MATERNAL FINAL w correct answers
The nurse obtains a stool specimen for ova and parasites . Which of the following is the responsibility of the nurse ? A) Keep this refrigerated B) Add alcohol to prevent odor C) See that it arrives at the laboratory promptly D) Discard it if is its not yellow to green
See that it arrives at the laboratory promptly Discard
A 6 - year - old has a diagnosis of streptococcal pharyngitis . When planning care , the nurse evaluates the client's symptoms for which of the following dangerous outcomes ? A) Swelled lymph nodes which obstruct the airway B) Infection , which may cause tooth abscess C) Development of rheumatic fever D) Nephrosis of the kidney
Development of rheumatic fever
The nurse is assessing a child who has just been admitted to the hospital for observations after a head injury . What is the most essential part of the nursing assessment to detect early signs of a worsening condition ? A) Vital signs B) Focal neurological signs C) Posturing D) Level of consciousness
Lev Level of consciousness
A 7 - year - old child is diagnosed with type 1 diabetes . What is one of the first symptoms noticed by parents when this illness develops in the child ? A) Loss of weight B) Craving for sweets C) Severe itching D) Swelling of soft tissue
Loss of weight
A nurse is caring for a school - age child who has had a cardiac catheterization . The child tells the nurse that her bandage is too wet . The nurse finds the bandage and bed soaked with blood . What is the most appropriate initial nursing action ? A) Apply direct pressure above the catheterization site B) Place the child in Trendelenburg C) Notify the provider D) Remove the dressing to monitor bleeding
Apply direct pressure above the catheterization site
A newborn is diagnosed with coarctation of the aorta . Which assessment should the nurse make when caring for this infant ? A) Observing for excessive crying B) Auscultating for a cardiac murmur C) Assessing femoral and radial pulses simultaneously D) Recording an upper extremity blood pressure
Assessing femoral and radial pulses simultaneously
A toddler is prescribed to receive 50 mg of an antibiotic . The medication available is 250 mg in 5mL . How many millilitres of the medication should the nurse provide to the patient ? A) 1 mL B) 5 mL C) 10 mL D) 0.1 mL
1 mL
The nurse is caring for a newborn diagnosed with patent ductus arteriosus . Which finding will the nurse assess that is consistent with this diagnosis ? A) Slow heart rate B) Expiratory grunt C) Machine like murmur heard at the left sub clavicular margin D) Absent femoral pulses
Machine like murmur heard at the left sub clavicular margin
Upon assessment of a 3 - year - old who has been diagnosed with croup , the nurse notes stridor while the child is asleep . Which of the following interventions would the nurse expect to perform to the client ? A) Administering an oral analgesic B) Urging the child to take oral fluids C) Teaching a child to take long slow breaths D) Assisting with racemic epinephrine nebulizer therapy
Assisting with racemic epinephrine nebulizer therapy
The nurse received an order to administer magnesium sulfate 2 grams per hour IV via infusion pump . The nurse has magnesium sulfate 20 grams in D5LR 1000mL available . What rate ( mL / hr ) would the nurse set the infusion pump ?
100
The nurse should expect the anterior fontanel to close at what age ? A) 2 to 4 months B) 12 to 18 months C) 6 to 8 months D) 6 to 8 weeks
12 to 18 months
An infant weighed 6 pounds at birth . What is the expected weight in pounds at 1 year of age ? A) 12 B) 18 C) 34 D) 27
18
Prenatal Testing is done to identify health issues that may interfere with the developing fetus . During which time frame would the nurse expect the 1 hour glucose tolerance test to be ordered on a healthy primigravida ? A) 36 weeks gestation B) 15-20 weeks gestation C) 24-28 weeks gestation D) 7-9 weeks gestation
24-28 weeks gestation
A child has a chronic , nonproductive cough and diffuse wheezing during the expiratory phase of respiration . What should this suggest to the nurse ? A) Bronchiolitis B) Pneumonia C) Tonsillitis D) Asthma
Asthma
Utilize the GTPAL system to classify a woman who is currently 18 weeks pregnant . This is her 4th pregnancy . She gave birth to one baby vaginally at 25 weeks who died , experienced a miscarriage , and has one living child who was delievered at 38 weeks gestation . What is her GTPAL? A) 32121 B) 42211 C) 32111 D) 41111
41111
At 1 minute after birth the nurse assesses the infant and notes : heart rate of 120 beats / min , strong flexion of extremities , a strong cry , active grimacing and a pink body but blue extremities . The nurse would calculate an Apgar score of which number for this infant ? A) 4 B) 6 C) 8 D) 9
9
The nurse receives an order to administer LR 1000mL of IV fluid with Pitocin 20 units . What is the IV rate ( mL per hour ) if you want to run the medication at 1mU / min ? ( whole number )
???
The school nurse is observing in the classroom . The child is speaking , then suddenly stops and stares for about 5 seconds , and then continues speaking . The nurse charts this experience as what type of seizure ? A) Tonic - clonic B) Febrile C) Absence D) Partial ( focal ) seizure
Absence
The nurse in labor and delivery is monitoring a client at 38 weeks gestation who presents for a nonstress test ( NST ) . In performing a non stress test , the nurse will observe for and document which of the following ? ( SATA ) A) Accelerations in the fetal heart rate B) Amount of amniotic fluid C) Fetal tone D) Decelerations in the fetal heart rate E) Variability in the fetal heart rate
Accelerations in the fetal heart rate Decelerations in the fetal heart rate Variability in the fetal heart rate
A student nurse notes that the population of a sexually transmitted infection Health Clinic consists largely of teenagers . The nurse explains that adolescents are at a greater risk for contracting STIs because of which factor ? A) The immune system of an adolescent is immature B) Untreated Urinary tract infection will develop into an STI C) Adolescents are risk takers and believe they are invincible D) Adolescents often lack parental supervision
Adolescents are risk takers and believe they are invincible
A hospitalized 2 - year - old child with croup is receiving corticosteroid therapy and the mother asks why the provider did not prescribe antibiotics ? What is the nurse's best response to the mother ? A)The child still has the maternal antibodies form birth and does not need antibiotics B) The child may be allergic to the antibiotics C) Antibiotics are not indicated unless a bacterial infection is the cause of the illness D) The child is too young for antibiotics
Antibiotics are not indicated unless a bacterial infection is the cause of the illness
A school nurse is preparing an educational presentation to a group of teens , parents , and teachers about how to prevent skin cancer . Which topics need to be included in the presentation ? ( Select all that apply ) A) Avoid getting a severe sunburn B) It is important to avoid tanning beds C) Sunscreen application needs to include tops of ears and back of neck D) Children need to apply sunscreen if out in the sun for longer than 60 minutes.- It should be if longer than 20 minutes E) There is a direct association between two or more episodes of sunburn and development of malignant melanoma
Avoid getting a severe sunburn It is important to avoid tanning beds Sunscreen application needs to include tops of ears and back of neck There is a direct association between two or more episodes of sunburn and development of malignant melanoma
On evaluation of a 7yr old with a burn injury , the nurse notes large blisters , Swelling , and red color to the injured tissue . The client is in extreme pain . This injury is consistent with which of the following degree of burn ? A ) 4th degree B) 2nd degree C ) 1st degree D ) 3rd degree
B1 2nd degree
The nurse visits the foster home of a newborn with failure to thrive syndrome . Which observation indicates a successful outcome for the child's care ? A) Birth mother has stopped visiting the child B) Birth father comes by the home to bring toys C) Child eagerly takes a bottle and is gaining weight D) Child is crying and has bruises over the lower legs
Child eagerly takes a bottle and is gaining weight
During a routine well child visit , the mother of a preadolescent client asks the nurse to explain signs of sexual abuse . The mother is concerned because an older male neighbor has been making comments and overly admiring the child when playing outdoors . What signs of sexual abuse should the nurse tell the mother to look for ? ( Select all that apply ) A) Child reports abdominal pain B) Child has a change in school performance C) Child demonstrates anxiety or trouble sleeping D) Child does not want to be left alone with a certain adult E) Child spends a great deal of time with peer group friends .
Child reports abdominal pain Child has a change in school performance Child demonstrates anxiety or trouble sleeping Child does not want to be left alone with a certain adult
A nurse is reviewing discharge instructions with the family of a child diagnosed with a urinary tract infection faction . Which instruction should the nurse include with discharge teaching regarding medications ? A) Complete the entire course of antibiotics ordered by the provider B) The child may choose to take the antibiotics or stop once he or she feels better C) As long as the fever does not return , the antibiotics have worked , and the parent may stop giving them to the child D) Save the remainder , if there is any left , in case the child has another infection and could use the rest of the prescription .
Complete the entire course of antibiotics ordered by the provider
The nurse is participating in a preschool health screening program . What are appropriate secondary health promotion activities ? ( Select all that apply ) . A) Conduct vision tests B) Conduct hearing tests C) Listen to heart sounds D)Measure gait and balance E) Review immunizations received
Conduct vision tests Conduct hearing tests Review immunizations received
Your client attempted suicide with a medication overdose . Which interventions would be most effective in preventing an adolescent from attemtping suicide again ? A) Assessing his financial level B) Help him learn better problem - solving skills at school C) Coordinate involvement of a mental health provider to allow children to express feelings D) Encourage him to make more friends at his after - school job
Coordinate involvement of a mental health provider to allow children to express feelings
The nurse is instructing the mother of a school age child with a leg cast about cast care at home . What should the nurse include in this teaching ? ( select all that apply ) A) Cover the cast with a plastic bag to bathe B) Remind that nothing is to be put inside the cast C) Recommend using magic markers for autographs D) Use the cool setting on a hair dryer to ease itchy skin E) Remain as active as possible with appropriate modifications
Cover the cast with a plastic bag to bathe Remind that nothing is to be put inside the cast Use the cool setting on a hair dryer to ease itchy skin Remain as active as possible with appropriate modifications
The nurse is concerned that a school - age child is developing pneumonia . What did the nurse most likely assess in this client ? ( Select all that apply ) A) Crackles ( rales ) B) Cool dry skin C) Elevated temperature D) Paroxysmal dry cough E) Productive harsh cough
Crackles ( rales ) Elevated temperature Productive harsh cough
An 18 month old child is admitted with signs of increased intracranial pressure . What would the nurse observe when assessing this patient ? A) Numbness of fingers and decreased temperature B) Increased pulse rate and decreased blood pressure C) Decreased level of consciousness and decreased respiratory rate D) Decreased level of consciousness and increased respiratory rate
Decreased level of consciousness and decreased respiratory rate
The nurse is reviewing normal and abnormal changes in pregnancy with a woman who is 32 weeks pregnant . Which of the following abnormal changes should the nurse address first ? A) Pedal edema at the end of the day B) Interest in non - nutritional food source C) Intermittent bouts of constipation D) Decreased or absent fetal movement
Decreased or absent fetal movement
The nurse notes that a child with a burn injury is prescribed daily debridement . What should the nurse instruct the child and parents about the purpose of the treatment ? A) Relieves pain B) Decreases risk for infection C) Reduces the need for topical medications D) Decreases the need for skin grafts
Decreases risk for infection
An infant is brought to the emergency department with poor skin turgor , weight loss , lethargy , and tachycardia . What does the nurse suspect is the problem ? A) Overhydration B) Potassium excess C) Sodium excess D) Dehydration
Dehydration
What is the most important observation the nurse should watch for in a newborn who has a salt - losing form of congenital adrenal hyperplasia ? A) Excessive cortisone secretion D) Dehydration C) Hypoglycemia D) Bleeding tendencies
Dehydration
The pediatric nurse is familiar with Kuchler - Ross's stages of grief . Parents who are feeling confused and refusing to discuss the disease with any provider are in which stage of grief ? A) Denial B) Grief C) Bargaining D) Acceptance
Denial
A 6 - month - old infant is admitted to the hospital because of a fever . When you obtain a health history , what data would the nurse obtain first ? A) Details about the fever B) Family profile C) History of past illnesses D) Review of systems
Details about the fever
While caring for a child with bacterial pneumonia , the nurse examines the child's respiratory system . What is an expected assessment finding for bacterial pneumonia ? A) Respiratory rate of 20 heard on auscultation B) Diminished breath sounds and crackles C) Longer inspiratory than expiratory rate noticed by inspection D) Absent lung sounds in the right lower lobe
Diminished breath sounds and crackles
The nurse is instructing an adolescent regarding sexual activity . What can the nurse include in her teaching ? ( Select all that apply ) A) Do not be influenced by friends to have sex B) The only 100 % effective method of preventing pregnancy is abstinence C) Learn about safe sex practices D) There is no harm in being sexually active if you take precautions E) Adolescence is is the time when all sexual activity begins
Do not be influenced by friends to have sex The only 100 % effective method of preventing pregnancy is abstinence Learn about safe sex practices
A child is taking valproic acid for epilepsy . What important information should the nurse . explain to the parents ? A) To brush his or her teeth four times a day B) Do not discontinue the drug abruptly C) Never to go swimming D) To avoid foods containing caffeine
Do not discontinue the drug abruptly
The nurse is teaching a child with type 1 diabetes mellites to administer her own insulin . The child is receiving a combination of short - acting and long - acting insulin . How will the nurse know that the child has appropriately learned the technique ? A) Administers the insulin into a doll at a 20 - degree angle B) Draws up the short acting insulin into the syringe first C) Wipes off the needle with an alcohol swab D) Administers the insulin intramuscularly into rotating sites .
Draws up the short acting insulin into the syringe first
The nurse in the cardiac clinic is caring for a new patient who has been referred to the clinic due to a new heart murmur heard by the pediatrician during the well child exam . What noninvasive diagnostic testing does the nurse expect the cardiologist to order first ?
Echocardiogram
The nurse is caring for a chronically ill adolescent . The nurse recommends which of the following to prevent the pediatric client from feeling lonely? A) Plan activities so there are time for rest periods B) Explain food choices available for the prescribed diet C) Teach the name and indications for all medication D) Encourage friends to be available through social media
Encourage friends to be available through social media
An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to? A) Provide for privacy B) Encourage parents to room in C) Explain procedures and routines D) Encourage contact with children the same age
Encourage parents to room in
A 5 - year - old child is placed in skeletal traction to immobilize a fracture . What is important for the nurse to encourage the parents to do with the child during immobilization ? A) Help the child to exercise the immobilized fracture every hour B) Engage the child in therapeutic play while confined to this position C) Help the child to drink plenty of fluids while lying flat D) Limit visitors to reduce infection
Engage the child in therapeutic play while confined to this position
The nurse is instructing the parents of a child with sickle - cell anemia on safety precautions . What should the nurse emphasize during this teaching ? A) Suggest the child participate in sports activities without restriction B) Treat upper respiratory infections with over the counter medication C) Ensure a consistent and daily intake of adequate fluids to prevent dehydration D) Remind to avoid immunizations to prevent the introduction of bacteria into body
Ensure a consistent and daily intake of adequate fluids to prevent dehydration
The nurse in the newborn nursery is reviewing the physician's orders to prepare a 2 day old newborn for circumcision . Which of the following findings on assessment of this patient would be a contraindication to the procedure ? A) Hydrocele B) Epispadias C) Cryptorchidism D) Phimosis
Epispadias
On assessment of a 3 year old toddler , the nurse notes that the left eye intermittently deviates medially . Mom confirms that she sees this often when the child is laughing or when she is tired . This finding is most consistent with which of the following ? A) Exotropia B) Esotropia C) Hypertropial D) Astigmatism
Esotropia
The nurse is caring for a preschool age child who is aware of impending death . What behavior should the nurse expect the child to demonstrate at this time ? A) Outbreaks of anger B) Verbalization of feelings C) Bargaining for another chance D) Fear of being separated from parents
Fear of being separated from parents
A woman arrives at the clinic for a pregnancy test . The first day of her last menstrual period ( LMP ) was May 13 , 2017. Her expected date of birth ( EDR ) would be ? A) February 6 , 2018 B) February 20 , 2018 C) January 20 , 2018 D) January 6 , 2018
February 20 , 2018
A 12 - year - old child has pyelonephritis . Which of the following would the nurse expect to observe when assessing the child ? ( SATA ) A) Flank pain B) Costovertebral angle tenderness Cj Watery diarrhea D) Fever E) Rash on the distal extremities
Flank pain Costovertebral angle tenderness Fever
The triage nurse is assessing a patient who has presented to the emergency department with complaints of pain in the left lower leg and ankle after a fall . On assessment , the nurse notes swelling to the lateral aspect of the left ankle , point tenderness , and crepitus on palpation . The nurse plans care for the patient recognizing that this presentation is most consistent with which of the following injuries ? A) Sprain B) Muscle strain C) Fracture D) Compartment syndrome
Fracture
toddler who has Kawasaki disease ( KD ) is admitted to the pediatric unit . Which of the following findings should the nurse expect to observe during the physical assessment ? ( SATA ) A) Generalized abdominal tenderness B) Strawberry tongue C) Productive cough for 5 days D) Edema for hands and feet E) conjunctivitis without exudate
Generalized abdominal tenderness Strawberry tongue Edema for hands and feet conjunctivitis without exudate
A child is experiencing anaphylactic shock . Which provider order would the nurse complete first ? A) Give epinephrine IM B) Begin IV with normal saline and corticosteroid C) Provide a beta - agonist ( albuterol ) via inhaler D) Place the patient on cardiac monitors
Give epinephrine IM
The parents of a child with acute glomerulonephritis ask the nurse to explain the cause of the disease . What organism should the nurse instruct the parents as being the cause for the disorder ? A) Group b streptococci B) One of the rhinoviruses C) Staphylococcus viridians D) Group A beta hemolytic streptococci
Group A beta hemolytic streptococci
A 24 year old G2P1001 presents to the office for her 36 week visit . Which of the following labs would the nurse expect the provider to order as routine scheduled testing ? A) Group Beta Strep B) Culture CBC C) 1 hour glucose tolerance test D) Urine drug screen
Group Beta Strep
Health teaching that the nurse would provide for parents of an immunosuppressed child focus on which important measure? A) Nutrition B) Pain control C) Hand washing D) Restricted visiting hours
Hand washing
The nurse is preparing to assess a toddler during a routine health maintenance visit . Which assessment will the nurse perform to determine the child's growth milestone ? A) Blood pressure B) Urine specimen C) Hemoglobin level D) Height and weight
Height and weight
The nurse is caring for a preschool aged child who needs a computerized tomography ( CT ) scan . Which action would the nurse use to --it prepare the child for this diagnostic test ? A) Tell the child to follow directions to avoid being hurt B) Help the child to pretend that the CT scan machine is a camera C) Explain that the child must behave because the technician is busy D) Tell the child that his parents cannot be with him
Help the child to pretend that the CT scan machine is a camera
A toddler insists on brushing his own teeth and dressing himself . What advice would you give his parents regarding this ? A) Helping with his own cares allows him to experience autonomy B) It is unusual for 2 - year - old to have such strong opinions C) His mother should continue to give full care in all aspects D) Leaving him alone in the bathtub is a good way to encourage autonomy .
Helping with his own cares allows him to experience autonomy
The nurse assesses that a fetus is in a breech presentation . Where would you auscultate for fetal heart sounds ? A) High in the abdomen B) Left lateral abdomen C) Low in the abdomen D) Right lateral abdomen
High in the abdomen
An 8 - year - old child presents with a diagnosis of sickle cell anemia . The child is hospitalized , and the nurse recognizes which of the following as the initial nursing intervention? A) Hydration and Pain Management B) Blood Administration and lab values for hemoglobin and hematocrit C) Antibiotic therapy and blood cultures D) Physical and occupational therapy
Hydration and Pain Management
During a routine well child check , an 8 year old child is having her visual acuity assessed . She reports that her vision is blurry at a close range and clear at a far range . Which of the following diagnoses is consistent with these symptoms ? A) Astigmatism B) Hyperopia C) Myopia D) Strabismus
Hyperopia
Which fluid should the nurse offer to help keep a post tonsillectomy child orally hydrated ? A) Milk B) Juice C) Ice chips D) Ginger ale
Ice chips
The nurse is caring for an 18 - month - old with bronchiolitis in the emergency room . Which of the following would be included in discharge teaching for the family ? A) Give plenty of milk to drink for adequate calcium intake B) Place a cool mist humidifier in his room C) He should sleep on a flat mattress without his head elevated D) Give bronchodilators every 2-4 hours
Place a cool mist humidifier in his room
A preadolescent client , a member of a single parent family has abdominal pain and the healthcare provider suspects that an appendectomy might need to be performed . The patient's father is asking for a second opinion , whereas the mother tells the nurse to be done to help the patient . What does the nurse need to assess before moving forward with panning care for this patient ? A) Permission to miss school B) Identify the custodial parent C) The type of health insurance D) Plans for help upon discharge
Identify the custodial parent
The nurse is providing discharge teaching to the child and her family following inpatient treatment for anaphylaxis . Which of the following statements by the partners or family would indicate the need for more instruction ? A) I will make family members and caregivers aware of all known allergens and triggers B) I will apply a medical alert bracelet to my child C) I will self - administer epinephrine if I begin to experience respiratory distress . D) If my symptoms resolve after injections , I should stay home and rest for the remainder of the day
If my symptoms resolve after injections , I should stay home and rest for the remainder of the day
Which statement by the nurse is most likely to gain the cooperation of a young child ? D) Do you want to take your medicine now ? A) It is time for you to drink your medicine now B) If you take this medicine , I can get you a popsicle C) If you don't drink this medicine , you will need to get a shot
If you take this medicine , I can get you a popsicle
A 3 - month - old is admitted to the hospital for failure to thrive . Which of the following are indications of failure to thrive in a 3 - month - old infant ? A) Interference with gastrointestinal absorption B) Infant falls below 5 % in growth percentile C) Limited calcium metabolism D) A reaction to severe stress
Infant falls below 5 % in growth percentile
The nurse is caring for a 10 - year - old child with growth hormone deficiency . Which therapy would you anticipate being prescribed for the child ? A) Short term aldosterone provocation B) Injections of growth hormone C) Oral administration of somatotropin D) Long term blocking of beta cells
Injections of growth hormone
A nurse is caring for a client who is in the first stage of labor with a report of ruptured membranes prior to admission to the labor unit . The nurse observes the fetal heart rate changes baseline from 150 / min to 110 / min . During a vaginal exam , the nurse notes a pulsation at the cervix . Which of the following actions should the nurse perform first ? A) Push the cord back into the cervical os B) Prepare the woman for immediate vaginal birth C) Place the client in the supine position D) Insert a gloved hand into the vagina to lift the presenting part off of the cord
Insert a gloved hand into the vagina to lift the presenting part off of the cord
A 4 - year - old child with a urinary tract infection is scheduled to have avoided cystourethrogram . What would a nurse do to prepare for the child for this procedure ? A) Inject a local anesthetic prior to the procedure B) Drink three glasses of water during the procedure C) Insert foley catheter for instillation of contrast D) Anticipate a headache afterward
Insert foley catheter for instillation of contrast
A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting therapeutic management of the child will begin with which nursing intervention? A) Intravenous fluids B) Oral rehydration solution C) Clear liquids 1 to 2 ounces at a time D) Administration of anti - diarrheal medication
Intravenous fluids
The student nurse is preparing education for the parents of a 6 - year - old that will begin iron supplementation following a diagnosis of iron - deficiency anemia . What should be included in the education ? ( Select all that apply ) A) Iron should be given with a glass of orange juice B) Iron should be given with food C) Iron may cause black tarry stools D) Iron may cause constipation E) Iron may cause increase in appetite
Iron should be given with a glass of orange juice Iron may cause black tarry stools Iron may cause constipation
Shortly after delivery , a newborn is diagnosed with hypocalcemia / hypoglycemia . What manifestations will the nurse assess in this client ? A) Jitteriness B) Constipation C) Excessive sleepiness D) A distended abdomen
Jitteriness
A nurse caring for a school aged child recovering from an open reduction for a fractured femur . Which assessment findings indicate that the child is developing an infection ? ( SATA ) A) Lethargy B) Increased pulse rate C) Reduced pulse in the ankle D) Cyanosis of the casted foot E) Increased body temperature
Lethargy Increased pulse rate Increased body temperature
The mother of a school age child is distraught because this child has been diagnosed with obesity . What teaching will the nurse provide to the family regarding achieving the goal of BMI within normal range ? ( select all that apply ) A) Explain that obesity will lead to an early death B) Maintain a balanced eating approach in the home C) Purchase books explaining the latest ways to lose weight D) Encourage participation in a new sport in which the child has an interest E) Encourage increased activity such as walking the dog after school
Maintain a balanced eating approach in the home Encourage participation in a new sport in which the child has an interest Encourage increased activity such as walking the dog after school
A 7 - year - old is diagnosed with osteomyelitis . Which of the following would you anticipate as a primary nursing intervention to include in the child's plan of care ? A) Maintaining intravenous antibiotic therapy B) Keeping the child quiet while in skeletal traction C) Restricting fluid to encourage red cell production D) Assisting the child with crutch walking placed in skeletal
Maintaining intravenous antibiotic therapy
During an assessment , the nurse determines that a 3 - month - old baby has a Moro reflex . What does this finding to indicate to the nurse ? A) It usually lasts until 9 months B) It will persist until the age of 1 year C) Most 3 month old's still have a Moro reflex D) If present at 3 months of age , a neurological exam is needed
Most 3 month old's still have a Moro reflex
Parents ask the nurse why their premature infant is receiving a feeding through the mouth rather than the nose . What is the best explanation by the nurse ? A) It is equally acceptable to use either insertion site B) Orogastric tube insertion can cause inflammation and obstruction of the nares C) Newborns are obligate nose breathers so nasogastric may obstruct their breathing D) Nasogastric tubes decrease the possibility of striking the vaginal nerve .
Newborns are obligate nose breathers so nasogastric may obstruct their breathing
Management of primary dysmenorrhea often requires a multifaceted approach . The nurse who provides care for a client with this condition should be that the optimal pharmacological therapy for pain relief is? A) Non - steroidal inflammatory drugs B) Oral contraceptives C) Aspirin D) Acetaminophen
Non steroidal inflammatory drugs
A nurse is caring for a client who is at 36 weeks of gestation and who had a suspected . placenta previa . Which of the following findings support this diagnosis ? A) Increasing abdominal pain with a non - relaxed uterus ) Painless bright red vaginal bleeding C) Abdominal pain with scant red vaginal bleeding D) Intermittent abdominal pain following passage of bloody mucus
Painless bright red vaginal bleeding
A nurse is caring for an adolescent who has a newly applied fiberglass cast for a fractured tibia . Immediately following application of the cast , the nurse should recognize that the priority nursing action is to do which of the following ? A) Explain the discharge instructions to the client and parents B) Apply an ice pack to the casted leg C) Provide range of motion exercises to the unaffected extremity D) Perform a neurovascular assessment
Perform a neurovascular assessment
A patient in labor with chronic back pain tells the nurse about taking a dose of hydrocodone / acetaminophen ( Vicodin ) for labor pain prior to coming to the hospital . What should the nurse prepare to do after the fetus is delivered ? A) Perform ongoing assessment of the infant for withdrawal symptoms after delivery B) Suggest that no additional narcotic pain medication be provided during labor C) Coach the patient in breathing techniques because other pain medication is contraindicated D) Request that the physician prescribe the same medication to be used for pain during labor .
Perform ongoing assessment of the infant for withdrawal symptoms after delivery
A 5 month old infant is brought to the emergency department with a reported history of fever , nasal drainage , and cough . Over the past day , the mom reports that the patient has demonstrated coughing spells that are followed by a grasp or whoop . The nurse recognizes that these symptoms are most consistent with which of the following illnesses ? A) Pertussis B) Respiratory syncytial virus C) Pneumonia D) Croup
Pertussis
What should the nurse teach the parents of a child with tetralogy of Fallot to do if the child suddenly becomes cyanotic and disconnected? A) Place in a knee chest position B) Lie prone and maintain the airway C) Lie supine with the head turned to one side D) Place in a semi - Fowler's position in an infant seat
Place in a knee chest position
A woman is 39 weeks gestation with severe abdominal pain that remains constant . She is being admitted to the labor and delivery unit . She suddenly experiences increased contraction frequently for every one to two minutes , has dark vaginal bleeding , and a rigid abdomen . What should the nurse expect at this time ? A) Placenta abruption B) Placenta previa C) Preterm labor D) Eclamptic seizure
Placenta abruption
A nurse is caring for a child who is experiencing a generalized tonic / clonic seizure . Which of the following is the priority action for the nurse to take ? A) Position the child in a side lying position B) Try to determine the seizure trigger C) Reorient the child to the environment D) Place a bite stick in the mouth to prevent injury to oral tissue
Position the child in a side lying position
The nurse in the pediatric clinic is providing teaching to the family of a 1 month old infant with gastroesophageal reflux . Which of the following will be included in the teaching ? A) Position the infant on his left side after every feed B) Less frequent feedings of larger volumes will minimize the symptoms C) Position upright for 30 minutes after feedings D) Discontinue breastfeeding until the symptoms have resolved
Position upright for 30 minutes after feedings
An adolescent client delivers a 9 lb baby after being in labor for 20 hours . During the immediate postpartum period , which potential complication is the highest priority for the nurse to assess for ? A) Endometritis B) Thrombophlebitis C) Amniotics D) Postpartum hemorrhage
Postpartum hemorrhage
Which technique should the nurse use to administer eardrops to a 4 - year - old child ? A) Press the pinna of the ear forward B) Pull the pinna of the ear downward C) Pull the pinna of the ear up and back D) Lift the pinna of the ear down and back
Pull the pinna of the ear up and back
The clinic is providing a federally approved car seat to an infant's family . The nurse should explain that the safest place to install this car seat in the vehicle is? A) Front facing in the back seat B) Rear facing in back seat C) Front facing in front seat with airbag on passenger side D) Rear facing in front seat if an airbag is on the passenger side
Rear facing in back seat
A child in kidney failure has had a kidney transplant . What should the nurse include in the teaching regarding postoperative care ? A) Full Body irradiation that will leave him nauseated B) A transient rash from t - cell suppression C) Reduce socialization for infection control precautions D) Burning on urination from high uric acid content
Reduce socialization for infection control precautions
The nurse is planning care for a preschool age child diagnosed with meningitis What should the nurse identify as a priority goal for this patient's care ? A) Inspect the teeth for obvious caries B) Reduce the pain related to NUCHAL rigidity C) Provide an opportunity for therapeutic play D) Increase stimulation opportunities to prevent coma
Reduce the pain related to NUCHAL rigidity
The nurse is preparing to administer blood products to the pediatric client . Which of the following reflects safe practice in administration of blood products ? A) Initiate the transfusion within 1 hour of receipt D) Infuse the blood products slowly over 6-8 hours B) Remain with the patienrpt for the first 15 minutes of the infusion C) Discard the transfusion bag in a red lyphstant bag immediately after the infusion is complex
Remain with the patienrpt for the first 15 minutes of the infusion
A nurse performs an admission assessment on a child and suspect's physical abuse . Based on the suspicion , the primary legal nursing responsibility is to do which of the following ? A) Refer the family to the appropriate support groups B) Assist the family in identifying resources and support systems C) Report the case in which the abuse is suspected to the local authorities and your supervisor or charge nurse D) Coordinate information with the primary physician so he may report the findings
Report the case in which the abuse is suspected to the local authorities and your supervisor or charge nurse
What education should a nurse provide to a parent to help their child complete Erikson's developmental task during the infant period ? A) Respond to the child's needs consistently B) Keep the child stimulated with many toys C) Talk to the child at a special time each day D) Expose the child to many caregivers to help learn variability
Respond to the child's needs consistently
The nurse teaches a 14 - year - old child about the proper use of a metered dose inhaler to control asthma symptoms . Which teaching points should the nurse include in these instructions ? Select all that apply ) A) Take two puffs at a time B) Shake the canister before using C) Wait 5 minutes between puffs D) Hold the breath for 5 to 10 seconds E) Activate the inhaler while taking a deep breath
Shake the canister before using Hold the breath for 5 to 10 seconds Activate the inhaler while taking a deep breath
Which personal protective equipment will the nurse wear while inserting a urinary catheter on a child positive for HIV and tuberculosis ? ( SATA ) A) Simple mask B) Sterile gloves C) N - 95 respiration D) Disposable gown E) Protective eye shield
Simple mask Sterile gloves Protective eye shield
A terminally ill child is awake at 2 am and continues to put on the call light . What should the nurse do regarding the child's behavior ? A) Provide with a sleeping aid B) Encourage a child to sleep C) Sit with the child until sleep comes D) Put on the television and dim the lights
Sit with the child until sleep comes
The nurse is caring for an adolescent female after a sexual assault . She notes which of the following to be consistent with past traumatic stress disorder ( PTSD ) ? ( SATA ) A) Sleep disturbances B) Resuming normal daily activities C) Hypervigilance D) Flashbacks Withdrawal from family
Sleep disturbances Hypervigilance Flashbacks Withdrawal from family
An infant is prescribed digoxin . The nurse teaches the parents that the action of digoxin is to do which of the following ? A) Slow and strengthen her heartbeat B) Increase the infant's heart rate C) Thicken the walls of the myocardium D) Prevent subacute bacterial endocarditis
Slow and strengthen her heartbeat
A nurse is providing care to a 9 year old child who has fractured his left distal radius . Which of the following actions should be included in the plan of care for this patient ? ( SATA ) A) Encourage ROM activities B) Stabilize the injury C) Elevate the arm D) Apply heat to the site of the injury E) Assess neurovascular status
Stabilize the injury Elevate the arm Assess neurovascular status
After an hour of oxytocin therapy , A laboring patient experiences contractions that last for a duration of 90 seconds occurring at a frequency of every 2 minutes . What priority action should the nurse take ? A) Asses the cervix for full dilation B) To start pushing if fully dilated C) Stop the INFUSION / contractions and notify the provider Instruct the patient to breathe in and out rapidly D) Administer oral orange juice for added potassium
Stop the INFUSION / contractions and notify the provider
A 7 year old child is brought to the emergency department for evaluation of a burn injury . On exam , the nurse notes large , ruptured blisters and a white or pale color ONLY SAYS RED / PINK to the injured tissue . The patient is in extreme pain . The most damaged part of this burn is consistent with a burn depth of : A) Full thickness ( 3rd 4th degree ) B) Superficial thickness ( 1st degree ) C) Deep partial thickness ( 2nd - 3rd degree ) D) Superficial partial thickness ( 2nd degree )
Superficial partial thickness ( 2nd degree )
A nurse in the newborn nursery is monitoring a newborn infant for respiratory distress syndrome Which assessment signs , if noted in the newborn , would alert the nurse to the possibility of this syndrome ? A) Tachypnea and retractions B) Acrocyanosis and grunting C) Hypotension and bradycardia D) Presence of barrel chest with clubbing
Tachypnea and retractions
The nurse is caring for an 8 month old baby diagnosed with spastic cerebral palsy . Which assessment finding supports this medical diagnosis ? A) The child has a strong Moro reflex when startled B) The child bears weight on both feet when held upright C) The child cries when held in a vertical suspension position D) The child holds the back very straight when in a sitting position
The child has a strong Moro reflex when startled
The nurse is planning teaching for the parents of a child with Legg - Calve - Perthes disease . What should the nurse emphasize when conducting this teaching ? A) Surgery is needed with supporting rods B) The child may have a non - weight bearing period C) The child will need passive range of motion exercises three times a day D) The child will need to exercise to increase muscle strength of the knee joint
The child may have a non - weight bearing period
The nurse evaluates teaching provided to a school - age child and parents about the medication pancrealipase for cystic fibrosis . Which observation indicates that teaching has been effective ? A) The child chews an enteric form of the medication B) The child takes a dose before having an afternoon snack C) The father tells the child that diarrhea is expected with this medication D) The mother opens the capsule and some medication spills on the fingers
The child takes a dose before having an afternoon snack
During a physical assessment , a 15 - year - old male expresses concern about being short in height . Which should the nurse respond to his client's concern ? A) most male adolescents stop growing by age 17 years B) Maximum height is typically achieved by age 14 years C) The epiphyseal lines of long bones close when signs of puberty occur D) The epiphyseal lines of long bones close by 18 to 20 years of age in males
The epiphyseal lines of long bones close by 18 to 20 years of age in males
The nurse is visiting the home of a previous history of physical neglect . Which observation indicates that interventions have not been successful ? A) The mother feeds the children a vegetarian diet B) The father encourages male children to play high school football C) The mother worries that immunizations will be painful for the children D) The father allows the children to stay home from school whenever they desire
The father allows the children to stay home from school whenever they desire .
The nurse is evaluating outcomes about a family's ability to care for an adolescent child who is recovering from a spinal cord injury . Which statement indicates that the family is transitioning in a healthy manner ? A) The patient states the inquiries " messed up " the rest of his life B) The mother states the need to have break several times per week C) The patient states fewer episodes of nausea when changing positions D) The mother and father state the ability to provide care for the child is becoming easier .
The mother and father state the ability to provide care for the child is becoming easier .
A 4 - year - old has developed acute lymphocytic leukemia ( ALL ) for which of the following reasons does the nurse take axillary , rather than rectal temperatures ? A) The child is anemic and had an increased risk of bleeding . B) The child has low white blood cell count, and a rectal temperature would decrease the blood cell count C) The rectum is highly vascular and rectal temps would result trauma to the tissue which may bleed easily or cause painful bruising D) The child is prone to diarrhea and inserting a rectal thermometer would cause further diarrhea
The rectum is highly vascular and rectal temps would result in trauma to the tissue which may bleed easily or cause painful bruising
After cardiac surgery , a child has chest tubes inserted that are attached to an under water seal drainage system . When should the nurse be prepared to clamp chest tubes? A) A clot obstructs the tubing B) The tube becomes disconnected C) Red stained drainage appears in a tube D) When the child is sitting up to help with coughing
The tube becomes disconnected
The mother of a child having myringotomy tubes placed asks , " Will my child lose hearing while the tubes are in place ? " What is the nurses best answer ? A) The tubes are inserted into a section of eardrum in which the hearing is not affected * B) There is some risk of permanent deafness , but the benefit of decreasing the infection is worth it C) Your son's hearing will decrease while the tubes are in place D) Have you asked your child's physician about that
The tubes are inserted into a section of eardrum in which the hearing is not affected
A school age child is diagnosed as having Cushing syndrome from a long term therapy with oral prednisone . What assessment finding is consistent with this child's diagnosis and treatment ? A) Child appears pale and fatigued B) There are purple striae on the abdomen C) The child is excessively tall for chronologic age D) The child is demonstrating signs of hypoglycemia
There are purple striae on the abdomen
A parent of a school - aged child is distressed to learn of the child is diagnosed with type 2 diabetes mellitus . The parent asks the nurse how this could happen because no one in the family has diabetes . Which response is most accurate ? A) Diabetes mellitus type 2 is caused by the pancreas not making enough insulin B) This disorder usually occurs when inadequate calories are ingested on a regular basis C) Because this disorder is genetic , someone in the family will eventually develop the illness D) This disorder is associated with metabolic disturbances that result in insulin resistance
This disorder is associated with metabolic disturbances that result in insulin resistance
A 6 - month - old girl is diagnosed as having atopic dermatitis . When interviewing her parents , they describe the following care measures . Which one would lead you to think more healthy teaching is needed ? A) The mother gives her daily bath without using soap B) After a bath , the mother applies Eucerin cream C) To aid healing , the father applies hydrocortisone cream to the lesions D) To dry lesions , the father applies alcohol to lesions daily
To dry lesions , the father applies alcohol to lesions daily
The nurse on the pediatric unit is caring for a child admitted for epiglottitis . Which of the following would be appropriate positioning for the patient ? A) Left lateral B) Upright C) Prone D) Supine with left tilt
Upright
The nurse is concerned that a pregnant patient is using cocaine . What should the nurse suggest to the healthcare provider to confirm this suspicion ? A) Urinalysis B) Electrocard Kilogram C) Complete blood count D) Stool test for occult blood
Urinalysis
A 7 year old child presents to the pediatric clinic with a reported history of low grade fever followed by the development of a rash . On assessment the nurse notes multiple red papules , vesicles , and crusted lesions scattered over the trunk , face , and extremities . What disease / disorder would the nurse expect the client is exhibiting ? A) Rubella ( German measles ) B) Atopic dermatitis ( eczema ) C) Coxsackievirus ( hand foot and mouth ) D) Varicella ( chicken pox )
Varicella ( chicken pox )
A 4 - year - old child is being prepared to undergo a bronchoscopy to remove an aspirated pea . Which statement by the parent would the nurse determine the need for further teaching ? A) Our child will be sedated during the procedure B) The healthcare provider will put a tube into my child's throat to get the pea out C) We can go with our child to the holding area and stay with him until the procedure starts D) We will be able to take our child home immediately after the procedure is completed
We will be able to take our child home immediately after the procedure is completed
Which statement would indicate that the client requires additional instruction about breast self - examination ? A) Yellow discharge from my nipple is normal if I am having my period B) I should also feel in my armpit area while performing my breast examination C) I should check my breasts a the same time each morning like after my period D) I should check each breast in a set way , such as in a circular motion
Yellow discharge from my nipple is normal if I am having my period
The pediatric nurse is assessing a 4 - month old infant in the clinic . The child's mother explains that they recently visited a theme park and afterwards learned that there had been four cases of measles diagnosed in children who had visited the park on the same day . When providing education to the mother regarding how she can protect her child from measles infections , the most appropriate statement for the nurse to make is which of the following ? A) You should not take your children to theme parks until they are at least 3 - year - old B) The doctor will prescribe an antiviral for you to give to your daughter for 5 days as post exposure prophylaxis C) Your daughter will be able to receive the measles vaccine after 12 months of age D) We can administer 1 measles vaccine today , and then repeat the dose when she is 12 months old .
Your daughter will be able to receive the measles vaccine after 12 months of age
Nursing considerations for a patient with seizures , what precautions should we take ?
a ) Don't stick anything in the airway , ensure patent airway b ) Move hard objects away to provide safe environment c ) Stay with child ,
