NUR418 Final Practice Exam

Which fetal station is closest to delivery? A. -2 B. +1 C. 0 D. +3

D. +3

A client is 48 hours post-delivery. While assessing fundal height, the nurse would expect the fundal height to be? A. 1 cm above the umbilicus B. 2cm above the umbilicus C. 1 cm below the umbilicus D. 2 cm below the umbilicus

D. 2 cm below the umbilicus The fundal height will decrease by 1 cm per day below the umbilicus. Therefore, if the woman is 48 hours postpartum (2 days) the fundal height will be 2 cm BELOW the umbilicus.

A client with preeclampsia is assessed with the following: blood pressure 158/100; urinary output 50 mL/hour; lungs clear to auscultation; urine protein 1+ on dipstick; and edema of the hands, ankles, and feet. Which new assessment finding indicates the client's condition is getting worse? A. Reflexes 2+ B. Platelet count 150,000 C. Blood pressure 158/104 D. Urinary output 20mL/hour

D. Urinary output 20mL/hour

The nurse is caring for an 18-month-old child and know the most developmentally appropriate pain scale is which of the following: A. Visual analogue scale B. Numeric C. FLACC D. Faces

C. FLACC

The nurse is providing information to parents of infants regarding home safety. Which information will the nurse most likely present that is specific to this age group? (Select all that apply) A. Crib Safety B. Do not allow siblings to hold the infant C. Diaper rash prevention D. Signs and symptoms of illness to report E. Avoiding taking the infant out in public

A. Crib Safety C. Diaper rash prevention D. Signs and symptoms of illness to report

Which instruction from the nurse is most appropriate when conducting teaching to new parents regarding infant care and feeding? A. Delay supplemental foods until the infant is 4 to 6 months old. B. Begin diluted fruit juice at 2 months of age, but wait 3 to 5 days before trying a new food. C. Add rice cereal to the nighttime feeding if the infant is having difficulty sleeping after 2 months of age. D. Delay supplemental foods until the infant reaches 15 pounds or greater.

A. Delay supplemental foods until the infant is 4 to 6 months old.

The nurse in a postpartum unit evaluates new parents for risk factors that can indicate problems with bonding/attachment. Which situations does the nurse recognize as a cause for bonding/attachment problems? (Select all that apply) A. The mother experienced eclampsia in the third trimester of pregnancy. B. The neonate is being treated for meconium aspiration syndrome. C. The mother experienced dystocia in the second phase of labor. D. The father of the neonate is in the military and not yet home on leave. E. The mother's mother lives next door and is available to help with the baby.

A. The mother experienced eclampsia in the third trimester of pregnancy. B. The neonate is being treated for meconium aspiration syndrome. C. The mother experienced dystocia in the second phase of labor. D. The father of the neonate is in the military and not yet home on leave. a) The nurse recognizes the mother who experienced eclampsia in the third trimester of pregnancy as being at risk for bonding/attachment problems.b)The nurse recognizes the mother whose neonate is being treated for meconium aspiration syndrome as being at risk for bonding/attachment problems. The mother is likely to be separated from the neonate.c)The nurse recognizes the parents of a neonate may experience bonding/attachment problems if the mother experienced dystocia in the second stage of labor. The condition is likely to have caused a long and exhaustive labor for both parents.d) Paternal bonding is important to the family. Absence makes this harder for the father and infant to bond.

When planning care for an infant newly diagnosed with a tracheoesophageal fistula, which potential problem is the highest priority? A. Risk for impaired infant attachment B. Risk for altered nutrition C. Risk for aspiration D. Risk for infection

C. Risk for aspiration

IV potassium is ordered for electrolyte replacement in your 4-year-old patient. Which lab value is most important for the RN to review prior to administration? A. Blood urea nitrogen (BUN) B. Carbon dioxide (CO2) C. Total bilirubin D. Creatinine

D. Creatinine The kidneys are critical for potassium excretion, so the RN should assure their function; creatinine level is the most specific to kidney function. BUN can be affected by the liver, so is not as specific. CO2 reflects acidosis and/or dehydration so is marginally relevant to potassium administration. Bilirubin level is not relevant.

An infant weighing 8 lb., 4 oz. at birth weighs 7 lb., 15 oz. three days later. What should the nurse explain to the parents about this change in the newborn's weight? A. "This weight loss is unusual." B. "This weight loss is less than expected." C. "This weight loss is excessive." D. "This weight loss is within normal limits."

D. "This weight loss is within normal limits."

An alert, afebrile, previously healthy 6-month-old infant is brought to the Emergency Department by his parents for a rapid, non-variable heart rate of 220 and fussiness. The triage RN most suspects which of the following: A. Infective endocarditis B. Congestive Heart Failure C. Prolonged QT Syndrome D. Supraventricular Tachycardia

D. Supraventricular Tachycardia A sustained, non-variable heart rate of 220 in an infant most likely reflects SVT. Endocarditis would present with fever and malaise and would have a slower, variable HR. CHF would present with fatigue and would have a slower, variable HR. Prolonged QT would have a slower, variable HR.

The nurse is preparing to administer an IM vaccine injection to a 1-year-old. The nurse knows which of the following is the best site for injection for this patient? A. Gluteus maximus B. Vastus lateralis C. Rectus femoris D. Deltoid

B. Vastus lateralis The vastus lateralis is the largest muscle in infants and toddlers, so is the least painful, and there are no critical nerves or central vasculature present.

The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? A. Eggs, bacon, rye toast, and lactose-free milk. B. Pancakes, orange juice, and sausage links. C. Oat cereal, breakfast pastry, and nonfat skim milk. D. Cheese, banana slices, rice cakes, and whole milk.

D. Cheese, banana slices, rice cakes, and whole milk.

The nurse is caring for a 17 year old expectant client who is currently at 28 weeks gestation who has been placed on bed rest to avoid premature labor. The client inquires on the true risk to the fetus if delivered early. What effects is the nurse most likely to discuss with the client? (Select all that apply) A. Developmental Delays B. Genetic Defects C. Cerebral palsy D. Vision and hearing disorders E. Respiratory disorders

A. Developmental Delays C. Cerebral palsy D. Vision and hearing disorders E. Respiratory disorders Premature birth impacts both the emotional well-being of parents and the length and quality of life for the preterm infant. A shorter gestational period increases the risk of complications related to immature body organs and systems that can have lifelong negative effects, including but not limited to:Respiratory disorders, Cerebral palsy, Vision and hearing disorders, Developmental delaysSource Text, p. 5Outcome 11.2Blooms ApplyNCLEX Risk Reduction

The nurse is caring for a 1-year-old at a well child appointment that is new to the clinic and being seen for the first time. The parents indicate that the child doesn't use many words. The nurse is interacting with the infant and notices a lack of responsiveness to the interaction. As the provider enters the room, she accidentally slams the door and the infant does not turn in the direction of the noise. What is the nurse most likely going to document and refer to the provider? A. Hearing impairment B. Developmental delay C. Visual impairment D. Communication Disorder

A. Hearing impairment

The nurse is caring for a middle school child who is on month nine of chemotherapy. The nurse understand some of the psychological adaptation related to this may include: A. Impact to normal childhood development B. Chronic stress for child and family C. Decreased level of activity D. Impact to autonomy and social interaction E. Impact on learning and routine development

A. Impact to normal childhood development B. Chronic stress for child and family D. Impact to autonomy and social interaction E. Impact on learning and routine development

The nurse is preparing education for nursing students in regard to risks associated with teen pregnancy. What areas is the nurse most likely to discuss related to Psychosocial disparities? A. Income is low and poverty is high B. Most teen mothers are unmarried C. Many teen mothers are unable to complete high school D. Risk of maternal chronic disease is higher among teen moms

A. Income is low and poverty is high B. Most teen mothers are unmarried C. Many teen mothers are unable to complete high school

During a routine check-up laboratory tests reveal that a 1-year-old child is positive for lead poisoning. Which of the following statements about lead poisoning are true? (Select all that apply) A. Lead poisoning can harm a child's growth, behavior, and ability to learn. B. Lead crosses the placenta. A newborn typically has a blood-lead concentration level similar to the mother's. C. There is no treatment for lead poisoning. D. Children age 3 and under are at the greatest risk for severe complications from lead poisoning.

A. Lead poisoning can harm a child's growth, behavior, and ability to learn. B. Lead crosses the placenta. A newborn typically has a blood-lead concentration level similar to the mother's. D. Children age 3 and under are at the greatest risk for severe complications from lead poisoning. The toxic effects of lead impact the development of a child's brain and nervous system. Lead is stored in the bone and released into the blood during pregnancy exposing the developing fetus. Young children age 3 and under are especially vulnerable because of their ways of playing and exploring, such as crawling and putting objects in their mouths. This increases the risk of contact with lead, and of lead entering their bodies through breathing or swallowing.

A 4-year-old child with moderate isonatremic dehydration is admitted for IV rehydration. If the child remains lethargic after a crystalloid bolus, what is the most likely reason? A. Low blood sugar B. High sodium level C. Acute renal failure D. Cardiac dysrhythmia

A. Low blood sugar

The nurse is working with the family of a 7-year-old newly diagnosed with Attention Deficit Hyperactivity Disorder (ADHD). The nurse most anticipates which of the following medications will be prescribed? A. Methylphenidate B. Metoprolol C. Lorazepam D. Olanzapine

A. Methylphenidate

The nurse is educating the mother of a newborn with a cyanotic heart defect about ways to decrease cardiac demands and minimize cardiac workload while providing adequate nutrition and growth potential. Which of the following should the nurse discuss with the mother? (Select all that apply) A. The "work" of breast-feeding is less than the work of bottle-feeding. B. Babies with heart disease tend to gain weight at a much slower rate. C. Nurse your baby 8-12 times a day to be sure the baby is getting enough milk. D. Bottle feeding your baby should only be done as a last resort

A. The "work" of breast-feeding is less than the work of bottle-feeding. B. Babies with heart disease tend to gain weight at a much slower rate. C. Nurse your baby 8-12 times a day to be sure the baby is getting enough milk. Sucking, swallowing and breathing are easier for a baby to coordinate, and the amount of oxygen available to your baby is greater while breast-feeding than when bottle-feeding. In general, when compared to bottle-fed babies, breast-fed babies with congenital heart defects have more consistent weight gain. The goal for feeding an infant with congenital heart disease is consistent weight gain. Most babies gain 1/2 to 1 ounce of weight per day. However, babies with heart disease tend to gain weight at a much slower rate. Your baby is probably getting enough milk if you're nursing 8-12 times a day, the baby is latching on well, and you can hear the baby gulping and swallowing. Your baby should have at least 6-8 wet diapers per day. A consistent weight gain will also tell you that your baby is getting enough milk.

The nurse is preparing to administer a weight-appropriate dose of parenteral ondansetron to a 2-year-old patient admitted for acute gastroenteritis. Which of the following topics are relevant for medication teaching with the family? A. The amount of medication administered is determined by your child's weight. B. This medication may cause your child to become combative. C. Your child should not have anything to eat or drink an hour before or after receiving this medication. D. This medication improves nausea and vomiting by blocking acid producing receptors in the GI tract.

A. The amount of medication administered is determined by your child's weight.

A 6-week-old is admitted to the hospital with influenza. The child is crying, and the father tells the nurse that his son is hungry. The nurse explains that the baby is not to have anything by mouth. The parent does not understand why the child cannot eat. Which is the nurse's best response to the parent? A. "We are giving your child intravenous fluids, so there is no need for anything by mouth." B. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." C. "When your child eats, he burns too many calories; we want to conserve the child's energy." D. Your child has too much nasal congestion; if we feed the child by mouth, the distress will likely increase."

B. "The shorter and narrower airway of infants increases their chances of aspiration so your child should not have anything to eat now." Infants are at higher risk of aspiration because their airways are shorter and narrower than those of adults. An infant with influenza has lots of nasal secretions and coughs up mucus. With all the secretions, the infant is at an even higher risk of aspiration

A female client with infertility is suspected as having a problem with patent fallopian tubes and ovum motility. The nurse expects that this client will be evaluated for all of the following health problems except which? A. Endometriosis B. Cervical stenosis C. Ectopic pregnancy D. Pelvic inflammatory disease

B. Cervical stenosis Cervical stenosis affects cervical mucus. Fallopian tube function and motility can be affected by endometriosis, ectopic pregnancy, and pelvic inflammatory disease.

To create a neutral thermal environment for a newborn immediately after delivery, the nurse should consider: A. Deep suction every hour while under the radiant warmer bed B. Providing care and assessments while the infant is skin-to-skin on the mother's chest C. Placing the newborn with the extremities extended and relaxed under the radiant warmer bed D. Placing the newborn with the extremities extended and relaxed and placing an hat on the newborn's head

B. Providing care and assessments while the infant is skin-to-skin on the mother's chest

The postpartum client is diagnosed with thrombophlebitis in the right leg. Which assessment finding requires immediate intervention by the nurse? A. Acute pain B. Redness C. Chest pressure D. Edema

C. Chest pressure A sudden onset of chest pain or pressure might indicate pulmonary embolus, which is a life-threatening complication of thrombophlebitis. This is the most abnormal finding, and requires immediate intervention by the nurse.

A client who is at 32 weeks' gestation is determined to be at high risk for ABO incompatibility. Which intervention should the nurse anticipate implementing? A. Intramuscular administration of 300 mcg of Rh immune globulin (RhoGAM). B. Obtain an antibody screen (indirect Coombs test) to determine whether the client has developed isoimmunity. C. Note the potential for ABO incompatibility and plan to carefully assess the neonate for the development of hyperbilirubinemia. D. Notify the primary care provider and document the potential need for treatment of fetal hemolytic anemia in the baby after delivery.

C. Note the potential for ABO incompatibility and plan to carefully assess the neonate for the development of hyperbilirubinemia. Unlike the situation with Rh incompatibility, antepartum treatment of ABO incompatibility is not warranted because it does not cause severe anemia. As part of the initial assessment, however, the nurse should note whether the potential for an ABO incompatibility exists in order to alert healthcare providers to the need for carefully assessing the newborn for the development of hyperbilirubinemia

The nurse is assessing a newly-admitted 5-year-old child with a diagnosis of acute pericarditis. Which assessment finding would the nurse most expect? A. Bilateral lower-extremity pain B. Chest pain on exhalation C. Pericardial friction rub D. Increased urinary output

C. Pericardial friction rub Inflammation of the pericardial sac produces a friction rub) Extremity pain is not associated with pericarditis. Pain on inspiration, not expiration, may be experienced with pericarditis. Pericarditis may result in decreased urinary output due to renal perfusion, but not increased.

Which developmental theoretical framework includes the sensorimotor, preoperational, concrete operational and formal operational stages? A. Erikson's Theory of Psychosocial Development B. Freud's Theory of Psychosexual Development C. Piaget's Theory of Cognitive Development D. Kohlberg's Theory of Moral Development

C. Piaget's Theory of Cognitive Development

In preparation for teaching a women's community center class about physiologic changes during menopause, the nurse is preparing a handout for students. Which information should the nurse include in this teaching? A. Due to changes in estrogen levels, the labia minora increase in size after menopause. B. The ovaries remain small after puberty, but they increase in size following menopause. C. After menopause, the endometrium continues to undergo monthly degeneration and renewal. D. Ovarian secretion of estrogen decreases between the ages of 45 and 55, after which point ovulatory activity ceases.

D. Ovarian secretion of estrogen decreases between the ages of 45 and 55, after which point ovulatory activity ceases.