurse is planning discharge for a client who is three days post partum which of the following non-pharmacological intervention should the nurse include in the plan of care for lactation suppression

Apply cabbage leaves to the breasts

A nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina after calling for assistance which of the following actions should the nurse take next

Apply internal upward pressure to the presenting part using two gloved fingers

A nurse is caring for a client who is in labor and who's fetus is in the right occiput posterior position the client is dilated to 8 cm and reports back pain which of the following actions should the nurse take

Apply sacral counterpressure

A nurse is assessing a client who gave birth vaginally 12 hours ago and palpate her uterus to the right above the umbilicus which of the following interventions should the nurse perform

Assist the client to empty her bladder

A nurse is assessing a client who has severe preeclampsia. Which of the following manifestations should the nurse expect?

Blurred Vision

A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider?

BUN 25 mg/dL

A nurse is admitting a client to the labor and delivery unit when the client states, "My water just broke". Which of the following interventions is the nurse's priority?

Begin FHR monitoring

A nurse is reviewing laboratory results of a newborn who is four hours old which of the following findings should the nurse report to the provider

Bilirubin of 9 mg/dL

A nurse is caring for a client who is at 41 weeks of gestation and has a positive contraction stress test for which of the following diagnostic test should the nurse prepare the client

Biophysical profile BPP

A nurse is caring for a client who is at 36 weeks of gestation and has a positive contraction stress test. The nurse should plan to prepare the client for which of the following diagnostic test?

Biophysicial profile

A nurse is reviewing the laboratory report of a newborn he was 24 hours old which of the following results should the nurse expect to report to the provider

Blood glucose 30 mg/dL

A nurse is teaching a client who is at 24 weeks of gestation regarding a one hour glucose tolerance test which of the following statements should the nurse include in the teaching

Blood glucose of 130 to 140 is considered a positive screening result

A nurse is caring for a client who is experiencing preeclampsia and has a new prescription for IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if the client develops magnesium toxicity?

Calcium Gluconate

A nurse in a family planning clinic is caring for a client who request an oral contraceptive which of the following findings in the clients history to the nurse recognizes a contraindication to oral contraceptives select all that apply

Cholecystitis Hypertension Migraine headaches

A nurse is providing teaching about nonpharmological pain management to a client who is breastfeeding and has engorgement. The nurse should recommend the application of which of the following items?

Cold cabbage leaves

A nurse is caring for a newborn who is undergoing photo therapy to treat hyperbilirubinemia which of the following actions should the nurse take

Cover the newborns eyes while under the photo therapy light

A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura which of the following findings should the nurse expect

Decrease platelet count

A nurse is providing teaching for a client who has a new prescription for combined oral contraceptives. Which of the following findings should the nurse include as an adverse effect of this medication?

Depression

A nurse is caring for a client who becomes unresponsive upon delivery of the placenta which of the following actions should the nurse take first

Determine respiratory function

A nurse in the antepartum clinic is assessing a client adaptation of pregnancy the client states that she is happy one minute and crying the next the nurse should interpret the clients statement as an indication of which of the following

Emotional lability

A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data

Episodes of vomit

A nurse is caring for a client who is at 22 weeks of gestation and reports concern about blotchy hyperpigmentation on her forehead which of the following actions should the nurse take

Explain to the client that this is an expected occurrence

A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use?

FACES

A nurse is performing a routine assessment on a client who is at 18 weeks of gestation. Which of the following findings should the nurse expect?

FHR 152/min

A nurse in an antepartum clinic is providing care for a client who is at 26 weeks of gestation. Upon reviewing the client's medical record, which of the following findings should the nurse report to the provider?

Fundal Height Measurement

A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate IV which of the following actions should the nurse take

Have calcium gluconate readily available

A nurse is caring for a client who is at 35 weeks of gestation and is undergoing a nonstress test that reveals a variable deceleration in the FHR. Which of the following actions should the nurse take?

Have the client change positions

A nurse is teaching a client who is at 35 weeks of gestation about manifestations of potential pregnancy complications to report to the provider which of the following manifestation should the nurse include

Headache that is unrelieved by analgesia

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Hematocrit 28%

A nurse is assessing a client who received carboprost for postpartum hemorrhage. Which of the following findings is an adverse effect of this medication?

Hypertension

A nurse is performing a vaginal exam on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take?

Insert two gloved fingers into the vagina and apply upward pressure to the presenting part

A nurse is assessing a newborn 12 hr after birth. Which of the following manifestations should the nurse report to the provider?

Jaundice

A nurse is planning care for a client who is to undergo a nonstress test which of the following actions should the nurse include in the plan of care

Instruct the client to press the provided button each time fetal movement is detected

A nurse in a women's health clinic is providing teaching about nutritional intake to a client who is it eight weeks of gestation the nurse should instruct the client to increase her daily intake of which of the following nutrients

Iron

A nurse is caring for a client who is pregnant and is at the end of her first trimester the nursing place the Doppler ultrasound stethoscope in which of the following locations to begin assessing the fetal heart tones

Just above the symphysis pubis

A nurse is caring for a client who is at 24 weeks of gestation and has a suspected placental abruption. Which of the following laboratory tests should the nurse expect the provider to prescribe?

Kleihauer-Betke test

A nurse is caring for a client who is to receive oxytocin to augment her labor. Which of the following findings contraindicates the infusion of the oxytocin infusion and should be reported to the provider?

Late Decelerations

A nurse is observing a new parent caring for her crying newborn who is bottle feeding. Which of the following actions by the parent should the nurse recognize as a positive parenting behavior?

Lays the newborn across her lap and gently sways

A nurse is assessing fetal heart tones for a client who is pregnant the nurse is determined the fetal position as left occipital anterior to which of the following areas of the clients abdomen sure the nurse apply the ultrasound transducer to assess the point of maximum intensity to the fetal heart

Left lower quadrant

A nurse is reviewing the medical record of a newly admitted client it was at 32 weeks gestation which of the following conditions is an indication for fetal assessment using electronic fetal monitoring

Oligohydramnios

A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. Which of the following actions should the nurse take?

Maintain the client of bed rest

A nurse on postpartum unit is caring for a client who is expecting hypovolemic shock after notifying the provider which of the following actions should the nurse take next

Massage clients fundus

A nurse is caring for a client who has uterine atony and is experiencing postpartum hemorrhage. Which of the following actions is the nurse priority?

Massage the client's fundus

A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?

Minimal arm recoil

A nurse is caring for a client who is at 15 weeks gestation, is Rh-negative, and has just had an amniocentesis. Which of the following interventions is the nurse's priority following the procedure?

Monitor the FHR

A nurse is planning care for a client who is in labor and is requesting epidural anesthesia for pain control which of the following actions should the nurse include in the plan of care

Monitor the clients blood pressure every 5 minutes following the first dose of the anesthetic solution

A nurse is assessing a client who is receiving morphine via IV bolus for pain following a C-section. The nurse notes a respiratory rate of 8/min. Which of the following medications should be administered?

Naloxone

A nurse is providing education about family bonding to parents who recently adopted a newborn. The nurse should make which of the following suggestions to aid the family's 7-year-old in accepting the new family memeber?

Obtain an gift from the newborn to present to the sibling

A nurse is caring for a client who is at 38 weeks of gestation. Which of the following actions should the nurse take prior to applying an external transducer for fetal monitoring?

Perform Leopold Maneuvers

A nurse is assessing a newborn who was delivered vaginally and experienced a tight nuchal cord. Which of the following findings should the nurse expect?

Petechiae over the head

A charge nurse on a labor and delivery unit is teaching a newly licensed nurse how to perform Leopoid maneuvers. Which of the following images indicates the first step of Leopoid maneuvers?

Picture of nurse palpating top of belly; where bottom is

A nurse is preparing to collect a blood specimen from a newborn via a heel stick. Which of the following techniques should the nurse use to help minimize the pain of the procedure for the newborn

Place the newborn skin to skin on the mothers chest

A nurse is providing discharge teaching to the parents of a newborn about car seat safety which of the following instruction should the nurse include

Place the retainer clip at the level of the newborns armpits

A nurse is reviewing the medical record of a client who has postpartum and has preeclampsia which of the following laboratory results should the nurse report to the provider

Platelets 50,000/mm3

A nurse in a provider's office is reviewing the medical record of a client who is in the first trimester of pregnancy. Which of the following should the nurse identify as a risk factor for the development of preeclampsia

Pregestational Diabetes Mellitus

A nurse is caring for a client who is at 32 weeks of gestation and has gonorrhea. The nurse should identify that the client is at an increased risk for which of the following complications?

Premature rupture of membranes

A nurse is creating a plan of care who is postpartum and adheres to traditional Hispanic cultural beliefs. Which of the following cultural practices should the nurse include in the plan of care?

Protects the client's head and feet from cold air

A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbillirubinemia. Which of the following actions should the nurse include in the plan?

Remove all clothing form the newborn except the diaper

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following findings should the nurse report to the provider?

Report of visual disturbances

A nurse is caring for a client who is at 22 weeks of gestation and is HIV positive. Which of the following actions should the nurse take?

Report the client's condition to the local health department

A nurse is assessing a client who has gestational diabetes mellitus and is experiencing hyperglycemia. Which of the following findings should the nurse expect?

Reports increased urinary output

A nurse in an antepartum clinic is assessing a client who is at 32 weeks of gestation. Which of the following findings should the nurse report to the provider?

Reports of decreased fetal movement

A nurse is assessing a late preterm newborn. Which of the following manifestations is an indication of hypoglycemia?

Respiratory distress

A nurse is caring for a client who is at 30 weeks of gestation and has a prescription for magnesium sulfate IV to treat preterm labor. The nurse should notify the provider of which of the following adverse effects?

Respiratory rate 10/min

A nurse is caring for a prenatal client who has parvovirus B19 (fifth disease). Which of the following actions should the nurse take?

Schedule an ultrasound examination

A nurse is teaching a client who has a new prescription for combined oral contraceptives about potential adverse effects of the medication for which of the following findings should the nurse instruct the client to notify the provider

Shortness of breath

A nurse is teaching a postpartum client about the steps the nurses will take to promote the security and safety of the clients newborn which of the following statement should the nurse make

Staff member to take care of your baby will be wearing a photo identification badge

A nurse is teaching a new mother how to use a bulb syringe to suction her newborn secretions which of the following instructions should the nurse include

Stop suctioning when the newborns cry sound clear

A nurse is assessing a newborn who is 16 hr old. Which of the following findings should the nurse report to the provider?

Substernal Retractions

A nurse is assessing a newborn who is 12 hours old which of the following manifestations require interventions by the nurse

Substernal chest retractions while sleeping

A nurse is assessing a client who is at 30 weeks of gestation during a routine prenatal visit which of the following findings should the nurse report to the provider

Swelling of the face

A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock?

Temp 39.1 Degrees C (102.4 Degrees F)

A nurse is planning care for a client who is in labor and is to have an amniotomy which of the following assessments for the nurse identify as a priority

Temperature

A nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone which of the following statements for the nurse make about the indication for the medication and administration

This medication stimulates fetal lung maturity

A nurse is speaking with a client who is trying to make a decision about tubal ligation the client asks what effect will this procedure have on my sex life which of the following responses should the nurse make

This procedure should have no effect on your sexual performance or adequacy

A nurse is caring for a client who is at 36 weeks of gestation and has a prescription for an amniocentesis. For which of the following reasons should the nurse prepare the client for an ultrasound?

To locate the pocket of fluid

A nurse is caring for a client who is in labor and reports increasing rectal pressure she's experiencing contractions 2 to 3 minutes apart each lasting 80 to 90 seconds in a vaginal examination reveals in her cervix is dilated to 9 cm the nurse should identify that the client is in which of the following phases of labor

Transition

A nurse is assessing a client who is 1 day postpartum and has a vaginal hematoma. Which of the following manifestations should the nurse expect?

Vaginal pressure

A nurse is transporting a newborn back to the parent's room following a procedure. Which of the following actions should the nurse take?

Verify that the parent's identification band matches the newborn's identification band

A nurse is caring for a newborn who was transferred to the nursery 30 minutes after birth because of mild respiratory distress which of the following actions should the nurse take

Verify the newborns identification

A nurse is assessing a newborn of a client who took a selective serotonin reuptake inhibitor during pregnancy which of the following manifestations should the nurse identify as an indication of withdrawal from an SSRI

Vomiting

A nurse is assessing a client who is at 38 weeks of gestation during a weekly prenatal visit. Which of the following findings should the nurse report to the provider?

Weight gain of 2.2 kg (4.8 lb)

A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm which of the following statement should the nurse include in the teaching

You should leave the diaphragm in place for at least six hours after intercourse

A school nurse is providing teaching to an adolescent about levonorgestrel contraception which of the following information should the nurse include in the teaching

You should take the medication within 72 hours following unprotected sexual intercourse

A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a nonstress test which of the following statements should the nurse include in the teaching

You will be offered orange juice to drink during a test

A nurse is caring for a client who is in active labor and has no cervical change in the last four hours which of the following statement should the nurse make

Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first?

a school age child who has sickle cell anemia and reports decreased vision in the left eye

A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?

palpate the dorsum of the child's feet

A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take?

perform a finger stick

A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?

use a semipermeable transparent depressing to cover the site

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip

wheezes

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

white rice

nurse is teaching a new parent about newborn safety. which instructions should the nurse include in the teaching

you can share your room with your baby for the next few weeks

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area.

zinc oxide

A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?

"Brush the child's teeth after giving the medication."

A nurse is assessing a newborn for manifestations of hypoglycemia which of the following findings should the nurse expect

Jitteriness

A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect?

abdominal distention

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?

loud, hard murmur

A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider?

restricted ability to move the toes

A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point?

right lower quadrant

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

schedule the toddler for a yearly rescreening

A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?

screen the child's visitors for indications of infection

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?

serum creatinine 3.0 mg/dL

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

serum potassium level 4.1 mEq/L

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?

sodium 140 mEq/L

A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes incipidus?

sodium 155 mEq/L