HESI PRACTICE FAMILY HEALTH
The nurse understands that in a child with cystic fibrosis (CF) which vitamin absorption is impaired? Select all that apply. 1.A 2.B 3.C 4.D 5.E
1, 3, 4, 5 ALL
A newborn infant is jaundiced due to Rh incompatibility. Which finding is most important for the nurse to report to the healthcare provider? 1. Bilirubin 2. Hemoglobin 3. Bruising 4. Oral intake
1. Bilirubin
You are teaching a family with a child who has cystic fibrosis (CF) about chest physiotherapy treatment (CPT). Which of the following teaching points are correct to include? SATA 1. It should be performed three to four times a day. 2 .It may cause bronchospasm. 3. It is all right to percuss over the spine or internal organs. 4 .When manually percussing you should use a cupped hand. 5. CPT can be done at any time including after eating.
1. It should be performed three to four times a day. 2 .It may cause bronchospasm. 4 .When manually percussing you should use a cupped hand.
Which child does the nurse anticipate to be most at risk for being hospitalized for respiratory syncytial virus (RSV)? 1.A three-month-old who was born at 30 weeks gestation 2.A 18-month-old with a tracheostomy 3.A four-year-old with a ventricular septal defect (VSD) 4.A five-year-old who was term but has never received any immunizations
1.A three-month-old who was born at 30 weeks gestation
Which should the nurse expect to be included in the treatment of the client experiencing acute asthma symptoms? Select all that apply. 1.Bronchodilators 2.Corticosteroids 3.Oxygen 4.Montelukast (Singular) 5.Immediate Intubation
1.Bronchodilators 2.Corticosteroids 3.Oxygen
Which indicates the earliest sign of hemorrhage in a child who has just had a tonsillectomy? 1.Frequent swallowing 2.Labored respirations 3.Tachypnea stridor 4.Dark brown emesis
1.Frequent swallowing
Which are signs and symptoms of respiratory distress in a two-month-old? Select all that apply. 1.Nasal flaring 2.Intercostal retractions 3.Coughing 4.Bronchovesicular lung sounds 5.Grunting
1.Nasal flaring 2.Intercostal retractions 5.Grunting
The nurse is assessing a client who is having a non-stress test (NST) at 41-weeks gestation. The nurse determines that the client is not having contractions, the fetal heart rate (FHR) baseline is 144 bpm, and no FHR accelerations are occurring. What action should the nurse take? 1. Check the client for urinary bladder distention 2 .Ask the client if she has felt any fetal movement 3.Have the mother stimulate the fetus to move 4.Notify the healthcare provider of the non reactive results
2 .Ask the client if she has felt any fetal movement
The nurse is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (select all thatapply) 1.Litmus paper 2.A sterile glove 3.A doppler 4.Sterile vaginal speculum 5.Fetal scalp electrode 6.An amniotic hook
2,3,6 2.A sterile glove 3.A doppler 6.An amniotic hook
Which client finding should the nurse document as a positive sign of pregnancy? 1. Last menstrual cycle occurred 2 months ago 2. Fetal heart tones heard with a doppler 3. Presence of braxton hicks contractions 4. A urine sample with a positive pregnancy test.
2. Fetal heart tones heard with a doppler
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. What action should the nurse take? 1. Check the client's blood pressure and fetal heart rate 2. Have the client breathe into her cupped hands 3. Notify the healthcare provider of the client's symptoms 4. Administer oxygen by face mask
2. Have the client breathe into her cupped hands
A child with chronic otitis media has bilateral myringotomy tubes placed. Which statement would indicate that the parent understands education about myringotomy tubes? 1."The tubes have to be surgically removed in 9 months or so." 2."The tubes were placed to equalize pressure." 3."These tubes won't affect my child being able to go swimming in the summer." 4."My child will still need to be on Amoxicillin prophylactically for six months."
2."The tubes were placed to equalize pressure."
2. A client in active labor at 39 weeks gestation tells the nurse she feels a wet saturation on the perineum. The nurse notices pale, straw-colored fluid with small white particles. After reviewing the fetal monitor strip for fetal distress, what action should the nurse implement? 1.Clean the perineal area 2.Perform a nitrazine test 3.Escort the client to the bathroom 4.Offer the client a bed pan
2.Perform a nitrazine test
A woman who gave birth 48 hours ago is bottle feeding her infant. During assessment, the nurse determines that both breasts are swollen, warm and tender upon palpation. What action should the nurse take? 1. Wear a loose fitting bra to prevent nipple irritation 2. Express small amounts of milk to relieve pressure 3. Apply cold compresses to both breasts for comfort 4. Instruct the client run warm water on her breasts
3. Apply cold compresses to both breasts for comfort
The nurse notes a pattern of the fetal heart rate deceasing after each contraction. What action should the nurse implement? 1. Prepare for an emergency cesarean section 2. Give 10 liters of oxygen via face mask 3. Continue to monitor the fetal heart rate pattern 4. Obtain an oral maternal temperature
3. Continue to monitor the fetal heart rate pattern
the nurse is giving discharge instructions for a client following a suction curettage for hydatidiform mole. The client asks why oral contraceptives are being recommended for the next 12 months. What information should the nurse provide? 1. Molar reoccurrences are higher if conception occurs within 1 year after an initial mutation 2. Pregnancy within 1 year decreases the chances of a future successful pregnancy 3. Oral contraceptives prevent a reoccurrence of a molar pregnancy 4. Diagnostic testing for human chorionic gonadotropin (hCG) levels are elevated by pregnancy
3. Oral contraceptives prevent a reocurrence of a molar pregnancy
The nursing student asks the nurse about genetic implications related to cystic fibrosis (CF). How should the nurse respond? 1."It is inherited as an autosomal dominant trait." 2."It is a genetic defect found primarily in non-Caucasian people." 3."If it is present in a child, both parents are carriers of the defective gene." 4."There is a 50% chance the siblings of an affected child will also be affected."
3."If it is present in a child, both parents are carriers of the defective gene."
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessment the nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? 1.Observe maternal vital signs 2.Document the color of the lochia 3.Assist the client to the bathroom 4.Notify the healthcare provider
3.Assist the client to the bathroom
A 4-week-old premature infant has been receiving epoetin alfa (Epogen) for the last three weeks. Which assessment finding indicates to the nurse that the drug is effective? 1.Slowly increasing urinary output over that last week 2.Respiratory rate changes from the 40s to the 60s 3.Changes in apical heart rate from the 180s to the 140s 4.Change in indirect bilirubin from 12 mg/dL to 8 mg/dL
3.Changes in apical heart rate from the 180s to the 140s
The nurse is planning for the care of a 30-year old primigravida with pre-gestational diabetes. What is the most important factor affecting this client's pregnancy outcomes? 1. Amount of insulin required prenatally 2. Mother's age 3. Number of years since diabetes was diagnosed 4. Degree of glycemic control during pregnancy
4. Degree of glycemic control during pregnancy
A four-year-old is presented to the urgent care center with a history of a sudden onset of a severe sore throat. He began drooling and has difficulty swallowing. The temperature is 102.2F (39.0C). Lung sounds are clear and there is no cough. The child is very anxious and flushed and is leaning forward in a tripod position. Based on these symptoms, the nurse anticipates a diagnosis of: 1.Acute Asthma Attack 2.Laryngotracheomalacia 3.Acute laryngotracheobronchitis (Croup) 4.Acute Epiglottitis
4.Acute Epiglottitis
The nurse is preparing a plan of care for a child with sickle cell crisis who will be admitted to the nursing unit. The nurse would include which intervention as a priority in the plan of care for the child? A. Initiate an intravenous (IV) line for the administration of fluids. B. Consult with the psychiatric department regarding genetic counseling. C. Call the blood bank and request preparation of a unit of packed red blood cells. D. Call the respiratory department to prepare for intubation and mechanical ventilation.
A. Initiate an intravenous (IV) line for the administration of fluids. The priorities in management of sickle cell crisis are hydration therapy and pain relief.
A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet? A Carrots B Chicken C Yogurt DCheese
B- Chicken the need for folic acid in the first quarter and animal meat is the first source, after dairy products, in the anemias section only specifies what we already know when it is not pathological, the most frequent are iron or folic acid deficiency
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents? A. Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged B, The chorea or movements are temporary and will eventually disappear C. Permanent life-style changes need to be made to promote safety in the home D. Consistent discipline is needed to help the child control the movements
B- The chorea or movements are temporary and will eventually disappear
The nurse should encourage the laboring client to begin pushing when A.there is only an anterior or posterior lip of cervix left. B.the client describes the need to have a bowel movement. C.the cervix is completely dilated. D.the cervix is completely effaced.
C.the cervix is completely dilated.
the nurse suspects that an adolescent have anorexia nervosa. Which characteristics may have been observed in the adolescent? A. Denying illness B. Dismissing food C. Seeking intimacy D. Being extroverted E. Maintaining rigid body control
Denying illness, dismissing food, maintaining rigid body control
The nurse is performing a routine assessment of a 3-year old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for a possible autistic spectrum disorder? a. Performs odd repetitive behaviors b. Shows indifference to verbal stimulation c. Strokes the hair of a hand held doll d. Has a history of temper tantrums
a. Performs odd repetitive behaviors
A mother brings her 8 mo. old baby boy to clinic bc he has been vomitting and had diarrhea for last 3 days. Which assessment is most important for nurse to make? a. Assess infant abdomen for tenderness b. Determine if the infant was exposed to a virus c. Measure the infant's pulse d. Evaluate the infant's cry
c. Measure the infant's pulse
the nurse has completed a teaching plan for the mother of a child who is taking digitalis and a diuretic for treatment of the heart failure. Choosing which lunch would indicate that the mother understands the best diet for her child?
peanut butter and banana sandwich with orange juice
The nurse is assessing a full-time newborns's breathing pattern. Which findings should the nurse assess further? (select all that apply) 1.Diaphragmatic with chest retraction 2.Heart rate of 158 beats per minute 3.Chest breathing with nasal flaring 4.Abdominal with synchronous chest movements 5.Grunting heard with a stethoscope 6.Shallow with an irregular rhythm
1. diaphragmatic with chest retraction 3 chest breathing with nasal flaring 5 grunting heard with stethoscope
When assessing the integument of a 24 hour old newborn, the nurse notes a pink papular rash with superimposed vesicles on the thorax, back and abdomen. What action should the nurse implement next? 1. document the finding as erythema toxicum 2. Notify the healthcare provider immediately 3. Obtain a culture from one of the vesicles 4. Move the newborn to an isolated nursery
1. document the finding as erythema toxicum
What action should the nurse implement to decrease the client's risk for hemorrhage after a cesarean section? 1. Give the Ringer's Lactated infusion at 125 mL/hr 2. Monitor urinary output via an indwelling catheter 3. Check the firmness of the uterus every 15 minutes 4. Assess the abdominal dressings for drainage
3. Check the firmness of the uterus every 15 minutes
A full-term infant is admitted to the newborn nursery and, after careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms is this newborn likely to have exhibited? 1. Scaphoid abdomen and anorexia 2. Apneic spells and grunting 3. Choking, coughing and cyanosis 4. Projectile vomiting and cyanosis
3. Choking, coughing and cyanosis 3 Cs
A gravid client develops maternal hypotension following regional anesthesia. What intervention(s) should the nurse implement? Select all the apply. 1. Administer oxygen 2. Assist the client to a sitting position 3. Monitor fetal status 4. Place the client in a lateral position 5. Increase IV fluids 6. Perform a vaginal examination
1. Administer oxygen 3. Monitor fetal status 4. Place the client in a lateral position 5. Increase IV fluids
The nurse is teaching a woman how to use her basal body temperature (BBT) pattern as a tool to assist her in conceiving a child. Which temperature pattern indicates the occurrence of ovulation, and therefore, the best time for intercourse to ensure conception? 1. Between the time the temperature falls and rises 2. Between 36 and 48 hours after the temperature rises 3. WIthin 72 hours before the temperature falls 4. When the temperature falls and remains low for 36 hours
1. Between the time the temperature falls and rises
A client at 28 weeks gestation calls the antepartal clinic and states that she is experiencing a small amount of vaginal bleeding which she describes as bright red. She further states that she is not experiencing any uterine contractions or abdominal pain. What instruction should the nurse provide? 1. Come to the clinic today for an ultrasound 2. Lie on your left side for about one hour and see if the bleeding stops 3. Go immediately to the emergency room 4. Bring a urine specimen to the lab tomorrow to determine if you have a urinary tract infection
1. Come to the clinic today for an ultrasound
A primigravida at 12 weeks gestation who just moved to the United States indicates she has not received any immunizations. Which Immunization(s) should the nurse administer at this time? Select all that apply. 1. Hepatitis B 2. Chickenpox 3. Rubella 4. Tetanus 5. Diptheria
1. Hepatitis B 4. Tetanus 5. Diptheria
At 14 weeks gestation, a client arrives at the Emergency Center complaining of a dull pain in the right lower quadrant of her abdomen. The nurse obtains a blood sample and initiates an IV. Thirty minutes after admission, the client reports feeling a sharp abdominal pain and a shoulder pain. Assessment findings include diaphoresis, a heart rate of 120 beats/minute, and a blood pressure of 86/48/ Which action should the nurse implement next? 1. Increase the rate of IV fluids 2. Check the hematocrit results 3. Administer pain medication 4. Monitor the client for contractions
1. Increase the rate of IV fluids
The nurse is interviewing a newly pregnancy client who is 16-years old. Which client statement indicates teaching is necessary for a safe pregnancy? (Select all that apply.)
"I hate milk." "I only want to gain 10 pounds." "I refuse to wear maternity clothes."
A 15-month-old is admitted to the pediatric unit with a history of a recent upper respiratory infection. Which symptom is consistent with the diagnosis of laryngotracheobronchitis (croup)? Select all that apply. 1.Reported inspiratory stridor which is worse at night. 2.Suprasternal retractions are present upon examination. 3.The toddler has a barking, seal-like, harsh cough. 4.Lung sounds have inspiratory wheezing. 5.Lung sounds with crackles in the bases bilaterally.
1, 2, 3
Which procedure evaluates the effect of fetal movement on fetal heart activity? 1.Contraction test 2.Sonography 3.Biophysical profile 4.Non-stress test (NST)
4.Non-stress test (NST)
A client is experiencing "back" labor and complains of intense pain in the lower lumbar-sacral area. What action should the nurse implement? 1. Perform effleurage on the abdomen 2. Encourage pant-blow breathing techniques 3. Apply counterpressure against the sacrum 4. Assist the client in guided imagery
3. Apply counterpressure against the sacrum
A multiparous client delivered a 7 lb 10 oz infant 5 hours ago. Upon fundal assessmenT, The nurse determines the uterus is boggy and is displaced above and to the right of the umbilicus. Which action should the nurse implement next? 1. Observe maternal vital signs 2. Document the color of the lochia 3. Assist the client to the bathroom 4. Notify the healthcare provider
3. Assist the client to the bathroom
One hour after giving birth to an 8-pound infant, a client's lochia rubra has increased from small to large and her fundus is boggy despite massage. The client's pulse is 84 beats/minute and blood pressure is 156/96. The healthcare provider prescribes Methergine 0.2 mg IM × 1. What action should the nurse take immediately? 1. Have the client empty her bladder and massage the fundus 2. Give the medication as prescribed and monitor for efficacy 3. Call the healthcare provider to question the prescription 4. Encourage the client to breastfeed rather than bottle feed
3. Call the healthcare provider to question the prescription Methergine is contraindicated for clients with elevated blood pressure, so the nurse should contact the healthcare provider and question the prescription
A client at 28 weeks gestation experiences blunt abdominal trauma. Which parameter should the nurse assess first for signs of internal hemorrhage? 1. Vaginal bleeding 2. Complaints of abdominal pain 3. Changes in the fetal heart rate pattern 4.Alteration in maternal blood pressure
3. Changes in the fetal heart rate pattern
A client with no prenatal care arrives at the labor unit screaming, "The baby is coming!" The nurse performs a vaginal examination that reveals the cervix is 3 centimeters dilated and 75% effaced. What additional information is most important for the nurse to obtain? 1. Gravidity and parity 2. Frequency and intensity of contractions 3. Date of last normal menstrual period 4. Time and amount of last oral intake
3. Date of last normal menstrual period] Evaluating the gestation of the pregnancy
The nurse is caring for a woman with previously diagnosed heart disease who is in the second stage of labor. Which assessment findings are of greatest concern? 1. Increased urinary output and tachycardia 2. Shortness of breath, bradycardia and hypertension 3. Edema, basilar rales, and an irregular pulse 4. Regular heart rate and hypertension
3. Edema, basilar rales, and an irregular pulse
A 40 week gestation primigravida client is being induced with an oxytocin (Pitocin) secondary infusion and complains of back pain in her lower back. Which intervention should the nurse implement? 1. Discontinue the oxytocin (Pitocin) infusion 2. Inform the healtcare provider 3. Place the client in a semi-Fowler position 4. Apply firm pressure to sacral area
4. Apply firm pressure to sacral area
A nulliparous client telephones the labor and delivery unit to report that she is in labor. What action should the nurse implement? 1. Emphasize that food and fluid intake should stop 2. Tell the woman to stay home until her membranes rupture 3. Suggest the client to come to the hospital for labor evaluation 4. Ask the client to describe why she thinks she is in labor
4. Ask the client to describe why she thinks she is in labor
A client with gestational hypertension is in active labor and receiving an infusion of magnesium sulfate. Which is the most important drug the nurse should have available for signs of potential toxicity? 1. Naloxone (Narcan) 2. Oxytocin (Pitocin) 3. Terbutaline (Brethine) 4. Calcuim gluconate
4. Calcuim gluconate
The nurse is assessing the umbilical cord of a newborn. Which finding constitutes a normal finding? 1. Three vessels, two veins and one artery 2. Two vessels, one artery and one vein 3. Two vessels, two arteries and no veins 4. Three vessels, two arteries and one vein
4. Three vessels, two arteries and one vein
A 42 week gestational client is receiving an intravenous infusion of oxytocin (Pitocin) to augment early labor. Which pattern of contractions should alert the nurse to discontinue the oxytocin infusion? 1.Early labor with contractions every 5 minutes lasting 40 seconds each 2.Active labor with contractions every 31 minutes lasting 60 seconds each 3.Active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each 4.Transition labor with contractions every 2 minutes lasting 90 seconds each
4. Transition labor with contractions every 2 minutes lasting 90 seconds each
A client in early labor is having uterine contractions every 3 to 4 minutes, lasting an average of 55 to 60 seconds. An internal uterine pressure catheter is inserted. The intrauterine pressure is 65 to 70 mmHg at the peak of a contraction and the resting tone is 6 to 10 mmHg. Based on this information, what action should the nurse implement. 1.Notify the client's healthcare provider 2.Bring the delivery table to the room 3.Prepare to administer an oxytocic 4.Document the finding in the client record
4.Document the finding in the client record
A client who delivered an infant an hour ago tells the nurse that she feels wet underneath her buttock. The nurse notes that both perineal pads are completely saturated and the client is lying in a 6-inch diameter pool of blood. Which action should the nurse implement next? 1.Inspect the perineum for lacerations 2.Obtain a blood pressure 3.Cleanse the perineum 4.Palpate the firmness of the fundus
4.Palpate the firmness of the fundus
A client at 35 weeks gestation visits the clinic for a prenatal check-up. Which complaint by the client warrants further assessment by the nurse? 1.Shortness of breath when climbing stairs 2.Backache with prolonged standing 3.Ankle edema in the afternoon 4.Periodic abdominal pain
4.Periodic abdominal pain
. What action should the nurse implement when caring for a newborn receiving phototherapy? 1.Apply an oil-based lotion to the skin 2.Reposition every 6 hours 3.Limit the intake of formula 4.Place an eyeshield over the eyes
4.Place an eyeshield over the eyes
What action should the nurse implement to prevent conductive heat loss in a newborn? 1.Place the infant under a radiant warming system .2 Dry the newborn with a warmed blanket 3.Position the crib away from the windows 4.Put a blanket on the scale when weighing the infant
4.Put a blanket on the scale when weighing the infant
When explaining "postpartum blues" to a client who is 1 day postpartum, which symptoms should the nurse include in the teaching plan? (Select all that apply.) 1.Panic attacks. 2.Disinterest in the infant. 3.Decreased need for sleep. 4.Tearfulness. 5.Mood swings.
4.Tearfulness. 5.Mood swings.
The nurse is performing a AGA on a full-term newborn during the first hour of transition using the Dubowitz scale. Based on this assessment, the nurse determines that the neonate has a maturity rating of 40 weeks. Which findings should the nurse identify to determine if the neonate is SGA? (Select all that apply.) a. admission weight of 4 lbs 15 oz b. head to heel length of 17 in c. frontal occipital circumference of 12.5 in d. skin smooth with visible veins and abundant vernix e. anterior plantar crease and smooth heel surfaces f. full flexion of all extremities in resting supine position
A,B,C
A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client's nursing care plan? A- Keep airway equipment at the bedside. B- Allow liberal family visitation C- Monitor blood pressure, pulse, and respirations q4h D- Assess temperature q1h
A- Keep airway equipment at the bedside.
The nurse is caring for a one-year-old child following surgical correction of hypospadias. What nursing action has the highest priority? A- Monitor urinary output B- Auscultate bowel sounds C- Observe appearance of stool D-Record percent of diet eaten
A- Monitor urinary output
The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) ask "how can our son have this disease? We are wondering if we should have any more children" What information should the nurse provide these parents? A-This is an inherited X-linked recessive disorder, which primarily affects male children in the family B-The male infant had a viral infection that went unnoticed and untreated, so muscle damage was incurred C-The XXXX muscle groups of males can be impacted by a lack of the protein dystrophin in the mother D-Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles
A-This is an inherited X-linked recessive disorder, which primarily affects male children in the family
The parents of a gifted child note that their child has been showing signs of rebellion and acting out. Which is one important thing to teach the parents about gifted children? A. They need boundaries like any other child B. Intense emotions require an outlet C. All discipline models approve physical aggression D. Gifted children should be allowed to freely express themselves
A. They need boundaries like any other child
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time? A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely. B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips. C. Her arms and hands receive the infant and she then cuddles the infant to her own body. D. She eagerly reaches for the infant and then holds the infant close to her own body.
B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? A. Obtain a culture of any sputum or wound drainage. B. Initiate normal saline IV at 50 ml/hr C. Administer a loading dose of penicillin IM D. Administer the initial dose of folic acid PO
B. Initiate normal saline IV at 50 ml/hr
A 28 year old client in active labor complains of cramps in her leg. What intervention should the nurse implement? a. massage the calf and foot b. extend the leg and dorsiflex the foot c. lower the leg off the side of the bed d. elevate the leg above the heart
b. extend the leg and dorsiflex the foot
The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement? A- Begin a training program lifting weights and running B- Splint affected joints during activity C- Exercise in a swimming pool D- Perform passive range of motion exercises twice daily
C- Exercise in a swimming pool
The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug? a- Respiratory rate of 22 breaths/min b- A large amount of lochia rubra c- Blood pressure 149/90 d- Positive Homan's sign
C- blood pressure 149/90
.The nurse assessing a 9-year-old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? A-Back pain for a few days B-A history of hypertension C-A sore throat last week D-Diuresis during the nights
C-A sore throat last week
A full term infant is transferred to the nursery from labor and delivery. Which information is most important for the nurse to receive when planning immediate care for the newborn? a. length of labor and method of delivery b. infant's condition at birth and treatment received c. feeding methods chosen by the parents d. history of drugs given to the mother during labor
b. infant's condition at birth and treatment received
During a well-child visit for their child, one of the parents who has an autosomal dominant disorder tells the nurse, "We don't plan on having any more children, since the next child is likely to inherit this disorder". How should the nurse respond? A- Explain that the risk of inheriting the disorder decrease by 50% with each child the couple has B- Acknowledge that the next that the next child will inherit the disorder since the first child did not C-Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked D- Confirm that there is a 50% chance of their future children inheriting the disorder
D- Confirm that there is a 50% chance of their future children inheriting the disorder
A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? A-Pain level B- Blood pressure C- Infusion site D- Contraction pattern
D- Contraction pattern
During a prenatal visit, the nurse discusses with a client the effects of smoking on the fetus. When compared with nonsmokers, mothers who smoke during pregnancy tend to produce infants who have a. lower apgar scores b. lower birth weights c. respiratory distress d. a higher rate of congenital anomalies
b. lower birth weights
The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12-year-old sibling at the child's bedside. Which instruction best supports family? A-While waiting for the healthcare provider, only one visitor may stay with the child B-All of you should leave while the healthcare provider sutures the child's forehead C-It is best if the sibling goes to the waiting room until the suturing is completed D-Please decide who will stay when the healthcare provider begins suturing
D-Please decide who will stay when the healthcare provider begins suturing
Twenty-four hours after admission to the newborn nursery, a full-term male infant develops localized edema on the right side of his head. The nurse knows that, in the newborn, an accumulation of blood between the periosteum and skull which does not cross the suture line is a newborn variation known as a. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks. b. a subarachnoid hematoma, which requires immediate drainage to prevent further complications c. modeling, caused by pressure during labor and will disappear within 2 to 3 days d. a subdural hematoma which can result in lifelong damage
a. a cephalhematoma, caused by forceps trauma and may last up to 8 weeks.
A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower extremities? a. wearing support stockings b. reduce salt in her diet c. move about every hour d. avoid constrictive clothing
c. move about every hour
Which toy is most appropriate for a 10-year-old child with acute rheumatic fever who is on strict bedrest?
checkers
In developing a teaching plan for expectant parents, the nurse plans to include information about when the parents can expect the infant's fontanels to close. The nurse bases the explanation on knowledge that for the normal new born, the a. anterior fontanel closes at 2 to 4 months and the posterior by the end of the first week b. anterior fontanel closes at 5 to 7 months and the posterior by the end of the second week c. anterior fontanel closes at 8 to 11 months and the posterior by the end of the first month d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
d. anterior fontanel closes at 12 to 18 months and the posterior by the end of the second month.
When assessing a client who is at 12-weeks gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? a. at 16-week gestation b. at 20-weeks gestation c. at 24-weeks gestation d. at 30-weeks gestation
d. at 30-weeks gestation
An expectant father tells the nurse he fears that his wife "is losing her mind". He states she is constantly rubbing her abdomen and talking to the baby, and that she actually reprimands the baby when it moves too much. What recommendation should the nurse make to this expectant father? a. reassure him that these are normal reactions to pregnancy and suggest that she discuss his concerns with the childbirth education nurse b. help him to understand that his wife is experiencing normal symptoms of ambivalence about the pregnancy and no action is needed. c. ask him to observe his wife's behavior carefully for the next few weeks and report any similar behavior to the nurse at the next prenatal visit. d. let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
d. let him know that these behaviors are part of normal maternal/fetal bonding which occur once the mother feels fetal movement.
Twenty minutes after a continuous epidural anesthetic is administered, a laboring client's blood pressure drops from 120/80 to 90/60. What action should the nurse take? a. notify the healthcare provider or anesthesiologist b. continue to assess the blood pressure q5min c. place the woman in a lateral position d. turn off continuous epidural
c. place the woman in a lateral position
A client at 39 weeks gestation is admitted to the L&D unit. Her obstetrical history includes 3 live births at 39 weeks, 34 weeks and 35 weeks gestation. Using the GTPAL system which designation is the most accurate summary of this client's obstetrical history? 1. 4-1-2-0-3 2. 3-0-3-0-3 3. 4-3-1-0-2 4. 3-1-1-1-3
1. 4-1-2-0-3
A client at 29 weeks gestation with possible placental insufficiency is being prepared for prenatal testing. Information about which diagnostic study should the nurse provide information to the client? 1.Ultrasonography 2.Maternal serum alpha-fetoprotein 3.Amniocentesis 4.Chorionic villus sampling -
1.Ultrasonography
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? A-Administer morphine sulphate B-Start IV fluids C-Place the infant in a knee-chest position D- provide 100% Oxygen by face mask
C-Place the infant in a knee-chest position
One day after vaginal delivery of a full-term baby, a postpartum client's white blood cell count is 15.000/mm. What action should the nurse take first? a-Check the differential, since the WBC is normal for this client b-Assess the client's temperature, pulse, and respirations q4h c-Assess the client's perineal area for signs of a perineal hematoma d-Notify the healthcare provider, since this finding is indicative of infection
a-Check the differential, since the WBC is normal for this client Note: During the first 10 to 12 days after partum is between 20,000-25, 000
A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? a-Discuss the need for cortisol and aldosterone replacement therapy after discharge b-Support the parents in their decision to assign sex of their child according to their preference c-Offer information about ultrasonography and genotyping to determine sex assignment d-Explain that corrective surgical procedures consistent with sex assignment can be delayed
a-Discuss the need for cortisol and aldosterone replacement therapy after discharge
A child with iron deficiency anemia is ordered ferrous sulfate (Ferralyn), an oral iron supplement. When teaching the child and parent how to administer this preparation, the mother asks why she needs to mix the supplement with citrus juice. Which response by the nurse is best? a. "The vitamin C in the citrus juice helps with iron absorption." b. "Having food and juice in the stomach helps with iron absorption." c. "The citrus juice counteracts the unpleasant taste of the iron." d. "There isn't a specific reason for it."
a. "The vitamin C in the citrus juice helps with iron absorption."
The nurse determines that an infant admitted for surgical repair of an inguinal hernia voids a urinary stream from the ventral surface of the penis. What action should the nurse take? a. Document the finding b. Palpate scrotum for testicular descent c. Assess for bladder distension d. Auscultate bowel sounds
a. Document the finding
While obtaining the vital signs of a 10 year old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2-3 minutes. Which assessment should the nurse implement? a. Inspect the posterior oropharynx b. Assess for teeth clenching or grinding c. Touch the tonsillar pillars to stimulate the gag reflex d. Ask the child to speak to evaluate change in voice tone
a. Inspect the posterior oropharynx
A mother brings her 3-week old infant to the clinic because the baby vomits after eating and always seems hungry. Further assessment indicates that the infant's vomiting is projectile, and the child seems listless. Which additional assessment finding indicates the possibility of a life threatening complication? a. Irregular palpable pulse b. Hyperactive bowel sounds c. Underweight for age d. Crying without tears
a. Irregular palpable pulse
the nurse is caring for a 5-year-old child with Reye's syndrome. Which goal of treatment most clearly relates to caring for this child? a. Reduce cerebral edema and lower intracranial pressure b. Avert hypotension and septic shock c. Prevent cardiac arrhythmias and heart failure d. Promote kidney perfusion and normal blood pressure
a. Reduce cerebral edema and lower intracranial pressure
A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this client's care? a. patellar reflex 4+ b. blood pressure 158/80 c. four hour urine output 240 ml d. respiration 12/minute
a. patellar reflex 4+
Client teaching is an important part of the maternity nurse's role. Which factor has the greatest influence on successful teaching of the gravid client? a. the client's readiness to learn b. the client's educational background c. the order in which the information is presented d. the extent to which the pregnancy is planned
a. the client's readiness to learn
The nurse is counseling a couple who has sought information about conceiving. For teaching purposes, the nurse should know that ovulation usually occurs a. two weeks before menstruation b. immediately after menstruation c. immediately before mensturation d. three weeks before menstruation
a. two weeks before menstruation
A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia. After returning to the postoperative neonatal unit, her RR and HR have increased during the last hour. Which intervention should the nurse implement? a. Notify the HCP of these findings b. Administer a PRN analgesic prescription c. Record the findings in the child's record d. Wrap the infant tightly and rock in rocking chair
b. Administer a PRN analgesic prescription
A two-year-old child with a heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What Action should the nurse implement? a. Determine the pulse deficit b. Administer the schedule dose c. Calculate the safe dose range d. Review the serum digoxin level
b. Administer the schedule dose
A 2-year-old girl is brought to the clinic by her 17 year old mother. When the nurse observes that the child is drinking sweetened soda from her bottle, what information should the nurse discuss with this mother? SATA a. A 2-year old should be speaking in 2 word phrases b. Dental caries are associated with drinking soda c. Drinking soda is related to childhood obesity d. Toddlers should be sleeping 10 hours a night e. Toddlers should be drinking from a cup by age 2
b. Dental caries are associated with drinking soda e. Toddlers should be drinking from a cup by age 2
When assessing a child for impetigo, the nurse expects which assessment findings? a. Small, brown, benign lesions b. Honey-colored, crusted lesions c. Linear, threadlike burrows d. Circular lesions that clear centrally
b. Honey-colored, crusted lesions
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on Nagele's rule, what is the estimated date of delivery? a. April 25, 2007 b. May 9, 2007 c. May 29, 2007 d. June 2, 2007
b. May 9, 2007
A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: a. monitor the child with a pulse oximeter in her office. b. prepare to ventilate the child. c. return the child to class. d. contact the child's parent or guardian.
b. prepare to ventilate the child.
Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis? a-Encourage fluid intake b-Promote complete bed rest c-Weight the child daily d-Administer vitamin supplements
c-Weight the child daily
A new mother who has just had her first baby says to the nurse, "I saw the baby in the recovery room. She sure has a funny looking head." Which response by the nurse is best? a. "this is not an unusual shaped head, especially for a first baby." b. "it may look funny to you, but newborn babies are often born with heads like your baby's" c. "that is normal; the head will return to a round shape within 7 to 10 days." d. "your pelvis was too small, so the baby's head had to adjust to the birth canal."
c. "that is normal; the head will return to a round shape within 7 to 10 days."
A 16 year old with acute myelocytic leukemia is receiving chemotherapy (CT) via an implanted medication port at the out-patient oncology clinic. What action should the nurse implement when the infusion is complete? a. Administer Zofran b. Obtain blood samples for RBCs, WBCs, and platelets c. Flush mediport w/ saline and heparin solution d. Initiate an infusion of normal saline
c. Flush mediport w/ saline and heparin solution
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic acidosis d. Metabolic alkalosis
c. Metabolic acidosis
A child has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? a. Respiratory alkalosis b. Respiratory acidosis c. Metabolic alkalosis d. Metabolic acidosis
c. Metabolic alkalosis
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most likely presenting symptom for a pediatric client with AIDS is: a. shortness of breath b. joint pain c. a persistent cold d. organmegaly
c. a persistent cold
A mother who is breastfeeding her baby receives instructions from the nurse. Which instructions is most effective to prevent nipple soreness? a. wear a cotton bra b. increase nursing time gradually c. correctly place the infant on the breast d. manually express a small amount of milk before nursing
c. correctly place the infant on the breast
A client at 32 weeks gestation is diagnosed with preeclampsia. Which assessment finding is most indicative of an impending convulsion? a. 3+ deep tendon reflexes. b. periorbital edema c. epigastric pain d. decreased urine output
c. epigastric pain
A 26-year-old, gravida 2, para 1 client is admitted to the hospital at 28-weeks gestation in preterm labor. She is given 3 doses of terbutaline sulfate (Brethine) 0.25 mg subcutaneously to stop her labor contractions. The nurse plans to monitor for which primary side effect of terbutaline sulfate? a. drowsiness and bradycardia b. depressed reflexes and increased respirations c. tachycardia and a feeling of nervousness. d. a flushed, warm feeling and a dry mouth
c. tachycardia and a feeling of nervousness.
The nurse should encourage the laboring client to begin pushing when a. there is only an anterior or posterior lip of cervix left. b. the client describes the need to have a bowel movement c. the cervix is completely dilated d. the cervix is completely effaced
c. the cervix is completely dilated
When preparing a class on newborn care for expectant parents, what content should the nurse teach concerning the newborn infant born at term gestation? a. milia are red marks made by forceps and will disappear within 7 to 10 days b. meconium is the first stool and is usually yellow gold in color c. vernix is a white, cheesy substance, predominantly located in the skin folds. d. pseudostrabismus found in newborns is treated by minor surgery
c. vernix is a white, cheesy substance, predominantly located in the skin folds.
A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress? a. Bilateral bronchial breath sounds b. Diaphragmatic respiration c. A resting respiratory rate of 35 breathe per minute d. Flaring of the nares
d. Flaring of the nares
A female adolescent client refuses to allow male nurses to care for her while she's hospitalized. Which of these health care rights is this adolescent exerting? a. Right to competent care b. Right to have an advance directive on file c. Right to confidentiality of her medical record d. Right to privacy
d. Right to privacy
A mother brings her 3 month old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family? a. The mother is a single parent and lives with her parents b. The mother states the baby is irritable during feedings c. The infant's formula has been changed twice d. The diaper area shows severe skin breakdown
d. The diaper area shows severe skin breakdown
