MB Exam III
An induction of a 42-week gravida with IV oxytocin (Pitocin) is begun at 0900 at a rate of 0.5 milliunit per minute. The woman's primary physician orders: Increase the oxytocin drip by 0.5 milliunit per minute every 10 minutes until contractions are every 3 minutes × 60 seconds. The nurse refuses to comply with the order. Which of the following is the rationale for the nurse's action? 1. Fetal distress has been noted in labors when oxytocin dosages greater than 2 milliunits per minute are administered. 2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. 3. It is unsafe practice to administer oxytocin intravenously to a woman who is carrying a postdates fetus. 4. A contraction duration of 60 seconds can lead to fetal compromise in a baby who is postmature.
2. The relatively long half-life of oxytocin can result in unsafe intravascular concentrations of the drug. shouldn't be increased less than every 30 minutes
The fetus of a 38-week-gestation client has been diagnosed with intrauterine growth restriction (IUGR). The nurse would expect that which of the following diagnostic assessments would be appropriate for the primary healthcare practitioner to order at this time? Select all that apply. 1. Biophysical profile. 2. Nonstress test. 3. Umbilical arterial Doppler assessment. 4. Chorionic villus sampling. 5. Human chorionic gonadotropin test.
1. Biophysical profile. 2. Nonstress test. 3. Umbilical arterial Doppler assessment. 1&2 look at well-being 3 is blood flow
A client just spontaneously ruptured membranes. Which of the following factors makes her especially at high risk for having a prolapsed cord? Select all that apply. 1. Breech presentation. 2. Station -3. 3. Oligohydramnios. 4. Dilation 2 cm. 5. Transverse lie.
1. Breech presentation. 2. Station -3. 5. Transverse lie.
A pregnant woman, 24 weeks' gestation, who has been diagnosed with severe choledocholithiasis is scheduled for a cholecystectomy under general anesthesia. In addition to routine surgical and postsurgical care, the nurses should pay special attention to which of the following? Select all that apply. 1. The circulating nurse should place the woman supine and slightly tilted to the left during the surgical procedure. 2. The circulating and post-anesthesia care nurses should assess the fetal heart rate regularly following the surgery. 3. The post-anesthesia care nurse should monitor the client's lochia and the firmness of her fundus. 4. The post-anesthesia care nurse should monitor the woman carefully for nausea and vomiting. 5. The post-anesthesia care nurse should place antiembolic stockings on the woman's legs.
1,2,4,5
A woman is to receive methotrexate IM for an ectopic pregnancy. The nurse should teach the woman about which of the following common side effects of the therapy? Select all that apply. 1. Nausea and vomiting. 2. Abdominal pain. 3. Fatigue. 4. Light-headedness. 5. Breast tenderness.
1. Nausea and vomiting. 2. Abdominal pain. 3. Fatigue. 4. Light-headedness.
A client has just done a fetal kick count assessment. She noted 6 movements during the past hour. If taught correctly, what should her next action be? 1. Nothing, because further action is not warranted. 2. Call the doctor to set up a nonstress test. 3. Redo the test during the next half hour. 4. Drink a glass of orange juice and redo the test.
1. Nothing, because further action is not warranted. minimum of 3 kicks per hour is normal
A nurse who is caring for a pregnant type I diabetic should carefully monitor the client for which of the following? Select all that apply. 1. Urinary tract infection. 2. Multiple gestation. 3. Metabolic acidosis. 4. Pathological hypotension. 5. Hypolipidemia.
1. Urinary tract infection. 3. Metabolic acidosis.
The school nurse is planning an educational program centered on abstinence for adolescents. Which of the following methods does the nurse recognize as the most effective way to present this program? 1. Use peer-led programs that emphasize the consequences of unprotected sexual contact. 2. Teach students methods to resist peer pressure. 3. Offer students the opportunity to care for a simulator infant for 1 week. 4. Offer statistics, pamphlets, and films discussing the consequences of unprotected sexual contact.
1. Use peer-led programs that emphasize the consequences of unprotected sexual Adolescents are most concerned with what their peers think-- have peer lead the program
The nurse is evaluating the effectiveness of bedrest for a client with mild preeclampsia. Which of the following signs/symptoms would the nurse determine is a positive finding? 1. Weight loss. 2. 2+ proteinuria. 3. Decrease in plasma protein. 4. 3+ patellar reflexes.
1. Weight loss. Positive = good Preeclampsia will have weight loss
A 36-week-gestation client is having cultures taken to determine whether she is colonized with group B strep. Which of the following sites is being cultured? Select all that apply. 1. Throat. 2. Nipple. 3. Vagina. 4. Rectum. 5. Nostrils.
3. Vagina. 4. Rectum.
A 3-year-old girl is attending her grandfather's funeral. Her parents have told her that her grandfather is in heaven with God. The child is taken up to the open casket with her parents. Which statement by the child describes a 3-year-old child's understanding of spirituality? 1. "Grandpa's body is here with us on Earth, and his spirit is in heaven." 2. "Grandpa is in heaven. Is this heaven?" 3. "Grandpa's spirit is no longer in his body." 4. "Grandpa won't need his body in heaven."
2. "Grandpa is in heaven. Is this heaven?" Kids think literally
An 18-year-old boy comes to the ER complaining of a rash and itching in the groin area. He is concerned that he has contracted a sexually transmitted disease and worries that his parents will find out. The nurse's best response is: 1. "We will need to contact your parents to let them know you are in the ER." 2. "We will not contact your parents regarding this visit." 3. "Who would you like us to contact about your visit here today?" 4. "We cannot promise that the hospital will not contact your parents."
2. "We will not contact your parents regarding this visit."
The nurse is caring for a 12-month-old girl. The child's mother asks if the unit has any toys that her daughter can play with. The nurse goes to the toy area in search of a toy for the child. Which toy is the best choice for this child? 1. A doll. 2. A musical rattle. 3. A board book. 4. Colorful beads.
2. A musical rattle.
A 16-year-old girl is having a discussion with her nurse about her recent diagnosis of lupus. The nurse understands how to best answer the young woman's questions about her prognosis because she understands that cognitively: 1. Adolescents are preoccupied with thoughts of the here and now. 2. Adolescents are able to understand and imagine possibilities for the future. 3. Adolescents are capable of thinking only in concrete terms. 4. Adolescents are overly concerned with past events and relationships.
2. Adolescents are able to understand and imagine possibilities for the future. Adolescents are abstract thinkers and are able to imagine possibilities for the future
A woman with a diagnosis of ectopic pregnancy is to receive medical intervention rather than a surgical interruption. Which of the following intramuscular medications would the nurse expect to administer? 1. Decadron (dexamethasone). 2. Amethopterin (methotrexate). 3. Pergonal (menotropin). 4. Prometrium (progesterone).
2. Amethopterin (methotrexate).
Which of the following findings would the nurse expect to see when assessing a first-trimester gravida suspected of having gestational trophoblastic disease (hydatidiform mole) that the nurse would not expect to see when assessing a first-trimester gravida with a normal pregnancy? Select all that apply. 1. Hematocrit 39%. 2. Grape-like clusters passed from the vagina. 3. Markedly elevated blood pressure. 4. White blood cell count 8,000/mm 3 . 5. Hypertrophied breast tissue.
2. Grape-like clusters passed from the vagina. 3. Markedly elevated blood pressure.
An obstetrician declares at the conclusion of the third stage of labor that a woman is diagnosed with placenta accreta. The nurse would expect to see which of the following signs/symptoms? 1. Hypertension. 2. Hemorrhage. 3. Bradycardia. 4. Hyperthermia.
2. Hemorrhage. Placenta sticks to uterine wall and mom hemorrhages
A 5-year-old boy has always been one of the shortest children in class since pre- school. His mother tells the school nurse that her husband is 6' and she is 5'7". She is concerned about her son's height. Based on her knowledge of a child's physical growth during the school-age years, what should the nurse tell the child's mother? 1. She should expect him to grow about 3 inches every year from ages 6 to 9 years. 2. She should expect him to grow about 2 inches every year from ages 6 to 9 years. 3. She should have him seen by an endocrinologist for growth hormone injections. 4. Be sure to have her son's growth reevaluated when he is 7 years old.
2. She should expect him to grow about 2 inches every year from ages 6 to 9 years.
A 5-year-old is at the pediatrician's office for his well-child checkup. The nurse will be administering three immunizations to the child. The nurse should expect which reaction from the child when she gives his immunizations? 1. The child will likely remain silent and still. 2. The child will likely cry and tell the nurse that it hurts. 3. The child will likely try to stall the nurse. 4. The child will likely remain still while telling the nurse that she is hurting him.
2. The child will likely cry and tell the nurse that it hurts.
A mother requests that her child receive the varicella vaccine at her 9-month well-child checkup. The nurse tells the mother that: 1. Children who are vaccinated will likely develop a mild case of the disease from the vaccine. 2. The nurse cannot give the vaccine. 3. The nurse will administer the vaccine after the physician examines the child. 4. The child will need a booster vaccination at 18 months of age.
2. The nurse cannot give the vaccine. Varicella is given at 12 months
A 6-month-old male is at his well-child checkup. The nurse weighs him, and his mother asks if his weight is normal for his age. The nurse's best response is: 1. "At 6 months his weight should be approximately three times his birth weight." 2. "Each child gains weight at his or her own pace." 3. "At 6 months his weight should be approximately twice his birth weight." 4. "At 6 months a child should weigh about 10 lb more than his or her birth weight."
3. "At 6 months his weight should be approximately twice his birth weight."
The nurse is instructing a new breastfeeding mother in the need to provide her pre- mature infant with an adequate source of iron in her diet. Which one of the following statements reflects a need for further education of the new mother? 1. "I will use only breast milk or an iron-fortified formula as a source of milk for my baby until she is at least 12 months old." 2. "My baby will need to have iron supplements introduced when she is 4 months old." 3. "I will need to add iron supplements to my baby's diet when she is 9 months old." 4. "When my baby begins to eat solid foods, I should introduce iron-fortified cereals to her diet."
3. "I will need to add iron supplements to my baby's diet when she is 9 months old." A premie needs iron supplements around 2 months old Term baby needs supplements starting at 5 months
A woman being induced with oxytocin (Pitocin) is contracting every 3 min × 30 seconds. Suddenly the woman becomes dypsneic and cyanotic and begins to cough up bloody sputum. Which of the following nursing interventions is of highest priority? 1. Check blood pressure. 2. Assess fetal heart rate. 3. Administer oxygen. 4. Stop oxytocin infusion.
3. Administer oxygen. s/s of amniotic fluid embolism--- oxygen is the most important
A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental mile- stones, what should the nurse caring for the child calculate his current weight as? 1. Approximately 16 lb 4 oz. 2. Approximately 20 lb 5 oz. 3. Approximately 24 lb 6 oz. 4. Approximately 32 lb 8 oz.
3. Approximately 24 lb 6 oz. 12 months = 3x weight
Four women request to labor in the hospital bathtub. In which of the following situations is the procedure contraindicated? Select all that apply. 1. Woman during transition. 2. Woman during second stage of labor. 3. Woman receiving oxytocin for induction. 4. Woman with meconium-stained fluid. 5. Woman with fetus in the occiput posterior position.
3. Woman receiving oxytocin for induction. 4. Woman with meconium-stained fluid.
The nurse is caring for a client who was just admitted to the hospital to rule out ectopic pregnancy. Which of the following orders is the most important for the nurse to perform? 1. Take the client's temperature. 2. Document the time of the client's last meal. 3. Obtain urine for urinalysis and culture. 4. Assess for complaint of dizziness or weakness.
4. Assess for complaint of dizziness or weakness.
A client is scheduled for an external version. The nurse would expect to prepare which of the following medications to be administered prior to the procedure? 1. Oxytocin (Pitocin). 2. Ergonovine (Methergine). 3. Betamethasone (Celestone). 4. Terbutaline (Brethine).
4. Terbutaline (Brethine).
According to developmental theories, which important event does the nurse understand is essential to the development of the toddler? 1. The child learns to feed self. 2. The child develops friendships. 3. The child learns to walk. 4. The child participates in being potty-trained.
4. The child participates in being potty-trained.
A nurse is monitoring a client who is receiving an amnioinfusion. Which of the following assessments is critical for the nurse to make to prevent a serious complication related to the procedure? 1. Color of the amniotic fluid. 2. Maternal blood pressure. 3. Cervical effacement. 4. Uterine resting tone.
4. Uterine resting tone. potential for fluid overload and the uterus could rupture
What would the nurse expect a 4-month-old to be able to accomplish? a. Hold a cup. b. Stand with assistance. c. Lift head and shoulders. d. Sit with back straight.
c. Lift head and shoulders.
Women who are given the job of caretaker for aging relatives are subject to caregiver strain due to a. feminine attributes. b. unequal gender. c. fixed gender roles. d. female inequality.
c. fixed gender roles. In some cultures women are obligated to care for the elders
The nurse is caring for four women who are in labor. The nurse is aware that he or she will likely prepare which of the women for cesarean delivery? Select all that apply. 1. Fetus is in the left sacral posterior position. 2. Placenta is attached to the posterior portion of the uterine wall. 3. Fetus has been diagnosed with meningomyelocele. 4. Client is hepatitis B surface antigen positive. 5. The lecithin/sphingomyelin ratio in the amniotic fluid is 1.5:1
1. Fetus is in the left sacral posterior position. 3. Fetus has been diagnosed with meningomyelocele.
A gravid woman has sickle cell anemia. Which of the following situations could precipitate a vaso-occlusive crisis in this woman? 1. Hypoxia. 2. Alkalosis. 3. Fluid overload. 4. Hyperglycemia.
1. Hypoxia.
The nurse is caring for a 32-week G8 P7007 with placenta previa. Which of the following interventions would the nurse expect to perform? Select all that apply. 1. Daily contraction stress tests. 2. Blood type and cross match. 3. Bedrest with passive range-of-motion exercises. 4. Daily serum electrolyte assessments. 5. Weekly biophysical profiles.
2. Blood type and cross match. 3. Bedrest with passive range-of-motion exercises. 5. Weekly biophysical profiles.
An ultrasound is being done on an Rh-negative woman. Which of the following pregnancy findings would indicate that the baby has developed erythroblastosis fetalis? 1. Caudal agenesis. 2. Cardiomegaly. 3. Oligohydramnios. 4. Hyperemia.
2. Cardiomegaly. one of the biggest signs of erythroblastosis fetalis
A diabetic client is to receive 5 units regular and 15 units NPH insulin at 0800. To administer the medication appropriately, what should the nurse do? 1. Draw 5 units regular in one syringe and 15 units NPH in a second syringe and inject in different locations. 2. Draw 5 units regular first and 15 units NPH second into the same syringe and inject. 3. Draw 15 units NPH first and 5 units regular second into the same syringe and inject. 4. Mix 5 units regular and 15 units NPH in a vial before drawing the full 20 units into a syringe and inject.
2. Draw 5 units regular first and 15 units NPH second into the same syringe and inject.
A woman with a history of congestive heart disease is 36 weeks pregnant. Which of the following findings should the nurse report to the primary healthcare practitioner? 1. Presence of striae gravidarum. 2. Dyspnea on exertion. 3. 4-pound weight gain in a month. 4. Patellar reflexes +2.
2. Dyspnea on exertion. 1 pound weight gain per week is normal in the 3rd trimester
A 16-year-old male is hospitalized for cystic fibrosis. He will be an inpatient for 2 weeks while he receives IV antibiotics. As the nurse caring for this patient, what action can you take that will most enhance his psychosocial development? 1. Fax the teen's teacher, and have her send in his homework. 2. Encourage the teen's friends to visit him in the hospital. 3. Encourage the teen's grandparents to visit frequently. 4. Tell the teen he is free to use his phone to call friends.
2. Encourage the teen's friends to visit him in the hospital.
A woman, 39 weeks' gestation, is admitted to the delivery unit with vaginal warts from human papillomavirus (HPV). Which of the following actions by the nurse is appropriate? 1. Notify the healthcare practitioner for a surgical delivery. 2. Follow standard infectious disease precautions. 3. Notify the nursery of the imminent delivery of an infected neonate. 4. Wear a mask whenever the perineum is exposed.
2. Follow standard infectious disease precautions. It can be transmitted, but c-section is still avoided according to CDC
A client is seen at 8 weeks' gestation for her first prenatal visit. During her last gynecological visit, the client's blood pressure was 100/60. Her blood pressure is now 150/90. For which of the following pregnancy-related illnesses should this client be assessed? 1. Hyperemesis gravidarum. 2. Hydatidiform mole. 3. Pre-eclampsia. 4. Gestational diabetes.
2. Hydatidiform mole. Most likely cause of acute rise in BP -- HTN is more chronic. she will have preeclamptic symptoms during 1st trimester
A client with mild pre-eclampsia who has been advised to be on bedrest at home asks why doing so is necessary. Which of the following is the best response for the nurse to give the client? 1. "Bedrest will help you to conserve energy for your labor." 2. "Bedrest will help to relieve your nausea and anorexia." 3. "Reclining will increase the amount of oxygen that your baby gets." 4. "The position change will prevent the placenta from separating."
3. "Reclining will increase the amount of oxygen that your baby gets." Think of intrauterine resuscitation
A client, 37 weeks' gestation, has been advised that she is positive for group B streptococci. Which of the following comments by the nurse is appropriate at this time? 1. "The doctor will prescribe intravenous antibiotics for you. A visiting nurse will administer them to you in your home." 2. "You are at very high risk for an intrauterine infection. It is important for you to check your temperature every day." 3. "The bacteria are living in your vagina. They will not hurt you but we will give you medicine in labor to protect your baby from getting sick." 4. "The bacteria cause scarlet fever. If you notice that your tongue becomes very red and that you feel feverish you should call the doctor immediately."
3. "The bacteria are living in your vagina. They will not hurt you but we will give you medicine in labor to protect your baby from getting sick."
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal? 1. +1. 2. +2. 3. +3. 4. +4.
3. +3. +2 is normal
Which of the following pregnant clients is most high risk for preterm premature rupture of the membranes (PPROM)? Select all that apply. 1. 31 weeks' gestation with prolapsed mitral valve (PMV). 2. 32 weeks' gestation with urinary tract infection (UTI). 3. 33 weeks' gestation with twins post-in vitro fertilization (IVF). 4. 34 weeks' gestation with gestational diabetes (GDM). 5. 35 weeks' gestation with deep vein thrombosis (DVT).
3. 33 weeks' gestation with twins post-in vitro fertilization (IVF).
The parents of a 7-month-old girl are attending a class on child safety. Following the class, what should the child's parents understand as one of the most common causes of injury and death for a 7-month-old child? 1. Poisoning. 2. Child abuse. 3. Aspiration. 4. Dog bites.
3. Aspiration.
A labor nurse is caring for a client, 30 weeks' gestation, who is symptomatic from a complete placenta previa. Which of the following physician orders should the nurse question? 1. Administer betamethasone (Celestone) 12 mg IM daily times 2. 2. Maintain strict bedrest. 3. Assess cervical dilation. 4. Regulate intravenous (Ringer's lactate: drip rate to 150 mL/hr).
3. Assess cervical dilation.
The nurse is assessing the Bishop score on a postdates client. Which of the following measurements will the nurse assess? Select all that apply. 1. Gestational age. 2. Rupture of membranes. 3. Cervical dilation. 4. Fetal station. 5. Cervical position.
3. Cervical dilation. 4. Fetal station. 5. Cervical position. Bishop is ----- Dilation Station Position Uterine tone Effacement
A client, G3 P2002, 40 weeks' gestation, who has vaginal candidiasis, has just been admitted in early labor. Which of the following should the nurse advise the woman? 1. She may need a cesarean delivery. 2. She will be treated with antibiotics during labor. 3. The baby may develop thrush after delivery. 4. The baby will be isolated for at least one day.
3. The baby may develop thrush after delivery.
The parents of a 2-year-old boy are concerned about his behavior. Since the child's admission to the hospital 2 days ago he has been crying much more than usual and is inconsolable much of the time. The nurse's best response to the child's parents is: 1. The child is in the detachment phase of separation anxiety, which is normal for children during hospitalization. 2. The child is in the despair stage of separation anxiety, which is normal for children during hospitalization. 3. The child is in the bargaining stage of separation anxiety, which is normal for children during hospitalization. 4. The child is in the protest stage of separation anxiety, which is normal for children during hospitalization.
4. The child is in the protest stage of separation anxiety, which is normal for children during hospitalization. During protest stage they cry a lot and can't be calmed down. they will also ask to go home a lot
A client is receiving terbutaline (Brethine) for preterm labor. Which of the following findings would warrant stopping the infusion? Select all that apply. 1. Change in contraction pattern from q 2 min × 90 sec to q 3 min × 30 sec. 2. Change in fetal heart pattern from no decelerations to early decelerations. 3. Change in beat-to-beat variability from minimal to moderate. 4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.
4. Change in fetal heart rate from 160 bpm to 210 bpm. 5. Change in the amniotic sac from intact to ruptured.
A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for which of the following? 1. Cervical cerclage. 2. Amniocentesis. 3. Nonstress testing. 4. Dilation and curettage.
4. Dilation and curettage. this is an incomplete abortion
A gravid woman has just been admitted to the emergency department subsequent to a head-on automobile accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which of the following complications of pregnancy? Select all that apply. 1. Placenta previa. 2. Transverse fetal lie. 3. Placental abruption. 4. Severe pre-eclampsia. 5. Preterm labor.
3. Placental abruption. 5. Preterm labor.
To plan early intervention and care for an infant with Down syndrome, the nurse considers knowledge of other physical development exemplars such as a. cerebral palsy. b.failure to thrive. c.fetal alcohol syndrome. d.hydrocephaly.
d.hydrocephaly.
The nurse identifies the family with a child graduating from college as being in the family life cycle of a. single young adult leaving home. b. new couple joins their families through marriage or living together. c. families with young children. d.launching children and moving on.
d.launching children and moving on.
The nurse is triaging a hysterical patient in the ER. The patient is crying, with uncontrollable spasms, trembling, and shouting. It is important to identify manifestation of illness in order to effectively treat a patient. The nurse identifies this as a culture-bound syndrome called a. shenjing sharo. b. loco de la cabeza. c. ataque de nervios. d. neuroasthenia.
c. ataque de nervios. A- Chinese when they have no energy C- same but no physical manifestations D. asian -- mental and physical fatigue
To plan early intervention and care for a child with a developmental delay, the nurse would consider knowledge of the concepts most significantly impacted by development, including a. culture. b. environment. c. functional status. d. nutrition.
c. functional status.
What does the nurse recognize as an example of Piagets concrete operational thinking? a. 2-year-old says, Its nighttime when his room is darkened. b. 4-year-old refers to the hospital as my house. c. 5-year-old coloring a picture of a puppy says, This is my puppy. d. 7-year-old says, I am sick because I have germs in my chest.
d. 7-year-old says, I am sick because I have germs in my chest.
What interrelated constructs facilitate a nurse to become culturally competent? a. Cultural diversity, self-awareness, cultural skill, and cultural knowledge b. Cultural desire, self-awareness, cultural knowledge, and cultural identity c. Cultural desire, self-awareness, cultural knowledge, and cultural diversity d. Cultural desire, self-awareness, cultural knowledge, and cultural skill
d. Cultural desire, self-awareness, cultural knowledge, and cultural skill KADS
The nurse is caring for a patient who was started on intravenous antibiotic therapy earlier in the shift. As the second dose is being infused, the patient reports feeling dizzy and having difficulty breathing and talking. The nurse notes that the patient's respirations are 26 breaths/min with pulse 112 beats/min and weak. The nurse suspects that the patient is experiencing a(n) a. suppressed immune response. b. hyperimmune response. c. allergic reaction. d. anaphylactic reaction.
d. anaphylactic reaction.
A 29-week-gestation woman diagnosed with severe pre-eclampsia is noted to have blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the past 2 days. Which of the following signs/symptoms would the nurse also expect to see? 1. Fundal height of 32 cm. 2. Papilledema. 3. Patellar reflexes of +2. 4. Nystagmus.
Papilledema
The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a cup? What is the nurses most accurate response? a. 5 months b. 9 months c. 1 year d. 2 years
a. 5 months
Prenatal teaching for a pregnant woman should include instructions to do which of the following? 1. Refrain from touching her pet bird. 2. Wear gloves when gardening. 3. Cook pork until medium well done. 4. Avoid sleeping with the dog.
2. Wear gloves when gardening. Because she can come into contact with animal feces --- can cause toxoplasmosis protozoa
A 39-year-old, 16-week-gravid woman has had an amniocentesis. Before discharge, the nurse teaches the woman to call her doctor if she experiences which of the following side effects? Select all that apply. 1. Fever or chills. 2. Lack of fetal movement. 3. Abdominal pain. 4. Rash or pruritus. 5. Vaginal bleeding.
1. Fever or chills. 2. Lack of fetal movement. 3. Abdominal pain. 5. Vaginal bleeding.
A 3-year-old female is hospitalized for an ASD repair. Her parents have decided to go home for a few hours to spend time with her siblings. The child asks when her mommy and daddy will be back. The nurse's best response is: 1. "Your mommy and daddy will be back after your nap." 2. "Your mommy and daddy will be back at 6 p.m." 3. "Your mommy and daddy will be back later this evening." 4. "Your mommy and daddy will be back in 3 hours."
1. "Your mommy and daddy will be back after your nap."
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with pre-eclampsia. In addition to obtaining baseline vital signs and placing the client on bedrest, the physician ordered the following four items. Which of the orders should the nurse perform first? 1. Assess deep tendon reflexes. 2. Obtain complete blood count. 3. Assess baseline weight. 4. Obtain routine urinalysis.
1. Assess deep tendon reflexes.
A biophysical profile (BPP) has been performed on a full-term client with severe pre-eclampsia. Which of the following interpretations should the nurse make regarding the BPP results of 4? 1. Fetal well-being is compromised. 2. Client's blood pressure is returning to normal. 3. Client is at high risk for seizure. 4. Fetus's amniotic sac is about to rupture.
1. Fetal well-being is compromised. total score of 10 -- lower the score the worse the baby is
A woman, G5 P0311, is in the post-anesthesia care unit (PACU) after a cervical cerclage procedure. During the immediate postprocedure period, what should the nurse carefully monitor this client for? 1. Hyperthermia. 2. Hypotension. 3. Uterine contractions. 4. Fetal heart dysrhythmias.
3. Uterine contractions. Preterm labor is a complication of cerclage
A 5-year-old boy is being screened for developmental delays using the Denver Developmental Screening Test. The child's mother is explaining to the nurse her understanding of the screening test. The nurse realizes that the child's mother needs further education about the test when she states which of the following? 1. "It screens my son's gross motor skills." 2. "It screens my son's fine motor skills." 3. "It screens my son's intelligence level." 4. "It screens my son's language development."
3. "It screens my son's intelligence level."
A 29-week-gravid client is admitted to the labor and delivery unit with vaginal bleeding. To differentiate between placenta previa and abruptio placentae, the nurse should assess which of the following? 1. Leopold maneuver results. 2. Quantity of vaginal bleeding. 3. Presence of abdominal pain. 4. Maternal blood pressure.
3. Presence of abdominal pain. Placenta abruptio is PAINFUL there is blood behind the placenta that causes pressure
During a prenatal interview, a client tells the nurse, "My mother told me she had toxemia during her pregnancy and almost died!" Which of the following questions should the nurse ask in response to this statement? 1. "Does your mother have a family history of cancer?" 2. "Did your mother tell you what she was toxic from?" 3. "Does your mother have diabetes now?" 4. "Did your mother say whether she had a seizure or not?"
4. "Did your mother say whether she had a seizure or not?" Toxemia = HTN -- nurse is looking for history or preeclampsia
Understanding cultural differences in health care is important because it will help the nurse to understand the manner in which people decide on obtaining treatments and medical care. In independent cultures an individual will a. put himself first. b. consult family members for advice. c. ask for a second opinion. d. travel great distances to receive the best care.
a. put himself first.
A nurse is about to inject RhoGAM into an Rh-negative mother. Which of the following is the preferred site for the injection? 1. Deltoid. 2. Dorsogluteal. 3. Vastus lateralis. 4. Ventrogluteal.
1. Deltoid. Can be administered into the butt too but deltoid is preferred
A client has been diagnosed with water intoxication after having received IV oxytocin (Pitocin) for over 24 hours. Which of the following signs/symptoms would the nurse expect to see? 1. Confusion, drowsiness, and vomiting. 2. Hypernatremia and hyperkalemia. 3. Thrombocytopenia and neutropenia. 4. Paresthesias, myalgias, and anemia.
1. Confusion, drowsiness, and vomiting.
A client with a complete placenta previa is on the antepartum clinical unit in preparation for delivery. Which of the following should the nurse include in a teaching session for this client? 1. Coughing and deep breathing. 2. Phases of the first stage of labor. 3. Lamaze labor techniques. 4. Leboyer hydrobirthing.
1. Coughing and deep breathing. because mom will have a C-section
A pregnant diabetic has been diagnosed with hydramnios. Which of the following would explain this finding? 1. Excessive fetal urination. 2. Recurring hypoglycemic episodes. 3. Fetal sacral agenesis. 4. Placental vascular damage.
1. Excessive fetal urination. polyuria boiiiiii
The nurse is admitting four full-term primigravid clients to the labor and delivery unit. The nurse requests pre-cesarean section orders from the healthcare practitioner for which of the clients? The client who has: Select all that apply. 1. Cervical cerclage. 2. FH 156 with beat-to-beat variability. 3. Maternal blood pressure of 90/60. 4. Full effacement. 5. Active herpes simplex 2.
1. Cervical cerclage. 5. Active herpes simplex 2 1 because there is fresh sutures that will tear 2 because its HSV
A 32-week-gestation client states that she "thinks" she is leaking amniotic fluid. Which of the following tests could be performed to determine whether the membranes had ruptured? 1. Fern test. 2. Biophysical profile. 3. Amniocentesis. 4. Kernig assessment.
1. Fern test. assesses for amniotic fluid under a microscope
A client, 42 weeks' gestation, is admitted to the labor and delivery suite with a diagnosis of acute oligohydramnios. The nurse must carefully observe this client for signs of which of the following? 1. Fetal distress. 2. Dehydration. 3. Oliguria. 4. Jaundice.
1. Fetal distress. oligohydraminos is common in post-term. fetal distress r/t cord compression because there isn't enough AFV
A gravid woman has been diagnosed with listeriosis. She eats rare meat and raw smoked seafood. Which of the following signs/symptoms would this woman exhibit? 1. Fever and muscle aches. 2. Rash and thrombocytopenia. 3. Petechiae and anemia. 4. Amnionitis and epistaxis.
1. Fever and muscle aches.
A client enters the labor and delivery suite. It is essential that the nurse note the woman's status in relation to which of the following infectious diseases? Select all that apply. 1. Hepatitis B. 2. Rubeola. 3. Varicella. 4. Group B streptococcus. 5. HIV/AIDS.
1. Hepatitis B. 4. Group B streptococcus. 5. HIV/AIDS.
Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? 1. Increasing fundal height measurements. 2. Pain-free vaginal bleeding. 3. Fetal heart accelerations. 4. Hyperthermia with leukocytosis.
1. Increasing fundal height measurements. increases 1 cm per month during pregnancy and 1 cm per hour when it has abrupted
A child has been diagnosed with rubella. What must the pediatric nurse teach the child's parents to do? 1. Notify any exposed pregnant friends. 2. Give oral penicillin every 6 hours for 10 full days. 3. Observe the child for signs of respiratory distress. 4. Administer diphenhydramine every 4 hours as needed.
1. Notify any exposed pregnant friends. Rubella is teratogenic -- hide your kids hide your wife
A gravid woman, 36 weeks' gestation with type 1 diabetes, has just had a biophysical profile (BPP). Which of the following results should be reported to the obstetrician? 1. One fetal heart acceleration in 20 minutes. 2. Three episodes of fetal rhythmic breathing in 30 minutes. 3. Two episodes of fetal extension and flexion of 1 arm. 4. One amniotic fluid pocket measuring 3 cm.
1. One fetal heart acceleration in 20 minutes. There should be a minimum of 2 every 2 mins
A nurse works in a clinic with a high adolescent pregnancy population. The nurse provides teaching to the young women to prevent which of the following high-risk complications of pregnancy? 1. Preterm birth. 2. Gestational diabetes. 3. Macrosomic babies. 4. Polycythemia.
1. Preterm birth. Teens are at higher risk for preterm birth
Immediately after a woman spontaneously ruptures her membranes, the nurse notes a loop of the umbilical cord protruding from the woman's vagina. Which of the following actions should the nurse perform first? 1. Put the client in the knee-chest position. 2. Assess the fetal heart rate. 3. Administer oxygen by tight face mask. 4. Telephone the obstetrician with the findings.
1. Put the client in the knee-chest position. Helps take wright off cord -- also can do trendelenburg
A 12-week-gravid client presents in the emergency department with abdominal cramps and scant dark red bleeding. Which of the following signs/symptoms should the nurse assess this client for? Select all that apply. 1. Tachycardia. 2. Referred shoulder pain. 3. Headache. 4. Fetal heart dysrhythmias. 5. Hypertension.
1. Tachycardia. 3. Headache. 4. Fetal heart dysrhythmias. 5. Hypertension
A woman, G1 P0000, is 40 5/7 weeks' gestation. Her Bishop score is 4. Which of the following complementary therapies do midwives frequently recommend to clients in similar situations? Select all that apply. 1. Sexual intercourse. 2. Aromatherapy. 3. Breast stimulation. 4. Ingestion of castor oil. 5. Aerobic exercise.
1. Sexual intercourse. 3. Breast stimulation. 4. Ingestion of castor oil.
A 13-year-old boy is hospitalized for a femur fracture. He was hit by a car while he and his friends were racing bikes near a major intersection. The child's parents are concerned about his judgment. What should the nurse understand? 1. The child's behavior is typical of young teens. 2. The child's behavior is related to hormonal surges during adolescence. 3. This was an isolated incident and will not likely happen again. 4. The child's behavior is related to teen rebellion.
1. The child's behavior is typical of young teens. Brain isn't fully developed and they have poor judgement
The nurse caring for a type 1 diabetic client who wishes to become pregnant notes that the client's HgbA 1c result was 7% today and the fasting blood glucose result was 100 mg/dL. Which of the following interpretations by the nurse is correct in relation to these data? 1. The client has been hyperglycemic for the past 3 months and is hyperglycemic today. 2. The client has been normoglycemic for the past 3 months and is normoglycemic today. 3. The client has been hyperglycemic for the past 3 months and is normoglycemic today. 4. The client has been normoglycemic for the past 3 months and is hyperglycemic today.
1. The client has been hyperglycemic for the past 3 months and is hyperglycemic today. normal A1C is below 6
During the delivery of a macrosomic baby, the woman develops a fourth-degree laceration. How should the nurse document the extent of the laceration in the woman's medical record? 1. Into the musculature of the buttock. 2. Through the urinary meatus. 3. Through the rectal sphincter. 4. Into the head of the clitoris.
3. Through the rectal sphincter. owch
A client is admitted in labor with spontaneous rupture of membranes 24 hours earlier. The fluid is clear and the fetal heart rate is 124 with moderate variability. Which assessment is most important for the nurse to make at this time? 1. Contraction frequency and duration. 2. Maternal temperature. 3. Cervical dilation and effacement. 4. Maternal pulse rate.
2. Maternal temperature. risk for infection!!!!!!!
In which of the following clinical situations would it be appropriate for an obstetrician to order a labor nurse to perform amnioinfusion? 1. Placental abruption. 2. Meconium-stained fluid. 3. Polyhydramnios. 4. Late decelerations
2. Meconium-stained fluid. it will dilute the concentration of meconium in the uterus
A known drug addict is in active labor. She requests pain medication. Which of the following actions by the nurse is appropriate? 1. Encourage the woman to refrain from taking medication to protect the fetus. 2. Notify the physician of her request. 3. Advise the woman that she can receive only an epidural because of her history. 4. Assist the woman to do labor breathing.
2. Notify the physician of her request. Every pt needs to be treated for pain regardless
A nurse notes a sinusoidal fetal heart pattern while analyzing a fetal heart tracing of a newly admitted client. Which of the following actions should the nurse take at this time? 1. Encourage the client to breathe with contractions. 2. Notify the practitioner. 3. Increase the intravenous infusion. 4. Encourage the client to push with contractions.
2. Notify the practitioner. r/t Rh problems, fetal anemia, hypoxia, and bleeding
Which of the following physical findings would lead the nurse to suspect that a client with severe pre-eclampsia has developed HELLP syndrome? Select all that apply. 1. +3 pitting edema. 2. Petechiae. 3. Jaundice. 4. +4 deep tendon reflexes. 5. Elevated specific gravity.
2. Petechiae. 3. Jaundice. dumb question -- only things r/t Hellp
The nurse caring for an 8-year-old boy is trying to encourage developmental growth. What activity can the nurse provide for the child to encourage his sense of industry? 1. Allow the child to choose what time to take his medication. 2. Provide the child with the homework his teacher has sent in. 3. Allow the child to assist with his bath. 4. Allow the child to help with his dressing change.
2. Provide the child with the homework his teacher has sent in. School aged kids are focused on education and get satisfaction in doing work
A gravid client is admitted with a diagnosis of third-trimester bleeding. It is priority for the nurse to assess for a change in which of the following vital signs? 1. Temperature. 2. Pulse. 3. Respirations. 4. Blood pressure.
2. Pulse.
A pregnant woman mentions to the clinic nurse that she and her husband enjoy working together on projects around the house and says, "I always wear protective gloves when I work." The nurse should advise the woman that even when she wears gloves, which of the following projects could be high risk to the baby's health? 1. Replacing a light fixture in the nursery. 2. Sanding the paint from an antique crib. 3. Planting tulip bulbs in the side garden. 4. Shoveling snow from the driveway.
2. Sanding the paint from an antique crib. Antique stuff can have lead based paint
An ultrasound has identified that a client's pregnancy is complicated by hydramnios. The nurse would expect that an ultrasound may show that the baby has which of the following structural defects? 1. Pulmonic stenosis. 2. Tracheoesophageal fistula. 3. Ventriculoseptal defect. 4. Developmental hip dysplasia.
2. Tracheoesophageal fistula. Baby will swallow an excess of amniotic fluid-- leading to GI abnormalities
The nurse caring for a 9-month-old is using the FLACC scale to rate her pain level. The child's parents ask the nurse what the FLACC scale is. Which is the nurse's best response? 1. "It estimates a child's level of pain utilizing vital sign information." 2. "It estimates a child's level of pain based on parents' perception." 3. "It estimates a child's level of pain utilizing behavioral and physical responses." 4. "It estimates a child's level of pain utilizing a numeric scale from 0 to 5."
3. "It estimates a child's level of pain utilizing behavioral and physical responses."
A client, 39 weeks' gestation, fetal heart baseline at 144 bpm, tells the admitting labor and delivery room nurse that she has had to wear a pad for the past 4 days "because I keep leaking urine." Which of the following is an appropriate action for the nurse to perform at this time? 1. Palpate the woman's bladder to check for urinary retention. 2. Obtain a urine culture to check for a urinary tract infection. 3. Assess the fluid with nitrazine and see if the paper turns blue. 4. Percuss the woman's uterus and monitor for ballottement.
3. Assess the fluid with nitrazine and see if the paper turns blue. tests the pH of fluid -- amniotic fluid is basic and will make the paper turn blue --- urine won't
The nurse is caring for two post-cesarean section clients in the postanesthesia suite. One of the clients had her surgery under spinal anesthesia, while the other client had her surgery under epidural anesthesia. Which of the following is an important difference between the two types of anesthesia that the nurse should be aware of? 1. The level of the pain relief is lower in spinals. 2. Placement of the needle is higher in epidurals. 3. Epidurals do not fully sedate motor nerves. 4. Spinal clients complain of nausea and vomiting.
3. Epidurals do not fully sedate motor nerves. the most important difference is depth of needle insertion anesthesia all spinal nerves are affected
The labor nurse has just received a shift report on four gravid patients. Which of the patients should the nurse assess first? 1. G5 P2202, 32 weeks, placenta previa, today's hemoglobin 11.6 g/dL. 2. G2 P0101, 39 weeks, type 2 diabetic, blood glucose (15 minutes ago) 85 mg/dL. 3. G1 P0000, 32 weeks, placental abruption, fetal heart (5 minutes ago) 120 bpm. 4. G2 P1001, 39 weeks, Rh-negative, today's hematocrit 31%.
3. G1 P0000, 32 weeks, placental abruption, fetal heart (5 minutes ago) 120 bpm.
A client, whose baby is exhibiting signs of erythroblastosis fetalis, is admitted to the labor and delivery unit. The nurse would expect to see which of the following fetal heart monitor tracings? 1. Marked fetal heart variability. 2. Prolonged fetal heart accelerations. 3. Sinusoidal fetal heart pattern. 4. Periodic variable decelerations.
3. Sinusoidal fetal heart pattern. Pattern that happens with erythroblastosis fetalis
A client had an epidural inserted 2 hours ago. It is functioning well, the client is hemodynamically stable, and the client's labor is progressing as expected. Which of the following assessments is highest priority at this time? 1. Assess blood pressure every 15 minutes. 2. Assess pulse rate every 1 hour. 3. Palpate bladder. 4. Auscultate lungs.
3. Palpate bladder. mom won't be able to feel her bladder is full and it can obstruct baby
A patient who is 24 weeks pregnant has been diagnosed with syphilis. She asks the nurse how the infection will affect the baby. The nurse's response should be based on which of the following? 1. She is at high risk for premature rupture of the membranes. 2. The baby will be born with congenital syphilis. 3. Penicillin therapy will reduce the risk to the fetus. 4. The fetus will likely be born with a cardiac defect.
3. Penicillin therapy will reduce the risk to the fetus.
Immediately prior to an amniotomy, the external fetal heart monitor tracing shows 145 bpm with early decelerations. Immediately following the procedure, an internal tracing shows a fetal heart rate of 90 bpm with variable decelerations. A moderate amount of clear, amniotic fluid is seen on the bed linens. The nurse concludes that which of the following has occurred? 1. Placental abruption. 2. Eclampsia. 3. Prolapsed cord. 4. Succenturiate placenta.
3. Prolapsed cord.
A 7-year-old female is being admitted to the hospital for a diagnosis of acute lympho- cytic leukemia. The nurse wants to gather information from the child regarding her feelings about her diagnosis. Which nursing action is most appropriate to gain infor- mation about how the child is feeling? 1. The nurse should actively attempt to make friends with the child before asking her about her feelings. 2. The nurse should ask the child's parents what feelings she has expressed in regard to her diagnosis. 3. The nurse should provide the child with some paper to draw a picture of how she is feeling. 4. The nurse should ask the child direct questions about how she is feeling.
3. The nurse should provide the child with some paper to draw a picture of how she is
A gravid woman who is 42 weeks' gestation has just had a 20-minute nonstress test (NST). Which of the following results would the nurse interpret as a reactive test? 1. Moderate fetal heart baseline variability. 2. Maternal heart rate accelerations to 140 bpm lasting at least 20 seconds. 3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds. 4. Absence of maternal premature ventricular contractions.
3. Two fetal heart accelerations of 15 bpm lasting at least 15 seconds.
During a prenatal examination, the nurse notes scarring on and around the woman's genitalia. Which of the following questions is most important for the nurse to ask in relation to this observation? 1. "Have you ever had vaginal or clitoral surgery?" 2. "Have you worn any piercings in your genital area?" 3. "Have you had a tattoo removed from your genital area?" 4. "Have you ever been forced to have sex?"
4. "Have you ever been forced to have sex?"
A client telephones the labor and delivery suite and states, "My bag of waters just broke and it smells funny." Which of the following responses would be appropriate for the nurse to make at this time? 1. "Have you notified your doctor of the smell?" 2. "The bag of waters always has an unusual odor." 3. "Your labor should start very soon." 4. "Have you felt the baby move since the membranes broke?"
4. "Have you felt the baby move since the membranes broke?"
Which of the following statements is appropriate for the nurse to say to a patient with a complete placenta previa? 1. "During the first phase of labor you will do slow chest breathing." 2. "You should ambulate in the halls at least two times each day." 3. "The doctor will deliver you once you reach 25 weeks' gestation." 4. "It is important that you inform me if you become constipated."
4. "It is important that you inform me if you become constipated." Bearing down causes too much pressure
A 13-year-old boy is visiting the pediatrician's office for his well-child checkup. The child tells the nurse that he is worried because his breasts are growing and they hurt. He tells the nurse he is afraid to take his shirt off in front of the other boys during gym class. What should the nurse tell him? 1. "The pediatrician will draw some blood to find out why your breasts are growing." 2. "It is just a slight hormonal imbalance that can be easily corrected with medication." 3." This is a normal condition of puberty that will resolve within a year or two." 4. "This is a rare finding that occurs in about 5% of boys during puberty."
4. "This is a rare finding that occurs in about 5% of boys during puberty." Gynecomastia!!! usually resolves in 2 years
The school nurse is preparing a discussion on nutrition with the fourth-grade class. Based on the childrens' developmental level, what information should she include in her presentation? 1. A review of the number of calories that a fourth-grade child should consume in a day. 2. A review of a list of high-calorie foods that all fourth-graders should avoid. 3. A review of how to read food labels so children know which foods are good for them. 4. A review of nutritious foods with basic scientific information about how they affect the body organs and systems.
4. A review of nutritious foods with basic scientific information about how they affect the body organs and systems. always avoid negativism and talk about POSITIVE effects
A 40-week-gestation client has an admitting platelet count of 90,000 cells/mm 3 and a hematocrit of 29%. Her laboratory values 1 week earlier were platelet count 200,000 cells/mm 3 and hematocrit 37%. Which additional abnormal laboratory value would the nurse expect to see? 1. Decreased serum creatinine level. 2. Elevated red blood count (RBC). 3. Decreased alkaline phosphatase. 4. Elevated alanine transaminase (ALT).
4. Elevated alanine transaminase (ALT). elevated liver enzymes
The nurse is to intervene when caring for a laboring client whose baby is exhibiting signs of fetal distress. Which of the following actions should the nurse take? 1. Administer oxygen via nasal cannula. 2. Place the client in high Fowler position. 3. Remove the internal fetal monitor electrode. 4. Increase the intravenous infusion rate.
4. Increase the intravenous infusion rate.
Which of the following nursing diagnoses would be most appropriate for a 15-year-old woman who is in her first trimester of pregnancy? 1. Sleep pattern disturbance related to discomforts of pregnancy. 2. Knowledge deficit related to care of infants. 3. Anxiety related to fear of labor and delivery. 4. Ineffective individual coping related to developmental level.
4. Ineffective individual coping related to developmental level.
A client has severe pre-eclampsia. The nurse would expect the primary healthcare practitioner to order tests to assess the fetus for which of the following? 1. Severe anemia. 2. Hypoprothrombinemia. 3. Craniosynostosis. 4. Intrauterine growth restriction.
4. Intrauterine growth restriction.
A client has been admitted with a diagnosis of hyperemesis gravidarum. Which of the following laboratory values would be consistent with this diagnosis? 1. PO2 90, PCO2 35, HCO 3 19 mEq/L, pH 7.3. 2. PO2 100, PCO2 30, HCO 3 21 mEq/L, pH 7.5. 3. PO2 60, PCO2 50, HCO 3 28 mEq/L, pH 7.3. 4. PO2 90, PCO2 45, HCO 3 30 mEq/L, pH 7.5.
4. PO2 90, PCO2 45, HCO 3 30 mEq/L, pH 7.5. they are in metabolic alkalosis
A woman, G3 P2002, is 6 cm dilated. The fetal monitor tracing shows recurring deep late decelerations. The woman's doctor informs her that the baby must be delivered by cesarean section. The woman refuses to sign the informed consent. Which of the following actions by the nurse is appropriate? 1. Strongly encourage the woman to sign the informed consent. 2. Prepare the woman for the cesarean section. 3. Inform the woman that the baby will likely die without the surgery. 4. Provide the woman with ongoing labor support.
4. Provide the woman with ongoing labor support. you need consent so yeah??
A client is on magnesium sulfate for severe pre-eclampsia. The nurse must notify the attending physician regarding which of the following findings? 1. Patellar and biceps reflexes of +3. 2. Urinary output of 30 mL/hr. 3. Respiratory rate of 16 rpm. 4. Serum magnesium level of 9 g/dL.
4. Serum magnesium level of 9 g/dL. mag toxicity -- normal is below 7
How can the nurse best facilitate the trust relationship between infant and parent while the infant is hospitalized? 1. The nurse should encourage the parents to remain at their child's bedside as much as possible. 2. The nurse should keep parents informed about all aspects of their child's condition. 3. The nurse should encourage the parents to hold their child as much as possible. 4. The nurse should encourage the parents to participate actively in their child's care.
4. The nurse should encourage the parents to participate actively in their child's care.
A woman, G3 P2002, 42 weeks' gestation, is admitted to the labor suite for induction. A biophysical profile (BPP) report on the client's chart states BPP score of 6 of 10. The nurse should monitor this client carefully for which of the following? 1. Maternal hypertension. 2. Maternal hyperglycemia. 3. Increased fetal heart variability. 4. Late fetal heart decelerations.
4. Late fetal heart decelerations. BPP combines HFR, breathing, NST, movement, mm tone, and AFV. A score of 8-10 is GOOD 4 or lower is really BAD and baby needs to be delivered right now
A pregnant Latina is being seen in the prenatal clinic with diarrhea, fever, stiff neck, and headache. Upon inquiry, the nurse learns that the woman drinks unpasteurized milk and eats soft cheese daily. For which of the following bacterial infections should this woman be assessed? 1. Staphylococcus aureus. 2. Streptococcus albicans. 3. Pseudomonas aeruginosa. 4. Listeria monocytogenes.
4. Listeria monocytogenes.
The fetal monitor tracing of a laboring woman who is 9 cm dilated shows recurring late decelerations to 100 bpm. The nurse notes a moderate amount of greenish-colored amniotic fluid gush from the vagina after a practitioner performs an amniotomy. Which of the following nursing diagnoses is appropriate at this time? 1. Risk for infection related to rupture of membranes. 2. Risk for fetal injury related to possible intrauterine hypoxia. 3. Risk for impaired tissue integrity related to vaginal irritation. 4. Risk for maternal injury related to possible uterine rupture.
2. Risk for fetal injury related to possible intrauterine hypoxia.
The nurse is caring for a 7-year-old female on the school-age unit. Her mother is con- cerned that she may have some developmental delays. Which of the following statements would indicate to the nurse that the child is not developmentally on track for her age: 1. The child is able to follow a four-to-five-step command. 2. The child started wetting the bed on this admission to the hospital. 3. The child has an imaginary friend named Kelly. 4. The child enjoys playing board games with her sister.
3. The child has an imaginary friend named Kelly. Most kids stop when they are 3 or 4
Which of the following long-term goals is appropriate for a client, 10 weeks' gestation, who is diagnosed with gestational trophoblastic disease (hydatidiform mole)? 1. Client will be cancer-free 1 year from diagnosis. 2. Client will deliver her baby at full term without complications. 3. Client will be pain-free 3 months after diagnosis. 4. Client will have normal hemoglobin and hematocrit at delivery.
1. Client will be cancer-free 1 year from diagnosis.
The nurse is performing a physical assessment on a 6-month-old baby. Which finding should the nurse understand as abnormal for this child? 1. The child's posterior fontanel is open. 2. The child's anterior fontanel is open. 3. The child has the beginning signs of tooth eruption. 4. The child is able to track and follow objects.
1. The child's posterior fontanel is open. Post. fontanel closes around 6-8 months