Module 1: Developmental Stages and Transitions

A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per minute. On the basis of this finding, what is the most appropriate action for the nurse to take? A. Placing the infant in an oxygen tent B. Contacting the registered nurse C. Documenting the findings D. Wrapping an extra blanket around the infant

C. Documenting the findings Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths per minute (average 40). The nurse would document the findings. Contacting the registered nurse, placing the infant in an oxygen tent, and wrapping an extra blanket around the infant are all unnecessary actions.

A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should: A. Brush and floss their teeth every morning and at bedtime B. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime C. Brush and floss their teeth after meals and at bedtime D. Brush their teeth every morning and at bedtime

D. Brush their teeth every morning and at bedtime Rationale: School-age children are able to assume responsibility for their own dental hygiene. Good oral health habits tend to be carried into the adult years, helping prevent cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by flossing between the teeth should be done after meals and before bedtime. It is important that parents set up a routine schedule for the child that promotes good daily oral hygiene and gives them responsibility for their own dental care.

A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a newborn infant. Before administering the vaccine, the nurse should: A. Obtain parental consent to administer the vaccine B. Check the infant's temperature C. Check the infant for jaundice D. Request that a hepatitis blood screen be performed on the infant

A. Obtain parental consent to administer the vaccine Rationale: Hepatitis B vaccine is for immunization against infection caused by all known subtypes of hepatitis B virus. The usual recommended schedule is to administer the vaccine at birth, at 1 month of age, and again at 6 months of age. Parental consent must be obtained before the vaccine is administered. Checking the infant's temperature, checking for jaundice, and requesting that a hepatitis blood screen be performed on the infant are all unnecessary.

A nurse is reviewing the medical notes of a client seen by the physician to determine whether the client is pregnant. The nurse determines that pregnancy was confirmed if which of the following findings is documented? A. Palpable fetal movement B. Thinning of the cervix C. Amenorrhea D. Positive result on home urine test for pregnancy

A. Palpable fetal movement Rationale: The positive indicators of pregnancy include auscultation of fetal heart sounds, fetal movement felt by the examiner, and visualization of the fetus with sonography. Amenorrhea is a presumptive sign of pregnancy because it is experienced and reported by the woman. Presumptive signs are not reliable indicators of pregnancy, because any may be caused by conditions other than pregnancy. Thinning of the cervix (the Hegar sign) and a positive pregnancy test result are probable indicators of pregnancy. A false-positive pregnancy test result may occur as a result of an error in reading, the presence of protein or blood in the urine, a recent pregnancy, a recent first-trimester abortion, or medications the client is taking.

A nurse is telling a pregnant client about the signs that must be reported to the physician or nurse-midwife. The nurse tells the client that the physician or nurse-midwife should be contacted if which of the following occurs? A. Puffiness of the face B. Morning sickness C. Breast tenderness D. Urinary frequency

A. Puffiness of the face Rationale: Danger signs in pregnancy include swelling of the fingers (rings become tight), puffiness of the face or around the eyes; vaginal bleeding, with or without discomfort; rupture of the membranes; a continuous pounding headache; visual disturbances; persistent or severe abdominal pain; chills or fever; painful urination; persistent vomiting; and a change in the frequency or strength of fetal movements. Morning sickness, breast tenderness, and frequent urination are common occurrences during pregnancy and do not warrant contacting the physician or nurse-midwife.

A sexually active married couple, discussing birth control methods with the nurse, express the need for a method that is convenient. Because the couple has told the nurse that family-planning goals have been met, which method of birth control does the nurse suggest? A. Sterilization B. Spermicide C. Male condom D. Diaphragm

A. Sterilization Rationale: If family planning goals have already been met, sterilization of the male or female partner may be desirable. When sexual activity is limited, use of a spermicide, condom, or diaphragm may be most appropriate.

A female client asks a nurse about the advantages of using a female condom. The nurse tells the client that one advantage is: A. That it offers protection against sexually transmitted infections (STIs) B. It can be used along with a male condom C. That it is 100% safe in preventing pregnancy D. That it does not have to be discarded after use and can be used several times before a new one must be obtained

A. That it offers protection against sexually transmitted infections (STIs) Rationale: A female condom is a loose-fitting tubular polyurethane pouch that is anchored over the labia and cervix. The condom, which is prelubricated, is available without a prescription. It cannot be combined with a male condom and should be used just once, then discarded. Like the male condom, the female condom provides protection against STIs. The pregnancy failure rate with typical use is approximately 21%.

The mother of a newborn who was circumcised before discharge from the hospital calls the nurse at the pediatrician's office and tells the nurse that she is concerned because she has noticed a yellow crust over the circumcision site. The nurse tells the mother: A. That the crust is to be expected as a normal part of healing B. To bring the infant to the pediatrician's office to be checked C. That it could indicate a sign of an infection and that the infant's temperature should be checked every 2 hours D. To remove the crust, using a warm, wet face cloth and a mild soap

A. That the crust is to be expected as a normal part of healing Rationale: After circumcision, a yellow crust may form over the circumcision site. This crust is a normal part of healing and should not be removed. The mother should be told to expect this occurrence. Yellow crusting or discharge is not a sign of infection, and the pediatrician does not need to be notified, because the finding is to be expected.

The mother of a 2-year-old tells the nurse that she is very concerned about her child because he has developed "a will of his own" and "acts as if he can control others." The nurse provides information to the mother to alleviate her concern, recalling that, according to Erikson, a toddler is confronting which developmental task? A. Initiative versus guilt B. Autonomy versus doubt and shame C. Industry versus inferiority D. Trust versus mistrust

B. Autonomy versus doubt and shame Rationale: According to Erikson, the toddler is struggling with the developmental task of acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers discover that they have wills of their own and that they can control others. Asserting their wills and insisting on their own way, however, often lead to conflict with those they love, whereas submissive behavior is rewarded with affection and approval. Toddlers experience conflict because they want to assert their own wills but do not want to risk losing the approval of loved ones. Trust versus mistrust is the developmental task of the infant. Initiative versus guilt is the developmental task of the preschool-age child. Industry versus inferiority is the developmental task of the school-age child.

A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100 beats per minute. On the basis of this finding, which priority action should the nurse take? A. Documenting the vital signs in the client's medical record B. Checking the client's uterine fundus C. Continuing to check the client's vital signs every 15 minutes D. Notifying the registered nurse immediately

B. Checking the client's uterine fundus Rationale: During the fourth stage of labor, the woman's vital signs should be assessed every 15 minutes during the first hour. An increasing pulse rate is an early sign of excessive blood loss, because the heart pumps faster to compensate for reduced blood volume. The blood pressure decreases as the blood volume diminishes, but this is a later sign of hypovolemia. The most common reason for excessive postpartum bleeding is that the uterus is not firmly contracting and compressing open vessels at the placental site. Therefore the nurse should check the client's uterine fundus for firmness, height, and positioning. Notifying the registered nurse immediately is not necessary unless the nurse is unable to determine the cause of bleeding and is unable to correct it. Continuing to check the client's vital signs every 15 minutes will delay necessary intervention. Although the findings will need to be documented, the priority action is to assess the client for bleeding.

A new mother asks the nurse, "I was told that my infant received my antibodies during pregnancy. Does that mean that my infant is protected against infections?" Which statement should the nurse make in response to the mother? A. "The transfer of your antibodies protects your infant until the infant is 12 months old." B. "If you breastfeed, your infant is protected from infection." C. "The immune system of an infant is immature, and the infant is at risk for infection." D.

C. "The immune system of an infant is immature, and the infant is at risk for infection." Rationale: Transplacental transfer of maternal antibodies supplements the infant's weak response to infection until approximately 3 to 4 months of age. Although the infant begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age the infant has only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of the adult IgA level. Breast milk transmits additional IgA protection. The activity of T-lymphocytes also increases after birth. Even though the immune system matures during infancy, maximal protection against infection is not achieved until early childhood. This immaturity places the infant at risk for infection.

The mother of an adolescent calls the clinic nurse and reports that her daughter wants to have her navel pierced. The mother asks the nurse about the dangers associated with body piercing. The nurse tells the mother that: A. It is important to discourage body piercing because of the risk of contracting human immunodeficiency virus (HIV) B. Infection always occurs when body piercing is done C. Body piercing is generally harmless as long as it is performed under sterile conditions D. Hepatitis B is a concern with body piercing

C. Body piercing is generally harmless as long as it is performed under sterile conditions Rationale: Generally body piercing is harmless if the procedure is performed under sterile conditions by a qualified person. Some of the complications that may occur are bleeding, infection, keloid formation, and the development of allergies to metal. The area needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent infection. HIV and hepatitis B infections are not associated with body piercing; however, they are a possibility with tattooing.

The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse tells the mother to place the child in a: A. Car safety seat in the back seat in a face-forward position B. Booster seat in a rear-facing position in the front seat C. Booster seat with one of the car's seat belts placed over the child D. Car safety seat in a face-forward position in the front seat

C. Booster seat with one of the car's seat belts placed over the child Rationale: A child needs to remain in a car safety seat until he or she weighs 40 lb. Once the child has outgrown the car safety seat, a booster seat is used. Booster seats are designed to raise the child high enough so that the restraining straps are correctly positioned over the child's chest and pelvis. The child should not be placed in the front seat. A car safety seat is used for the child who weighs less than 40 lb. These seats are placed in the middle of the back seat in a rear-facing position.

A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff calls the nurse and reports that the blood glucose level is 40 mg/dL. On the basis of this result, which action should the nurse take first? A. Ask the laboratory to draw another blood sample in 2 hours and repeat the test B. Document the results in the newborn's medical record C. Contact the registered nurse D. Hold the next scheduled feeding

C. Contact the registered nurse Rationale: The blood glucose level for a newborn infant should remain above 40 mg/dL. If glucose is not constantly available to the brain, permanent damage may occur. The nurse would most appropriately contact the registered nurse to obtain prescriptions regarding feeding the infant with a low blood glucose. The nurse would also follow agency policy regarding feeding infants with a low blood glucose level if such a policy exists. A common practice is to feed the infant if the glucose level is 40 mg/dL or less. Holding the next scheduled feeding is harmful. Although the nurse would document the laboratory result, this is not the most appropriate initial action. Another blood sample may need to be drawn if it is prescribed, but asking the laboratory to repeat the test in 2 hours is not the appropriate action.

A nurse monitoring a client in labor notes this fetal heart rate pattern (see figure) on the electronic fetal monitoring strip. The most appropriate nursing action would be to: A. Stop the oxytocin (Pitocin) infusion B. Administer oxygen with a face mask at 8 to 10 L/min C. Continue to monitor the client and fetal heart rate patterns D. Notify the registered nurse of the findings

C. Continue to monitor the client and fetal heart rate patterns Rationale: Early decelerations are not associated with fetal compromise and require no intervention. They occur during contractions as the fetal head presses against the woman's pelvis or soft tissues, such as the cervix. Early decelerations have a gradual rather than an abrupt decrease from baseline. They have a consistent appearance in that one early deceleration looks similar to others. Early decelerations mirror the contraction, beginning near its onset and returning to the baseline by the end of the contraction, with the low point of the deceleration occurring near the contraction's peak. The rate at the lowest point of the deceleration usually remains greater than 100 beats per minute.

The nurse notes that a client in later adulthood has tremors of the hands. On the basis of this finding, the nurse should take which action? A. Notify the registered nurse immediately B. Ask the registered nurse about referring the client to a neurological specialist C. Document the findings D. Obtain a prescription for a muscle relaxant

C. Document the findings Rationale: Senile tremors are occasionally noted in clients in later adulthood. These benign tremors include intentional tremor of the hands, head-nodding (as if saying yes), and tongue protrusion. Because this finding is an age-related occurrence, obtaining a prescription for a muscle relaxant, notifying the registered nurse immediately, and asking about referring the client to a neurological specialist are unnecessary and incorrect.

An older client reports that she has been awakening during the night, awakens early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these reported data, the nurse should take which action? A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours B. Ask the registered nurse to obtain a prescription for a nighttime sedative C. Document the findings in the medical record D. Report the findings to the registered nurse

C. Document the findings in the medical record Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Because the reported data are normal age-related changes, the nurse would document the findings. There is no reason to report the findings to the registered nurse. Sedatives should be avoided. The consumption of caffeinated beverages is likely to increase disruption of sleep patterns.

A licensed practical nurse (LPN) is assisting a registered nurse (RN) perform a physical assessment of a 12 month old infant. The RN comments that the infant's head circumference is the same as the chest circumference. On the basis of this finding, the LPN anticipates that the RN will take which action? A. Tell the mother that the infant is growing faster than expected B. Report the presence of hydrocephalus to the healthcare provider C. Document these measurements in the infant's health-care record D. Suggest to the healthcare provider that a skull x-ray be performed

C. Document these measurements in the infant's health-care record Rationale: The head circumference growth rate during the first year is approximately 0.4 inch (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling the mother that the infant is growing faster than expected, and suggesting that a skull x-ray be performed are incorrect.

A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago. The nurse notes that the woman's radial pulse rate is 55 beats per minute. On the basis of this finding, which action by the nurse is most appropriate? A. Helping the woman get out of bed and walk B. Reporting the finding to the registered nurse immediately C. Documenting the finding D. Performing active and passive range-of-motion exercises

C. Documenting the finding Rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may occur. The lower pulse rate reflects the large amount of blood returning to the central circulation after delivery of the placenta. The increase in central circulation results in increased stroke volume and permits a slower heart rate to provide adequate maternal circulation. It is not necessary to notify the registered nurse immediately, because a pulse rate of 55 beats per minute is a normal finding. The client should remain on bed rest in the immediate postpartum period. Although range-of-motion exercises are important for the client on bed rest, this action is unrelated to the data in the question. Therefore, the most appropriate nursing action is to document the finding.

A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that the score is 6. The nurse should take which most appropriate action? A. Provide no action except to support the infant's spontaneous efforts B. Initiate cardiopulmonary resuscitation C. Gently stimulate the infant by rubbing his back while administering oxygen D. Recheck the score in 5 minutes

C. Gently stimulate the infant by rubbing his back while administering oxygen Rationale: The Apgar score is a method of rapid evaluation of an infant's cardiorespiratory adaptation after birth. The nurse scores the infant at 1 minute and 5 minutes in five areas: heart rate, respiratory effort, muscle tone, reflex response, and color. The infant is assigned a score of 0 to 2 in each of the five areas, and the scores are totaled. If the score ranges from 8 to 10, no action is needed other than support of the infant's spontaneous efforts and continued observation. If the score falls between 4 and 7, the nurse gently stimulates the infant by rubbing his back while administering oxygen. The nurse also determines whether the mother received opioids, which may have depressed the infant's respirations. If the score is between 1 and 3, the infant needs resuscitation.

A client is pregnant for the sixth time. She tells the nurse that she has had three elective first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a daughter who was born at 36 weeks' gestation. In calculating the gravidity and para (parity), the nurse determines that the client is: A. Gravida 3, para 6 B. Gravida 2, para 6 C. Gravida 6, para 2 D. Gravida 2, para 2

C. Gravida 6, para 2 Rationale: The term gravida refers to the number of pregnancies, of any duration, that a woman has had. Parity (para) refers to the number of pregnancies that have progressed past 20 weeks at delivery. Therefore this client is gravida 6 (pregnant for the sixth time), para 2 (has a son and a daughter). Pregnancy outcomes may also be described with the GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live births (L). The GTPAL for this client would be G = 6, T = 1, P = 1, A = 3, L = 2.

A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking into account Erik Erikson's theory of psychosocial development. According to Erikson's theory, which of the following tasks represents the primary developmental task of this child? A. Gaining independence from parents B. Developing a sense of trust in the world C. Mastering useful skills and tools D. Developing a sense of control over self and body functions

C. Mastering useful skills and tools Rationale: According to Erikson's theory of psychosocial development, the school-age child's task is to master useful skills and tools of the culture (industry versus inferiority). Gaining independence from parents is the psychosocial task of the adolescent. Developing a sense of trust in the world is the psychosocial task of an infant. Developing a sense of control over self and body functions is the psychosocial task of the toddler.

A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is 1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report the amount of lochial flow? A. Scant B. Heavy C. Moderate D. Light

C. Moderate Rationale: Lochia is the discharge from the uterus, consisting of blood from the vessels of the placental site and debris from the deciduas, that occurs during the postpartum period. Use the following guide to determine the amount of flow: scant = less than 2.5 cm (1 inch) on menstrual pad in 1 hour; light = less than 10 cm (4 inches) on menstrual pad in 1 hour; moderate = less than 15 cm (6 inches) on menstrual pad in 1 hour; heavy = saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.

A nurse is planning dietary measures for an older client who is experiencing dysphagia. Which of the following actions should the nurse include in the plan of care? A. Consulting with the physician regarding feeding through an enteral tube B. Ensuring that most of the diet consists of liquids C. Monitoring the client during meals to ensure that food is swallowed D. Encouraging the client to feed herself

C. Monitoring the client during meals to ensure that food is swallowed Rationale: Clients with dysphagia must be assisted during meals, and the nurse should carefully observe the client to ensure that foods are successfully swallowed instead of being trapped in the mouth. The diet should be nutritionally balanced and consist of both solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration pneumonia. Thickeners can be added to liquids, because thin liquids are most difficult to swallow for clients with dysphagia. Clients with severe dysphagia may require enteral tube feedings, but there is no information in the question to indicate that the dysphagia is severe.

A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse and notes that it is synchronized with the sounds heard through the fetoscope. Which action should the nurse take? A. Asks the mother to lie still while both the FHR and the radial pulse rate are counted. B. Count the FHR for 30 seconds and then count the radial pulse rate of the mother for 30 seconds. C. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. D. Count the FHR for 60 seconds, ensuring that it is synchronized consistently with the mother's radial pulse.

C. Move the fetoscope to another area on the mother's abdomen to locate the fetal heart. Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on the maternal abdomen, over the fetal back. The nurse would then palpate the mother's radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse would move the fetoscope to another area on the mother's abdomen to locate the FHR. The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that may be heard are the funic souffle (blood flowing through the umbilical cord) and the uterine souffle (blood flowing through the uterine vessels). The funic souffle is synchronized with the FHR; the uterine souffle is synchronized with the mother's pulse.

According to Erik Erikson's developmental theory, which of the following choices are developmental tasks of the middle adult? A. Making decisions concerning career, marriage, and parenthood B. Verbalizing readiness to assume parental responsibilities C. Providing guidance during interactions with his children D. Redefining self-perception and capacity for intimacy

C. Providing guidance during interactions with his children Rationale: According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Making decisions concerning career, marriage, and parenthood; redefining self-perception and capacity for intimacy; and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult.

A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, the nurse tells the group that infants: A. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs B. Must have needs ignored for short periods to develop a healthy personality C. Rely on the fact that their needs will be met D. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality

C. Rely on the fact that their needs will be met Rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore the other options are incorrect.

A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor. Which action should the nurse, on suddenly noting the presence of late decelerations on the fetal heart rate (FHR) monitor, take first? A. Checking the woman's blood pressure and pulse B. Notifying the registered nurse C. Stopping the oxytocin infusion D. Increasing the intravenous (IV) rate of the nonadditive solution

C. Stopping the oxytocin infusion Rationale: Oxytocin stimulates uterine smooth muscle, resulting in increased strength, duration, and frequency of uterine contractions. The nurse monitors the client who is receiving oxytocin closely and, if uterine hypertonicity or a nonreassuring FHR pattern, such as late decelerations occurs, intervenes to reduce uterine activity and increase fetal oxygenation. The nurse would first stop the oxytocin infusion. The nurse would next increase the IV rate of the nonadditive solution, place the woman in a side-lying position, and administer oxygen through a snug face mask at a rate of 8 to 10 L/min. The nurse would then notify the nurse-midwife or physician of the adverse reaction, the nursing interventions taken, and the response to interventions. The nurse would monitor the woman's vital signs while she is receiving oxytocin, but this would not be the first action in this situation.

The parents of an adolescent tell the school nurse that they are frustrated because their daughter has become self-centered, lazy, and irresponsible. The nurse should tell the parents: A. That this type of behavior is usually the result of parents' spoiling a child B. That their daughter will need to see a child psychologist if the behavior continues C. That this is normal behavior for an adolescent D. To restrict any social privileges until the behavior stops

C. That this is normal behavior for an adolescent Rationale: Identity formation is the major developmental task of adolescence. Energy is focused within the self, and the adolescent is sometimes described as egocentric or self-absorbed. Frustrated parents often describe teenagers during this phase as self-centered, lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on himself or herself, and determine who he or she is going to be. Erikson describes the conflict of this phase of psychosocial development as identity formation versus role confusion. The assertions that a psychologist is needed and that the behavior is the result of spoiling are incorrect. Restriction of social privileges will cause resentment and rebellion in the adolescent.

A nurse is conducting a psychosocial assessment of a young adult. Which of the following observations would lead the nurse to determine that the client is demonstrating a sign of emotional health? Select all that apply. Select all that apply. A. The young adult verbalizes unrealistic fears. B. The young adult is sensitive to criticism. C. The young adult verbalizes satisfaction with friendships. D. The young adult has a sense of meaning and direction in life. E. The young adult verbalizes disappointment with life.

C. The young adult verbalizes satisfaction with friendships. Rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long-term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears. D. The young adult has a sense of meaning and direction in life. Rationale: Most young adults have the physical and emotional resources and support systems to meet the many challenges, tasks, and responsibilities they face. Signs of emotional health in the young adult include a sense of meaning and direction in life, successful negotiation of transitions, absence of feelings of being cheated or disappointed by life, attainment of several long-term goals, satisfaction with personal growth and development, reciprocated feelings of love for a partner, satisfaction with social interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and no unrealistic fears.

A nurse is caring for an older client who has a bronchopulmonary infection. The nurse monitors the client's ability to maintain a patent airway because the normal aging process: A. Decreases the number of alveoli and increases the function of those remaining B. Increases respiratory system compliance C. Increases the production of surfactant D. Decreases an older client's ability to clear secretions

D. Decreases an older client's ability to clear secretions Rationale: Respiratory changes related to the normal aging process decrease an older adult's ability to clear secretions and protect the airway. In healthy older adults, the number of alveoli does not change or reduce significantly; their structure, however, is altered. Respiratory system compliance decreases with advancing age because of a progressive loss of elastic recoil of the lung parenchyma and conducting airways and reduced elastic recoil of the lung and opposing forces of the chest wall. Production of surfactant in the lung does not usually decrease with aging, nor does it increase. However, the production of alveolar cells responsible for surfactant production is diminished.

A pregnant client asks a nurse about the use of noninvasive acupressure as a complementary alternative therapy to relieve nausea. The nurse tells the client that: A. The physician or nurse-midwife needs to provide a prescription for acupressure B. Complementary alternative therapies should not be used during pregnancy C. It is all right to try any type of complementary alternative therapy to relieve the nausea D. Devices that apply pressure alone are available over the counter

D. Devices that apply pressure alone are available over the counter Rationale: As a complementary alternative therapy, acupressure over the Neiguan acupuncture point (approximately three fingers' width above the wrist crease on the inner arm) is performed with the use of electrical impulses or with a device that applies pressure alone. Devices that apply an electrical impulse over this point require a prescription from a physician or nurse-midwife. Devices that apply pressure alone are available over the counter. Certain types (those that are noninvasive and are not harmful) may be acceptable for use during pregnancy. Not all types of complementary alternative therapies can be used during pregnancy, because some may be harmful to the mother, fetus, or both.

The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the nurse that her infant is teething, and asks what can be done to relieve the infant's discomfort. The nurse instructs the mother to: A. Obtain an over-the-counter (OTC) topical medication for gum-pain relief B. Rub the infant's gums with baby aspirin that has been dissolved in water C. Schedule an appointment with a dentist for a dental evaluation D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast

D. Give the infant cool liquids or a Popsicle and hard foods such as dry toast Rationale: Although sometimes asymptomatic, teething is often signaled by behavior such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking, excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It is unnecessary to obtain a dental evaluation, but a health-care professional should further investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea. The nurse may suggest that the mother provide cool liquids and hard foods such as dry toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications for gum relief should only be used as directed by the healthcare provider. Home remedies such as rubbing the gums with aspirin should be discouraged, but acetaminophen (Tylenol), administered as directed for the child's age, can relieve discomfort.

A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which adverse effect of the block does the postpartum nurse monitor the woman? A. Hypertension B. Vomiting C. Pruritus D. Headache

D. Headache Rationale: The adverse effects associated with a subarachnoid block include maternal hypotension, bladder distention, and postdural headache. Postdural headache occurs as a result of cerebrospinal fluid leakage at the site of dural puncture. A spinal headache is postural, worsening when the woman is upright and possibly disappearing when she is lying flat. Bed rest with oral or intravenous hydration helps relieve the headache. Nausea, vomiting, and pruritus are adverse effects associated with the use of intrathecal opioids.

A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully reviews the assessment with the young adult because such clients: A. Are exposed to hazardous substances B. Are unable to afford health insurance C. Are at risk for a serious illness D. Ignore physical symptoms and postpone seeking health care

D. Ignore physical symptoms and postpone seeking health care Rationale: Young adults are usually quite active, experience severe illnesses less commonly than members of older age groups, tend to ignore physical symptoms, and often postpone seeking health care. Clients in this developmental stage may benefit from a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and other chronic diseases. Young adults are not at risk for serious illness. The young adult may or may not be exposed to hazardous substances and may or may not be able to afford health insurance.

A nurse is taking the vital signs of a pregnant client who has been admitted to the labor unit. The nurse notes that the client's temperature is 100.6° F, the pulse rate is 100 beats per minute, and respirations are 24 breaths per minute. On the basis of these findings, what is the most appropriate nursing action? A. Recheck the vital signs in 1 hour B. Document the findings in the client's medical record C. Continue collecting subjective and objective data D. Notify the registered nurse of the findings

D. Notify the registered nurse of the findings Rationale: The woman's temperature should range from 98° F to 99.6° F. The pulse rate should be 60 to 90 beats per minute, and respirations should be 12 to 20 breaths per minute. A temperature of 100.4° F or higher, especially in the presence of an increased pulse rate and faster respirations, suggests infection, and the registered nurse should be notified. Although the findings would be documented, the nurse would most appropriately contact the registered nurse. Once the nurse has contacted the registered nurse, the nurse would continue the assessment. Vital signs would be rechecked as prescribed or in accordance with agency protocol.

A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory of psychosocial development to select an appropriate activity. The nurse selects an activity that will assist the child in developing: A. A sense of industry B. A sense of trust C. Initiative D. Autonomy

A. A sense of industry Rationale: According to Erikson, the central task of the school-age years is the development of a sense of industry. The school-age child replaces fantasy play with "work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of infancy. Development of autonomy is the task of toddlerhood. Development of initiative is the task of the preschooler.

A multigravida pregnant woman asks the nurse when she will start to feel fetal movements. Around which week of gestation does the nurse tell the mother that fetal movements are first noticed? A. 8 weeks B. 12 weeks C. 6 weeks D. 16 weeks

D. 16 weeks Rationale: Fetal movements (quickening) are first noticed by the multigravida pregnant woman at 16 to 20 weeks of gestation and gradually increase in frequency and strength. The other options are incorrect.

A nurse is discussing birth control methods with a client who is trying to decide which method to use. On which major factor that will provide the motivation needed for consistent implementation of a birth control method should the nurse focus? A. Work and home schedules B. Family planning goals C. Desire to have children in the future D. Personal preference

D. Personal preference Rationale: Personal preference is a major factor in providing the motivation needed for consistent implementation of a birth control method. The nurse should educate the client about the various contraceptive methods available so that expressions of preference may be based on understanding. The desire to have children in the future, work and home schedules, and family planning goals may affect the choice of birth control method but are not motivating factors.

A pregnant client tells the nurse that she has a 2-year-old child at home and expresses concern about how the toddler will adapt to a newborn infant's being brought into the home. Which of the following statements is the most appropriate response for the nurse to make to the client? A. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." B. "Don't be concerned; any 2-year-old would welcome a newborn." C. "If your 2-year-old becomes angry or jealous, you should have the child seen by a child psychologist." D. "A 2-year-old toddler will be more concerned about exploring the environment, so there's no reason to be concerned."

A. "Even though a 2-year-old may have little perception of time, if any changes in sleeping arrangements need to be made for the newborn they should be carried out several weeks before birth." Rationale: Danger signs in pregnancy include swelling of the fingers (rings become tight), puffiness of the face or around the eyes; vaginal bleeding, with or without discomfort; rupture of the membranes; a continuous pounding headache; visual disturbances; persistent or severe abdominal pain; chills or fever; painful urination; persistent vomiting; and a change in the frequency or strength of fetal movements. Morning sickness, breast tenderness, and frequent urination are common occurrences during pregnancy and do not warrant contacting the physician or nurse-midwife.

A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the episiotomy site. Which action by the nurse is the most appropriate? A. Administering an intravenous (IV) opioid analgesic B. Applying an ice pack to the perineum C. Assisting the woman in taking a warm sitz bath D. Contacting the registered nurse

B. Applying an ice pack to the perineum Rationale: Ice causes vasoconstriction and is most effective if applied to the perineal area soon after birth to prevent edema and numb the area. Ice is used for the first 12 to 24 hours after a vaginal birth. Sitz baths, which provide continuous circulation of water, cleanse and comfort the traumatized perineum. Warm water is most effective after 24 hours have elapsed since delivery. An IV opioid analgesic is not necessary. Rather, an anesthetic spray that will decrease surface discomfort may be used. It is not necessary to notify the registered nurse.

A nurse is teaching a pregnant client about nutrition and food sources that are high in folic acid. Which of the following food items does the nurse tell the client contains the highest amount of folic acid? A. Broccoli B. Oranges C. Pinto beans D. Lettuce

C. Pinto beans Rationale: Foods high in folic acid include beans (black, kidney, pinto, refried), peanuts, orange juice and oranges, asparagus, peas, broccoli, lettuce, and spinach. Pinto beans contain 294 mcg per 1-cup serving. An orange contains 44 mcg per 1-cup serving, lettuce contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving.

A nurse is assessing the language development of a 9-month-old infant. Which developmental milestone does the nurse expect to note in an infant of this age? A. The infant babbles. B. The infant babbles single consonants. C. The infant says "Mama." D. The infant smiles and coos.

C. The infant says "Mama." Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A 1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4-month-old. Single-consonant babbling occurs between 6 and 8 months of age.

The nurse provides information to a pregnant client who is experiencing nausea and vomiting about measures to relieve the discomfort. Which statement by the mother indicates the need for further information? A. "I should keep dry crackers at my bedside and eat them before I get out of bed in the morning." B. "I need to avoid eating fried or greasy foods." C. "I should eat five or six small meals a day rather than three full meals." D. "I need to be sure to drink adequate fluids with my meals."

D. "I need to be sure to drink adequate fluids with my meals." Rationale: To alleviate nausea and vomiting, the client should avoid drinking fluids with meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an empty stomach and avoid spicy foods and foods with strong odors, such as onion and cabbage.

A nurse is performing a skin and peripheral vascular assessment on a client in later adulthood. Which of the following observations would the nurse expect to note as an age-related finding? A. Loss of hair on the lower legs B. Bounding dorsalis pedis pulse C. Thin, ridged toenails D. Thick skin on the lower legs

A. Loss of hair on the lower legs Rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become more difficult to find. They would not be bounding. Trophic changes associated with arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs) also occur normally with aging.

A nurse provides information to a client about the use of a diaphragm. Which of the following statements indicates to the nurse that the client needs further information on how to use the diaphragm? A. "I can leave the diaphragm in place as long as I want after intercourse." B. "I need to reapply spermicidal cream with repeated intercourse." C. "The diaphragm needs to be filled with spermicidal cream before insertion." D. "The diaphragm can be inserted as long as 6 hours before intercourse."

A. "I can leave the diaphragm in place as long as I want after intercourse." Rationale: The diaphragm may be inserted as long as 6 hours before intercourse and must remain in place for at least 6 hours after. Because of the risk of toxic shock syndrome, the diaphragm must not remain in place for more than 24 hours. The diaphragm must be filled with spermicidal cream or jelly before insertion, and the spermicide must be reapplied before intercourse is repeated.

A nurse provides instructions to a mother about crib safety for her infant. Which statement by the mother indicates a need for further instructions? A. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." B. "Wood surfaces on the crib need to be free of splinters and cracks." C. "The drop side needs to be impossible for my infant to release." D. "I need to keep large toys out of the crib."

A. "The distance between the slats needs to be no more than 4 inches wide to prevent entrapment of my infant's head or body." Rationale: The distance between slats must be no more than 2 ⅜ inches to prevent entrapment of the infant's head and body. The mesh in a mesh-sided crib should have openings smaller than ¼ inch. The drop side must be impossible for the infant to release, and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother should avoid placing large toys in the crib, because an older infant may use them as steps to climb over the side, possibly resulting in serious injury.

An older female client asks a nurse why her hair has turned gray. Which of the following responses is most appropriate for the nurse to make to the client? A. "The skin on the scalp becomes thin, causing moisture to escape." B. "A loss of melanin occurs in the normal aging process." C. "It is caused by hereditary factors." D. "The number of sweat glands and blood vessels decreases in the normal aging process."

B. "A loss of melanin occurs in the normal aging process." Rationale: The number of melanocytes, which provide pigment and hair color, decreases with age, giving older adults less protection from ultraviolet rays, paler skin color, and graying hair. Although the skin becomes thinner with the aging process and the number of sweat glands and blood vessels decreases, these changes are unrelated to graying hair. Heredity factors influence when the process of graying begins but do not cause the graying of hair.

Immediately after delivery, the nurse assesses the woman's uterine fundus. At what location does the nurse expect to be able to palpate the fundus? A. At the level of the umbilicus B. Midway between the symphysis pubis and umbilicus C. In the pelvic cavity D. 2 cm above the umbilicus

B. Midway between the symphysis pubis and umbilicus Rationale: Immediately after delivery, the uterus is about the size of a large grapefruit or softball. The fundus may be palpated midway between the symphysis pubis and the umbilicus but then rises to a level just above the umbilicus and then sinks to the level of the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus begins to descend by approximately 1 cm, or one finger's breadth, per day. By the 10th to 14th day, the fundus is in the pelvic cavity and cannot be palpated abdominally.

A nurse in a daycare setting is planning play activities for 2- and 3-year-old children. Which of the following toys are most appropriate for these activities? A. Finger paints and card games B. Simple board games and puzzles C. Blocks and push-pull toys D. Videos and cutting-and-pasting toys

C. Blocks and push-pull toys Rationale: Toys for the toddler should meet the child's needs for activity and inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger paints, and bubbles; push-pull toys; large balls; sand and water play; blocks; painting; coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board games, videos, and cutting-and-pasting toys are more appropriate play activities for the preschooler.

A nurse provides information about feeding to the mother of a 6-month-old infant. Which statement by the mother indicates an understanding of the information? A. "Meats are really important for iron, and I should start feeding meats to my infant right away." B. "Fluoride supplementation is not necessary until permanent teeth come in." C. "Egg white should not be given to my infant because of the risk for an allergy." D. "I can mix the food in the my infant's bottle if he won't eat it."

C. "Egg white should not be given to my infant because of the risk for an allergy." Rationale: Egg white, even in small quantities, is not given to the infant until the end of the first year of life because it is a common food allergen. Fluoride supplementation may be needed beginning at of 6 months, depending on the infant's intake of fluoridated tap water. Foods are never mixed with formula in the bottle. It may be difficult for the infant to consume the formula, and it will also be difficult to determine the infant's intake of the formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old. Rice cereal may be introduced first because of its low allergenic potential; or, depending on the pediatrician's preference, fruits and vegetables may be introduced first.

A nurse reviews the health history of a client who will be seeing the physician to obtain a prescription for a combination oral contraceptive (estrogen and progestin). Which of the following findings in the health history would cause the nurse to determine that use of a combination oral contraceptive is contraindicated? A. The client is being treated for hypertension. B. The client has type 2 diabetes mellitus. C. The client has been treated for breast cancer. D. The client has hyperlipidemia.

C. The client has been treated for breast cancer. Rationale: Combination oral contraceptives contain both estrogen and progestin and are contraindicated during pregnancy and for women who have (or have a history of) the following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular disease, coronary-artery disease, myocardial infarction, known or suspected breast cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver tumors, and undiagnosed abnormal genital bleeding. They are used with caution in women with diabetes mellitus, women who smoke heavily, women with risk factors for cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating elective surgery in which thrombosis might be expected.

A nurse is gathering subjective data from a client who is seeking a prescription for an oral contraceptive. To identify risk factors associated with the use of an oral contraceptive, which question does the nurse ask? A. "Do you engage in strenuous exercise such as jogging?" B. "Are you dieting?" C. "Do you normally have menstrual cramps with your periods?" D. "Do you smoke cigarettes?"

D. "Do you smoke cigarettes?" Rationale: Oral contraceptives have been associated with venous and arterial thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke. The risk of thromboembolitic phenomena is increased in the presence of other risk factors, especially heavy smoking and a history of thrombosis. Additional risk factors include hypertension, cerebrovascular disease, coronary artery disease, and surgery in which postoperative thrombosis might be expected. Dieting, menstrual cramping, and strenuous exercise are not risk factors associated with the use of oral contraceptives.

A nurse is performing an external and ophthalmoscopic examination of an older client. Which age-related change would the nurse would expect to note?

Rationale: Age-related changes of the retina include narrowed and straightened blood vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called drusen, near the macula. Conjunctivitis is not an age-related change and is characterized by the presence of a red sclera. Purulent material in the anterior chamber of the eye occurs with iritis and is not an age-related change. It is characterized by the presence of white material or drainage in the eye. Red blood vessels, a clear fundus, and a yellow-orange optic disc are all normal, not age-related, findings.

A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats per minute. The nurse should: A. Document the findings B. Wait 15 minutes and then recheck the FHR C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time D. Notify the registered nurse of the finding

A. Document the findings Rationale: The normal fetal heart depends on gestational age (usually higher in the first trimester) and is generally in the range of 120 to 160 beats per minute. A FHR of 160 beats per minute is within the normal range, so documentation is the only action indicated.

A nurse is assessing the motor development of a 24-month-old child. Which of the following activities would the nurse expect the mother to report that the child can perform? Select all that apply. A. Turn the pages of a book one at a time B. Dress himself appropriately C. Go to the bathroom without help D. Put on and tie his shoes E. Align two or more blocks

A. Turn the pages of a book one at a time Rationale: By 24 months of age, the toddler can put on simple items of clothing but cannot differentiate front and back. Some other activities that children at this age can perform include zipping large zippers, putting on shoes, washing and drying their hands, aligning two or more blocks, and turning the pages of a book one at a time. The fine motor skill needed to tie shoes is not yet developed. By the age of 4 to 5 years, the child is more independent and can dress, eat, and go to the bathroom without help. E. Align two or more blocks Rationale: By 24 months of age, the toddler can put on simple items of clothing but cannot differentiate front and back. Some other activities that children at this age can perform include zipping large zippers, putting on shoes, washing and drying their hands, aligning two or more blocks, and turning the pages of a book one at a time. The fine motor skill needed to tie shoes is not yet developed. By the age of 4 to 5 years, the child is more independent and can dress, eat, and go to the bathroom without help.

The mother of a toddler asks the nurse when she will know that her child is ready to start toilet training. The nurse tells the mother that which of the following observations is a sign of physical readiness? A. The child can eat using a fork and knife. B. The child no longer has temper tantrums. C. The child can remove his or her own clothing. D. The child has been walking for 2 years.

C. The child can remove his or her own clothing. Rationale: Signs of physical readiness for toilet training include the following: The child can remove her own clothing; is willing to let go of a toy when asked; is able to sit, squat, and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2 years, and an absence of temper tantrums are not signs of physical readiness.

A Muslim woman and her husband are seen in the health care clinic because the woman suspects that she is pregnant. When planning for the physical assessment of the woman, the nurse ensures that: A. A female physician examines the woman B. Written permission is obtained from the woman to obtain subjective health data C. The woman is examined without any other people in the examining room D. The woman's husband remains in the examining room at all times

A. A female physician examines the woman Rationale: Fear, modesty, and a desire to avoid examination by men may keep some women from seeking health care during pregnancy. In many cultures (e.g., Muslim, Hindu, Latino), exposure of a woman's genitals to men is considered demeaning. Nurses must remember that the reputations of women from these cultures depend on their demonstrated modesty. It is best for a female physician or practitioner to perform the examination. If this is not possible, the woman should be carefully draped, with her legs completely covered. A female nurse should remain with the woman at all times. Obtaining permission from the husband may be necessary before an examination or treatment can be performed.

A nurse performs a nonstress test on a pregnant client. The nurse determines that the results are nonreactive if which of the following findings is noted on the electronic monitoring recording strip? A. Absence of accelerations after fetal movement B. Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds in response to fetal movement C. Two fetal heart accelerations within a 20-minute period, peaking at 15 beats per minute above baseline and lasting 15 seconds from baseline to baseline D. Accelerations without fetal movement with fetal heart rate (FHR) increases of 15 beats per minute for 15 seconds

A. Absence of accelerations after fetal movement Rationale: In a nonreactive (nonreassuring) stress test, the monitor recording would not demonstrate the required characteristics of a reactive (reassuring) recording within a 40-minute period. In a reactive (reassuring) recording, at least two fetal heart accelerations, with or without fetal movement detected by the woman, occur within a 20-minute period, peak at least 15 beats per minute above the baseline, and last 15 seconds from baseline to baseline.

A postpartum nurse provides information to a new mother who is being discharged from the maternity unit about signs and symptoms that should be reported to her health care provider. Which statement by the mother indicates a need for further information? A. "I will call my nurse-midwife if I get any redness, swelling, or tenderness in my legs." B. "Feelings of pelvic fullness or pelvic pressure are a sign of a problem." C. "Frequent urination and burning when I urinate are expected." D. "My temperature needs to remain within a normal range."

C. "Frequent urination and burning when I urinate are expected." Rationale: The new mother is instructed to notify the nurse-midwife or physician if any of the following occurs: fever; localized areas of redness, swelling, or pain in either breast that is not relieved by support or analgesics; persistent abdominal tenderness; feelings of pelvic fullness or pressure; persistent perineal pain; frequency, urgency, or burning on urination; a change in the character of lochia (increased amount, resumption of bright-red color, passage of clots, foul odor); localized tenderness, redness, swelling, or warmth of the legs; and swelling, redness, drainage from, or separation of an abdominal incision.

A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction? A. "I should wear cool, light clothing in warm weather." B. "I should drink extra fluids during the summer." C. "I need to wear additional antiperspirant and deodorant in warm weather." D. "I need to wear a hat with a wide brim when I go outdoors."

C. "I need to wear additional antiperspirant and deodorant in warm weather." Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and reduced evaporative heat loss because of decreased sweating. The need for antiperspirants and deodorants is decreased. However, older adults are at a greater risk of heatstroke as a result of a compromised cooling mechanism; they should therefore avoid heat exposure over long periods and in areas of high humidity. The older adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing when outdoors. It is also important that the older adult maintain adequate hydration, particularly during the summer and in hot climates.

A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline rate when the fetus is moving. The nurse interprets this finding as: A. An indication of fetal distress B. An indication of the need to contact the physician C. A nonreassuring sign D. A reassuring sign

D. A reassuring sign Rationale: When assessing the FHR, the nurse determines that the findings are reassuring or whether further steps should be taken to clarify data or correct problems. Reassuring signs include an average rate between 120 and 160 beats per minute at term; a regular rhythm or a rhythm with slight fluctuations; accelerations from the baseline rate, often occurring with fetal movement; and the absence of decreases from the baseline rate. A nonreassuring sign suggests fetal distress, warranting immediate intervention and indicating the need to contact the physician.

A sexually active adolescent asks the school nurse about the use of latex condoms and the prevention of sexually transmitted infections (STIs). The nurse tells the adolescent that: A. Use of a latex condom is a good method for preventing pregnancy B. The only way to prevent transmission of STIs is abstinence C. A spermicide needs to be used along with a condom to prevent transmission of STIs D. Use of a latex condom can prevent transmission of STIs

D. Use of a latex condom can prevent transmission of STIs Rationale: Use of a condom during intercourse can prevent transmission of STIs. Abstinence is not the only way to prevent transmission of an STI. A spermicide used along with a condom will help prevent pregnancy, not an STI. One disadvantage of condoms is that they may fail to prevent pregnancy. Also, using a latex condom to prevent pregnancy is unrelated to preventing the transmission of STIs.

A mother asks the nurse when her child should have his first dentist visit. The nurse tells the mother: A. At age 3 B. Soon after the first primary tooth erupts, usually around 1 year of age C. Twelve months after the first primary tooth erupts D. Just before beginning kindergarten

B. Soon after the first primary tooth erupts, usually around 1 year of age Rationale: The child should see the dentist soon after the first primary tooth erupts at around 1 year of age. Therefore the remaining options are incorrect. Parents should be aware of the dental guidelines for children and should not delay necessary dental care.

A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth. The nurse tells the mother to: A. Dip the infant's pacifier in maple syrup so that the infant will suck B. Use diluted fluoride and rub the teeth with a soft washcloth C. Use a small amount of toothpaste and a soft-bristle toothbrush D. Use water and a cotton swab and rub the teeth

D. Use water and a cotton swab and rub the teeth Rationale: Because the primary teeth are used for chewing until the permanent teeth erupt and because decay of the primary teeth often results in decay of the permanent teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the development of healthy teeth, but infants usually receive fluoride when formula and cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste is not recommended because infants tend to swallow it, possibly ingesting excessive amounts of fluoride. Dipping the infant's pacifier in maple syrup is unacceptable because of the risk of tooth decay.

A nurse is reviewing the medical record of an older client with presbycusis. Which of the following findings would the nurse expect to note in the client's record? A. Difficulty hearing low-pitched tones B. Improved hearing ability during conversational speech C. Unilateral conductive hearing loss D. Difficulty hearing whispered words in the voice test

D. Difficulty hearing whispered words in the voice test Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing loss in older adults. Typically the loss is bilateral, resulting in difficulty hearing high-pitched tones. The condition is revealed when the client has difficulty hearing whispered words in the voice test and difficulty hearing consonants during conversational speech.

A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks pregnant. Which piece of equipment does the nurse use to assess the FHR? A. Doppler transducer B. Fetoscope C. Stethoscope D. Pulse oximetry on the client and a fetoscope

A. Doppler transducer Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation. The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12 weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry is not used to auscultate fetal heart sounds.

Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomical site does the nurse administer it? A. Deltoid muscle B. Vastus lateralis muscle C. Gluteal muscle D. Rectus femoris muscle

B. Vastus lateralis muscle Rationale: Vitamin K is administered to the newborn infant in the hour after birth to help prevent hemorrhagic disease. The best site for intramuscular injection is the infant's vastus lateralis muscle, although, if necessary, the rectus femoris muscle may be used. The large vastus lateralis muscle is located away from the sciatic nerve, as well as the femoral artery and vein. The rectus femoris muscle is nearer these structures, and an injection there is more hazardous. The deltoid muscle is not used to administer intramuscular injections in the newborn infant. The gluteal muscles are never used until a child has been walking for at least a year. These muscles are poorly developed and dangerously near the sciatic nerve.

A nurse in the newborn nursery, performing an assessment of a newborn, prepares to measure the chest circumference. The nurse places the tape measure around the infant: A. 2 inches below the nipples B. In the axillary area C. At the level of the umbilicus D. At the level of the nipples

D. At the level of the nipples Rationale: The chest circumference of the infant is measured at the level of the nipples. It is usually 2 to 3 cm smaller than the head's circumference. The average circumference of the chest is 30.5 to 33 cm (12 to 13 inches). (If molding of the head is present, the head and chest measurements may be equal at birth.) The other options are incorrect anatomical areas for measuring chest circumference.

The mother of a 5-year-old asks the nurse how often her child should undergo a dental examination. The nurse tells the mother that the child should have a dental examination: A. Every 3 months B. Whenever a new primary tooth erupts C. Every 6 months D. Once a year

C. Every 6 months Rationale: Dental examinations for a 4- to 5-year-old child should be conducted every 6 months. Every 3 months, once a year, and whenever a new primary tooth erupts are all incorrect.

A nurse is assessing a newborn infant for jaundice. Which of the following actions should the nurse take to assess the infant for its presence? A. Apply pressure with a finger on the infant's forehead B. Squeeze the infant's brachial area C. Apply pressure with a finger over the umbilical area D. Squeeze the infant's nail beds

A. Apply pressure with a finger on the infant's forehead Rationale: To assess an infant for jaundice, pressure is applied with a finger over a bony area such as the nose, forehead, or sternum for several seconds to empty all capillaries in that spot. If jaundice is present, the blanched area will appear yellow before the capillaries refill. Jaundice is first noticeable in the head and then progresses gradually toward the abdomen and extremities because of the newborn infant's circulatory pattern. Squeezing the infant's nail beds and brachial area and applying pressure with a finger over the umbilical area are all incorrect methods of assessing for jaundice. Assessing for jaundice in natural light is recommended because artificial lighting and reflection from nursery walls may distort the actual skin color. Visual assessment of jaundice does not, however, provide an accurate assessment of the level of serum bilirubin.

An amniocentesis is scheduled for a pregnant client who is in the third trimester of pregnancy. The nurse tells the client that the most common indication for amniocentesis during the third trimester is: A. Determination of fetal lung maturity B. Checking the amniotic fluid for intrauterine infection C. Checking the fetal cells for chromosomal abnormalities D. Determination of whether alpha-fetoprotein (AFP) is present in the amniotic fluid

A. Determination of fetal lung maturity Rationale: The most common indications for amniocentesis in the third trimester are determination of fetal lung maturity and evaluation of the fetus' condition when the woman has Rh isoimmunization. The most common purpose for midtrimester amniocentesis is to examine fetal cells in the amniotic fluid to identify chromosomal abnormalities. Midtrimester amniocentesis is also performed to evaluate the fetus' condition when the woman is sensitized to Rh-positive blood, to diagnose intrauterine infection, and to investigate amniotic-fluid AFP and acetylcholinesterase when the maternal serum AFP concentration is increased.

A mother of twin toddlers tells the nurse that she is concerned because she found her children involved in sex play and didn't know what to do. The nurse should tell the mother: A. That if the behavior continues, she will need to bring her children to a child psychologist B. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity C. To separate her children during playtime D. To tell her children that what they are doing is bad and that they will be punished if they are caught doing it again

B. That if she notes the behavior again she should casually tell her children to dress and to direct them to another activity Rationale: Sex play and masturbation are common among toddlers. Parents should respect the toddler's curiosity as normal without judging the toddler as bad. Parents who discover children involved in sex play may casually tell them to dress and direct them to another play activity, thereby limiting sex play without producing feelings of shame or anxiety. Bringing the children to a child psychologist, separating them at play, and punishing them are all inappropriate.

A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse provides information to the client about the procedure. The nurse tells the client that: A. That she may need to drink fluids before the test and may not void until the test has been completed B. She will be positioned on her back for the procedure C. The procedure takes about 2 hours D. A probe coated with gel will be inserted into the vagina

A. That she may need to drink fluids before the test and may not void until the test has been completed Rationale: For a transabdominal ultrasound, the woman is positioned on her back, with her head elevated, but is turned slightly to one side to prevent supine hypotension. A wedge or rolled blanket is placed under one hip to help her maintain this position comfortably. If a full bladder is necessary, the woman is instructed to drink several glasses of clear fluid 1 hour before the test and told that she should not void until the test has been completed. Warm mineral oil or transmission gel is spread over her abdomen, and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The procedure takes 10 to 30 minutes. For transvaginal ultrasonography, a transvaginal probe is inserted into the vagina.

A nurse is performing an admission assessment on an older client who will be seen by a physician in a health care clinic. When the nurse asks the client about sexual and reproductive function, he reports concern about sexual dysfunction. The nurse's next action should be to: A. Report the client's concern to the physician B. Ask the client about medications he is taking C. Document the client's concern in the medical record D. Tell the client that sexual dysfunction is a normal age-related change

B. Ask the client about medications he is taking Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of chronic illness and medication use is higher among older adults than in the younger population. Illnesses and medications can interfere with the normal sexual function of older men and women. Although the nurse may report the client's concern and document the concern in his medical record, the next action is to ask the client about the medications he is taking.

A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day, the nurse watches as the mother bathes the infant. The nurse determines that the mother is performing the procedure correctly if she: A. Washes the diaper area first B. Uncovers only the body part being washed C. Washes the infant's chest first D. Uses a cotton-tipped swab to carefully clean inside the infant's nose

B. Uncovers only the body part being washed Rationale: Bathing should start with the eyes and face, usually the cleanest areas. Next, the external ear and the areas behind the ears are cleansed. The infant's neck should be washed because formula, lint, or breast milk often accumulates in the folds of the neck. The hands and arms are then washed. Next, the infant's legs are washed, and the diaper area is washed last. The person administering the bath should keep the infant warm by uncovering only the area being washed. Cotton-tipped swabs are not used to clean the infant's ears or nose because injury could occur if the infant were to move suddenly.

A nurse-midwife, performing a vaginal examination of a client who suspects that she is pregnant, documents the presence of the Chadwick sign. The nurse reads the client's record and interprets this sign as indicating: A. A thinning of the cervix B. That the cervix was seen to be violet C. That cervical softening is present D. A positive sign of pregnancy

B. That the cervix was seen to be violet Rationale: One probable sign of pregnancy is the Chadwick sign — violet coloration of the cervix, which is normally pink. The color change, which also extends into the vagina and labia, occurs because of increased vascularity of the pelvic organs. Thinning of the cervix is termed the Hegar sign, and softening of the cervix is called the Goodell sign. These are both probable signs of pregnancy.

A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse tells the mother: A. To monitor the infant for infection and, if a fever develops, to contact the pediatrician B. That this is normal for breastfed infants C. To decrease the number of feedings by two per day D. That the stools should be solid and pale yellow to light brown

B. That this is normal for breastfed infants Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. Decreasing the number of feedings might be harmful to the newborn. Because this finding is an expected occurrence in a breastfed infant, infection is not a concern.

A nurse is assessing language development in a toddler from a bilingual family. The nurse expects that the child's language development: A. Is developing as expected B. Will require assistance from a speech therapist C. Is more advanced than expected D. Is slower than expected

D. Is slower than expected Rationale: Although the age at which children begin to talk varies widely, most can communicate verbally by the second birthday. The rate of language development depends on physical maturity and the amount of reinforcement the child has received. Children of bilingual families, twins, and children other than firstborns may have slower language development. A child from a bilingual family does not require assistance from a speech therapist to ensure language development.

A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The nurse plans care knowing that the most likely primary concern of the teenager is: A. Obtaining adequate rest and sleep B. Obtaining adequate nutrition C. Keeping up with schoolwork D. Body image

D. Body image Rationale: Body image is of particular importance to an adolescent. Teenagers tend to be concerned about their weight, complexion, sexual development, and acceptance by their peers. They are not concerned about obtaining adequate nutrition and tend to eat fast foods and junk foods and may experiment with weight-management techniques such as fasting, diet pills and laxatives, self-induced vomiting, and fad diets. Keeping up with schoolwork may be important to some teenagers, but it is not usually the primary concern. Along with engaging in increasingly independent activities, teenagers tend to stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep is not teenagers' primary concern.

A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which of the following findings is noted? A. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side. B. The infant turns to the side that is touched. C. The fingers curl tightly and the toes curl forward. D. The toes flare and the big toe is dorsiflexed.

D. The toes flare and the big toe is dorsiflexed. Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about car safety. The nurse tells the mother: A. That because of the infant's weight it is acceptable to hold the infant as long as the mother and infant are sitting in the middle of the back seat of the car B. That it is acceptable to place the infant in the front seat in a rear-facing infant safety seat as long as the car has passenger-side air bags C. To place the infant in a booster seat in the front seat of the car with the shoulder and lap belts secured around the infant D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat

D. To secure the infant in the middle of the back seat in a rear-facing infant safety seat Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant. Infants weighing less than 20 lb and those younger than 1 year should always be in the middle of the back seat in a rear-facing car safety seat. An infant must be placed in an infant safety seat and is never to be held by another person when riding in a car.

A nurse gathering subjective data from a client during a health assessment plans to ask the client about the medical history of the client's extended family. About which family members would the nurse ask the client? A. Foster children and their parents B. Wife's children from a previous marriage C. Wife and wife's parents D. Aunts, uncles, grandparents, and cousins

D. Aunts, uncles, grandparents, and cousins Rationale: The extended family includes relatives, (aunts, uncles, grandparents, and cousins) in addition to the nuclear family. The nuclear family consists of husband and wife and perhaps one or more children. A blended family is formed when parents bring unrelated children from prior or foster-parenting relationships into a new joint living situation.

A rubella titer is performed on a pregnant client, and the results indicate a titer of less than 1:8. The nurse tells the client that: A. She must have been exposed to the rubella virus at some point in her life B. The test results are normal C. She has developed immunity to the rubella virus D. The test will need to be repeated during the pregnancy

D. The test will need to be repeated during the pregnancy Rationale: A client is not immune to rubella if the titer is 1:8 or less. If the client is not immune, retesting will be performed during the pregnancy. Additionally, rubella immunization is required after delivery if the client is not immune. Therefore telling the client that she has developed immunity to the rubella virus, telling her that she may have been exposed to rubella, and telling her that the test results are normal are all incorrect.

A home health care nurse is visiting a male African-American client who was recently discharged from the hospital. Which family member does the the nurse ensure is present when teaching the client about his prescribed medications? A. The client's mother B. The client's son C. The client's father D. The client's grandson

A. The client's mother Rationale: African-American families are oriented around women. Within the African-American family structure, the wife/mother is often charged with the responsibility of protecting the health of family members. The African-American woman is expected to assist each family member in maintaining good health and in determining the course of treatment if a family member becomes ill. The nurse must recognize the importance of the African-American woman in disseminating information and in assisting the client in making decisions. Although the African-American man may be included in the decision-making process, the African-American family is often matrifocal, so the nurse ensures that the woman is present. Therefore the other options are incorrect.

A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse tells the clients that: A. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses B. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza C. They must stay in the house and ask a neighbor or family member to run their errands D. It is best to do grocery shopping and other errands late in the day

A. Wearing a scarf around the nose and mouth will help reduce the transmission of airborne viruses Rationale: During peak influenza season, older clients should avoid crowds to decrease the risk of contracting influenza. The nurse should encourage clients to do their shopping and other errands early in the morning, when crowds are smaller, or to have someone else shop for them. The use of a scarf across the nose and mouth can help reduce the transmission of airborne viruses. Drinking eight 8-oz glasses of fluid a day will not reduce the risk of contracting influenza; however, it will prevent dehydration if illness occurs.

A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the Leopold maneuvers to determine the position of the fetus and then places the fetoscope over the: A. Brachial area of one extremity of the fetus B. Back of the fetus C. Carotid artery in the neck of the fetus D. Chest of the fetus

B. Back of the fetus Rationale: The nurse would use the Leopold maneuvers to identify the position of the fetus and to determine the location of the fetal back. The fetal heart rate is most easily heard through the fetal back because it usually lies closest to the surface of the maternal abdomen. Because of the position of the fetus in the maternal abdomen (fetal position), auscultation of the FHR over the chest, carotid artery, or brachial area is not possible.

A client in labor complains of back discomfort. Which position that will best aid in relieving the discomfort does the nurse encourage the mother to assume? A. Hands and knees B. Supine C. Prone D. Standing

A. Hands and knees Rationale: "Back labor," in which the back of the fetal head puts pressure on the woman's sacral promontory (occiput posterior position), is common. The discomfort of back labor is difficult to relieve with medication alone. Positions that encourage the fetus to move away from the sacral promontory are the hands-and-knees position and leaning forward over a birthing ball (a sturdy ball similar to a beach ball). These positions reduce back pain and enhance the internal-rotation mechanism of labor. It would be difficult for the woman to assume a prone position. The supine position places the client at risk for supine hypotension. A standing position might increase pressure, worsening the woman's backache.

A nurse is determining the estimated date of delivery for a pregnant client, using Nagele's rule, and notes documentation that the date of the client's last menstrual period was August 30, 2013. The nurse determines the estimated date of delivery to be: A. July 6, 2014 B. May 6, 2014 C. May 30, 2014 D. June 6, 2014

D. June 6, 2014 Rationale: Nagele's rule is often used to establish the estimated date of delivery. This method involves subtracting 3 months and adding 7 days to the date of the first day of the last normal menstrual period, then correcting the year. Subtracting 3 months from August 30, 2013, brings the date to May 30, 2013; adding 7 days brings it to June 6, 2013. Finally, the year is corrected, bringing the estimated date of delivery to June 6, 2014.

A nurse provides information to a pregnant client with hemorrhoids about measures that will alleviate her discomfort. Which of the following actions does the nurse tell the client to take? Select all that apply. Select all that apply. A. Elevate her hips on a pillow when resting or during sleep B. Shower daily but avoid sitting in a bathtub C. Contact the nurse-midwife if any bleeding occurs D. Sleep lying on her back E. Apply cool compresses to the hemorrhoids

A. Elevate her hips on a pillow when resting or during sleep Rationale: To relieve the discomfort of hemorrhoids, the client should take frequent tepid baths. The client is also instructed to apply cool witch hazel compresses or anesthetic ointment to the hemorrhoids and to assume a side-lying position with the hips elevated on a pillow. The client may experience some bleeding, which is normal. However, if the bleeding persists, the physician or nurse-midwife should be contacted. E. Apply cool compresses to the hemorrhoids Rationale: To relieve the discomfort of hemorrhoids, the client should take frequent tepid baths. The client is also instructed to apply cool witch hazel compresses or anesthetic ointment to the hemorrhoids and to assume a side-lying position with the hips elevated on a pillow. The client may experience some bleeding, which is normal. However, if the bleeding persists, the physician or nurse-midwife should be contacted.

A nurse is caring for a pregnant client in the labor unit who suddenly experiences spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes that it is clear, with creamy white flecks. What is the most appropriate action for the nurse to take on the basis of this finding? A. Check the client's temperature. B. Document the findings. C. Report the findings to the nurse-midwife. D. Obtain a sample of the amniotic fluid for laboratory analysis.

B. Document the findings. Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy white fetal skin lubricant. Therefore the nurse would most appropriately document the findings. Checking the client's temperature, reporting the findings to the nurse-midwife, and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary. Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green fluid indicates that the fetus passed meconium before birth. If abnormalities are noted, the nurse should notify the nurse-midwife.

A nurse observes a nursing assistant communicating with a hearing-impaired client in later adulthood. The nurse should intervene if the nursing assistant: A. Speaks at a normal rate and volume B. Overarticulates words C. Uses facial expressions or gestures D. Uses short sentences

B. Overarticulates words Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client needs to be able to see the speaker's face and lips. The nurse would watch to see that the nursing assistant avoided situations in which there is a glare or shadows on the client's field of vision. The nurse would also remind the assistant to reduce or eliminate background noise, speak at a normal rate and volume, and refrain from overarticulating or shouting. The assistant should use short sentences and pause at the end of each sentence and should use facial expressions or gestures to give useful clues.

A hepatitis B screen is performed on a pregnant client, and the results indicate the presence of antigens in the client's blood. On the basis of this finding, the nurse determines that: A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth B. The results indicate that the mother does not have hepatitis B C. The client needs to receive the hepatitis B series of vaccines D. The results are negative

A. Hepatitis immune globulin and vaccine will be administered to the newborn infant soon after birth Rationale: A hepatitis B screen is performed to determine the presence of antigens in maternal blood. If they are present, the newborn will need to receive hepatitis immune globulin and vaccine soon after birth. Therefore, noting that the results are negative, noting that the client needs to receive the hepatitis B series of vaccines, and noting that the results indicate that the mother does not have hepatitis B are all incorrect interpretations.

A nurse is developing a plan of care for an older client that will help maintain an adequate sleep pattern. Which of the following actions should the nurse include in the plan? A. Discouraging the use of a night light at bedtime B. Discouraging social interaction, particularly at bedtime C. Encouraging at least one daytime nap D. Encouraging bedtime reading or listening to music

D. Encouraging bedtime reading or listening to music Rationale: Measures that will help maintain an adequate sleep pattern include balancing daytime activities with rest, discouraging daytime naps, promoting social interactions, and encouraging bedtime reading or listening to music. The use of a night light will foster an environment that is both helpful and safe.

A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip and suspects cord compression. The nurse should immediately: A. Notify the registered nurse B. Insert a gloved finger into the mother's vagina to feel for cord compression C. Perform a vaginal examination on the mother D. Position the mother so that her hips are elevated

D. Position the mother so that her hips are elevated Rationale: Conditions that restrict blood flow through the umbilical cord may result in variable decelerations. If cord compression is suspected, the mother is immediately repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal presenting part toward her diaphragm. A hands-and-knees position may also reduce compression of a cord that is trapped behind the fetus. Several position changes may be required before the pattern improves or resolves. The nurse may need to contact the registered nurse, but this would not be the immediate action. Although the nurse may check the woman's vaginal area for the presence of the umbilical cord, a vaginal exam is not performed because of the possibility of further compromise of blood flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved finger into the vagina to feel for the cord.

A woman in labor whose cervix is not completely dilated is pushing strenuously during contractions. Which method of breathing should the nurse encourage the woman to perform to help her overcome the urge to push? A. Cleansing breaths B. Blowing repeatedly in short puffs C. Deep inspiration and expiration at the beginning and end, respectively, of each contraction D. Holding her breath and using the Valsalva maneuver

B. Blowing repeatedly in short puffs Rationale: If a woman pushes strenuously before the cervix is completely dilated, she risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and breath-holding, helping overcome the urge to push strenuously. The woman would be encouraged to blow repeatedly, using short puffs, when the urge to push is strong. Cleansing breaths (deep inspiration and expiration at the beginning and end of each contraction) are encouraged during the first stage of labor to provide oxygenation and reduce myometrial hypoxia and to promote relaxation. The woman would not be encouraged to hold her breath or perform the Valsalva maneuver, which is a bearing-down maneuver.

A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should: A. Allow the toddler to play with other children in the nursing unit playroom B. Spend as much time as possible with the toddler C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room D. Keep hospital routines as similar as possible to those at home

D. Keep hospital routines as similar as possible to those at home Rationale: The nurse can decrease the stress of hospitalization for the toddler by incorporating the toddler's usual rituals and routines from home into nursing care activities. Keeping hospital routines as similar to those of home as possible and recognizing ritualistic needs gives the toddler some sense of control and security and eases feelings of helplessness and fear. Spending as much time as possible with the toddler and allowing the toddler to play with other children and select the toys he would like to play with may be appropriate interventions, but keeping the hospital routine as similar as possible to the routine at home will best maintain the toddler's sense of control and security and ease feelings of helplessness and fear.

Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The nurse is providing information to the client and her spouse about the medication and tells the couple that: A. The physician should be notified immediately if breast engorgement occurs B. If the oral tablets are not successful, the medication will be administered intravenously C. The couple should engage in coitus once a week during treatment D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies

D. Multiple births occur in a small percentage of clomiphene-facilitated pregnancies Rationale: Multiple births (usually twins) occur in a small percentage (8% to 10%) of clomiphene-facilitated pregnancies, and the couple should be informed of this. The medication is available in 50-mg tablets for oral use. There is no available intravenous form. Breast engorgement is a common side effect of the medication that reverses after medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus at least every other day during this time.

A nurse is weighing a breastfed 6-month-old infant who has been brought to the pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The nurse notes that the infant now weighs 13 lb. The nurse should: A. Tell the mother that semisolid foods should not be introduced until the infant's weight stabilizes B. Tell the mother to decrease the daily number of feedings because the weight gain is excessive C. Tell the mother that the infant should be switched from breast milk to formula because the weight gain is inadequate D. Tell the mother that the infant's weight is increasing as expected

D. Tell the mother that the infant's weight is increasing as expected Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of age. If the infant is 6 lb 8 oz, at birth, a weight of 13 lb at 6 months of age is to be expected. Semisolid foods are usually introduced between 4 and 6 months of age.