Maternal-Neonatal Pt 2

A nurse is teaching the proper use of crutches to a school-age child with a femur fracture with no weight bearing. What will the nurse include with teaching about walking with crutches? "After advancing both crutches the length of one step, move your 'good' leg forward." "After advancing both crutches the length of one step, move your 'bad' leg forward." "Advance one crutch forward on the affected side, then advance your 'good' leg." "Advance the one crutch forward on your good side, then advance your 'bad' leg."

"After advancing both crutches the length of one step, move your 'good' leg forward." Explanation: When walking with crutches, a child should be instructed to advance both crutches, then advance the unaffected leg. The unaffected leg then supports much of the weight associated with ambulation. It will not be effective to move the affected leg forward first. It wouldn't be safe for the child to advance only one crutch.

A nurse is reinforcing education to the parents of an 18-month-old infant diagnosed with bilateral otitis media about the prescribed medication amoxicillin and clavulanate potassium. Which statement by the parents indicates the education has been effective? "It can cause petechiae." "It can cause headache." "It can cause diarrhea." "It can cause a rash."

"It can cause diarrhea." Explanation: Diarrhea is a common adverse effect of amoxicillin and clavulanate potassium suspension. Red rash and petechiae occur less commonly. Headache is not a common adverse effect and would be difficult to determine in an 18-month-old infant. Remediation:

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is SIDS most likely to occur? 6 months to 1 year, peaking at 10 months 6 to 8 weeks 1 week to 1 year, peaking at 2 to 4 months 1 to 2 years

1 week to 1 year, peaking at 2 to 4 months Explanation: SIDS can occur anytime between ages 1 week and 1 year. The incidence peaks at ages 2 to 4 months.

Which statement accurately describes estrogen and progesterone levels during the 16th week of pregnancy? Both estrogen and progesterone levels are rising. The estrogen level is much higher than the progesterone level. Both estrogen and progesterone levels are declining. The estrogen level is much lower than the progesterone level.

Both estrogen and progesterone levels are rising. Explanation: Until the seventh month of pregnancy, both estrogen and progesterone are secreted in progressively greater amounts. Between the seventh and ninth months, estrogen secretion continues to increase while progesterone secretion drops slightly. This increasing estrogen-progesterone ratio promotes the onset of uterine contractions.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? Take vital signs every 4 hours. Monitor temperature every 4 hours. Decrease environmental stimulation. Encourage the parents to hold the child.

Decrease environmental stimulation. Explanation: A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? Administering antibiotics with meals as prescribed Administering digestive enzymes before meals as prescribed Providing high-fiber snacks Providing small, frequent meals

Document the adolescent's choice and offer to discuss feelings about the medication. Explanation: The client has the right to choose whether to take the medication. The nurse should try to determine the reason for the adolescent not wanting the medication other than choice (e.g., side effects, fear of falling asleep and not waking). The other options do not support the autonomy of the adolescent to make an informed decision.

A nurse is caring for a client who has just delivered a neonate, and finds that the fundus is boggy and deviated to the right. Which action taken by the nurse helps with uterine involution? Have the client void. Assess the client's vital signs. Evaluate lochia characteristics. Massage the fundus.

Have the client void. Explanation: Having the client void can determine whether the boggy, deviated fundus results from a full bladder — the most common cause of these fundal findings. Vital sign assessment is unnecessary unless the nurse suspects hemorrhage from delayed involution. Evaluation of the lochia is done to detect possible hemorrhage. If the uterus remains boggy after the client voids, or if hemorrhage is suspected, the nurse should massage the fundus.

A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate? Administering packed red blood cells Performing fundal massage Inserting an indwelling urinary catheter Performing a pad count

Performing a pad count

A girl, age 15, is 7 months pregnant. When teaching parenting skills to an adolescent, the nurse knows that which teaching strategy is most effective? Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model Initiating a parent support group with older first- and second-time mothers Providing age-appropriate reading material and time to ask questions Lecturing the adolescent about infant care

Providing a one-on-one demonstration and requesting a return demonstration, using a live infant model Explanation: Providing one-on-one demonstration and requesting a return demonstration using a live infant model is the most effective teaching strategy for an adolescent. Because adolescents absorb less information through reading, providing age-appropriate reading materials is the least effective way to teach parenting skills to an adolescent. Initiating a parent support group is effective for providing support; however, a teenage parent support group is best for this age-group. Lecturing is ineffective with this age-group.

After delivering an 8-lb (3.6 kg) girl, a client asks the nurse what her daughter should receive for the first feeding. For a bottle-fed neonate, the first feeding usually consists of which of the following? Sterile water Standard infant formula Glucose water Enriched infant formula

Sterile water Explanation: For a bottle-fed neonate, the first feeding usually consists of sterile water, which is less irritating than glucose water or infant formula if aspirated.

Which of the following correctly defines puerperium? The days spent in the hospital The first hour after birth The 6 weeks following birth The duration of breast-feeding

The 6 weeks following birth Explanation: Puerperium is defined as the 6 weeks postpartum.

Which behavior demonstrated by a 6-year-old would help the nurse recognize a learning disability as opposed to attention deficit hyperactivity disorder (ADHD)? The child has a difficult time reading a chapter book. The child reverses letters and words while reading. The child is always getting into fights during recess. The child is easily distracted and reacts impulsively.

The child reverses letters and words while reading. Explanation: Children who reverse letters and words while reading have dyslexia. Two of the most common characteristics of children with ADHD include inattention and impulsiveness. Although aggressiveness may be common in children with ADHD, it isn't a characteristic that will aid in the diagnosis of this disorder. Six-year-old children aren't usually cognitively ready to read a chapter book.

Parents of a 6-year-old child tell a physician that the child has been having periods of unawareness with short periods of staring. Based on his history, the child is probably having which type of seizure? Myoclonic Complex partial Typical absence Tonic

Typical absence

A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order: a barium enema. suprapubic aspiration. nasogastric (NG) tube insertion. indwelling urinary catheter insertion.

a barium enema. Explanation: A barium enema commonly is used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.

A nurse in a well-child clinic is collecting data on children for scoliosis screening. Which child is at greatest risk for scoliosis? 14-year-old boy 6-year-old girl 10-year-old girl 8-year-old boy

10-year-old girl Explanation: Scoliosis is 5 times more common in girls than boys, and its peak age of incidence is between ages 8 and 15. Therefore, the 10-year-old girl is at greatest risk for scoliosis. The 8-year-old or 14-year-old boy may develop scoliosis, but it is more common in females. A 6-year-old girl is typically too young to be diagnosed with scoliosis.

The nurse is teaching a group of adolescents about automobile safety. Which is the most effective teaching method for this age-group? Lecturing about the effects of drugs and alcohol use on driving Providing written materials on the hazards of driving Coordinating a panel of peers who were involved in motor vehicle accidents Showing an animated video about the responsibilities of driving

Coordinating a panel of peers who were involved in motor vehicle accidents Explanation: Coordinating a panel of peers to discuss motor vehicle accidents and their prevention is more effective for this age-group. Adolescents are more likely to listen to others their age who have experienced similar circumstances. Lecturing about the effects of drugs and alcohol on driving will most likely be ineffective for this age-group. Adolescents won't be motivated to read the written materials. Animated videos aren't age-appropriate and may minimize the importance of the material.

During each prenatal checkup, the nurse obtains the client's weight and blood pressure and measures fundal height. What is another essential part of each prenatal checkup, that the nurse would include in the assessment? Evaluating the client for edema Measuring the client's hemoglobin (Hb) level Obtaining pelvic measurements Determining the client's Rh factor

Evaluating the client for edema Explanation: During each prenatal checkup, the nurse should evaluate the client for edema, a possible sign of pregnancy-induced hypertension. The client's Hb is measured during the first prenatal visit, at 24 to 28 weeks' gestation, and at 36 weeks' gestation. The pelvis is measured and the Rh factor determined during the first prenatal visit.

After collecting data on an adolescent with sickle cell anemia, the nurse assists with formulating a nursing diagnosis of Impaired skin integrity. Which finding best supports this nursing diagnosis? Hemangiomas Swelling of the hands and feet Leg ulcers Petechiae

Leg ulcers Explanation: In sickle cell anemia, sickling of red blood cells leads to increased blood viscosity and impaired circulation. Diminished peripheral circulation makes the adolescent or adult with sickle cell anemia susceptible to chronic leg ulcers. In children younger than age 2 who have sickle cell anemia, swelling of the hands and feet (hand-foot syndrome) commonly occurs during a vaso-occlusive crisis as a result of infarction of short tubular bones. Petechiae aren't associated specifically with sickle cell anemia. Hemangiomas, benign tumors of dilated blood vessels, aren't linked to sickle cell anemia.

A client in labor has been given an epidural anesthetic. When collecting data on the client immediately following the epidural administration, which finding would be most important for the nurse to report? Maternal respirations decrease from 20 breaths to 14 breaths/minute. Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Maternal pulse increases from 78 to 96 beats/minute. Maternal temperature increases from 99° F (37.2° C) to 100° F (37.8° C).

Maternal blood pressure decreases from 130/70 to 98/50 mm Hg. Explanation: As the epidural anesthetic agent spreads through the spinal canal, it may produce hypotensive crisis, which is characterized by maternal hypotension, decreased beat-to-beat variability, and fetal bradycardia. Maternal blood pressure that decreases from 130/70 to 98/50 mm Hg is the most important finding following administration of epidural anesthesia. The respiratory rate, pulse rate, and temperature are within normal limits for a laboring client.

The nurse is caring for an adolescent client who lost consciousness after being struck in the head during a soccer game and was subsequently diagnosed with a concussion. For which prescriptions from the health care provider will the nurse seek clarification? Select all that apply. Take acetaminophen 300mg with 30mg codeine for headache every 4 hours PRN. Perform a neurological assessment every hour for the next 12 hours. Avoid physical exertion for the next 48 hours. Take no food or fluids by mouth for the next 12 hours. Refrain from cognitive activities that exacerbate headache, such as reading.

Take acetaminophen 300mg with 30mg codeine for headache every 4 hours PRN. Take no food or fluids by mouth for the next 12 hours. Explanation: Concussions are a form of traumatic brain injury that impair functioning and are common in adolescents due to sports-related injuries. Assessment for worsening symptoms and supportive care is typical management. Therefore, performing a neurological assessment hourly for the next 12 hours is reasonable. Avoiding activities, both physical and cognitive, that can exacerbate symptoms is also advised. Some clients with concussion will find cognitive activities such as using a computer or reading exacerbates headaches or nausea. Although the client may have nausea, the client does not need to be kept NPO unless actively vomiting, so the nurse should have this prescription clarified. The nurse also clarifies the prescription for an opioid analgesic such as codeine, as these medications can alter cognitive responses, interfering with the assessment of evolving symptoms. Additionally, opioids should not be the first line of analgesia for headache in adolescents. Acetaminophen or ibuprofen are more appropriate.

One day after an appendectomy, a 9-year-old client rates his pain at 4 out of 5 on the pain scale but is playing video games and laughing with his friend. Which of the following would the nurse document on the child's chart? The child is in no apparent distress, and no pain medication is needed at this time. The child rates pain at 4 out of 5. Pain medication administered as prescribed. The child doesn't understand the pain scale. Performed teaching to help child match his pain rating to how he appears to be feeling. The child rates his pain at 4 out of 5; however, he appears to be in no distress. Reassess when he's visibly showing signs of pain.

The child rates pain at 4 out of 5. Pain medication administered as prescribed. Explanation: Pain is what the child says it is, and the nurse must document what the child reports. If a child's behavior appears to differ from the child's rating of pain, believe the pain rating. A child who uses a passive coping behavior (such as distraction) may rate pain as more intense than children who use active coping behavior (such as crying). Making judgments about pain based on behavior can result in children being inadequately medicated for pain.

An otherwise-healthy adolescent has meningitis and is receiving I.V. and oral fluids. The nurse should monitor this client's fluid intake because fluid overload may cause: heart failure. dehydration. cerebral edema. hypovolemic shock.

cerebral edema.

A client who is 7 weeks' pregnant comes to the clinic for her first prenatal visit. She reports smoking 20 to 25 cigarettes per day. When planning the client's care, the nurse anticipates informing her that if she does not stop smoking, her fetus will develop: a neural tube defect. intrauterine growth retardation. a cardiac abnormality. a renal disorder.

intrauterine growth retardation. Explanation: The risk of intrauterine growth retardation may increase with the number of cigarettes a pregnant woman smokes. Neural tube defects, cardiac abnormalities, and renal disorders are associated with multifactorial genetic inheritance, not maternal cigarette smoking.

A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is: providing a daily bath. monitoring the blood glucose level closely. assessing vital signs every 30 minutes. elevating the head of the bed 60 degrees.

monitoring the blood glucose level closely. Explanation: Most TPN solutions contain a high glucose content, placing the client at risk for hyperglycemia. Therefore, the most important nursing action is to monitor the child's blood glucose level closely. A child receiving TPN isn't likely to require vital sign assessment every 30 minutes or elevation of the head of the bed. A daily bath isn't a priority.

The nurse is caring for a toddler admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report? polyuria proteinuria ketonuria glucosuria

proteinuria Explanation: In nephrotic syndrome, the glomerular membrane of the kidneys becomes permeable to proteins. This condition results in massive proteinuria, which the nurse can detect with a reagent strip. Nephrotic syndrome typically does not cause glucosuria or ketonuria. Because the syndrome causes fluids to shift from plasma to interstitial spaces, it is more likely to decrease urine output than to cause polyuria (excessive urine output).

A client is admitted to the facility in preterm labor. To halt her uterine contractions, the nurse expects the health care provider to prescribe: betamethasone. dinoprostone. oxytocin. terbutaline.

terbutaline. Explanation: Terbutaline, a selective beta2-receptor agonist, is used to inhibit preterm uterine contractions. Betamethasone is used to accelerate surfactant production in preterm labor. Dinoprostone is used to induce fetal expulsion and promote cervical dilation and softening. Oxytocin is used to impede uterine blood flow — for example, in hemorrhage.

Which use of restraints in a school-age child should the nurse question? to substitute for observation to ensure the child's comfort or safety to facilitate examination to aid in carrying out procedures

to substitute for observation Explanation: Restraints should never be used as a punishment or as a substitute for observation because if a child is at risk for self-harm when left alone, the child requires one-on-one observation. Ensuring the child's comfort or safety (restraining to keep an I.V., drainage tube, or orthopedic device in place), facilitating examination, and carrying out procedures are all valid reasons for restraint. Restraining devices aren't without risk and must be checked and documented every 1 to 2 hours.

A postpartum client who had a cesarean birth reports right calf pain to the nurse. The nurse observes that the client has nonpitting edema from her right knee to her foot. Based on this finding, the nurse would anticipate which test as the priority? venous duplex ultrasound of the right leg venogram of the right leg noninvasive arterial studies of the right leg transthoracic echocardiogram

venous duplex ultrasound of the right leg Explanation: Right calf pain and nonpitting edema may indicate deep vein thrombosis (DVT). Postpartum clients and clients who have had abdominal surgery are at increased risk for DVT. Venous duplex ultrasound is a noninvasive test that visualizes the veins and assesses blood flow patterns. A venogram is an invasive test that utilizes dye and radiation to create images of the veins; it wouldn't be the first test to perform. Transthoracic echocardiography looks at cardiac structures and isn't indicated at this time. Right calf pain and edema are symptoms of venous outflow obstruction, not arterial insufficiency.

A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction? "Give the elixir with water or juice." "Monitor the child for episodes of diarrhea." "Give the iron preparation with milk." "Give the iron preparation before meals."

"Give the elixir with water or juice." Explanation: Because iron preparations may stain the teeth, the nurse should instruct the parents to give the elixir with water or juice. The iron preparation shouldn't be given with milk because milk impedes iron absorption. This preparation may darken the stools and cause constipation; parental instruction regarding increased fluid intake and fiber intake can prevent constipation. To prevent GI upset, the nurse should instruct the parents to mix the iron preparation with water or fruit juice and have the child take it with meals. (Giving it with fruit juice may be preferable because vitamin C enhances iron solubility and absorption.)

The parent of an adolescent diagnosed with Legg-Calvé-Perthes disease (LCPD) asks the nurse, "What caused this condition?" Which nursing response is appropriate? "The health care provider can give you more information." "Exposure to toxins in the womb can result in this condition." "The hip joint has been damaged due to lack of blood supply." "Taking antibiotics causes this disorder."

"The hip joint has been damaged due to lack of blood supply." Explanation: Legg-Calvé-Perthes disease (LCPD) is a disease of one or both hips. The nurse will convey that this condition results from a lack of blood supply to the hip joint. Poor blood supply to bones results in fractures and poor bone healing. The cause of this spontaneous, yet temporary, reduction of blood flow to the femoral head is unknown. It may be caused by an injury or another disease process. It tends to run in families and affects boys five times more frequently than girls. The nurse will not defer the question to the health care provider, as a reasonable and objective response can be given. LCPD is not caused by exposure to toxins in the womb nor by taking antibiotics.

A newly hired graduate nurse asks the nurse preceptor at what gestational age would a primigravida expect to feel quickening. At what week would the preceptor tell the graduate this client would expect to feel quickening? 12 weeks 14 to 16 weeks 18 to 22 weeks By the end of the 26th week

18 to 22 weeks Explanation: The nurse needs to distinguish between a client who's having her first baby and one who has already had a baby. For the client who's pregnant for the first time, quickening occurs around 18 to 22 weeks. Women who have had children will feel quickening earlier, usually around 16 to 18 weeks, because they recognize the sensations.

Which physiologic response should the nurse expect during the early postpartum period? Urinary urgency and dysuria Rapid diuresis Hypotension Increased GI motility

Rapid diuresis Explanation: During the early postpartum period, glomerular filtration rate increases and progesterone levels drop; these physiologic responses result in rapid diuresis. Urinary urgency shouldn't occur, although a woman may feel anxious about voiding. Blood pressure should change only minimally following childbirth, and a residual decrease in GI motility may occur.

A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should complete which of the following tasks? Ask her to void. Instruct her to drink 1 L of fluid. Prepare her for I.V. anesthesia. Ask her to lie on her left side.

Ask her to void. Explanation: To prepare a client for amniocentesis, the nurse should ask her to empty her bladder to reduce the risk of bladder perforation. Before transabdominal ultrasound, the nurse may instruct the client to drink 1 L of fluid to fill the bladder (unless ultrasound is done before amniocentesis to locate the placenta). Amniocentesis doesn't require I.V. anesthesia. The client should be supine during the procedure; afterward, she should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate cardiac output.

What should the nurse do to ensure a safe hospital environment for a toddler? Place the child in a youth bed. Move stacking toys out of reach. Pad the crib rails. Move the equipment out of reach.

Move the equipment out of reach. Explanation: Toddlers are curious and may try to play with items such as equipment that is within their reach. Doing so is dangerous. Toddlers in a strange hospital environment still need the security of a crib. Padded crib rails are necessary if seizure activity is present. Stacking toys are appropriate for this age-group and don't present a safety hazard.

Which sign indicates respiratory distress in a neonate? Acrocyanosis Nasal flaring Abdominal movements Periods of apnea lasting less than 15 seconds

Nasal flaring Explanation: Nasal flaring is a sign of respiratory distress in a neonate. Acrocyanosis, abdominal movements, and short periods of apnea that last less than 15 seconds are all normal findings in the neonate.

After determining that a pregnant client is Rh-negative, the health care provider orders an indirect Coombs test. What does the nurse tell this client is the purpose of performing this test? To determine the fetal blood Rh factor To determine the maternal blood Rh factor To detect maternal antibodies against fetal Rh-negative factor To detect maternal antibodies against fetal Rh-positive factor

To detect maternal antibodies against fetal Rh-positive factor Explanation: The indirect Coombs test measures the number of antibodies against fetal Rh-positive factor in maternal blood. The maternal blood Rh factor is determined before the indirect Coombs test is done. No maternal antibodies against fetal Rh-negative factor exist.

After collecting data on a neonate, the nurse determines that maternal estrogen has been transferred to the fetus based on which finding? weak sucking response enlarged breast tissue soft skin vernix caseosa

enlarged breast tissue Explanation: Engorged breast tissue is common in both male and female neonates in their first few days of life due to the transmission of maternal estrogen to the fetus. Weak sucking response is not related to estrogen. Soft skin and vernix caseosa are signs of full-term, well-developed neonates and are not related to estrogen.

An 18-month-old child comes to the primary health care provider's office for a well-baby checkup. Which foods should the nurse recommend as providing the best sources of dietary iron for the child? cheese, yogurt, and fresh fish berries, turkey, and cheese peanut butter, green vegetables, and raisins yellow vegetables, citrus fruits, and white bread

peanut butter, green vegetables, and raisins Explanation: Peanut butter, legumes, green vegetables, and dried fruits are sources high in iron. Cheese, yogurt, fresh fish, yellow vegetables, citrus fruits, white bread, berries, turkey, and cheese are lower in iron content.

Which finding would the nurse associate with a partial-thickness burn in a 9-year-old child? erythema and pain minimal damage to the epidermis necrosis through all layers of skin tissue necrosis through most of the dermis

tissue necrosis through most of the dermis Explanation: A client with a deep partial-thickness burn will have tissue necrosis to the epidermis and dermis layers. Necrosis through all skin layers is seen with full-thickness injuries. Erythema and pain are characteristic of superficial injury. With deep burns, the nerve fibers are destroyed and the client will not feel pain in the affected area. Superficial burns present with slight epidermal damage.

The nurse is reinforcing education regarding insulin injections with an 11-year old child with diabetes Type I. Which guideline is appropriate to follow? Self-injection techniques should be taught only when the child can reach all injection sites. The parents do not need to be involved in learning this procedure. At age 11, the child should be old enough to give injections independently. Self-injection techniques are not usually taught until the child reaches 16 years of age.

At age 11, the child should be old enough to give injections independently. Explanation: The parents must supervise and manage the child's therapeutic program, but the child should assume responsibility for self-management as soon as he can. Children can learn to collect their own blood for glucose testing at a relatively young age (4 to 5 years), and most can check their blood glucose level and administer insulin at all injection sites by about age 9. Some children can do it earlier.

When performing cardiopulmonary resuscitation on a 7-month- old infant, which location would the nurse use to evaluate the presence of a pulse? Carotid artery Femoral artery Brachial artery Radial artery

Brachial artery Explanation: The brachial artery is the best location for evaluating the pulse of an infant younger than age 1. A child of this age has a very short and often fat neck, so the carotid artery is inaccessible. The femoral artery is usually inaccessible because of clothing and diapers. The radial artery may not be palpable if cardiac output is low, even if there is a heartbeat.

A child with diabetes insipidus receives desmopressin acetate (DDAVP). When evaluating for therapeutic effectiveness, the nurse would interpret which finding as a positive response to this drug? Increased urine glucose level Relief of nausea Decreased urine output Decreased blood pressure

Decreased urine output Explanation: The primary action of DDAVP is to stimulate water reabsorption by the kidneys, thereby decreasing the urine output. DDAVP has no effect on glucose levels, blood pressure, or nausea.

The nurse is providing care for a pregnant client in her second trimester. Glucose tolerance test results show a blood glucose level of 160 mg/dl. The nurse should anticipate that the client will need to: start using insulin. be taught about diet. start taking an oral antidiabetic drug. monitor her urine for glucose.

be taught about diet. Explanation: The client's blood glucose level should be controlled initially by diet and exercise, rather than insulin. The client will need to watch her overall diet to control her blood glucose level. Oral antidiabetic drugs aren't prescribed for pregnant clients. Urine sugars aren't an accurate indication of blood glucose levels.

The nurse is assessing the newborns of four mothers. To which newborn would the nurse pay special attention to for the development of respiratory distress syndrome (RDS)? the infant born at 35 weeks 6 days gestation the infant requiring a forceps delivery the first-born infant of a twin pregnancy the infant born to a mother who smokes

the infant born at 35 weeks 6 days gestation Explanation: Prematurity is the single most important risk factor for developing RDS. The second-born infant of a twin pregnancy and infants delivered by cesarean birth are also at increased risk for RDS. The infant born to a mother who smokes will most likely be small for gestational age but not at increased risk for RDS. Delivery by forceps does not have any correlation to RDS.

A pregnant client tells the nurse that she doesn't like milk and can't possibly drink three to four glasses per day as recommended by her health care provider. What is the best response by the nurse? "I did not like milk either, but I drank it during pregnancy." "Are there any dairy products that you do like?" "It is important for the baby that you drink your milk." "Do not worry; you can just take calcium supplements."

"Are there any dairy products that you do like?" Explanation: The nurse should determine if the client likes other dairy products that could serve as nutritional substitutes for milk. Telling the client that the nurse did not like milk but drank it anyway takes the focus off the client. Clients should attempt to get the required vitamins and nutrients from food sources versus supplements. Telling the client that it is important that she drink milk for the health of the baby does not address the problem of the client not liking milk.

The nurse is reinforcing education with parents about therapeutic management of their neonate diagnosed with congenital hypothyroidism. Which response by a parent would indicate the need for further education? "My baby will need regular measurements of his thyroxine levels." "As my baby grows, his thyroid gland will mature and he won't need medications." "Treatment should begin as soon as possible after diagnosis is made." "Treatment involves lifelong thyroid hormone replacement therapy."

"As my baby grows, his thyroid gland will mature and he won't need medications." Explanation: Treatment involves lifelong thyroid hormone replacement therapy that begins as soon as possible after diagnosis. The goal of treatment is to abolish all signs of hypothyroidism and to reestablish normal physical and mental development. The drug of choice is synthetic levothyroxine. Regular measurements of thyroxine levels are important in ensuring optimal treatment.

A school nurse is planning a program on skin cancer prevention for a group of teenagers. Which instruction should the nurse emphasize during the program? "Stay out of the sun between 1 p.m. and 3 p.m." "Tanning booths are a safe alternative for those who wish to tan." "Sun exposure is safe, provided you wear protective clothing." "Examine your skin once per month, looking for suspicious lesions or changes in moles."

"Examine your skin once per month, looking for suspicious lesions or changes in moles." Explanation: To increase the detection of skin cancer in its early stages, the nurse should emphasize to the teenage group the importance of monthly skin self-examinations and yearly examinations by a primary care provider. The nurse should also teach the teens to avoid the sun's ultraviolet rays between 10 a.m. and 3 p.m. to reduce the risk of skin cancer. Repeated exposure to artificial sources of ultraviolet radiation, such as tanning booths, increases the risk of skin cancer. Although protective clothing offers a little defense against skin cancer, some of the sun's harmful rays can penetrate clothing.

Which action should the nurse include in the plan of care for a 2-month-old infant with heart failure? Feed the infant when he cries. Weigh and bathe the infant before feeding. Bathe the infant and administer medications before feeding. Allow the infant to rest before feeding.

Allow the infant to rest before feeding. Explanation: Because feeding requires so much energy, an infant with heart failure should rest before feeding. Bathing and weighing the infant and administering medications should be scheduled around feedings. An infant expends e

When caring for a toddler, the nurse should understand that a child in this age-group works to achieve which developmental task? Initiative Autonomy Trust Industry

Autonomy Explanation: The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task. Developing trust is the infant's task. Developing industry is the task of the school-age child.

Which nursing intervention has the highest priority in the care of an infant during the first 24 hours after surgery for cleft lip? Carefully clean the suture line after feedings using sterile technique. Position the infant in the prone position after feedings. Allow the infant to cry to promote lung expansion. Provide the infant with a pacifier to satisfy the urge to suck.

Carefully clean the suture line after feedings using sterile technique. Explanation: The suture line must be cleaned after each feeding to reduce the risk of infection, which could adversely affect the healing and cosmetic results. The incision should be cleaned carefully so the sutures are not disrupted. A sterile solution should be used to reduce the risk of infection. The infant should not be placed on his abdomen in the prone position because this puts pressure on the incision and may affect healing. Anticipatory care should be provided to reduce the risk of the infant crying, which puts pressure on the incision. Pacifiers and other firm objects should not be placed in the infant's mouth because they can disrupt the suture line.

When developing a postoperative plan of care for an infant scheduled for cleft lip repair, the nurse should assign highest priority to which intervention? Comforting the child as quickly as possible Maintaining the child in a prone position Restraining the child's arms at all times, using elbow restraints Avoiding disturbing any crusts that form on the suture line

Comforting the child as quickly as possible Explanation: After surgery to repair a cleft lip, the primary goal of nursing care is to maintain integrity of the operative site. Crying causes tension on the suture line, so comforting the child as quickly as possible is the highest nursing priority. Parents may help by cuddling and comforting the child. The prone position is contraindicated after surgery because rubbing on the sheet may disturb the suture line. Elbow restraints may cause agitation; if used to prevent the child from disturbing the suture line, they must be removed, one at a time, every 2 to 4 hours so that the child can exercise and the nurse can assess for skin irritation. Crusts forming on the suture line contribute to scarring and must be cleaned carefully.

A nurse and a nursing student drive to the home of a client with postpartum depression and discover the client and her baby completely naked in the backyard. The client is unable to communicate in an effective manner. What is the nurse's most appropriate response to resolve this situation? Contact the client's partner to come home from work and immediately take her to the emergency department. Contact the client's physician and the baby's pediatrician. Ask the nursing student to stay with the client while the nurse performs the last home visit in the community. Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation.

Contact the nursing supervisor to clarify the appropriate actions in this acute mental health situation. Explanation: The nurse should contact the immediate nursing supervisor to clarify or guide the correct nursing actions in this acute mental health situation. Community mental health services may be available that could visit the home and assess and intervene in this situation. The nurse should help the mother and baby inside and stay with them until the supervisor advises how best to manage the situation. It is inappropriate to call the client's partner and have them come home because the nurse first needs to assess and address any immediate safety concerns for the mother and baby. Asking the nursing student to remain with this client while the nurse leaves is inappropriate because this may jeopardize the safety of the nursing student. In addition, given the context, the care required may be beyond the nursing student's scope of practice.

The nurse is gathering data on a 1-month-old infant. Which data obtained by the parents indicate the infant may have a cardiac defect? The infant is gaining weight. The infant has been hyperactive. The infant is not taking formula well. The infant has pink, mucous membranes.

The infant is not taking formula well. Explanation: Infants and children with heart defects tend to have poor nutritional intake and weight loss, indicating poor cardiac output, heart failure, or hypoxemia. The child appears lethargic or tired because of the heart failure or hypoxia. Gray, pale, or mottled skin may indicate hypoxia or poor cardiac output. Pink, moist mucous membranes are normal.

One day after a client gives birth, the nurse performs a postpartum assessment. The nurse finds a moderate amount of lochia rubra on the client's perineal pad. Which action should the nurse? Document this as a normal finding Notify the health care provider Massage the fundus Obtain vital signs

Document this as a normal finding Explanation: Lochia rubra, the first stage of lochia, typically lasts for the first 4 postpartum days. Bright red, it contains a mixture of blood, mucus, and tissue debris. Therefore, moderate rubra immediately postpartum is a normal finding. There is no need to notify a health care provider. The is no indication for massaging the fundus. The amount of blood loss does not have any significant effect on the vital signs.

A premature infant in the neonatal intensive care unit is actively dying and on comfort care measures only. The infant is grimacing with a respiratory rate of 20 breaths/minute. The parents ask the nurse to administer an opioid analgesic. What should the nurse do first? Contact the healthcare provider about the infant's respiratory rate. Stimulate infant to increase respiratory rate prior to administering the opioid. Ensure the parents know opioids can cause further respiratory depression. Administer the opioid as prescribed by the healthcare provider.

Ensure the parents know opioids can cause further respiratory depression. Explanation: The infant is actively dying and on comfort measures only, so the nurse's priority is the infant's and the parent's comfort. The nurse helps prepare the parents by making them aware of the effects of the opioid to ensure they are giving an informed request for this treatment. Once the parents indicate understanding, the nurse can provide the treatment. The respiratory rate is significantly lower than normal for a premature infant, which could be due in part to previous administration of opioids, so the parents should be made aware of this. However, the infant is showing some evidence of pain (grimacing), and the opioid is prescribed to treat this pain, so the nurse does not need to contact the healthcare provider. The nurse should not stimulate the infant, because doing so could cause more discomfort.

A 3-year-old child has had surgery to remove a Wilms tumor. Which action should the nurse take first when the parent asks for pain medication for the child? Gather data regarding the child's pain using a pain scale of 1 to 10. Get the pain medication ready for administration. Check for the last time pain medication was administered. Gather data regarding the child's pain using a smiley face pain scale.

Gather data regarding the child's pain using a smiley face pain scale. Explanation: The first action by the nurse should be to gather data from the child regarding pain. A 3-year-old child is too young to use a pain scale from 1 to 10, but can easily use the smiley face pain scale. After gathering data regarding the child's pain, the nurse should then investigate the time the pain medication was last given and administer the medication accordingly.

The nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? Decreased diarrhea Increased energy level Increased appetite Increased urine output

Increased urine output Explanation: Increased urine output, a sign of improving kidney function, typically is the first sign that a child with APSGN is improving. Increased appetite, an increased energy level, and decreased diarrhea aren't specific to APSGN.

When questioned, a pregnant client admits she sometimes has several glasses of wine with dinner. The nurse expects the health care practitioner to explain the client that her alcohol consumption puts her fetus at risk for which condition? Alcohol addiction Anencephaly Down syndrome Learning disability

Learning disability Explanation: Maternal alcohol use during pregnancy may cause fetal and neonatal central nervous system deficits such as learning disabilities. It also may lead to characteristic physical anomalies and growth retardation. Maternal alcohol use doesn't cause alcohol addiction in the fetus or neonate. Anencephaly occurs when the cranial end of the neural tube fails to fuse before the 26th day of gestation; this condition isn't related to maternal alcohol use. Down syndrome results from a chromosomal disorder.

The nurse is participating in the care of a client who has given birth to a 7 pound, 4 ounce baby. The nurse observes bleeding saturating the pad. What is the priority intervention at this time to control the bleeding? Massage the fundus. Replace the pad and apply pressure to the vagina. Increase the IV fluids. Administer oxytocin as ordered.

Massage the fundus. Explanation: The initial intervention is to massage the fundus because it may relax after birth. The fundus should be firm and midline. For the first hour after birth, the height of the fundus is at the umbilicus or even slightly above it and then decreases one fingerbreadth in size daily. Never palpate the uterus without supporting the lower segment because it may invert and cause massive hemorrhage.

When planning a program to educate adolescents about acquired immunodeficiency syndrome (AIDS), which action might lead to better acceptance of the program? Invite health care providers to host workshops in community centers. Obtain peer educators to provide information about AIDS. Survey the community to evaluate the level of education. Set up clinics in community centers and supply condoms readily.

Obtain peer educators to provide information about AIDS. Explanation: Peer education programs have shown that teens are more likely to pose questions to peer educators than to adults, and that peer education can change personal attitudes and the perception of the risk of HIV infection. The other approaches would be helpful but wouldn't necessarily make the outreach program more successful.

A child, age 14, is hospitalized for nutritional management and drug therapy after experiencing an acute episode of ulcerative colitis. Which nursing intervention would be appropriate? Administering digestive enzymes before meals as prescribed Providing small, frequent meals Administering antibiotics with meals as prescribed Providing high-fiber snacks

Providing small, frequent meals Explanation: Clients with ulcerative colitis, also known as inflammatory bowel syndrome, tolerate small, frequent meals better than a few large meals daily. Eating large amounts of food may exacerbate the abdominal distention, cramps, and nausea typically caused by ulcerative colitis. Frequent meals also provide the additional calories needed to restore nutritional balance. This client doesn't lack digestive enzymes and therefore doesn't need enzyme supplementation. Antibiotics are contraindicated because they may interfere with the actions of other prescribed drugs and because ulcerative colitis isn't caused by bacteria. High-fiber foods may irritate the bowel further.

A client, 7 months pregnant, is receiving the tocolytic agent terbutaline, 17.5 mcg/minute intravenous (I.V.), to halt uterine contractions. She also takes prednisone, 5 mg by mouth twice per day, to control asthma. To detect an adverse interaction between these drugs, what should the nurse monitor this client for? Increased uterine contractions Pulmonary edema Asthma exacerbation Hypertensive crisis

Pulmonary edema Explanation: When administered concomitantly with prednisone or another corticosteroid, terbutaline may cause pulmonary edema. Concomitant administration of a corticosteroid and terbutaline doesn't cause increased uterine contractions, asthma exacerbation, or hypertensive crisis. Add a Note

During a health teaching session, a student, age 14, asks the school nurse the reason for using underarm deodorant. The nurse should base the response on which physiologic change occurring during adolescence? The apocrine sweat glands reaching secretory capacity An increase in adipose tissue distribution, which boosts sweat production The sebaceous glands becoming highly active The eccrine sweat glands becoming fully functional

The apocrine sweat glands reaching secretory capacity Explanation: The apocrine sweat glands grow in conjunction with hair follicles in the underarm areas; during adolescence, they reach their secretory capacity. Although adipose tissue increases during adolescence, this increase isn't associated with sweat production. The eccrine sweat glands, distributed over the entire body, aren't associated with pubertal physiologic changes. The sebaceous glands contribute to acne, not sweat production. Add a Note

The nurse is teaching a pregnant client how to distinguish prelabor contractions from true labor contractions. Which statement about prelabor contractions is accurate? They're regular. They're usually felt in the abdomen. They start in the back and radiate to the abdomen. They become more intense during walking.

They're usually felt in the abdomen. Explanation: Prelabor contractions are usually felt in the abdomen. In contrast, true labor contractions are regular, start in the back and radiate to the abdomen, and become more intense during walking.

A child is seen at the health care provider's office. During the interview period the child's parent reports the child has a grade 1 heart murmur. The nurse is aware that this murmur has which characteristic? a sound that can be heard with the naked ear a sound softer than the heart sounds a sound associated with a precordial thrill a sound equal to the heart sounds

a sound softer than the heart sounds Explanation: A grade 1 heart murmur is usually difficult to hear and softer than the heart sounds. A grade 2 murmur is usually equal to the heart sounds. A grade 4 murmur can be associated with a precordial thrill. A thrill is a palpable manifestation associated with a loud murmur. A grade 6 murmur can be heard with the naked ear or with the stethoscope off the chest.

The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to: place the toddler in a bathtub and check on him frequently. allow the toddler to bathe as much of himself as he can with supervision. provide total care because the toddler is too young to assist. allow the toddler to bathe himself using a basin with water at the bedside.

allow the toddler to bathe as much of himself as he can with supervision. Explanation: A toddler should be encouraged to bathe himself as much as he can, with supervision. When he's finished, the nurse should bathe the areas that the toddler was unable to wash. Doing so fosters independence, which is important to toddlers, but maintains their safety. Toddlers should never be left unattended near water, whether contained in a bathtub or basin, to prevent accidental drowning.

The nurse is checking the legs of a client who's 36 weeks pregnant. Which finding should the nurse expect? absent pedal pulses bilateral dependent edema sluggish capillary refill unilateral calf enlargement

bilateral dependent edema Explanation: As the uterus grows heavier during pregnancy, femoral venous pressure rises, leading to bilateral dependent edema. Factors interfering with venous return, such as sitting or standing for long periods, contribute to edema. Absence of pedal pulses and sluggish capillary refill signal inadequate circulation to the legs; an unexpected finding during pregnancy. Unilateral calf enlargement, also an abnormal finding, may indicate thrombosis.

A 10-year-old child has been experiencing insatiable thirst and urinating excessively and the serum glucose is normal. Which condition is the child most likely experiencing? type 1 diabetes hyperthyroidism diabetes insipidus type 2 diabetes

diabetes insipidus Explanation: Polydipsia and polyuria with normal serum glucose are indicative of diabetes insipidus. Interview and laboratory results can determine whether the origin is neurogenic or nephrogenic. Type 1 or 2 diabetes mellitus present with an elevated serum glucose. A child with hyperthyroidism may present as dehydrated from the excessive sweating and rapid respirations that accompany this hypermetabolic state.

A nurse is assisting with the care of a pregnant client experiencing mild active bleeding from placenta previa. The nurse suspects that an emergency cesarean birth may be necessary based on which finding? absence of pooling of vaginal bleeding under the client maternal blood pressure of 130/82 mm Hg maternal heart rate of 78 beats/minute fetal heart rate of 80 beats/minute

fetal heart rate of 80 beats/minute Explanation: A fetal heart rate of 80 beats/minute indicates fetal distress, indicating the need for a cesarean birth. Maternal blood pressure and heart rate would be considered within normal parameters. Bleeding, especially if noted as pooling under the client, indicates active bleeding and an indication that cesarean birth may be necessary.

The nurse is caring for a postpartum client after giving birth to a healthy neonate. When checking the client's fundus, which finding would the nurse most likely note? fundus 1 cm above the umbilicus 1 hour postpartum fundus 1 cm above the umbilicus on postpartum day 3 fundus palpable in the abdomen at 2 weeks postpartum fundus slightly to right; 2 cm above umbilicus on postpartum day 2

fundus 1 cm above the umbilicus 1 hour postpartum Explanation: Within the first 12 hours postpartum, the fundus is usually approximately 1 cm above the umbilicus. The fundus should be below the umbilicus by postpartum day 3. The fundus shouldn't be palpated in the abdomen after day 10. A uterus that isn't midline or is above the umbilicus on postpartum day 3 might be caused by a full, distended bladder or a uterine infection.

A primigravida client is in labor. Her cervix is 5 cm dilated and 75% effaced; the fetus is at 0 station. The client requests medication to relieve the discomfort of contractions, and the health care provider prescribes an epidural regional block. When assisting with the procedures, which position should the nurse help the client to assume when the epidural is administered? lateral lithotomy supine prone

lateral Explanation: The client should be placed on her left side, with her shoulders parallel and legs slightly flexed. The epidural space, the potential space between the dura mater and the ligamentum flavum, is readily accessed with the client on her side. The lithotomy, supine, or prone position do not allow proper access to the epidural space.

The nurse is working as part of multidisciplinary team in developing the plan of care for a premature neonate. Breast milk is being encouraged as part of the plan. The nurse understands that the use of breast milk for this neonate would help prevent which condition? hyaline membrane disease necrotizing enterocolitis Turner syndrome Down syndrome

necrotizing enterocolitis Explanation: Components specific to breast milk have been shown to lower the incidence of necrotizing enterocolitis in premature neonates. Hyaline membrane disease isn't directly influenced by breast milk or breast-feeding. Down syndrome and Turner syndrome are genetic defects that aren't influenced by breast milk.

An adolescent is admitted to the pediatric unit for evaluation of abdominal pain. Which individuals should collaborate in caring for this client? Select all that apply. nurse physician pharmacist social worker client

nurse physician pharmacist social worker client Explanation: Collaboration of care involves all disciplines involved in caring for the client, particularly the client as the center of care. Nurses assigned to the client provide direct care, and the physician, pharmacist, and social worker provide input to the care of the client.

A healthy, 6-month-old infant is brought to the well-baby clinic for a checkup. When checking the infant's anterior fontanel the nurse expects it to be: open. sunken. closed. bulging.

open. Explanation: The anterior fontanel is open in a healthy, 6-month-old infant. Normally, it closes between ages 9 and 18 months. It should feel flat and firm. A sunken fontanel indicates dehydration. Although coughing or crying may cause temporary bulging, persistent bulging and tenseness of the fontanel signals increased intracranial pressure.

A nurse is obtaining data from a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition? positive Homans sign negative Kernig's sign positive Kernig's sign negative Brudzinski's sign

positive Kernig's sign Explanation: A positive Kernig's sign indicates nuchal rigidity, caused by an irritative lesion of the subarachnoid space. A positive Brudzinski's sign also is indicative of the condition. A positive Homans sign may indicate venous inflammation of the lower leg. Negative signs mean that the condition is not present.

A client has just been diagnosed with having a hydatidiform mole. When reviewing the client's medical record, what is the most significant risk factor? prior molar gestation high socioeconomic status primigravida age in 20s or 30s

prior molar gestation Explanation: A previous molar gestation increases the risk for developing a subsequent molar gestation by four to five times. Adolescents and clients age 40 years and older are at increased risk for molar pregnancies. Multigravidas, especially those with a prior pregnancy loss, and those with lower socioeconomic status are at an increased risk for this problem.

A nurse is caring for 10-year-old child with sickle cell anemia admitted for vaso-occlusive crisis. Which would be the most appropriate activity for the nurse to provide for the child? exercising in the physical therapy department finger painting walking in the hallways reading

reading Explanation: During a vaso-occlusive crisis, the child needs to minimize oxygen consumption by resting. Reading is a quiet, age-appropriate activity. Walking in the hallway and exercising in the physical therapy department are too strenuous for a child in vaso-occlusive crisis. Finger painting is not an appropriate activity for a 10-year-old.

The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit: a preference for eating alone. strong food preferences. an increased appetite. consistent table manners.

strong food preferences. Explanation: A toddler typically exhibits strong food preferences, eating one type of food for several days and excluding others. A toddler can't be expected to use consistent table manners. Generally, the appetite decreases during the toddler stage because of a slowed growth rate. A toddler typically enjoys socializing during meals and often imitates others.

A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin augmentation. The nurse who's caring for her should stay alert for: uterine inversion. uterine atony. uterine involution. uterine discomfort.

uterine atony. Explanation: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery.

A 14-year-old is seen in the pediatrician's office with a history of mild sore throat, low-grade fever, a diffuse maculopapular rash, and reports swelling of the wrists and redness in the eyes. The nurse interprets these findings as indications of which condition? rubella varicella rubeola roseola

rubella Explanation: Rubella presents with a diffuse maculopapular rash, mild sore throat, low-grade fever, and, occasionally, conjunctivitis, arthralgia, or arthritis. Rubeola is associated with high fever, which reaches its peak at the height of a generalized macular rash and typically lasts for 5 days. Roseola involves high fever and is abruptly followed by a rash. Varicella presents with fever, small erythematous macules on the trunk or scalp, which progress to papules, and clear vesicles on an erythematous base

During chemotherapy for lymphoma, a child, age 15, is at risk for stomatitis. Which statement by the child supports a nursing diagnosis of Deficient knowledge related to mouth care? "I rinse my mouth every 2 to 4 hours with a solution of baking soda and water." "I don't use bottled mouthwashes." "I use a soft toothbrush to clean my teeth." "I remove white patches on my tongue and cheeks with my toothbrush."

"I remove white patches on my tongue and cheeks with my toothbrush." Explanation: White patches on the tongue and oral mucosa indicate infection; the client should report, not remove, them. The child should use a soft toothbrush to prevent injury to the fragile oral mucosa. To prevent stomatitis, the child should rinse the mouth every 2 to 4 hours with a nonirritating solution, such as baking soda and water or normal saline solution, and should avoid commercial mouthwashes containing alcohol, which may dry the oral mucosa.

The nurse admits a client in active labor at 38 weeks gestation. The client says to the nurse, "I was not expecting to go into labor so soon, so I did not have time to shave down there." How should the nurse respond? "There is no medical reason for shaving the pubic area for the birth, so you don't need to worry about it." "It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?" "It is your choice. It can make it much easier to keep the perineal area clean during labor and in the postpartum period." "We do not recommend shaving the pubic area, because it greatly increases the risk of perineal infections. But it is your choice."

"It is not medically necessary and is based on the client's preference. Would shaving make you more comfortable?" Explanation: The nurse bases the response on the current recommendations, which is to not routinely shave the pubic and perineal area for vaginal births. Evidence has shown no difference in infection rates between women who are shaved versus not. Therefore, the nurse emphasizes that it is the client's choice and does not state it is recommended in order to make it easier to keep the area clean. The nurse should not dismiss the client's feelings by telling the client "not to worry about it."

The nurse encourages a postpartum client to discuss the childbirth experience. Which client outcome is most appropriate for this client "The client demonstrates an understanding of the neonate's physical needs related to labor and delivery." "The client demonstrates an understanding of her physical needs related to labor and delivery." "The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." "The client demonstrates the ability to care for the neonate completely by time of discharge."

"The client demonstrates the ability to integrate the childbirth experience and progress to the task of maternal role attainment." Explanation: Discussing the childbirth experience helps the client acknowledge and understand what happened during this event. The nurse should give the client a chance to ask questions about the event and seek clarification, if needed. After the client discusses the event, she may be able to shift the focus away from herself and begin the tasks that will help her assume the maternal role. The nurse must determine the client's understanding of her physical needs and those of her neonate after teaching and demonstrating care techniques; discussing the childbirth experience won't help her meet these needs.

A nurse is discussing nutrition with a primigravida client. The nurse is informed that the client knows that calcium is important during pregnancy but that client and the client's family do not consume many milk or dairy products. What advice should the nurse give? "After the first trimester, calcium is not as important because all fetal organ structures are formed." "You could supplement your diet with 1800 mg of over-the-counter calcium tablets." "The prenatal vitamins that are recommended will satisfy all dietary requirements." "You should consume other nondairy foods that are high in calcium."

"You should consume other nondairy foods that are high in calcium." Explanation: Food is considered the ideal source of nutrients. However, milk and dairy are not the only food sources of calcium. The client should consume other nondairy foods that are high in calcium, such as dark green leafy vegetables. Although prenatal vitamins are generally recommended, they do not satisfy all requirements. The calcium requirement for pregnancy is 1300 mg/day. Over-the-counter supplements are not always safe and should be specifically recommended by the health care provider. Although it is true that all fetal organs are formed by the end of the first trimester, development continues throughout pregnancy. Calcium requirements remain at 1300 mg/day throughout pregnancy.

When assisting in developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate? Padded side rails Oxygen mask and bag system at bedside Arm restraints while asleep Cardiorespiratory monitoring

Arm restraints while asleep Explanation: Restraints should never be used on a child with a seizure disorder because they could harm the child if a seizure occurs. Padded side rails will prevent the child from being injured during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.

A neonate must receive an eye preparation to prevent ophthalmia neonatorum. How should the nurse administer this preparation? By allowing the eyelid to close during medication instillation By letting the medication drip onto the surface of the eye By positioning the neonate so that the head remains still By holding the neonate in the football position

By positioning the neonate so that the head remains still Explanation: After positioning the neonate securely so that the head remains still, the nurse should hold the eyelid open and instill the medication into the conjunctival sac. Holding the neonate in the football position doesn't secure the head.

The nurse is caring for an 8-year old child with acute asthma. Which data collection finding should the nurse immediately report to the charge nurse? The child's respiratory rate is 24 breaths/minute. The pulse oximeter reading is 95%. During auscultation, breath sounds are diminished bilaterally and no wheezing is audible. The child's mother reports that the child sometimes forgets to take his inhaler.

During auscultation, breath sounds are diminished bilaterally and no wheezing is audible. Explanation: Typically during an acute asthma attack, wheezing is increased and the client has increased respiratory distress. Diminished breath sounds and no wheezing on auscultation indicate that the child isn't moving air in and out and is in respiratory distress. A respiratory rate of 24 breaths/minute in an 8-year-old child is normal. An oxygen saturation of 95% is slightly low, possibly indicating the need for oxygen or the need to clear the airway, but this finding isn't as important at this time as the diminished breath sounds and lack of wheezing. The fact that the mother makes the 8-year-old responsible for taking his medication is of concern and needs to be investigated but this issue isn't the priority at this time.

The nurse is caring for a 7-year-old child hospitalized with cystic fibrosis. To help the child manage secretions and avoid respiratory distress, which nursing intervention would be a priority? Perform chest physiotherapy every 4 hours. Give pancreatic enzymes as prescribed. Place the child in an oxygen tent, and have oxygen administered continuously. Serve a high-calorie diet.

Perform chest physiotherapy every 4 hours. Explanation: Chest physiotherapy must be performed in a child with cystic fibrosis because it aids in loosening secretions in the entire respiratory tract. Pancreatic enzymes aid in the absorption of necessary nutrients, not in managing secretions. Oxygen therapy does not aid in loosening secretions and can cause carbon dioxide retention and respiratory distress in children with cystic fibrosis. A high-calorie diet is appropriate but does not facilitate respiratory effort.

A client is experiencing an early postpartum hemorrhage. Which action by the nurse is most appropriate? Inserting an indwelling urinary catheter Performing fundal massage Administering packed red blood cells Performing a pad count

Performing fundal massage Explanation: The nurse should immediately perform fundal massage to ensure that the uterus is well contracted. After performing fundal massage, the nurse should notify the physician. The physician will likely order insertion of an indwelling catheter to make sure that a distended bladder, which prevents uterine contraction, isn't causing the hemorrhage. The physician will also prescribe an oxytocic agent. If hemorrhaging persists, the physician may prescribe packed red blood cells. A pad count is inappropriate in this situation.

Which assessment finding indicates that the infant latch during breast-feeding needs further intervention? The baby's mouth covers the nipple and 2 to 3 cm of the areolar radius. The baby's nose, cheeks, and chin are touching the breast. The baby swallows audibly. The baby's lips smack.

The baby's lips smack. Explanation: A baby who's smacking his lips isn't latched on properly. An improper latch can injure the mother's nipples. The other options indicate a successful latch.

An adolescent prenatal client asks about getting fat while pregnant. To prevent which condition, the nurse says, "Because of your age, you need to gain enough weight to be in the upper portions of your recommended weight"? birth of a premature neonate a difficult birth birth of a low-birth-weight neonate gestational hypertension

birth of a low-birth-weight neonate Explanation: Adolescents, especially those younger than age 15, are at higher risk for delivering low-birth-weight neonates unless they gain adequate weight during pregnancy. Gaining weight is not associated with preventing a difficult birth, risk of gestational hypertension, or a premature neonate.

The nurse is assuming care for a 10-year-old client who has been diagnosed with irritable bowel syndrome (IBS). Which assessment finding is most concerning to the nurse? fever constipation generalized abdominal pain bloating

fever Explanation: Irritable bowel syndrome (IBS) refers to a pattern of symptoms affecting the large intestine, or colon, that includes abdominal pain, abdominal cramping, bloating, gas, and constipation or diarrhea. It does not have an identifiable cause and occurs more often in females than in males. It is considered a functional disorder, meaning that the gastrointestinal tract behaves abnormally but the colon's tissues are not damaged. Triggers, such as gas-producing foods, food sensitivities, and stress, have been identified as seeming to irritate the bowel and instigate symptoms. The nurse will be most concerned about a fever; this is not a sign associated with IBS, so it suggests the emergence of a new health problem for this client. Although the nurse will be attentive to the client's reports of constipation, generalized abdominal pain, and bloating, these are expected symptoms associated with IBS.

A neonate develops significant respiratory distress about 14 hours after birth. After reviewing the neonate's medical record, the nurse finds that the neonate's mother experienced prolonged rupture of membranes. Based on the nurse's knowledge of this condition, the nurse suspects that which organism most likely contributed to this problem? Candida albicans chlamydia trachomatis Escherichia coli group B beta-hemolytic streptococci

group B beta-hemolytic streptococci Explanation: Transmission of group B beta-hemolytic streptococci to the fetus results in respiratory distress that can rapidly lead to septic shock. This organism is a major cause of infection in the neonate. E. coli is the second most common cause. Candida albicans may be acquired from the birth canal. C. trachomatis infection causes neonatal conjunctivitis and pneumonia.

A nurse is part of a team providing care to a neonate with a myelomeningocele. When implementing the neonate's plan of care, what is the priority action by the nurse? promoting neural tube sac drainage preventing infection conserving body heat ensuring adequate nutrition

preventing infection Explanation: The nurse needs to provide special care to the neural tube sac of a neonate born with a myelomeningocele to prevent infection. Allowing the sac to dry could result in cracks that allow microorganisms to enter. Pressure on the sac could cause it to rupture, creating a portal of entry for microorganisms. Promoting neural tube sac drainage may also place the neonate at risk for infection. Administering antibiotics and keeping the sac free from urine and stool are other measures to prevent infection. Adequate nutrition is a concern for all neonates, including those with a myelomeningocele. Like all neonates, a neonate with a myelomeningocele must be kept warm, but care must be taken to avoid drying out the neural tube sac with a radiant heater or exerting pressure on the sac by using a sheet or blanket.

A postpartum client is scheduled for discharge tomorrow. The nurse is reinforcing discharge instructions with the client. The nurse determines that the client understands the information when stating that she will report which finding to her health care provider? episiotomy discomfort temperature of 99.2° F (37.3° C) whitish vaginal discharge 2 weeks after birth redness, warmth, and pain in a breast

redness, warmth, and pain in a breast Explanation: Signs of mastitis include a reddened, warm, painful area on the breast, as well as fever, headache, and flu-like symptoms. If these symptoms occur, the client should contact her healthcare provider for treatment. Episiotomy discomfort may persist for up to 6 weeks after birth. A temperature of 99.2° F is not significant unless it persists. A whitish vaginal discharge, lochia alba, normally occurs 2 weeks after birth.