Exam 2: Evolves combined
38. Otitis media may be preventable, and you teach many parents about ways to avoid ear infections, especially in infants. Which of the following can contribute to occurrences of otitis media in infants? (Select 2)
-Bottle-propping -Exposure to passive smoke
21. Which of the following nursing diagnoses apply to Sarah at this time? (Select 2)
-Deficient Fluid Volume related to fluid losses from fever, vomiting, and diarrhea -Risk for Imbalanced Nutrition: Less than Body Requirements related to anorexia and vomiting, and increased needs associated with fever
Which isolation precautions should be observed when working with Angela?
-Droplet precautions -Standard precautions
11. Which of Jason's measurements are recorded on clinical growth charts? (Select 3)
-Length -Head circumference -Weight
39. Jeffrey's immunization status is reviewed before he leaves. All immunizations are current. He will be going to Kindergarten in the fall. Which of the following boosters, which are usually given at the 4-6 year old visit, will he need at that time? (Select 3)
-MMR (measles, mumps, rubella) -IPV (inactivated poliovirus) -DTap (diphtheria, tetanus, acellular pertussis)
26. Which of the following are appropriate rehydration solutions for Sarah? (Select 2)
-Pedialyte -Rehydralyte
32. On his mother's lap, Jeffrey is crying quietly with his hand over his right ear as he is examined by the Nurse Practitioner. Which of the following are important assessments when an upper respiratory tract infection has been present and an ear infection is suspected? (Select 5)
-Pharynx and nasal mucosa -Tympanic membranes -Sinuses -External auditory canals and pinna -Auricular and cervical lymph glands
29. Which of the following are associated with acute otitis media? (Select 4)
-Recent upper respiratory tract infection -History of allergies -Passive smoking in the home -Fever
Clinical manifestations of bronchiolitis can include:
-Tachypnea -Tachycardia -Adventitious breath sounds -Retractions -Apneic episodes
36. Mrs. Deakin is given amoxicillin for Jeffrey. The concentration of the amoxicillin is 250 mg/5 mL. To receive 266 mg, Jeffrey needs to take ______mL. (Round answer to nearest tenth)
5.3
How should oxygen be delivered to Angela?
Blow-by
7. You record a weight of 3.7 kg (8 pounds 1 ounce) for Jason and note that his birth weight was 3.6 kg (8 pounds). Your correct judgment regarding Jason's change in weight since birth is that:
His weight is as expected at two weeks of age
15. You also discuss car seat safety with Mrs. Deakin. You explain that Jason must always be in an approved infant car restraint. Which of the following is an appropriate place and position for Jason to ride in the car at this time?
In the back seat facing backward
Most cases of epiglottitis are caused by the bacterium Heamophilus influenae tybe b (Hib). You know that epiglottitis due to Haemophilus influenzae tybe b (Hib) is transmittable through contact with:
Nasopharyngeal/respiratory secreations
You observe Joey's respiratory rate to be 34 breaths per minute. Other assessments relevant in evaluating Joey's work of breathing include:
O2 sat chest auscultation for wheezing chest observation for retractions degree of dyspnea peak expiratory flow rate (PEFR)
Which of the physician's orders should you implement FIRST?
Oxygen by nasal cannula at 3 liters per minute
Supplemental oxygen may be ordered for Abby, if her oxygen saturation (SpO2) level falls below 92% on room air. Abby's SpO2 has been 93-95% on room air. If oxygen is needed, which of the following oxygen delivery devices will be best for Abby, given her age of three months?
Oxygen hood
Your teaching about peak flow monitoring includes which of the following correct information?
Peak flow monitoring is useful in monitoring asthma symptoms Joey's personal best peak expiratory flow rate (PEFR) will need to be determined Peak expiratory flow rate (PEFR) should be measured daily
Melissa is running around the ED bed. Which of the following comments to Melissa's parents is best?
Please try to calm Melissa down. Running around can make her cough worse
You stress to Joey and his mother that during an acute asthma exacerbation Joey is to use the ______ inhaler.
Proventil (albuterol)
3. Which of the following will be used to assess physical sexual maturity?
Tanner stages
13. Jason will receive a number of immunizations over the next few months. These include: (Select 4)
-A second dose of hepatitis B vaccine (HepB) -Hib (haemophilus influenzae type b) vaccine -IPV (inactivated poliovirus) vaccine -PCV (pneumococcal conjugate) vaccine
19. It is imperative that Sarah's hydration status be assessed. In addition to urine color and amount, which of the following assessments are important when evaluating hydration status? (Select 5)
-Behavior -Quality of pulses -Skin turgor -Capillary refill -Characteristics of mucous membranes
30. Jeffrey has a high fever. A diagnosis of meningitis must be ruled out in any infant or child with a high fever. Which of the following might be observed in an infant or child with meningitis? (Select 5)
-Bulging (tense) fontanel in an infant -Vomiting -Nuchal rigidity -Irritability -High-pitched cry in an infant
18. When Mrs. Deakin is situated in the examining room, you ask about the reason for today's visit (history of present complaint). Which of the following are important subjective data to gather from Mrs. Deakin? (Select 6)
-Character and frequency of Sarah's bowel movements -Whether or not Sarah has had a fever -Whether or not new foods have been added to Sarah's diet -Whether or not siblings or other family members are also ill -The amount and color of Sarah's urine over the last few days -Whether or not Sarah has had any medications
It is important that child caregivers know how to respond when a child has an obstructed airway from foreign body aspiration. Which of the following interventions would be appropriate if a young child choked on a coin and was wheezing, but was able to breathe and talk?
-Continue to observe breathing -Comfort the child and keep him as quiet as possible in a position of comfort
Signs and symptoms that are common in croup conditions include which of the following?
-Wheezing -Hoarseness -Harsh cough -Dyspnea
Mrs. Smith looks at the oximeter display and comments "Joey's oxygen is low, isn't it?" Which response to her comment is best?
"Yes, it is hard for Joey to get enough oxygen right now."
14. Which of the following comments by Mrs. Deakin indicate a need for further education? (Select 5)
-"One of the crib slats broke and was removed." -"I usually put Jason to sleep on his stomach because he prefers that position." -"Jason's crib mattress is nice and soft." -"Jason's room is cool, so I place a few blankets on him at night." -"Jason is restless so I get up and change his position a lot during the night."
For Joey, the physician's IV order reads, "dextrose 5% in 0.45% sodium chloride at 65 mL per hour." You verify the appropriateness of the IV rate by calculating Joey's maintenance fluid requirements to be ______ mL each 24 hours.
1560 The daily maintenance fluid requirement for a child is the minimum volume of fluid needed by the body to maintain homeostasis (100 mL/kg for the first 10 kg, 50 mL/kg for the second 10 kg, 20 mL/kg for any remaining kg). Joey weighs 23 kg (51 pounds). Joey's daily fluid requirements are calculated as follows: \r 10 kg x 100 mL/kg + 10 kg x 50 mL/kg + 3 kg x 20 mL/kg \r 1000 mL + 500 mL + 60 mL = 1560 mL fluid requirement for 24 hours (65 mL per hour) for a child weighing 23 kg. The IV fluid rate ordered is appropriate for Joey.
8. Mrs. Deakin asks when the "spaces" will close. You explain to Mrs. Deakin that the anterior fontanel is expected to close by:
18 months of age
You know that Angela will be started on antibiotics. After ____ on antibiotics, epiglottitis due to Haemophilus influenzae b (Hib) will no longer be communicable.
24 hours
35. Jeffrey will receive ________mg of amoxicillin three times a day. (Round answer to nearest whole number)
267
Rocephin (ceftriaxone), ordered for Joey, arrives from the pharmacy mixed in 25 mL of 0.9% sodium chloride. You administer the medication using microdrip tubing and an infusion pump. You set the infusion pump at _____________mL per hour to administer the Rocephin (ceftriaxone) over 30 minutes.
50
37. You also review with Mrs. Deakin the appropriate dose of acetaminophen for Jeffrey. Acetaminophen is available in many different concentrations. Mrs. Deakin reports the concentration she uses at home is 160 mg/5 mL. Jeffrey will need _______mL to receive 200 mg of acetaminophen. (Do not round answer)
6.25
In preparation for insertion of an IV catheter, EMLA anesthetic cream (lidocaine 2.5% and prilocaine 2.5%) was applied to Abby's skin earlier, at the intended catheter insertion site. The area is covered with Tegaderm. The anesthetic effect of EMLA takes effect, and the IV catheter can be inserted:
60 minutes after EMLA application
25. Sarah is mildly dehydrated. Sarah weighs 14 kg (30.8 pounds). She should receive __________mL of fluid over a 4-hour period for initial rehydration.
700
34. Jeffrey weighs 20 kg (44 pounds). His daily dose of amoxicillin will be ________mg based on a safe dose range of 40 mg/kg/day administered in three divided doses.
800
The physician's order indicates that humidified oxygen be administered by nasal cannula. In response to the order for this mode of oxygen delivery, what should you do?
Administer the oxygen by nasal cannula as ordered
Which patient should you assess first?
Angela, the three-year-old child with possible epiglottitis
2. Ashley and Mark are prepubescent, meaning that they are:
Beginning to develop physical secondary sex characteristics
10. A consistently depressed (sunken) anterior fontanel is also cause for concern. A sunken anterior fontanel is usually a sign of:
Dehydration
1. Ashley (11 years) and Mark (12 years) are both considered adolescents. Adolescence includes three developmental phases: early, middle, and late adolescence. Ashley and Mark are in which phase of adolescence?
Early adolescence
Joey is actively coping with his hospitalization, and exhibits cooperative behaviors. As his nurse, how can you best help him cope and remain cooperative?
Encourage him to talk about his thoughts and feelings related to procedures and treatments
You continuously observe Joey during and after Proventil (albuterol) treatment. Which of the following may occur as side effects of Proventil (albuterol)?
Excitement Nausea tachycardia
12. An immunization record is started for Jason. Mrs. Deakin has provided you with paper work indicating that Jason was vaccinated before he was discharged from the hospital where he was born. Which vaccine is recommended for newborns?
Hepatitis B vaccine (HepB)
33. For each ear, the middle ear is examined. To straighten the ear canal, the pinna is pulled:
Up and back
Joey will be continued on Prelone (prednisolone) today, and will also be on the drug for the next few days. Optimally, daily doses of Prelone (prednisolone) should be given:
in the morning
9. A consistently bulging (tense) anterior fontanel may be abnormal, and a result of:
increased intracranial pressure
Proventil (albuterol) is used as frontline treatment for an asthma exacerbation. Its primary therapeutic action is to:
induce bronchodilation
You are also told that Joey voided 200 mL of light yellow urine in the last eight hours. You interpret this as:
normal
To evaluate the effectiveness of the Proventil (albuterol) nebulizer treatment, you will assess Joey's:
peak expiratory flow rate (PEFR) work of breathing
15. Mark expresses concern that his sister is younger but taller than he is. Which of the following responses to Mark would be best?
"Boys experience a growth spurt at a later age than girls."
12. As Maria prepares to leave, which of the following statements would indicate that she understands the information given to her regarding gestational diabetes?
"I am upset with this diagnosis, but if I can maintain a normal blood glucose, me and my baby will probably be okay." This statement by Maria would suggest that she appropriately understands that there are risks associated with gestational diabetes, but that these risks can be controlled to some extent.
30. Austin's parents have had some initial teaching about chest physiotherapy (CPT). Which of the following statements by Austin's mother would lead you to believe more teaching is necessary?
"I feel bad about having to wake Austin during the night for a treatment."
19. Mrs. Johnson becomes agitated and says "I'm already late for work, these physicals have taken so long! Can't I read these later and mail them back to you?" Which response on your part is best?
"I'm sorry, I cannot administer the vaccines to your children until you have read and signed the forms."
30. Which of the following interventions are appropriately implemented? (Select 6)
-Education regarding the importance of condom use for the prevention of HIV and sexually transmitted diseases (STDs) -Antibiotic therapy for Ashley -Antibiotic therapy for Ashley's boyfriend -Education regarding increased risk for pelvic inflammatory disease and fertility problems -Emphasis on competing treatment and avoidance of sexual intercourse until treatment is completed - Discussion of abstinence from sexual intercourse as an option in avoiding sexually transmitted diseases (STDs) and the only 100% birth control method
10. The adolescent's right to confidentiality is designed to: (Select 2)
-Encourage the adolescent to seek healthcare and advice without fear -Support the adolescent's growing sense of autonomy
17. Which of the following responses to Mr. Brown's questions, "How can this be? How did this happen?" is best?
"You and Mrs. Brown are both carriers of the cystic fibrosis gene."
With regard to rupture of membranes, which questions are important?
A. "What time did your 'water break'?" C. "What was the color of the fluid?"
31. In working with Katie, her developmental stage is considered. She is almost 3 years old. According to Erikson, Katie is emerging from which psychosocial stage of development?
A. Autonomy vs. Shame and Doubt
The nursery nurse demonstrates how to position, feed, and burp John, and then observes Lily. She knows that the teaching about formula-feeding has been successful when Lily states which of the following?
A. I will always hold John in my arms giving him a bottle
Which of the following should be available at Lily's bedside while she is receiving magnesium sulfate?
A. calcium gluconate
32. You tell Mrs. Brown that it is not difficult to make an increased calorie formula. You explain that the best way is to:
Add one additional scoop of formula powder to each 8 ounce bottle
In response to the order for Stradol (butorphanol tartrate), which of the following is indicated?
Administer the Stradol as ordered
With some difficulty, you are able to determine Angela's respiratory and pulse rates. By which route should Angela's temperature be taken?
Axillary route
18. An appropriate weight gain for a 6-week-old infant is approximately:
B. 1 ounce per day
20. Katie is to be NPO. In addition, all of the following are ordered for Katie. Which should you implement FIRST?
B. 30% O2 by nasal cannula
29. Katie's parents are instructed in proper use of an oral syringe. This involves placing the syringe in Katie's mouth and directing the flow of medication ________________
B. Along the side of her tongue and cheek, a little at a time, allowing time for her to swallow
8. If untreated, a moderate to large Ventricular Septal Defect (VSD) can lead to:
B. Congestive heart failure
Susan has noticed some darkening of her face in the shape of a "mask." You advise her that this is normal and record it as ___________________________
CHLOASMA
22. To evaluate for the expected effects of the Lasix (furosemide) on Katie's condition, your nursing care should include: (Select all that apply.)
D. Strict intake and output E. Weight measurements
You identify this as a/an________ deceleration
Early
You know that the Mantoux/PPD test is used to determine if a person:
Is infected with the tuberculosis bacillus
Adam's father wants to know if Adam can have a bottle. You tell him that Adam:
Should have nothing by mouth
You know that foreign body aspiration is most common in which age group?
Six months to five years
Based on your assessment of Susan (3 cm dilated, 80% effaced, fetus at zero station) and your interpretation of her data, you determine that she is now in which stage of labor?
Stage one (until cervix is fully dilated)
25. To prevent spread of infection from a hospitalized infant or child with cystic fibrosis to other vulnerable children, which is most important?
Strict adherence to hand hygiene guidelines
15. The gold standard test for diagnosing cystic fibrosis is a/an:
Sweat test
You determine Joey's peak expiratory flow rate (PEFR), using a peak flow meter. Joey's PEFR is 140 liters per minute. Which of the following best describes what PEFR measures?
The maximum rate at which a person can exhale air in one second during a forced expiration
With chest auscultation you also hear scattered mild expiratory wheezing in all lung fields. You know that wheezing associated with an asthma exacerbation is a result of:
air moving through small passages
When John describes to you the advantages he sees in breastfeeding, you agree when he says:
breastfed babies experience fewer respiratory illnesses than formula-fed babies breastfed babies are not likely to have allergies to their mother's breast milk breastfeeding is more economical
You examine a recent strip from the fetal monitor. The abnormal fetal heart rate pattern you observe is interpreted as a ___ deceleration
late
Susan inquires, "Is this what my mother calls "the baby dropping?" You acknowledge her mother's information, and tell Susan that this event is called ___________________________
lightening
the vaginal discharge that occurs during the postpartum period (puerperium), which and consists of blood, tissue, and mucous, is called
lochia
The correct term for the cone shape of a vaginally-delivered infant's head is
molded
10. Steffy wonders whether or not she will be able to have anything for pain relief during labor. You correctly inform her that:
narcotic analgesics will be prescribed if necessary
The hormone responsible for milk ejection is
oxytocin
You know that this practice of consuming non-food substances, common to some cultures, is called ________________
pica
After delivery, a declining level of estrogen allows for rising levels of the hormone responsible for milk production. You know that the hormone that stimulates milk production is
prolactin
apply erythromycin ophthalmic ointment to the newborn's eyes to:
protect the infant from gonorrheal or chlamydial infection
You tell Susan that this "fluttering" is probably fetal movement. This first recognition of fetal movements by the mother is called _____________________
quickening
Susan expresses concern about engorged breasts. Some of her friends have told her that it's painful. You discuss engorgement with Susan and suggest:
to help avoid engorgement, feed Jason at least every 2-3 hours around the clock to help avoid engorgement, make sure Jason is positioned for good milk transfer during feedings if engorgement occurs, express some milk prior to feedings to facilitate latching-on
35. Austin is displaying signs of developmental delay.
true
6. After explaining to Steffy the detrimental effects of alcohol on her baby, you ask her to tell you what she has learned. Which of the following responses by Steffy would suggest a need for repeat instruction?
"It is unlikely that my baby will have alcohol-related problems since I have only had a few beers since I became pregnant."
7. You are asked to provide an in-service education program on drug use during pregnancy for a group of perinatal nurses. Which of the following comments would suggest that your teaching was effective? Select all that apply (there are 3 correct answers).
"Short-term behavioral interventions may be effective for treating women who use drugs during pregnancy." "Substance abuse/dependence are complex disorders." "Birth weight and newborn outcome are positively associated with drug treatment compliance."
22. Which question is appropriately asked of Ashley at this time?
"What do you think about your size and weight?"
5. Jason remains asleep in his mother's arms. You prepare to obtain his pulse rate. Which pulse rate should be determined?
Apical pulse rate
9. Which of the following general guidelines should you explain to Maria at this time? (Select all)
-A snack is recommended at bedtime To prevent low morning blood glucose levels, many women require a bedtime snack. A snack providing carbohydrate, protein, and fat is recommended (such as milk, cheese, crackers, and fruit). -Simple carbohydrates should be avoided Simple carbohydrates (glucose, cake, soda, fruit juice, and candy) should be avoided as they cause a rapid and short-lived rise in blood glucose. -Fruits and vegetables are advised Fruits and vegetables provide fiber as well as complex carbohydrates (which are digested slowly, allowing for more even blood glucose levels) and protein, all of which are recommended. -What she can eat will to some extent depend on her activity level What Maria can eat will to some extent depend on her activity level. In general, when Maria is more active, her blood glucose level will be lower, indicating a need for more carbohydrates and calories.
33. You review Emily's lab results. Which of the following lab tests might you expect to see elevated with liver dysfunction? (Select 5)
-AST -ALT -Alkaline phosphatase -GGT -Billirubin
Abby must be critically observed for signs of respiratory decompensation and impending respiratory failure. Which of the following changes in Abby's condition, if noted, might indicate impending respiratory failure?
-Change in apical pulse rate from 170 to 80 beats per minute -Change in respiratory rate from 50 to 20 breaths per minute
20. Which of the following are possible contributing factors to the development of acne in adolescents? (Select 5)
-Environmental irritants -Androgens -Hereditary factors -Menstrual cycle -Poor hygiene
6. You prepare to take four-point blood pressures on Katie. Which of the following are true about four-point blood pressures in newborns? (Select all that apply.)
A. Four-point blood pressures involve obtaining BP measurements on all four extremities B. BPs should be taken while the infant is resting quietly D. When BP is measured by auscultation, the point at which the first sound is heard is recorded as the systolic reading F. For accurate BP readings, the BP cuff should totally encircle the extremity
34. Which of the following principles of preoperative teaching are implemented with Katie and her family? (Select all that apply.)
A. Information provided should be repeated and reinforced B. Katie's parents should be provided with information about surgery well in advance of surgery D. Previous experiences should be considered when new information is presented
15. When Katie is six weeks old, the visiting nurse appropriately becomes most concerned about which aspect of Katie's behavior and development?
A. Katie sweats and tires easily during feedings
4. You know that a murmur is an abnormal vibratory sound heard anywhere in the cardiac cycle. A full description of a murmur should include: (Select all that apply.)
A. Location B. Intensity D. Radiation E. Pitch F. Timing G. Quality
You advise Susan to return to the clinic regularly for prenatal visits. Provided there are no complications, she can anticipate visits to occur: A. every month throughout pregnancy B. every four weeks until 28 weeks, every two weeks until 36 weeks, then weekly until delivery C. every six weeks until 36 weeks, then weekly until delivery D. every four weeks until 24 weeks, every two weeks until 32 weeks, then weekly until delivery
B. every four weeks until 28 weeks, every two weeks until 36 weeks, then weekly until delivery Traditionally, monthly prenatal visits (every four weeks) are recommended during the first 28 weeks of pregnancy. Visits increase to every two weeks from the 28th to the 36th week, and then every week from 37 weeks until delivery. Visits increase because the risk of complications associated with pregnancy increases as pregnancy advances.
Which of the following approaches would be useful in maintaining John's temperature within normal range?
C. using a radiant warmer during procedures
Based on your assessment, you determine that the fetus is in a/an ____ presentation
Cephalic/vertex/occiput
2. S1 is heard loudest at which anatomical landmark?
D. Apex of the heart
32. Given Katie's stage of development and the knowledge that her thinking is concrete, which approaches are best to use when Katie is prepared for procedures and surgery? (Select all that apply.)
D. When accurate, reassure Katie that her mommy and daddy will be able to stay with her E. When possible, allow Katie to touch equipment F. When possible, allow Katie to do things for herself
Which of the following approaches would be best for the nursery nurse to take to facilitate mother-infant boding?
D. invite Lily to come with her to the special care nursery to visit John
Which of the following statements to Lily would convey accurate information about formula feeding?
D. some infants may develop an allergy to cow's milk formula
Lily asks for more information about what will happen to her int he hospital. Which of the following information should be communicated?
D. you will be encouraged to rest
John's weight falls below the 10th percentile. His length is average. This type of growth restriction is called:
DISPROPORTIONAL ASYMMETRIC
Based on Susan's assessment data and history, you identify which of the following as a priority nursing diagnosis for Susan at this time?
Deficient fluid volume related to inadequate intake of fluids.
Lily mentions she is afraid about having "one of those exams." An appropriate way for your to proceed would be to:
Discuss with Lily the physical examinations that will be necessary
24. Which of the following would indicate that Ventolin (albuterol) therapy is effective?
Easier breathing
4. Which of the following approaches would initially be useful in helping Steffy quit smoking? Select all that apply (there are 2 correct answers).
Encouraging her husband to stop smoking Referring her to a self-help support group
20. Inhalation Pulmozyme (dornase alfa) is being used with Austin to:
Facilitate airway clearance
17. You know that vaginal delivery, when fetopelvic disproportion is present, can result in which of the following?
Fracture of the infant's clavicle Vaginal delivery, when cephalopelvic disproportion is present, can result in physical trauma, as the fetus is forced through the birth canal. Fractures to the clavicle are most common, although fractures to the femur and humerus may also occur.
Which of the following assessments would be considered normal at this time?
Fundus is firm, at the midline, and two fingerbreadths below the umbilicus
6. Given the respiratory data you have collected on Austin, you determine that Austin is:
Having labored respirations, but not in acute distress
5. One of the hormones, __________, facilitates the transport of glucose into cells where it can be used for energy.
Insulin Insulin, secreted by the pancreas, facilitates the transport of glucose into cells where it can be used for energy. Ultimately, it lowers blood glucose level.
26. In a hospital setting, if a child with CF had Burkholderia cepacia cultured from his respiratory secretions, which of the following would apply?
It would not be wise to have him share a room with another CF patient
At this point, which of the following would be appropriate advice for Susan?
Let me help you assume the knee-chest position if the urge to push is uncomfortable Don't push yet. Pant through contractions if you need to
17. To determine Mark's weight status category, which of the following is used?
Mark's body mass index (BMI) percentile at 75%
13. Which of the following is true with regard to normal fat digestion?
Most healthy people absorb at least 93% of the fat the eat
The newborn is prone to hypothermia because:
Newborns have a large body surface to body weight ratio Blood vessels are close to the skin surface There is minimal subcutaneous fat
4. After Jason's health history is obtained, you prepare to collect essential physical exam data. Jason is sleeping soundly in his mother's arms. Which assessment should be done first?
Respiratory rate
Because Susan had an epidural she has not exhibited some of the signs/behaviors that otherwise characterize the transition phase. These include:
amnesia between contractions diaphoresis reluctance to be touched physical shaking
Early deceleration is caused by
compression of the head
11. Steffy tells you that she has read that babies of mothers on methadone may experience seizures during labor. You correctly explain to her that:
continuing methadone treatment throughout labor should prevent fetal seizures
3. With regard to smoking, Steffy asks whether "cutting back now" would help her baby. You correctly inform her that:
cutting back may improve the chances that her baby would be of normal weight at delivery
You perform a vaginal exam to check for shortening and thinning of cervix. This is called
effacement / effacing
The term that describes the expected gradual reduction in size of the uterus after delivery as it contracts to return to normal size is
involution
A number of factors may affect the length of time a woman's labor will last. These include:
maternal activity and position the parity of the mother fetal position and size
9. During pregnancy, Steffy has received the lowest possible dose of methadone, although dosage schedule has changed. Dosing schedule during pregnancy is affected by the fact that:
methadone clearance from the mother is fastest during the second and third trimesters
You correctly explain to Joey and his mother that Prelone (prednisolone) is being given to:
reduce airway inflammation
Susan decides to rest in bed. Which of the following positions are acceptable?
right lateral left lateral
Based on your assessment, you position the ultrasound transducer on Susan's abdomen at the:
right lower quadrant
5. You go on to explain to Steffy that alcohol consumption can be especially damaging to her baby during:
the first trimester of pregnancy, when organ cells are dividing rapidly
18. Which of the following responses would be best?
"There is no way at this time to predict how sick Austin may be or what his life expectancy might be."
3. You prepare to teach Maria about gestational diabetes. Which approach would provide a good beginning?
"This was upsetting news for you. Can you tell me what you've been told?" This response would be best. It would validate Maria's concerns and attempt to identify current learning needs and start with what Maria already knows. This is an important principle of teaching.
24. Which of the following are appropriate interventions for Sarah's care? (Select 3)
-Excellent handwashing -Oral rehydration therapy -Disinfection of toilets and diapering surfaces
24. Priority nursing diagnoses that apply to Ashley at this time include: (Select 3)
-Imbalanced Nutrition: Less Than Body Requirements related to refusal to eat enough food to supply adequate calories -Disturbed Self-Concept related to inaccurate perception of self as "flabby" and "fat" -Risk for hypothermia related to decreased subcutaneous tissue
23. Besides tachycardia and agitation, what other effects of Ventolin (albuterol) therapy might Austin experience? (Select 2)
-Increase in coughing -Onset of or increase in wheezing
11. As Ashley and Mark experience their adolescent years, risk-taking and risk for injury may increase. This is because adolescents: (Select 4)
-May test their independence from parents by participating in behaviors disapproved of by parents -Often feel indestructible and invincible -Have a strong need for peer approval -Have a strong need to discharge energy
38. After your discussion with Emily, you explain that you will be caring for her again tomorrow. You need to review and validate Emily's knowledge and understanding related to: (Select 5)
-Medications -Physician's instructions -Clinic follow-up -Who to call with questions -Diet
14. Katie is breastfeeding well prior to discharge, but Mrs. Mills' knowledge of breastfeeding needs reinforcement. Which statement by Mrs. Mills indicates the need for further breastfeeding teaching?
A. "I will breastfeed Katie every four hours around the clock."
30. On assessment, it is determined that Katie has fallen from her normal growth curve. Katie weighs 26 pounds (11.8 kg) and is 36.5 inches (93 cm) in length. Using a clinical growth chart for girls 0-36 months, what percentiles is Katie in for weight and length?
A. Below 10th percentile for weight, and below 50th percentile for length
You determine that Susan is now in which phase of stage one labor?
Active phase
23. If on abdominal examination, a steady pain localized in the right lower quadrant was noted, which medical diagnosis would be highly suspected?
Appendicitis
As a small-for-gestational-age (SGA) and preterm infant, John is especially prone to which of the following problems?
B. bleeding tendency; D. temperature instability; E. hypoglycemia; G. polycythemia
Which of the following actions is indicated, given Lily's current data?
B. have the physician see Lily immediately
A glucose check done on John reveals a glucose value of 28 mg/dl. Which of the following actions is indicated?
B. notify the pediatrician and prepare to feed John formula or breast milk
16. Which set of vital signs, obtained for Katie, indicate a compromised state?
C. Heart rate 164, respirations 60, BP 78/48
Lily will need a lot of prenatal teaching, and you have already started thinking about this. Because Lily is an adolescent, which of the following approaches may work best when teaching Lily about nutrition and exercise in pregnancy?
C. explain how healthy eating and exercise habits will help LIly look and feel better
Under which of the following conditions would Lily's magnesium sulfate be withheld?
C. respiratory rate 10, urinary output of 22 mL over one hour
25. Ashley's stage of psychosocial development (almost 14 years) should be understood as she is treated for her health problem. According to Erikson, in which psychosocial stage of development is Ashley?
Identity vs. Role confusion
In working with Joey, his developmental level is considered. According to Erikson, Joey is in which psychosocial stage of development?
Industry vs. Inferiority
You continue your assessment of Joey's work of breathing with auscultation of his breath sounds. Using the diaphragm of your stethoscope, you use which of the following approaches?
Listen to breath sounds anteriorly and posteriorly Listen to at least one breath at each location Listen to breath sounds bilaterally
4. You determine that the nursing diagnosis, Deficient Knowledge: Blood Glucose Control, is applicable to Maria. Which of the following goal statements applies?
Maria will discuss situations that have the potential for increasing blood glucose levels. It would be realistic to expect that after learning about diabetes, Maria could discuss situations that might affect her blood glucose level. A client goal should be realistic, and measurable in client behavioral terms.
At the next assessment, Susan's uterus is midline. The fundus feel boggy at one fingerbreadth below the umbilicus, what should you do first?
Massage Susan's uterus
20. Based on Sarah's signs and symptoms and your assessment findings, you determine that she is probably:
Mildly to moderately dehydrated
26. As a breastfeeding woman, Maria will require:
More calories during lactation Breastfeeding women require 500 calories above their non-pregnant caloric need to meet their breastfeeding needs and those of their babies.
21. Given his age and condition, which mode of delivery would be most beneficial with Austin?
Nebulizer
Which of the following is the expected progression of lochial changes during the puerperium?
Rubra, serosa, alba
As Susan and John admire their new son, you notice a sudden gush of blood from Susan's perineum and an apparent lengthening of the umbilical cord. You recognize that these signs indicate
separation of the placenta
To ease Joey's work of breathing you have Joey assume a position of comfort. You anticipate Joey will want to:
sit up
After the placenta has been expelled, Dr. Cooper asks you to start a Pitocin (oxytocin) drip, at a concentration of 10 units in 1000 mL Lactated Ringer's. You know that Pitocin (oxytocin) is administered at this time to:
stimulate uterine contractions
You correctly measured Joey's peak expiratory flow rate (PEFR) by asking him to:
take one deep breath, close his lips tightly around the flow meter mouthpiece, and blow out as hard and fast as he could
zero station means that
the baby's presenting part is at the level of the mother's ischial spines
Other laboratory and diagnostic tests are ordered for Lily. These appropriately include:
A. venereal disease research laboratory test (VDRL); D. rubella titer; E. liver enzymes; F. CBC
After quietly introducing yourself, which subsequent actions on your part are indicated?
Ask Angela's mother to support Angela in her preferred position, and take her vital signs
In counseling Susan about sexual activity during pregnancy, which of the following comments would be best? A. "You are very fortunate. Most women don't want anything to do with sex during pregnancy." B. "It is common for sexual desire to vary during pregnancy." C. "It's great that you enjoy sex now. You will need to abstain from sex after 36 weeks." D. "Be very careful about sexual relations during pregnancy. Orgasm can cause preterm labor."
B. "It is common for sexual desire to vary during pregnancy." This comment would be appropriate. Sexual desire during pregnancy is variable. However, during the first trimester, when the pregnant woman is fatigued and experiencing nausea, sexual desire may diminish. The second trimester may bring an increased libido, with an improved sense of well-being. In the third trimester, sexual desire may wane, as physical bulkiness and fatigue become major concerns. In general, however, sexual desire during pregnancy is highly individual.
John's low birth weight is most likely due to:
B. poor circulation to the placenta
27. Austin's Respiratory Therapist contacts you to discuss timing and method of chest physiotherapy (CPT). Which time is best for CPT?
Between feedings
You explain that the contractions she describes are common during late pregnancy and function to increase blood flow to the uterus. They are referred to as ____________________ contractions.
Braxton Hicks
16. The best answer to Mr. Brown's question at this time will be:
Brief
27. Katie's parents have been waiting to see her. Before allowing Katie's parents to see her, you should:
D. Explain what Katie will look like, and about the equipment that will be attached to her
Lily's age and subsequent immature skeletal and endocrine systems increase her risk of pregnancy'related complications. Because of her age, Lily is also more likely to:
D. Have an inadequate diet
10. Maria is taught about the relationship between stress and blood glucose level. You are confident that she understands this relationship when she tells you that during times of stress:
Her blood glucose may be higher Hormones associated with the stress response result in glucose stores being released and mobilized to supply energy. During stressful periods, whether physiological or emotional, Maria's blood glucose level may rise if her insulin levels are not sufficient in metabolizing the increased glucose load.
3. You take Austin and his parents to an exam room. Given your initial impression of Austin, your next action should be to:
Obtain Austin's vital signs
14. Austin's poor weight gain, slow growth, and placement below the 5th percentile for weight and height (length) indicate failure to thrive. In Austin's case, failure to thrive is classified as:
Organic
28. Given Austin's age, what form of chest physiotherapy (CPT) is most appropriate?
Postural drainage with percussion
31. Which approach is best to take with Mark at this time?
Praise Mark for his courage in telling you about his fear of alcohol "binging"
Which of the physician's orders should you implement next?
Proventil (albuterol) 2.5 mg in 2 mL normal saline by nebulizer
3. The second heart sound, S2, represents the closure of two valves, the aortic valve and the ____________ valve.
Pulmonic or Pulmonary
15. This tracing is obtained during Maria's nonstress test (NST). You correctly evaluate the tracing as:
Reactive This tracing is correctly evaluated as reactive (and normal) as the fetal heart rate increases with movement.
What is the best nursing action to take at this time?
Suggest that John take a short break and have another family member coach Susan temporarily
12. Steffy knows her baby may experience withdrawal from methadone after delivery. Tearful, she asks what will happen. You correctly tell her that her baby may: Select all that apply (there are 4 correct answers).
have some shaking not feed well have a high-pitched cry sweat a lot
You question Susan about whether or not she has had any abnormal vaginal discharge or itching. During pregnancy, women are more prone to develop vaginal yeast infections due to a/an __________________ in vaginal pH.
increase
You remind Susan that it is important for her to try to urinate every two hours. The rationale for this is that a distended bladder can:
interfere with fetal descent cause difficulty in voiding after delivery increase the pain associated with uterine contractions
You also determine that the fetus is at zero station....Your response is based on the knowledge that zero station means that:
the baby's presenting part is at the level of the mother's ischial spines
Based on your assessment of this male neonate, you determine that his 1-minute Apgar score is
9
2. You prepare to explain the oral glucose tolerance test (OGTT) to Maria. Which of the following explanations would be accurate?
"You will be given a drink that is high in glucose and have some blood samples taken." This explanation would be accurate. An OGTT evaluates the ability of the body to metabolize glucose. After a fasting blood sample is drawn, Maria will drink a solution that is high in glucose. Blood is subsequently drawn at intervals (generally one, two, and three hours). Maria is advised to fast the morning of the test.
7. Maria was noticeably quiet when she was told about her diabetes, and had few questions. Now tearful, she asks, "Will I have diabetes for the rest of my life?" Which response would be best?
"Your ability to handle glucose is impaired during pregnancy. In most women, this disappears after delivery." This response would appropriately address Maria's question with a simple, accurate response. Most women with gestational diabetes return to a non-diabetic state after pregnancy. However, Maria may again develop gestational diabetes with subsequent pregnancies, as well as permanent type 2 diabetes (insulin resistance combined with defective insulin secretion) later in life.
Based on data presented, nursing diagnoses appropriate for Abby include:
-Ineffective Airway Clearance related to increased respiratory secretions -Risk for Deficient Fluid Volume related to decreased fluid intake and insensible water loss -Interrupted Family Processes related to hospitalization -Activity Intolerance related to increased work of breathing and decreased tissue oxygenation
3. You inquire further to determine if Jason is getting enough nutrition. Which of the following suggest that Jason is probably receiving enough breast milk? (Select 5)
-Jason sleeps at least two hours after a feeding -Jason has a bowel movement after most feedings -Jason has 6-8 wet diapers in each 24-hour period -Jason nurses every 2-4 hours for 15 minutes -Jason is a content, alert, and responsive baby
22. Which of the following characterize hypoglycemia in the newborn and may therefore be observed in Frank Jr.? (Select all)
-Jitteriness Jitteriness commonly characterizes hypoglycemia in the newborn. -Hypotonia Hypotonia commonly characterizes hypoglycemia in the newborn. Lack of muscle strength may cause poor feeding. -Respiratory rate of 80 A newborn may experience a rapid respiratory rate (tachypnea) as a result of hypoglycemia. Tachypnea may also occur with a variety of cardiac anomalies or respiratory distress syndrome, both of which are more common in infants of diabetic mothers. -Twitching of extremities Twitching of the extremities commonly characterizes hypoglycemia in the newborn.
23. Which of the following, evident with Ashley, are consistent with anorexia nervosa? (Select 4)
-Low body temperature -Dry skin and brittle nails -Weight loss despite increase in stature -Irregular menses
13. Taking a preventive approach, you discuss with Ashley some of the risks associated with smoking, alcohol, and drug use. Which of the following are accurately included in your discussion? (Select 4)
-Many young people who try cigarettes become regular users -The younger a person is when she starts smoking, the harder it is to quit in the future -The younger a person is when she starts smoking, the greater the chance of developing serious health problems -Once drugs or alcohol are used, it becomes very hard to quit
Susan's pitocin drip is infusing with an infusion pump at a rate of 60 mL per hour ___ milliunit of drug is infusing per minute
10
16. Mark is 144.8 cm (57 inches) tall and weighs 41 kg (90 pounds). Using a clinical growth chart for boys 2-20 years (Stature-for-age and Weight-for-age), what percentiles is Mark in for stature and weight? (Select growth chart button at left to view relevant growth chart.)
25th percentile for stature, 50th percentile for weight
Which of the following is considered a positive sign of pregnancy that could be present at this point in Susan's pregnancy (eight weeks gestation)? A. Fetal cardiac activity or body movement noted on ultrasound B. Palpation of fetal movements by an examiner C. Ballottement noted on vaginal examination D. Uterine souffle auscultated with Doppler
A. Fetal cardiac activity or body movement noted on ultrasound Ultrasonography is a noninvasive technique that can detect the presence of fetal cardiac activity or body movement as early as 6-7 weeks gestation. Detection of fetal cardiac activity or movement by ultrasound would be a positive sign of pregnancy. At eight weeks gestation, fetal activity could be demonstrated on ultrasound.
Which of the following interventions should be included in Lily's discharge plan?
A. ensure that Lily has a scheduled apt for a postpartum checkup; B. Invite Lily's g-mom to talk to with nurse and Lily about her discharge plans; C. Arrange for a home visit by a community health nurse; D. Ensure that Lily has info on how to apply for participation in a food assistance prog; E. Provide edu. regarding reproductive physiology and contraception; F. confer with the social worker regarding Lily's status at school
You also review Susan's lab work, recalling that pregnancy tests on urine or blood are determined to be positive based on the presence of a particular hormone. This biologic marker of pregnancy is: A. human chorionic gonadotropin B. estrogen C. progesterone D. follicle-stimulating hormone
A. human chorionic gonadotropin Human chorionic gonadotropin (HCG), produced by the trophoblast cells of the placenta soon after implantation of a fertilized ovum, is a biologic marker of pregnancy. It can be detected in maternal serum and urine as early as six days after conception, depending on the test performed. It reaches its maximum level in 50-70 days. The presence of HCG in Susan's blood is considered a probable sign of pregnancy. Positive pregnancy tests can also occur if the client has certain tumors which produce HCG. Progesterone is not a biological marker of pregnancy, but increases in progesterone levels are critical for the maintenance of a pregnancy.
You goals in preparing Lily for hospitalization include:
A. involving Lily's grandmother in care planning; B. decreasing Lily's anxiety; D. helping Lily understand what is happening to her body; E. obtaining Lily's cooperation in the plan of care
Which of the following, if noted on a fetal monitor tracing is cause for concern?
A. late deceleration
If late decelerations were observed as Lily's labor progressed, which of the following would likely be indicated?
A. oxygen by face mask; C. repositioning of Lily in a side-lying positions
Before Lily and her grandmother leave the clinic, you make sure that they are able to verbalize the need to call the clinic immediately if Lily begins to experience signs of worsening preeclampsia, which include:
A. pain in the right upper abdominal quadrant; B. a decrease in fetal activity; C. more than 1+ proteinuria; E. blind spots in her field of vision
In preparing Lily for her physical exam, you ask her to void. This will empty her bladder and facilitate her exam. Also, Lily's urine is checked for:
A. protein; B. Glucose; D. Ketones
Which of the following nursing diagnoses apply to Lily at this time?
A. risk for infection; D. Risk for fluid volume imbalance; E. impaired comfort
You prepare Lily for her physical exam. Which of the following assessments are planned as part of this exam?
A. testing for reflexes; B. Pelvic measurements; D. measurement of fundus; E. Pap smear; F. Auscultation of the fetal heart; G. Breast Exam
8. Steffy says that she is glad that she has been on methadone, and is no longer on heroin. If Steffy were still taking heroin, she would be at greater risk for which of the following complications of pregnancy?
Abruptio placentae
26. In working with Ashley, it is also important to realize that she can reason and problem-solve. She can think about possibilities, as well as future consequences related to her actions. This kind of thinking ability is called:
Abstract thinking
4. Austin is crying and is in his mother's arms. Which approach is best as you plan your assessment of Austin?
Allow Austin to stay in his mother's arms as you begin your assessment
2. You tell Steffy that each time she smokes, her baby is affected. Which vital sign changes are likely to occur within minutes of Steffy smoking a cigarette? Select all that apply (there are 2 correct answers).
An increase in her blood pressure and pulse An increase in the fetal heart rate
1. You provide Steffy with a great deal of information about smoking and pregnancy. This includes the fact that cigarette smoking during pregnancy is associated with: Select all that apply (there are 2 correct answers).
An increased risk for low birth weight babies An increased risk for preterm labor
What measures could you suggest to Susan to help decrease or alleviate the annoying discomfort of heartburn? Select all that apply (there are 3 correct answers). A. Lie down for 15-30 minutes immediately after eating B. Avoid fatty and gas-producing foods C. Maintain good posture D. Take any over-the-counter liquid antacid after meals E. Eat six small meals a day instead of three large meals
B. Avoid fatty and gas-producing foods C. Maintain good posture E. Eat six small meals a day instead of three large meals Fatty and gas-producing foods are known to contribute to heartburn. It would be appropriate to recommend to Susan that they be avoided. Maintaining an erect, non-stooped posture would promote emptying of the stomach and prevent gastroesophageal reflux, which could contribute to heartburn. With advancing pregnancy, the stomach is displaced upward and compressed by the uterus. Stomach capacity is thus decreased. Eating six small meals a day instead of three large ones should help prevent heartburn associated with overfilling of the stomach and subsequent gastroesophageal reflux.
33. Katie receives conscious sedation for heart catheterization, and tolerates the procedure well. She is now awake and alert, and her gag reflex has returned. Which of the following are indicated at this time? (Select all that apply.)
B. Bed rest C. Frequent vital signs D Bilateral lower extremity pulse assessments E. Maintenance of a pressure dressing at a catheter insertion site F. Encourage oral fluids
13. Ventricular Septal Defect (VSD) can cause congestive heart failure. Which of the following may be signs of congestive heart failure? (Select all that apply.)
B. Breathing difficulty C. Swelling of Katie's hands or feet D. Decrease in diaper wetting E. Change in sleep/wake habits
25. In administering liquid Lanoxin (digoxin) to Katie, you plan on implementing which of the following correct techniques of oral Lanoxin (digoxin) administration with infants?
B. Counting the apical pulse for one minute prior to administering the drug
In a child like Joey with an asthma exacerbation, rapid breathing generally indicates which of the following?
The child's physiologic coping mechanisms are working to maintain adequate tissue oxygenation
14. In preparing Maria for the nonstress test (NST), you explain that it is designed to insure that:
The fetus is relatively healthy Fetal movements and heart rate are concurrently monitored during a NST. The stress associated with movement is expected to cause a concurrent normal acceleration in fetal heart rate (FHR), indicating a relatively healthy fetus.
9. You review Ashley's immunization history with her mother. Ashley has not received the hepatitis B vaccine series. Which of the following approaches is likely to be taken by the Nurse Practitioner today?
The hepatitis B vaccine series will be started today
17. Which of the following infants is NOT given the DTaP vaccine at this six-month visit?
The infant who developed hives and had difficulty breathing after a previous DTaP injection
Joey is able to effectively use a mouthpiece for his Proventil (albuterol) treatment. The nebulizer treatment is continued until:
The medication has evaporated
Which of the following statements would indicate that Susan understands correct information on breastfeeding?
To break suction, I will insert my finger into the corner of Jason's mouth before removing him from the breast When Jason has a growth spurt, he will want to nurse more often which will increase my milk supply
7. Before weighing Austin, you determine his height (length) by measuring from his heels to the top of his head as he lies supine.
True
It is presumed that Abby has bronchiolitis due to respiratory syncytial virus (RSV). RSV infections of the respiratory tract are highly contagious and easily spread.
True
16. You spend time speaking with Mrs. Deakin about Jason's emotional care and developmental stage. According to Erikson, Jason is in which psychosocial stage of development?
Trust vs. Mistrust
In response to the occurrence of a late deceleration, which of the following actions should be carried out FIRST?
Turn on left side
Which of the following expected effects of epinephrine treatment should help alleviate Melissa's respiratory distress?
Vasoconstriction
John asks "Why does he need to have a shot already?" Your explanation to John is based on the knowledge that:
Vitamin K is needed to prevent bleeding problems in the early neonatal period Newborns are unable to synthesize vitamin K due to absence of intestinal flora at birth
6. Especially with infants, weight should be obtained at every well-child and sick-child visit. Which of the following do you correctly implement to weigh Jason?
Weigh Jason nude on an infant scale
When should teaching regarding prevention of foreign body aspiration be done with Adam's father?
When Adam nears discharge
18. Mark has a cold. Should he receive vaccines at this visit?
Yes, Mark should be immunized at this visit
27. Even though this is a sick-child visit, Sarah's immunization record is reviewed. Sarah has received the following recommended immunizations on schedule: HepB, DTaP, Hib, IPV, PCV, Varicella, and MMR. Which recommended vaccine is considered at this time since Sarah has not received it?
`HepA
Joey's lab results are now available. His WBC (white blood count) is interpreted as abnormal at 12000/mm3, with neutrophils increased at 80% and a shift to the left. These lab values are consistent with:
a bacterial infection
A pulse oximeter attached to Joey displays an oxygen saturation reading (SpO2) of 92%, and a heart rate of 116 beats per minute. You correctly interpret the SpO2 of 92% as:
abnormal
You recall that the pathophysiology of asthma includes:
airway inflammation bronchospasm airway obstruction
You know that Tilade (nedocromil sodium) is commonly used with children with mild asthma. Its primary therapeutic action is to:
decrease histamine release
To measure the frequency contractions you examine a 10-minute strip and:
determine the time from the beginning of one contraction to the beginning of the next
36. When you review Emily's pulmonary function tests (PFTs), you realize that she has severe CF lung disease.
false
The anesthesiologist performs the epidural procedure and Susan begins to feel almost immediate relief from painful contractions. You know that a priority nursing intervention is to:
frequently monitor Susan's blood pressure for hypotension
These assessments are done to detect the onset of the complication of pregnancy called __________________________.
gestational hypertension
Prelone (prednisolone) 45 mg by mouth is ordered for Joey. Your drug reference indicates that a safe and appropriate dose for a child with an acute asthma exacerbation is 1-2 mg/kg/day. Joey weighs 23 kg (51 pounds). You determine that:
the drug dose of Prelone (prednisolone) ordered for Joey is safe and appropriate
Fetal heart rate increases can be associated with a variety of factors. These include:
the mother receiving the drug Brethine (terbutaline) The mother receiving the drug Yutopar (ritodrine) Maternal fever or infection Fetal anemia Also, Maternal Dehydration Maternal Hyperthyroidism
Continuing your discussion of Prelone (prednisolone), you explain to Joey and his mother that the medication should be taken:
with food
If a child like Joey, with an acute asthma exacerbation, suddenly exhibited an absence of wheezing and increased retractions, this would suggest:
worsening of the child's condition
19. Which of these medications is being given to help correct Austin's malabsorption?
Creon 5 (pancreatic enzymes)
19. Based on an analysis of the data obtained on Katie thus far, which of the following is relevant and has priority?
C. Potential Complication: Congestive Heart Failure
As you monitor Lily, you remain alert for which of the following complications of preeclampsia?
C. abruptio placentae
Which of the following comments would be best to make at this time?
C. I know this is upsetting to you
Because Lily has sought prenatal care so late, she is at risk for:
B. Preterm birth
Lily's fetal heart tracing indicates:
A. early deceleration
As you approach Angela's treatment area, you recall what you know about epiglottitis. You know that:
-Epiglottitis is usually caused by a bacterium -Epiglottitis usually occurs in young children -Epiglottitis is serious and communicable
24. Lanoxin (digoxin) is available in liquid form, and ordered for administration by mouth. Lanoxin (digoxin) is available at a strength of 0.05 mg per mL. To administer 88 mpg, what volume of the drug should be prepared in an oral syringe?
C. 1.76 mL
14. Referring to Tanner's stages, Mark's sexual maturity is rated as:
Tanner stage 2
11. If Austin's condition were to change, which of the following changes would suggest hypoxia and the need for prompt medical evaluation to determine if oxygen was indicated? (Select 5)
-Increase in respiratory rate from 62 to 70 -Increase in pulse rate from 150 to 170 -Change in behavior from quiet to irritable -Decrease in oxygen saturation from 95% to 93% -Decrease in respiratory rate from 62 to 28
24. Which of the following apply to Maria at this time? (Select all)
- Acute Pain related to surgical procedure Acute Pain related to surgical procedure is an appropriate nursing diagnosis for Maria at this time. - Risk for Deficient Fluid Volume related to surgery Maria has experienced both a surgical procedure and normal postpartum blood loss. Risk for Deficient Fluid Volume applies as a nursing diagnosis. - Risk for Infection due to cesarean birth Risk for Infection is an important diagnosis. Surgical intervention predisposes to infection. Mothers who have had cesarean births have a higher incidence of endometritis than mothers who have had vaginal births. - Risk for Urinary Retention related to cesarean birth Risk for Urinary Retention due to cesarean birth does apply to Maria. Since acute episodes of urinary retention after delivery are treatable with catheterization, this problem is often addressed as a collaborative problem instead of a nursing diagnosis.
31. Creon 5 is a small gel cap filled with tiny enteric-coated beads. In reviewing possible methods of giving the enzymes, you offer Mrs. Brown the following options: (Select 2)
-"Open the capsule in Austin's mouth and immediately give him his bottle." -"Open the capsule, pour the beads into some cereal, and feed this to Austin."
27. To meet Ashley's nutritional needs, which of the following approaches are appropriately implemented? (Select 2)
-Ashley and her family members work on her nutritional plan together -Ashley is expected to monitor her own diet and keep a diary of her eating habits
Angela resists as you attempt to apply a finger probe to obtain an SpO2 reading. Her color becomes dusky, and her breathing sounds brassy and seems more labored. On admission to the Emergency Department (ED), Angela's SpO2 was 95%. What should you do?
-Call for a physician -Apply oxygen
28. Which of the following nutritional guidelines are correct and included as part of Ashley's nutritional counseling? (Select 3)
-Caloric intake should come from a combination of fats, proteins, and carbohydrates -Intake of sugars (simple carbohydrates) and saturated fats should be limited -Whole grain selections are preferred from the bread/cereal/rice/pasta group
8. Maria asks about problems that she or her baby may have because of the diabetes. You know that gestational diabetes increases risk for: (Select all)
-Cephalopelvic disproportion Persistent fetal hyperglycemia and hyperinsulinemia result in excessive fetal fat stores or macrosomia. The excessive size of the fetus often contributes to cephalopelvic disproportion and a subsequent difficult delivery (dystocia) that may require a cesarean section. -Gestational hypertension Gestational hypertension and preeclampsia occur more frequently in pregnancies complicated by diabetes. Preexisting vascular damage in women with pregestational diabetes increases this risk.
25. On the postpartum unit, Maria begins to breastfeed Frank Jr. With regard to breastfeeding, which of the following is/are appropriate for Maria? (Select all)
-Encourage Maria to take medication for pain 15-30 minutes before a feeding Maria will have pain at her incision site. Taking pain medication would allow for a more comfortable feeding, and help ensure a more successful breastfeeding experience. -Encourage Maria to hold Frank Jr. in the football hold The football hold would be a comfortable feeding position as it would keep the weight of Frank Jr. off Maria's incision. -Reassure Maria about her ability to breastfeed All breastfeeding mothers need encouragement. Mothers who have had cesarean births can breastfeed as well as those who have vaginal births. -Advise Maria to avoid use of pacifiers with Frank Jr If a breastfeeding infant becomes accustomed to a pacifier, he may experience nipple confusion and suck less well on the breast. The use of a pacifier should be discouraged.
Standard precautions and Contact precautions apply for Abby's care. To correctly implement these precautions, which of the following will be indicated during Abby's hospitalization?
-Handwashing -Placement of Abby in a private room -Use of clean gloves by caregivers when providing direct care to Abby -Use of a gown by caregivers when providing direct care to Abby
18. Given that Maria will be having a cesarean section, specific blood tests are required. These include: (Select all)
-Hemoglobin and hematocrit Most surgical procedures, including cesarean section, are associated with a risk for bleeding and perhaps significant blood loss. Overdistention of the uterus, as with a macrosomic fetus, can increase risk for bleeding. Baseline hemoglobin and hematocrit levels, as part of a complete blood count, provide data to help the nurse and other providers determine the extent of any surgical blood loss. -Electrolytes Limited intake prior to cesarean section, in conjunction with the administration of intravenous fluids, the stress associated with labor and delivery, and any fluid loss during the surgical procedure, can cause serum electrolyte levels to fluctuate. Baseline levels provide data to help the nurse and other providers determine the extent of any changes. -Type and cross-match Most surgical procedures, including cesarean section, are associated with a risk for bleeding and perhaps significant blood loss. A type and cross-match should be done to insure that Maria's blood type is known and that blood is available if necessary.
1. You recognize that a number of factors in Maria's history increase her risk for developing gestational diabetes. These include: (Select all)
-Her age of 37 years Pregnant women less than 25 years old with no other risk factors are considered at low risk for gestational diabetes. Those who are age 40 and older are considered high risk. At age 37, Maria is at an average to high risk for development of gestational diabetes. -Her pre-pregnancy Body Mass Index (BMI) of 27 Overweight women (BMIs greater than 25) are considered to be at increased risk for gestational diabetes. -Her grandmother has type 2 diabetes Both gestational diabetes and type 2 diabetes involve a genetic susceptibility to insulin resistance.
31. Some forms of bacterial meningitis can be prevented with immunization. Which vaccines are designed to prevent invasive bacterial infections that can result in meningitis? (Select 2)
-Hib -PCV
2. Your initial health history of Jason will be comprehensive. Which of the following should be included as part of Jason's initial health history? (Select 5)
-His medical history -A family medical history -A psychosocial history -A nutrition history -A review of systems
8. Ashley wants to know when she will get her "period." You correctly tell her that there is no way of knowing for sure, but commonly menstruation begins:
1-2 years after breast tissue starts to develop
19. Which of the following equipment for use with a newborn is normally available in the Operating Room when a cesarean delivery is being performed? (Select all)
-Oxygen delivery equipment Oxygen equipment should be available in the Operating Room for both vaginal and cesarean deliveries. It is not routinely administered but must be available should the newborn experience respiratory distress or show signs of hypoxia. -Laryngoscope A laryngoscope suitable for a newborn should be available in the Operating Room for both vaginal and cesarean deliveries. A laryngoscope may be required to insure a patent airway and/or facilitate suctioning should the newborn infant be compromised. Infants delivered by cesarean section have more difficulty clearing secretions from respiratory passages. The cesarean-delivered newborn does not benefit from the 'thoracic squeeze' experienced by newborns delivered vaginally. -Suction equipment It is essential to have suction equipment in the Operating Room, for both vaginal and cesarean deliveries. It is not uncommon for mucous secretions to obstruct a newborn's nasal and/or oral cavities after birth, necessitating suction to maintain a patent airway. -Stethoscope A newborn stethoscope should be available in the Operating Room for all deliveries. It is used to assess the newborn's heart rate and breath sounds, and check for murmurs.
12. The malabsorption that occurs in CF is commonly characterized by: (Select 3)
-Poor weight gain and delayed growth despite constant eating -Steatorrhea -Abdominal bloating
34. For an adolescent, what forms of chest physiotherapy (CPT) are appropriate? (Select 5)
-Postural drainage with hand or mechanical percussion -Positive expiratory pressure (PEP) -Autogenic drainage -Flutter -High frequency chest wall oscillation (inflatable vest)
21. Mark has received advice regarding acne from his school nurse. Which advice was correct? (Select 2)
-Practice stress management techniques -Avoid squeezing or popping pimples
29. Ashley's sexual high-risk behavior, engaging in unprotected sexual intercourse, puts her at risk for which of the following? (Select 6)
-Pregnancy -Trichomonas vaginalis -Chlamydia trachomatis -Gonococcal infection -Herpes simplex virus type 2 -Human Immunodeficiency Virus (HIV) infection
4. For girls, Tanner's sexual maturity ratings evaluate: (Select 2)
-Pubic hair growth and distribution -Breast changes and growth
5. For boys, Tanner's sexual maturity ratings evaluate: (Select 4)
-Pubic hair growth and distribution -Penis growth and development -Testes growth and development -Scrotum growth and development
8. Infants with CF commonly experience which of the following? (Select 3)
-Pulmonary congestion -Cough -Wheezing
5. Besides oxygen saturation and rhythm of respirations, respiratory function assessment should include: (Select 5)
-Respiratory rate -Mechanics of breathing -Breath sounds -Skin color -Chest rise and fall
10. Of the vital signs and clinical data collected during your assessment of Austin, which do you interpret as abnormal? (Select 2)
-Respiratory rate of 62 -Crackles in all lung fields
9. Which of the following manifestations may also occur in infants and children with CF? (Select 2)
-Salty-tasting skin -Meconium ileus
1. For each patient seen, your nursing assessment upon meeting the patient is usually brief. This brief nursing assessment generally includes: (Select 5)
-The child's stature (length) and weight -Any allergies the child may have -Current medications being taken by the child -The child's vital signs -The reason for the clinic visit
37. Information to present in your discussion with Emily includes: (Select 5)
-The importance of appropriate protection to prevent sexually transmitted diseases -Her ability to conceive -The impact of a pregnancy on her CF disease process -The likelihood of having a baby with CF -Referral to a women's health provider who is familiar with cystic fibrosis all but c
13. Which of the following should be addressed when counseling Maria during this 28th week visit? (Select all)
-The need to daily fetal movement counts At this point in her pregnancy, Maria should be taught to do daily fetal movement (kick) counts. This involves taking note of fetal movements to insure that they have not decreased or stopped. -A review of diet guidelines Although Maria's diabetes has been successfully controlled, it is important that she continue to be encouraged in following her diet. -The desirability of attending prenatal classes Maria, a primigravida, should be encouraged to attend prenatal classes to prepare her for the birth of her baby, which is three months away. -The need to report specific abnormal signs and symptoms Complications may occur during the last trimester. Maria should be instructed to report a sudden discharge of vaginal fluid, vaginal bleeding, severe abdominal pain, chills, fever, dysuria, diarrhea, severe backache or flank pain, decrease in fetal movement, uterine contraction/pressure/cramping, visual disturbances, swelling of the face, severe or continuous headaches, or epigastric pain. -A review of exercise guidelines Although Maria's diabetes has been successfully controlled, it is important that she continue to be encouraged in following her usual exercise pattern. A change in exercise pattern could result in poor glucose control.
You recall what you know about bronchiolitis. You know that bronchiolitis:
-Usually occurs in infants and young children -Is often caused by a virus
11. Additional teaching with Maria at this time should include discussion regarding which of the following? (Select all)
-With gestational diabetes, diet and exercise are usually sufficient to control glucose levels In many women with gestational diabetes, proper nutrition combined with appropriate and adequate activity/exercise is enough to control blood glucose levels effectively. Blood glucose monitoring is necessary to ensure adequate control. -Women who have gestational diabetes have a greater chance of developing type 2 diabetes mellitus later in life Although gestational diabetes is a temporary diabetes that should resolve after delivery, research has shown that women with a history of gestational diabetes are at increased risk of developing type 2 diabetes later in life. This risk is lower if the client maintains normal weight, eats a proper diet, and participates in regular exercise.
29. Austin's parents will need to perform chest physiotherapy (CPT) at home. What techniques will be most useful in teaching Austin's parents how to perform CPT at home? (Select 3)
-Written instructions on how to do CPT -Video or live demonstration of CPT being done -Monitored return demonstration of CPT technique
Which of the following information should be communicated to Susan regarding the benefits of smoking cessation at this point in her pregnancy? Select all that apply (there are 3 correct answers). A. It will decrease the risk of intrauterine growth restriction (IUGR) and giving birth to a low-birth-weight infant B. It will increase the oxygen supply to the fetus C. It will reduce the risk of preterm labor and premature rupture of membranes D. It will reduce the risk of neural tube defects
A. It will decrease the risk of intrauterine growth restriction (IUGR) and giving birth to a low-birth-weight infant B. It will increase the oxygen supply to the fetus C. It will reduce the risk of preterm labor and premature rupture of membranes Maternal smoking interferes with diffusion of nutrients and oxygen to the developing fetus and is associated with low birth weight infants, secondary to the vasoconstrictive effect of smoking on placental vessels Oxygen supply to the fetus is reduced with maternal smoking for a number of reasons. Smoking causes vasoconstriction of placental vessels, interfering with diffusion of nutrients and oxygen to the developing fetus. Also, maternal hemoglobin has a greater affinity for carbon monoxide (found in cigarette smoke) than for oxygen. Thus, oxygen levels are lower in women who smoke. In turn, less oxygen is available to the developing fetus. There is a recognized association between maternal smoking and the incidence of preterm labor and premature rupture of membranes. These may be related to the decreased placental perfusion associated with smoking.
37. The experiences of hospitalization and surgery may have affected Katie in a number of ways. Her parents are made aware that these kinds of experiences often cause children of Katie's age to exhibit which of the following? (Select all that apply.)
A. Loss of some developmental milestones B. Uncooperative behavior
You teach Susan to expect which of the following breast changes as her pregnancy progresses? Select all that apply (there are 4 correct answers). A. Nipples will darken and become more erectile B. Blood vessels will become visible at the skin surface C. Striae gravidarum may appear D. Stretching may cause minor ulcerations to appear E. Liquid may be expressed from the nipples as pregnancy advances
A. Nipples will darken and become more erectile B. Blood vessels will become visible at the skin surface C. Striae gravidarum may appear E. Liquid may be expressed from the nipples as pregnancy advances Nipples darken during pregnancy due to the influence of the hormone, melonocyte stimulating hormone (MSH). Increased estrogen levels cause increased vascularity of the breasts, which may cause the nipples to be more erectile. Blood vessels in the breasts become more visible during pregnancy due to increased blood flow. Primigravidas may have more obvious venous congestion. Striae gravidarum, or stretch marks, may appear along the outer aspects of the breasts as enlargement occurs. During the first trimester, a precolostrum secretion may be present. Colostrum, the precursor to milk, is present in the breasts as early as the third month of gestation. Colostrum usually cannot be expressed until 16 weeks or later, but sometimes can be expressed sooner in women who have breastfed in the recent past. These breast secretions may be clear or creamy yellow-white in color.
23. You need to verify the accuracy of the prescribed drug doses. Your recent drug reference verifies that a loading dose of 50 mcg/kg Lanoxin (digoxin) in three divided doses is appropriate. Given Katie's weight of 4.4 kg, a loading dose of 220 mpg in three divided doses is:
A. Safe as ordered
Susan asks you, "How much is too much vomiting?" You advise Susan to call the clinic if she experiences which of the following? Select all that apply (there are 3 correct answers). A. She urinates less frequently than usual, and her urine becomes darker in color B. Her palms become reddened and itch C. She vomits blood or her throat becomes sore from vomiting D. She vomits everything she eats or drinks in a 24-hour period
A. She urinates less frequently than usual, and her urine becomes darker in color C. She vomits blood or her throat becomes sore from vomiting D. She vomits everything she eats or drinks in a 24-hour period With excessive vomiting, Susan could become dehydrated. With dehydration, the body would retain fluid as a compensatory measure, and urine output would decrease. Urine would also become more concentrated, and darker in color. It is appropriate that Susan be advised to report signs of dehydration. Vomiting blood and a very sore throat are significant. They could be the result of a tear in the mucosa of the esophagus, secondary to retching (dry heaves). Susan should seek medical attention immediately if these occur. A client who is unable to keep food or drink down for 24 hours, or is unable to stop vomiting, should be seen by her healthcare provider as soon as possible. Antiemetic medication and rehydration might be needed.
9. If Katie presented with cyanosis in the first days of life, which congenital heart defect would have been suspected?
A. Tetrology of Fallot (TOF)
You know that Lily is at risk for health problems associated with her pregnancy. Which of the following contribute to Lily's risk?
A. The fact that Lily has sought prenatal care late in her pregnancy; B. Lily's family history of hypertension; C. Lily's age of 17 years; E. Lily's low income level
After arriving on the postpartum unit, Lily wants to know if the nurses and doctors are still worried about her BP. The best response is:
A. The risk of high BP that occurs with preeclampsia can continue for a few days after delivery.
1. When the heart is examined, both the diaphragm and bell stethoscope pieces are used for auscultation. In general, the diaphragm is best for hearing high-pitched sounds, and the bell is most useful for hearing low-pitched sounds.
A. True
You need to decide on a room for Lily. Which labor adeliversy recovery (LDR) room placement would be most appropriate for Lily?
A. a room close to the nursing station
If you were the nurse caring for Lily, which of the following assessments would you consider important and incorporate into her care plan?
A. abdominal pain; B. presence of headache; C. Visual disturbances; D. deep tendon reflexes; F. level of consciousness; G. Edema
Theorists have identified three developmental tasks to be accomplished as the mother-child relationship evolves throughout pregnancy. You know that during this first trimester, Susan's developmental task is to: A. accept the biologic fact of pregnancy B. accept the fetus as distinct and separate from herself C. prepare realistically for parenting D. acknowledge that she will be a good mother
A. accept the biologic fact of pregnancy Acceptance of the biologic fact of pregnancy characterizes the first trimester. The pregnant woman needs to acknowledge "I am pregnant" as she accepts the immediate reality of the pregnancy itself.
Which of the following suggestions are appropriately made to Susan to help alleviate her symptoms? Select all that apply (there are 2 correct answers). A. Eat a large breakfast Eating a large meal in the morning would distend Susan's stomach and increase the likelihood of nausea and vomiting. Eating a large meal in the morning should be avoided. B. Eat small frequent meals throughout the day Correct Small, frequent meals are recommended for the pregnant woman who is experiencing nausea and vomiting. An empty stomach or one that is overloaded would increase the likelihood of nausea and vomiting. C. Eat dry toast or crackers before getting out of bed Correct Eating a dry carbohydrate, such as toast or crackers, before getting out of bed in the morning, often helps to prevent the nausea associated with "morning sickness." If nausea is present before rising, it is advisable to remain in bed after eating a dry carbohydrate until the feeling of nausea subsides. D. Drink plenty of fluids when nausea occurs Increasing fluids would not be useful in alleviating nausea. Fluids can distend the stomach, increasing nausea. Small amounts of fluid, alternated hourly with dry carbohydrates, may be helpful in alleviating nausea.
B. Eat small frequent meals throughout the day C. Eat dry toast or crackers before getting out of bed Small, frequent meals are recommended for the pregnant woman who is experiencing nausea and vomiting. An empty stomach or one that is overloaded would increase the likelihood of nausea and vomiting. Eating a dry carbohydrate, such as toast or crackers, before getting out of bed in the morning, often helps to prevent the nausea associated with "morning sickness." If nausea is present before rising, it is advisable to remain in bed after eating a dry carbohydrate until the feeling of nausea subsides.
5. Murmur intensity is graded using a classification system with six levels of intensity. The physician correctly grades Katie's murmur as:
B. Grade IV
7. Coarctation of the Aorta (COA) is characterized by pulses and pressures that may be abnormal. Pulse and pressure variations expected with COA include: (Select all that apply.)
B. Higher blood pressures on both upper limbs E. Bounding pulses in the upper extremities
In formulating a plan of care based on Susan's symptoms of nausea and vomiting, which of the following is determined to be an appropriate nursing diagnosis? A. Risk for Injury related to malnutrition B. Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting C. Imbalanced Nutrition: Less than Body Requirements related to inadequate knowledge of good nutrition D. Deficient Fluid Volume related to nausea and vomiting
B. Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting Susan's diet is lacking in caloric intake, protein, and calcium, substances deemed especially necessary during pregnancy. Because Susan is experiencing nausea and vomiting, she is likely to be eating less, and may often be "losing" what she eats. Imbalanced Nutrition: Less than Body Requirements related to nausea and vomiting is an appropriate nursing diagnosis for Susan.
36. Katie's parents are made aware that she needs antibiotics if dental visits of invasive procedures are required in the next six months. The antibiotics are needed to protect against:
B. Infective endocarditis
11. Infants with congenital heart defects often require surgical repair. After surgery, assessing for low cardiac output is critical. Which of the following assessments could be associated with a low cardiac output? (Select all that apply.)
B. Mottled skin D. Extremities cool to touch E. Decreasing blood pressure
28. Your nursing interventions should maximize Katie's cardiac functioning and help alleviate symptoms of congestive heart failure. Which of the following are important in achieving these goals? (Select all that apply.)
B. Promoting rest C. Providing frequent small feedings (when Katie is no longer NPO)
17. Katie wakes up as the nurse weighs her. She weighs 9 pounds 8 ounces (4.4 kg). Last week she weighed 8 pounds (3.6 kg). In analyzing this data, the nurse determines that this weight gain is:
B. Unexpected for a 6-week-old infant
Lily is receiving magnesium sulfate. Magnesium sulfate is:
B. a central nervous system depressant used to reduce the possibility of seizures
Susan mentions, "I've heard that it is normal to be a little anemic during pregnancy." You understand that Susan is probably referring to the "physiologic anemia of pregnancy." This is related to: A. a decrease in red blood cell production B. an increase in plasma volume in excess of an increase in red blood cells C. hemolysis of maternal red blood cells by fetal antibodies that cross the placenta
B. an increase in plasma volume in excess of an increase in red blood cells During pregnancy, Susan's plasma volume will increase by 50%, but her red blood cells will increase only by 18-30%, depending on whether or not she takes iron supplements. This results in hemodilution, with a corresponding decrease in normal hemoglobin and hematocrit values. This is often referred to as the "physiologic anemia of pregnancy" or the "hemodilution of pregnancy."
After analyzing Susan's responses, you explain that feelings of ambivalence about pregnancy: A. are normal for fathers, but not for mothers B. are common among expectant mothers and fathers C. suggest an increased risk for future child abuse
B. are common among expectant mothers and fathers Ambivalence is a common response to pregnancy for both parents, even when the pregnancy is desired. Such feelings are usually resolved as the second trimester begins, but may persist throughout pregnancy.
You discuss the signs of "true labor" with Susan. You recognize that your teaching has been effective when Susan describes "true labor" contractions as: Select all that apply (there are 2 correct answers). A. contractions that begin in the abdomen and radiate to the back B. contractions that intensify with walking or position change C. contractions that become more regular as time goes by
B. contractions that intensify with walking or position change C. contractions that become more regular as time goes by Contractions that become more intense with walking or position change are typically associated with true labor. Contractions that become more regular with time and increase in intensify, frequency, and duration are typically associated with true labor.
During Susan's pelvic examination, a bluish discoloration of the cervix and vaginal mucosa is observed. This is a sign of pregnancy and is documented as _____________.
Chadwick's sign
22. You notice that Austin becomes agitated after his nebulizer treatment. You also determine that his pulse rate increases. Which of the following is indicated?
Continue to monitor and document Austin's response to nebulizer treatments
During Susan's last trimester, she and John attend childbirth preparation classes. These classes are intended to teach expectant parents that: Select all that apply (there are 3 correct answers). A. analgesics will not be needed during labor and delivery if breathing and relaxation techniques are used B. fear, tension, and pain during labor and delivery can be reduced and dealt with effectively C. understanding of the labor and delivery process can enhance participation and control during labor and delivery D. perception of painful uterine contractions during labor and delivery can be altered through relaxation and breathing
B. fear, tension, and pain during labor and delivery can be reduced and dealt with effectively C. understanding of the labor and delivery process can enhance participation and control during labor and delivery D. perception of painful uterine contractions during labor and delivery can be altered through relaxation and breathing Fear, tension, and pain during labor and delivery can usually be reduced or controlled with effective use of relaxation and breathing techniques and analgesics, if needed. Understanding the labor and delivery process enables mothers (and coaches) to participate more effectively in measures designed to facilitate the natural course of labor and delivery. Informed mothers (and coaches) also tend to participate more cooperatively with staff members assisting with labor and delivery. Perception of painful uterine contractions can be altered with effective use of relaxation and breathing techniques. Distraction is also an important component of this process.
Which of the following should be available in Lily's room to insure her safety?
B. oxygen; D. suction equipment
20. Frank stays with Maria for a few minutes, then goes to the Nursery, where Frank Jr. is having his blood drawn by heel stick. Which of the following laboratory tests is most important for Frank Jr. this soon after birth?
Blood glucose It is essential that Frank Jr.'s glucose level be checked immediately after birth, and every hour for the next three hours. Infants of diabetic mothers may experience neonatal hypoglycemia (plasma glucose less than 40 mg/dl), especially in the 1-3 hour period after birth. High levels of insulin are still produced by the infant after birth in anticipation of high glucose levels that were present in utero. Neonatal hypoglycemia requires early identification and prompt intervention. Generally, capillary blood is drawn via a heel stick.
You instruct Susan about taking her daily iron supplement. Which of the following statements should be included in the teaching session? Select all that apply (there are 2 correct answers). A. "Take the iron supplement first thing in the morning to avoid gastrointestinal discomfort." B. "Drink a glass of milk along with your iron supplement." C. "Increase your intake of citrus fruits and juices." D. "If tolerated, take the iron supplement on an empty stomach."
C. "Increase your intake of citrus fruits and juices." D. "If tolerated, take the iron supplement on an empty stomach." Iron absorption is enhanced when intake of Vitamin C is increased. Citrus fruits and juices, tomatoes, melons, and strawberries are all high in Vitamin C and should be encouraged when iron supplements are prescribed. Absorption is optimal when an iron supplement is taken on an empty stomach. Pregnant women taking iron supplements should be encouraged to take supplements on an empty stomach, provided gastrointestinal distress is not a problem.
You advise Susan that an appropriate weight gain during pregnancy based on her weight and height would be: A. 15 pounds (7 kg) B. 15 - 25 pounds (7 - 11.5 kg) C. 25 - 35 pounds (11.5 - 16 kg) D. 28 - 40 pounds (12.5 - 18 kg)
C. 25 - 35 pounds (11.5 - 16 kg) An appropriate weight gain during pregnancy for Susan, who is normal weight for her height, would be 25-35 pounds (11.5 - 16 kg). For a woman who is underweight, an appropriate weight gain would be 28-40 pounds (12.5 - 18 kg). For a woman determined to be overweight, an appropriate weight gain would be 15-25 pounds (7 - 11.5 kg). For a woman who is obese, an appropriate weight gain during pregnancy would be at least 15 pounds (7 kg).
Which of the following would you recognize as a sign of abruptio placentae?
C. Abdominal pain with no palpable relaxation between contractions
26. Many of the infants and children you care for take Lanoxin (digoxin). If you prepared to administer Lanoxin (digoxin) to an awake newborn with congestive heart failure, and determined that the apical pulse rate was 140 beats per minute (last recorded rate was 150), what would you do?
C. Administer the Lanoxin (digoxin) as ordered
12. Katie's parents are made aware of her Ventricular Septal Defect (VSD) diagnosis. Katie's mother immediately begins to cry. Katie's father, who is standing beside his wife, does not respond. Which of the following would be most therapeutic?
C. Allow Katie's mother to cry and place your hand on her arm to comfort her
21. After applying a nasal cannula and starting oxygen, you insert an IV line and administer 8 mg Lasix (furosemide) IV push. Lasix (furosemide) is ordered for Katie to:
C. Decrease the workload of her heart
Adolescents frequently avoid seeking early prenatal care. Factors associated with this include the adolescent's:
C. Denial of pregnancy; D. Lack of trust in the healthcare system; E. Inability to pay for medical care
The HELLP syndrome is a severe complication of preeclampsia that can occur in Lily, even in her post-delivery period. This complication is characterized by:
C. elevated AST and ALT levels; D. right upper quadrant pain; E. decreased hemoglobin; F. increased bilirubin level; G. thrombocytopenia
You care for many pregnant clients and are alert for signs and symptoms of preeclampsia. You know that the major manifestations of preeclampsia are caused by:
C. multisystem vasoconstriction
The nurse caring for Lily in the LDR room needs to be alert for which of the following complications?
C. postpartum hemorrhage
You appropriately reassure Lily and her grandmother that the purpose of Lily's admission to the hospital is to:
C. prevent the development of complications associated with preeclampsia
6. You go on to explain that the inadequate supply of insulin seen with diabetes interferes with the metabolism and utilization of __________, the body's preferred source of fuel.
Carbohydrates Carbohydrates are the body's preferred source of fuel. When energy needs are not met by carbohydrates, stores of fat and protein are used, in severe cases resulting in ketoacidosis.
Susan has been monitored for 15 min. Which of the following actions on your part is indicated?
Continue to monitor the fetal heart rate
Susan is curious about when she should gain all this weight. Your response is based on the concept that: A. primigravidas should gain two pounds (0.9 kg) per week throughout pregnancy B. most women gain more than half their weight by the end of the first trimester C. amount of weight gain is more critical than the pattern of weight gain D. 2-5 pounds (0.9 - 2.3 kg) should be gained in the first trimester, then an average of one pound per week thereafter
D. 2-5 pounds (0.9 - 2.3 kg) should be gained in the first trimester, then an average of one pound per week thereafter The recommended pattern of weight gain during pregnancy is 2-5 pounds (0.9 - 2.3 kg) during the first trimester, and an average of one pound (0.5 kg) per week during the second and third trimesters. The developing fetus increases in size more dramatically during the second and third trimesters. Poor weight gain during the first trimester is associated with an increased risk of a small-for-gestational age (SGA) infant. Poor weight gain in the last half of pregnancy is associated with increased risk for preterm delivery.
35. During Katie's second postoperative day, she is less sedated and more awake. Determining if Katie has pain is a priority. Which of the following techniques is best for assessing whether or not Katie has pain?
D. Have Katie use the Wong-Baker FACES Pain Rating Scale
10. Yesterday, you took care of Tom, a 15-month old toddler with Tetrology of Fallot (TOF). When blood was taken, he became upset and started to struggle and cry. His color turned blue, and his respiratory rate increased to 44 breaths per minute. Your initial action was correct. This was to:
D. Place Tom in the knee-chest position
2. You made the judgment that Austin's breathing is labored, based on a quick observation. Which of the following, when observed in an infant, is a sign of labored breathing?
Grunting with inspiration
Which of the following statements by Lily would best demonstrate that she understood the reason for her hospitalization and treatment?
If I rest on my left side, more blood will go to my baby and my blood pressure will go down
Susan knows to notify her care provider immediately if she suspects her membranes have ruptured. This is important due to the increased risk of ___________________ with ruptured membranes.
Infection
12. Because Ashley is not currently participating in any high-risk behaviors, you should:
Initiate a discussion of high-risk behaviors and their consequences, in hope of preventing them
22. He then does an abdominal exam on Sarah, using the techniques of inspection, palpation, percussion, and auscultation. In which order are these techniques implemented?
Inspection, auscultation, percussion, and palpation
23. Given Maria's gestational diabetes, what can be anticipated after delivery?
Insulin requirements can be expected to decrease Insulin requirements decrease after the client with gestational diabetes gives birth. Placental hormones such as human placental lactogen (hPL), which promoted insulin resistance, begin to decline shortly after delivery of the placenta.
21. Frank Jr.'s blood glucose is 38 mg/dl, which is slightly low. The nurse taking care of Frank Jr. should proceed to:
Notify the pediatrician and prepare to administer a formula or breast-milk feeding A glucose reading below 40 mg/dl is considered low and it would be appropriate for the nurse to report this finding to the pediatrician. A feeding of formula or breast milk is usually given to increase blood glucose.
16. When admitted to the obstetrical unit, Maria's glucose level is 130 mg/dl. You notify the obstetrician, anticipating that which of the following may be ordered?
Regular insulin subcutaneously The stress of labor has caused Maria's glucose level to increase, and it is likely that levels will tend to be high and fluctuate throughout labor and delivery. Regular insulin, with an onset of action of 30-60 minutes, and a peak action of 2-5 hours, is considered a short-acting insulin. Administered subcutaneously, it can quickly lower glucose level as needed. Throughout labor, it will be administered on a sliding scale.
To evaluate the effectiveness of racemic epinephrine treatment, which of the following assessments is most pertinent?
Respiratory rate
As Joey's antibiotic is infusing, a care plan is started. Which of the following apply?
Risk for fear Activity intolerance Potential Complication: Acute Hypoxia
1. One of your responsibilities today is obtaining an initial health history for Jason. You know that a health history gather ______ data.
Subjective
Susan's current vital signs are BP 110/70, P 80. Comparing them to baseline vital signs (BP 118/74, P 68) recorded during Susan's first visit, which of the following do you determine? A. Susan's vital signs are considered normal B. Susan's vital signs are considered abnormal
Susan's vital signs are considered normal During pregnancy, increases in blood volume, cardiac A. output, and basal metabolic rate cause changes in vital signs. Normal increases in heart rate up to 10-15 beats per minute can be expected during the second trimester. Blood pressure usually remains at prepregnancy levels during the first trimester. During the second trimester, BP decreases by 5-10 mm Hg, probably due to peripheral vasodilation caused by hormones of pregnancy. In the third trimester, blood pressure should approximate readings from the first trimester. Slight cardiac hypertrophy and grade II systolic ejection murmurs are also common, due to increases in blood volume and cardiac output.
6. Referring to Tanner's stages, Ashley's sexual maturity (breasts) is rated as:
Tanner stage 2
7. Ashley's exam also includes assessment of pubic hair distribution. A small amount of fine straight hair is noted along her labia. Referring to Tanner's stages, Ashley's sexual maturity (pubic hair) is rated as:
Tanner stage 2
28. Before Mrs. Deakin leaves the office, she mentions that Sarah started having temper tantrums recently. She wants to know if these are normal. You correctly advise Mrs. Deakin that:
Temper tantrums are common and normal in toddlers
