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A pregnant client tests positive for the hepatitis B virus (HBV), and the client asks the nurse whether she will be able to breastfeed the baby as planned after delivery. The nurse makes which response to the client?
"Breastfeeding is allowed once the baby has been vaccinated."
A pregnant client is positive for the human immunodeficiency virus (HIV). The nurse educates the client and determines that there is a need for further teaching if the client makes which statement?
"Breastfeeding my newborn will be the best option for my baby."
The nurse reinforces instructions to a client with mild preeclampsia on home care. Which comment by the client indicates that teaching is effective?
"I need to check my urine with a dipstick every day for protein and call my health care provider if it is 2+ or more."
The nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse reinforces instructions to the mother regarding care related to the infection. Which statement by the mother indicates the need for further teaching?
"I need to isolate my infant for 48 hours after starting the antibiotics."
The nurse is reinforcing instructions to an adolescent with type 1 diabetes mellitus regarding insulin administration and rotation sites. Which statement made by the adolescent would indicate an understanding of the instructions?
"I need to use one major site for the morning injection and another major site for the evening injection for 2 to 3 weeks before changing major sites."
A client is pregnant, has a history of heart disease, and has been instructed on care at home. Which statement by the client indicates that she understands her needs?
"I should avoid stressful situations."
The nurse tells a client she is now beginning the second stage of labor. The nurse realizes the client understands the occurrences of this stage when the client makes which statement?
"My cervix is completely dilated."
The new breastfeeding mother has been seen in the clinic for the treatment of mastitis. Which comment by the mother indicates a need for further teaching?
"My left breast is sore, so I will offer only my right breast frequently for breastfeeding."
A client asks the nurse why her newborn baby needs an injection of vitamin K (phytonadione). The nurse should make which statement to the client?
"Newborns are deficient in vitamin K. This injection prevents your baby from abnormal bleeding."
The nurse attempts to encourage a new mother to understand and to accept the cesarean section that was necessary to deliver her baby, rather than to focus on the surgical aspect of the procedure. Which nursing statement provides the best encouragement?
"Tell me about the delivery of your baby."
The nurse is caring for a newborn in the nursery and notes that the primary health care provider has documented that the child has gastroschisis. The parents ask the nurse about the treatment for the disorder. Which statement should the nurse make to the parents?
"The defect will be closed surgically after all of the contents have been returned to the abdominal cavity."
A contraction stress test is scheduled for the client. The woman asks the nurse about the test. Which response describes the most accurate description of the test?
"The uterus is stimulated to contract by either small amounts of oxytocin or by nipple stimulation."
Which statement by a pregnant client who is human immunodeficiency (HIV) positive indicates her understanding of the risk to her newborn during delivery?
"There is a risk of transmission from HIV-positive mothers to their newborn, although the newborn may be asymptomatic at birth."
The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made?
"This brace will correct my curve."
A client is 8 weeks pregnant and has waves of nausea accompanied by vomiting throughout the day. Food odors consistently precipitate the nausea. Her husband has an important business dinner planned, and she is reluctant to attend because of the nausea and vomiting. This has placed a strain on the husband-wife relationship. Which statement by the nurse indicates an understanding of the problem?
"You feel you are having difficulty fulfilling your role as a wife."
The nurse is talking to a pregnant client with human immunodeficiency virus (HIV) infection regarding care for the newborn after delivery. The client asks the nurse about the feeding options that are available. Which response should the nurse make to the client?
"You will need to bottle-feed your newborn."
The nurse-midwife is conducting a session on the process of conception with a group of nursing students. Which statements reflect that the nursing students understand the process of conception? Select all that apply.
1."Fertilization occurs in the outer third of the fallopian tube." 2."Only 1 sperm will penetrate the ovum to produce fertilization." 4."Implantation occurs in the anterior or posterior fundal region of the uterus." 5."The ovary produces hormones to maintain the pregnancy before placental development."
Which should be included in the plan of care for a pregnant teenager to reinforce instructions regarding dental care?
Tell the dental office staff that she is pregnant.
The nurse is reinforcing the teaching of parents of a diabetic child on the differences between type 1 and type 2 diabetes mellitus. Which statements by the parents indicate understanding of the teaching? Select all that apply.
1."The onset of diabetes is sudden with type 1 3."Type 2 diabetes can often be managed with diet only." 4."Type 1 diabetes can be managed with oral hypoglycemics." 5."Three symptoms of type 1 diabetes are polyuria, polydipsia and polyphagia."
The nurse is providing discharge teaching regarding skin care to a new mother of a 2-day-old infant. Which statements by the mother demonstrate an understanding of how to care for the infant's skin? Select all that apply.
2."We will apply ointments containing zinc oxide to the baby's bottom to prevent diaper rash." 3."To prevent diaper rash, we will change our baby's diaper as soon as he has pooped or peed."
Which safety measures should be implemented at delivery and when working in the newborn nursery? Select all that apply.
2.Adhere to standard precautions during delivery and in the nursery. 4.Instruct the parents to not release their newborn infant to anyone wearing improper identification. 5.Fingerprint the mother and footprint the infant on the identification card before removing the infant from the delivery room.
The nurse is reviewing the record of a pregnant client and notes that the primary health care provider has documented the presence of Chadwick's sign. The prenatal client asks the nurse to explain Chadwick's sign. Which information provided by the nurse is accurate? Select all that apply.
2.Chadwick's sign is a probable sign of pregnancy. 3.Chadwick's sign may be present as early as 6 weeks' gestation. 4.Chadwick's sign is a bluish discoloration of the vagina and cervix
Before attempting to deliver the placenta after a precipitate delivery, the nurse waits for which signs as an indication of placental separation? Select all that apply.
2.Change in uterine shape 4.Lengthening of the umbilical cord 6.Sudden gush of dark blood from the introitus
The nurse is collecting data from a client during the first prenatal visit at 12 weeks' gestation. The client is anxious to know what the fetus will look like at this time. The nurse correctly responds to the client by providing which information? Select all that apply.
2.Earliest taste buds present. 4.Lecithin begins to appear in amniotic fluid (weeks 27-28). 5.Sex can be determined as internal and external organs are sex specific.
The nurse is caring for a postpartum client who is being treated for thrombophlebitis. The client is receiving an anticoagulant by intravenous infusion. The nurse monitors for adverse effects of the anticoagulant by checking the client for which signs/symptoms? Select all that apply.
2.Epistaxis 4.Hematuria 5.Ecchymosis
The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has an android pelvic shape. The nurse understands that which characteristics are included with this pelvic shape? Select all that apply.
2.Heart shaped 4.Convergent sidewalls 6.Narrow interspinous diameter
The nurse in the prenatal clinic is collecting data regarding the client's nutritional knowledge. The nurse determines that the client understands the food items that are high in folic acid when the client states that she will be sure to eat which food items? Select all that apply.
2.Liver 3.Beans
The nurse is reinforcing the teaching to parents of a diabetic child about the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse include when reinforcing the teaching? Select all that apply.
2.Sweating 4.Dizziness 5.Trembling
A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse should perform which actions in order to protect the child from injury? Select all that apply.
2.Turn the client to the side during a seizure. 3.Keep side rails and other hard objects padded.
The primary health care provider is performing a vaginal examination on a pregnant woman. Which assessments are considered to be normal physiological changes in the vagina? Select all that apply.
2.Vaginal secretions increase. 4.Bluish discoloration of the vagina. 5.Higher levels of glycogen in vaginal secretions.
The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value?
20,000 mm3
The nurse is collecting data from a pregnant client who is currently at 28 weeks' gestation. At her prior prenatal visit, her fundal height measured 22 cm. The nurse measures the fundal height at this visit in centimeters and should expect which finding?
26 cm
The nurse is teaching a prenatal class on the anatomy and physiology of the female reproductive system including hormones. Estrogen produces which effects, either directly or indirectly, during pregnancy? Select all that apply.
3.Increases blood flow to the uterine vessels 4.Stimulates development of the breast ducts 5.Causes vascular changes in the mucous membranes of the nose and mouth
The nurse is caring for a neonate that is 3 hours old and should assess for which signs of cold stress? Select all that apply.
3.Mottling of skin 5.Increased respirations with apnea
The nurse is preparing to care for a newborn who is receiving phototherapy. Which measures should be implemented? Select all that apply.
4.Monitor the skin temperature closely. 5.Reposition the newborn every 2 hours. 6.Cover the newborn's eyes with shields or patches.
A blood glucose screening measurement is performed on a pregnant client, and the results indicate that the blood glucose is elevated. Which prescription should the nurse anticipate for the client?
A 3-hour glucose tolerance test
The nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which priority item at the newborn's bedside?
A bottle of sterile normal saline
The nurse is providing instructions to a pregnant client with genital herpes about the measures that need to be implemented to protect the fetus. Which instruction should the nurse provide to the client?
A cesarean section will be necessary if vaginal lesions are present at the time of labor.
The nurse is assigned to work in the delivery room and is assisting with caring for a client who has just delivered a newborn. The nurse is monitoring for signs of placental separation knowing that which indicates that the placenta has separated?
A change in the uterine contour
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition?
A chronic disability characterized by impaired muscle movement and posture
A 1-year-old child is diagnosed with intussusception. The mother of the child asks the nurse to describe the disorder. The nurse should base the response on which description of this disorder?
A condition in which a proximal segment of the bowel prolapses into a distal segment of the bowel
The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item should the nurse place at the bedside in preparation for the child's return from surgery?
A cooling blanket
A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which finding is noted?
A decrease in urine output to 0.5 mL/kg/hr
The perinatal client is admitted to the obstetrical unit during an exacerbation of a heart condition. When planning for the nutritional requirements of the client, the nurse should consult with the dietitian to ensure which dietary measure?
A diet that is high in fluids and fiber to decrease constipation
The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic?
A greater risk of infection than a simple fracture
The nurse is collecting data from a prenatal client. The nurse determines that which situation places the client in the high-risk category for contracting human immunodeficiency virus (HIV)?
A history of intravenous (IV) drug use in the past year
A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which is an unassociated risk factor related to otitis media?
A history of urinary tract infections
The nurse's assignment is to visit a new mother at home who was recently discharged from the hospital. Which finding should the nurse expect to note in a healthy breastfeeding mother and newborn?
A mother breastfeeding with the newborn in a tummy-to-tummy position without signs of cracked nipples; the baby demonstrates bursts of sucking followed by a pause and swallow
A nonstress test is performed on a client, and the results are documented in the chart. The results are documented as a reactive nonstress test. Which interpretation should the nurse make of these results?
A negative test
The nurse palpates the anterior fontanel of a newborn and notes that it feels soft. What does this datum indicate to the nurse?
A normal finding
A client who is pregnant has been instructed on prevention of genital tract infections. Which statement by the client indicates an understanding of these prevention measures?
"I should choose underwear with a cotton panel liner."
The nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is best described by which statement?
Cerebral palsy is a chronic disability characterized by a difficulty in controlling the muscles.
A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child?
Drink a half a cup of orange juice before soccer practice.
The nurse is collecting data on an infant with a diagnosis of suspected Hirschsprung's disease. Which question to the mother will most specifically elicit information regarding this disorder?
"Does your infant have foul-smelling, ribbon-like stools?"
The nurse is assisting in developing a plan of care for a client in the fourth stage of labor who received an epidural. Which statement by the mother is most likely to occur at this time related to her birth experience?
"I do not feel any urges yet to empty my bladder."
The nurse collects data from a pregnant client diagnosed with iron deficiency anemia during her third trimester for additional risk factors associated with the anemia. Which statement made by the client should the nurse question to receive more information?
"I have had mild vaginal spotting twice since my last prenatal visit."
The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching?
"I know that my child will outgrow this problem, just give him time."
The nurse reinforces home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further teaching?
"I need to give frequent, small, nutritious meals if my child starts to vomit."
The nurse is reinforcing instructions to a mother who is bottle-feeding a baby and who is complaining of breast engorgement. Which statement by the client indicates a need for further teaching?
"I should avoid wearing a bra at this time."
The nurse reinforces discharge instructions to the mother of a 5-day-old postterm newborn who required ventilatory support for 3 days for meconium aspiration. Which statement indicates that the mother needs further teaching?
"I understand that my baby will be susceptible to contracting all respiratory infections throughout his childhood."
The nurse reviews the home care instructions with a parent of a 3-year-old with pertussis. Which statement by the parent indicates a need for further teaching?
"I understand this whooping cough is viral and I have to let it run its course."
The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching?
"I will insert a glycerin suppository before the dilation."
A perinatal client with a history of heart disease has been instructed on care at home. Which statement made by the client indicates the need for further teaching?
"It is best to rest on my right side."
The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching?
"The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."
The nurse is teaching a pregnant woman about the physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the purposes of estrogen. Which responses should the nurse make to the client? Select all that apply.
3."It stimulates the breasts to prepare for lactation." 6."It stimulates uterine development to provide an environment for the fetus."
A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which on the handout? Select all that apply.
3.It is transmitted as an autosomal recessive trait. 4.It is a disease that causes mucous formation to be abnormally thick. 5.It is a chronic multisystem disorder affecting the exocrine glands.
When collecting data from a pregnant client at risk for disseminated intravascular coagulation (DIC), which factors should the nurse consider significant?
A client who is gravida II who has just been diagnosed with dead fetus syndrome; fetal demise occurred 2 months ago
The nurse is preparing for the administration of ribavirin to a child with respiratory syncytial virus. Which supplies will the nurse obtain for the administration of this medication?
A pair of goggles
The nurse in the labor room is assisting in caring for a client in the active stage of labor. The nurse is told that the fetal heart rate pattern shows multiple late decelerations on the monitor strip. Based on this information, the nurse prepares for which appropriate nursing action?
Administering oxygen via face mask
The nurse is monitoring a new mother in the fourth stage of labor for signs of hemorrhage. Which sign noted in the mother indicates an early sign of excessive blood loss and shock?
An increase in the pulse rate from 88 to 102 beats per minute
The nurse is reviewing the care plan for a client with a diagnosis of dystocia who experienced this same problem with a previous pregnancy. Which client problem should the nurse expect to note on the plan of care?
Anxiety related to a slow progress of labor
A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?
Apply an ice pack to the injection site.
A client in active labor with intact membranes is complaining of back discomfort. An analgesic was administered 1 hour ago but has not relieved the discomfort. The nurse should avoid which measure at this time to assist in relieving the back discomfort?
Assist the client to ambulate in the room.
An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?
Avoid tub baths until the stent has been removed.
During a routine prenatal visit the client states, "I have not been able to get my wedding ring off for the past 2 days. I guess the heat is making my fingers swell." Which should the nurse check further?
Blood pressure changes and the presence of protein in the urine
The nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for an early sign of increased ICP by checking for which sign?
Changes in level of consciousness
The nurse is collecting data on a postpartum client and performs which best intervention when checking for thrombophlebitis in the legs?
Checks the calf areas for redness or swelling
A client has just delivered a viable newborn. The first nursing action to initiate attachment is which?
Determine the parents' desires for contact with the newborn.
The nurse performs a blood glucose test on a newborn infant whose mother has diabetes mellitus and obtains a reading of 50 mg/dL. Which action should the nurse implement based on this finding?
Document the finding because it is within the normal range.
The nurse is monitoring the vital signs of a client after delivery of a healthy newborn one day ago and notes that the mother's apical pulse is 56 beats/min. Which nursing action is appropriate related to this finding?
Document the finding.
A primipara is being evaluated in the clinic during her second trimester of pregnancy. Which occurrence indicates an abnormal physical finding that necessitates further testing?
Fetal heart rate of 180 beats per minute
The nurse is reinforcing instructions to a pregnant client regarding the need to consume folic acid in the diet. The nurse determines that the client understands the instructions when the client states that it is necessary to include which food item in the diet?
Green, leafy vegetables
The nurse is planning for the nursery room admission of a large-for-gestational-age (LGA) infant. In getting ready to care for this infant, the nurse prepares equipment for which diagnostic test?
Heel stick blood glucose
A client calls the primary health care provider's office to schedule an appointment because a home pregnancy test was performed and the results were positive. The nurse determines that the home pregnancy test identified the presence of which in the urine?
Human chorionic gonadotropin (hCG)
The nurse is gathering data from a prenatal client with heart disease. The nurse carefully evaluates vital signs, monitors for weight gain, and checks the fluid and nutritional status. For which complication is the nurse collecting data?
Increase in circulating volume
A pregnant client in the prenatal clinic states that her last menstrual period (LMP) began April 5 and ended April 12. According to Nägele's rule, which is the estimated date of delivery (EDD)?
January 12
The nurse is caring for a woman in labor who is experiencing a precipitate delivery. Until help arrives, the nurse places the client into which optimal position?
Lateral Sims'
A pregnant client asks the prenatal clinic nurse what the fetal period of development means. Which is correct information about the fetal period?
Longest period of fetal development
A pregnant client at 36 weeks' gestation experiences painless bleeding and is admitted to the labor room. In addition to maintaining complete bed rest, which other actions should the nurse include in the plan of care?
Monitor IV fluid intake and monitor the fetal heart rate.
The nurse is caring for a client in preterm labor when her membranes rupture. Which is the initial nursing action?
Monitor the fetal heart rate.
The nurse assisting in the care of a woman in labor should focus primarily on which client at the time of delivery?
Newborn
The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which should be a component of the instructions that the nurse reinforces to the mother?
No live virus vaccines should be administered to the child.
A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?
Notify the registered nurse of the finding.
A mother arrives at the emergency department with her child and a diagnosis of epiglottitis is documented. Which of the primary health care provider's prescription should the nurse question?
Obtain a throat culture.
The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should instruct the mother to do which?
Pad crib rails and table corners.
The nurse is about to reinforce discharge instructions to a postpartum client who delivered a healthy newborn infant. The occurrence of which event should be reported to the primary health care provider?
Pain, redness, or swelling in the breasts
A pregnant woman who is at 38 weeks' gestation arrives at the emergency department. She reports the presence of bright red vaginal bleeding and denies the presence of any pain. Based on this information, what does the nurse determine the client may be experiencing?
Placenta previa
The nurse is instructing a pregnant client in her first trimester about nutrition. The nurse should correct which misunderstanding on the part of the client about nutrition during pregnancy?
Pregnancy greatly increases the risk of malnourishment for the mother.
The nurse is assigned to care for a 2-year-old child who has been admitted to the hospital for surgical correction of cryptorchidism. What is the highest priority in the postoperative plan of care for this child?
Prevent tension on the suture.
The nurse assists a pregnant client with cardiac disease in identifying resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to accomplish which tasks?
Reduce excessive maternal stress and fatigue.
The nurse is preparing a client for a cesarean delivery. A urinary catheter is to be inserted into the client's bladder, and the client asks the nurse why this is necessary. The nurse appropriately replies by telling the client that which is the catheter's primary purpose?
Reduce the risk of injuring the bladder during the surgery.
A male child who had surgery to correct hypospadias is seen in a primary health care provider's office for a well-baby checkup. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias?
Renal anomalies
The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease?
Respiratory disease caused by a virus involving the parotid gland
A postpartum client asks the nurse when she may resume sexual activity. Which response should the nurse give to the client?
Sexual activity may be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped.
The nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which immediate problem as the priority for the infant?
Skin disruption
During initial data collection of a client who is pregnant, the nurse notes that the laboratory report shows leukopenia, thrombocytopenia, anemia, and an elevated erythrocyte sedimentation rate. The nurse suspects human immunodeficiency virus (HIV). Which laboratory study further supports the presence of HIV?
T lymphocyte levels
The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions should the nurse reinforce to the client?
The bladder must be full during the examination.
An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. Which indicates that the treatment is effective?
The child has a productive cough of thick sputum.
A client has just had surgery to deliver a nonviable fetus because of abruptio placentae. She has just been told that she is developing disseminated intravascular coagulopathy. She begins to cry and screams, "God, just let me die now!" Which problem would direct care for this client?
The client feels hopeless about the situation.
A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Several diagnostic studies are performed to determine the presence of this disease. When evaluating the diagnostic results, the nurse should expect to note which evidence if this child has Hodgkin's disease?
The presence of Reed-Sternberg cells
A nursing instructor is observing a nursing student caring for a newborn with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by which action?
Covering the bladder with a sterile, nonadhering moist dressing
A mother of a child with cystic fibrosis asks the clinic nurse about the disease. How should the nurse respond to the mother about the disease?
Cystic fibrosis is a chronic multisystem disorder affecting the exocrine glands.
A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The primary health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse should expect which blood pressure readings in the child's legs and arms?
Decreased in the legs and increased in the arms
The nurse is caring for the nullipara woman in labor. The nurse understands that the primary health care provider must be contacted if which condition becomes apparent?
Decreased periods of uterine relaxation between contractions
A primigravida's membranes rupture spontaneously. Which action should the nurse take first?
Determine the fetal heart rate.
A child is hospitalized with Rocky Mountain spotted fever (RMSF). The health record reveals documentation that the child was bitten by a tick 2 weeks ago. The child presents with complaints of headache, fever, and anorexia, and the nurse notes a rash on the palms of the hands and soles of the feet. The nurse reviews the primary health care provider's prescriptions and anticipates that which medication should be prescribed?
Doxycycline
The nurse is reinforcing instructions to a pregnant client regarding measures to prevent heartburn. The nurse should instruct the client to take which best measure?
Drink decaffeinated coffee and tea.
An 8-day-old infant is irritable, has a high-pitched persistent cry, and a temperature of 99.4° F. The infant is also tachypneic and diaphoretic, continues to lose weight, and is hyperactive to environmental stimuli. The nurse determines that these behaviors may be consistent with what problem?
Drug withdrawal
The nurse is assigned to care for a client admitted to the postpartum unit following delivery of a full-term healthy infant. The nurse checks the mother's temperature and notes that it is 100.4° F (38° C). Which nursing action is appropriate?
Encourage oral fluids.
A client is scheduled to have an elective cesarean delivery. How should the nurse allay the client's feelings of anxiety?
Encourage the client to discuss her concerns and desires regarding anesthesia options.
The nurse is assisting in caring for a newborn with respiratory distress syndrome. Which initial action should the nurse plan to best facilitate bonding between the newborn and parents?
Encourage the parents to touch their newborn.
The nurse who is caring for a postpartum mother being tested for endometritis notes that the client has little interest in caring for her infant. Which intervention should best facilitate the client's participation in infant care?
Encouraging the client to take pain medication as prescribed
A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which information in the discussion?
Enteric precautions are necessary for hepatitis B (HBV) but not for hepatitis A (HAV).
The nursing student is preparing to administer a medication to a newborn as a preventive measure against ophthalmia neonatorum. The nursing instructor asks the student to identify the medication and placement for the prophylaxis of ophthalmia neonatorum caused by gonococcal or chlamydia infection. The student correctly identifies which medication and location?
Erythromycin, eyes
The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1.8. Which should the nurse anticipate to be prescribed by the primary health care provider?
Administration of a subcutaneous rubella virus vaccine
Following a tonsillectomy, which of the primary health care provider's prescriptions should the nurse question?
Allow ice cream when awake.
The nurse is assigned to care for the client after a cesarean section. To prevent thrombophlebitis, the nurse should encourage the woman to take which priority action?
Ambulate frequently.
A client who is breastfeeding her newborn infant is experiencing nipple soreness. To relieve the soreness, which action should the nurse suggest to the client?
Begin feeding on the less sore nipple.
The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?
Blood cultures
Which test would the nurse anticipate for a teenage client who has been treated for vaginal Candida infections repeatedly in the last 6 months to assist in the identification of the underlying chronic pathology?
Blood glucose level
A newborn infant has coarctation of the aorta (COA). The nurse should expect to note which findings in the infant?
Bounding radial pulses and absent or weak femoral and pedal pulses
The nurse is assisting with caring for a client who has a placenta previa. The nurse understands that a cervical examination should not be performed on the client primarily because it could have which consequence?
Cause hemorrhage
The nurse is caring for a 3-hour-old infant and notes that the infant has not eaten since birth, is jittery, and has a weak cry. The mother states that she can't get the baby to eat. Which action should the nurse take first?
Check the blood glucose level.
While assisting with the measurement of fundal height, the client at 36 weeks' gestation states that she is feeling lightheaded. On the basis of the nurse's knowledge of pregnancy, the nurse determines that this is most likely a result of which reason?
Compression of the vena cava
The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?
Conjunctival hyperemia
A nursing student is assigned to a client in labor. The nursing instructor asks the student to describe fetal circulation, specifically the ductus venosus. The instructor determines that the student understands the structure of the ductus venosus if the student states which about the ductus venosus?
Connects the umbilical vein to the inferior vena cava
The nurse is reinforcing instructions to a maternity client on how to keep a fetal activity diary. Which instruction should the nurse provide the client?
Contact the primary health care provider if the baby's movements are fewer than 10 times in 2 hours.
The client is in the second stage of labor. As the baby begins to crown, the primary health care provider administers a pudendal nerve block in preparation for an episiotomy. Which action should the nurse take?
Continue to assess vital signs and fetal heart rate the same as before the nerve block.
The nurse reviews the record of a 1-year-old child seen in the clinic and notes that the primary health care provider has documented a diagnosis of celiac crisis. Which symptom should the nurse expect to note in this condition?
Profuse, watery diarrhea
The nurse is assisting in performing a prenatal examination on a client in the third trimester of pregnancy. The primary health care provider performs Leopold's maneuvers on the client. Which maneuver indicates the position of the fetus?
Second
The nurse is assisting in planning care to meet the emotional needs of a pregnant woman. Which nursing intervention is least likely to assist in meeting her emotional needs?
Providing the mother with pamphlets and booklets to read about the pregnancy
A pregnant client asks the nurse about the type of exercises that are allowable during the pregnancy. The nurse should instruct the client that which is the safest exercise?
Swimming
The nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn should alert the nurse to the possibility of this syndrome?
Tachypnea and retractions
If a precipitate delivery is imminent, which is the appropriate nursing action?
Put on sterile gloves, and gently guide the baby's head and shoulders out.
The nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. Which action should the nurse take?
Reassure the child that this is a temporary condition.
The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?
Rectal
The nurse palpates the fundus and checks the character of the lochia of a postpartum client who is in the fourth stage of labor. Which lochia characteristic should the nurse expect to note?
Red
A client who consumes alcohol frequently is in the first trimester of pregnancy. Which is the expected outcome when the nurse initiates interventions to assist the client to cease alcohol consumption?
Reducing the risk of teratogenic effects to developing fetal organs, tissues, and structures
A client is admitted for an emergency cesarean section delivery. Contractions are occurring every 15 minutes. The client has a temperature of 100° F and ate 2 hours ago. Which intervention has priority?
Report the time of last food intake to the primary health care provider.
While a client is holding and talking to her newborn immediately following delivery, she begins to cry. How does the nurse interpret the client's behavior?
The client is experiencing a normal response to birth.
A client beginning week 30 of gestation comes to the clinic for a routine visit. Which observation by the nurse indicates a need for further teaching?
The client is wearing knee-high hose.
The nurse has reinforced instructions to a postpartum client who is hepatitis B positive on how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure?
Washes and dries her hands before feeding
The nurse is collecting data from a pregnant client when the client asks the nurse about the purpose of the fallopian tubes. Which is the accurate response the nurse should make?
Where fertilization occurs
The nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flow meters. The nurse identifies which goal as appropriate for this child?
Expresses feelings of mastery and competence with breathing devices
When planning care for a woman with gestational hypertension (GH), the nurse plans to encourage which maternal behavior?
Expression of hope for a positive outcome
The nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is appropriate?
Forty-eight hours after using the antibiotic ointment
A woman is 24 weeks pregnant. She had a previous stillborn neonate at 38 weeks' gestation and a pregnancy that ended at 34 weeks with the birth of a stillborn girl. She states she has a 4-year-old son and an 8-year-old daughter who live with her at home and were both born at 38 weeks. What is her gravidity and parity, using the five-digit system (GTPAL)?
G (5) T (0) P (4) A (0) L (2)
An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. Which initial nursing intervention is appropriate?
Give the child 6 oz of a regular cola drink.
A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do?
Give the child acetaminophen for the discomfort as per discharge instructions.
An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion? Refer to chart.View Chart
Glucose level at 2 am of 65 mg/dL
The nurse enters a new mother's room and finds that the mother is crying and that the infant is undressed on the bed in front of the mother. The mother looks at the nurse and says, "I can't even dress this baby!" After reassuring the client, which nursing action is the most appropriate?
Have the mother place the infant in the bassinet and assist the mother in dressing the baby.
A pregnant client tells the nurse that she has been craving "unusual foods." On further data collection, the nurse discovers that the client has been ingesting daily amounts of white clay dirt from her backyard. Which laboratory result indicates a physiological consequence of a result of this practice?
Hemoglobin 9.1 g/dL
The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?
Hiccupping and spitting up after a meal
The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern?
Infection
During a prenatal visit of a client diagnosed with placenta previa, the primary health care provider defers doing a vaginal examination. The nurse understands that this examination is avoided in this situation because of what potential risk?
Initiating severe hemorrhage
The nurse is reinforcing instructions to a pregnant client about the warning signs in pregnancy that require the need to notify the primary health care provider. The nurse determines that further teaching is needed if the client states that it is necessary to call the primary health care provider if which occurs?
Irregular, painless contractions
A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct?
Is a type of skin traction that pulls the hip and leg into extension
The client arrives at the prenatal clinic for her first prenatal assessment. The client tells the nurse that the first day of her last menstrual period (LMP) was October 20, 2019. Using Nägele's rule, the nurse determines the estimated date of birth is which date?
July 27, 2020
The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the primary health care provider's prescriptions does the nurse question?
Keep the head of the bed elevated 45 degrees.
The nurse is measuring the fundal height of a client who is at 30 weeks of gestation. In preparing to perform the procedure the nurse should take which action?
Place the client in a supine position and place a wedge under the right hip.
A preschool child who was admitted to the hospital for a minor surgery develops a rash on the second day after hospitalization and is diagnosed with chicken pox (varicella). The nurse should take which action to provide safety for all children on the unit?
Place the infected child and any immunocompromised children in isolation.
At 5:00 am a client is admitted to the maternity unit after experiencing 3 hours of labor at home. The assessment determines that the fetal heart rate (FHR) is 140 beats per minute with the fetus at station 0 and strong contractions occurring every 3 minutes. It is now 11:00 am with little progress, and the FHR is decreasing. It is most appropriate for the nurse to anticipate the need to perform which action?
Prepare the client for a cesarean delivery.
The client received epidural anesthesia during labor and had a forceps delivery after pushing for 2 hours. At 6 hours postpartum, the client's systolic blood pressure (BP) dropped 20 points, the diastolic BP dropped 10 points, and her pulse is 120 beats per minute. The client is very anxious and restless. The nurse is told that the client has a vulvar hematoma. Based on this diagnosis, the nurse should plan which action?
Prepare the client for surgery.
The nurse institutes measures for the client with placental abruption to minimize alterations in fetal tissue perfusion. The nurse determines that fetal tissue perfusion is adequate if which is noted?
Presence of accelerations
On the second postpartum day, a woman complains of burning on urination, urgency, and frequency of urination. A urine sample is collected for urinalysis, and the results indicate the presence of a urinary tract infection. The nurse reinforces instructions to the new mother regarding measures to take for the treatment of the infection. Which statement by the mother indicates the need for further teaching?
"Foods and fluids that will increase urine alkalinity should be consumed."
A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented? Select all that apply.
2.Contact 3.Airborne
A woman diagnosed previously with gestational hypertension is returning to the clinic for her scheduled prenatal appointment. During the assessment, the nurse is concerned that she is developing signs/symptoms that indicate that her mild gestational hypertension is progressing. What assessment findings indicate to the nurse that the mild gestational hypertension is progressing? Select all that apply.
4.Blood pressure (BP) 165/120 mm Hg 5.Complaints of headache for the last 12 hours
The nurse is collecting data from a client who has been diagnosed with placenta previa. Which findings should the nurse expect to note? Select all that apply.
4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus
The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.
4.Bright red vaginal bleeding 5.Soft, relaxed, nontender uterus 6.Fundal height may be greater than expected for gestational age
The nurse is providing nutritional counseling to a new mother who is breastfeeding her newborn. The nurse instructs the mother to increase her daily caloric intake by which amount?
500 calories per day
A client tells the nurse her contractions are getting stronger and that she is getting tired. She appears restless, asks the nurse not to leave her alone, and states, "I can't take it anymore." Based on the client's behavior, the nurse should suspect the client is how far dilated?
8 to 10 cm
A pregnant client is seen in the health care clinic with reports of morning sickness. When the client asks the nurse about measures to relieve this situation, what is the nurse's appropriate suggestion?
Consume dry crackers before getting out of bed.
The nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate?
Document the findings.
The nurse is adding to a plan of care for a postpartum client. Which intervention should promote parent-infant bonding?
Encourage her to hold the infant even when the infant is crying.
The nurse is monitoring a client who is receiving oxytocin to augment labor. The nurse determines that the dosage should be decreased and notifies the registered nurse if which is noted?
Fetal tachycardia
The nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which sign/symptom that is indicative of this common complication?
Nuchal rigidity
The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?
Obtain a blood glucose reading.
A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?
Oozing from injection sites
A client who experienced abruptio placentae is at risk for disseminated intravascular coagulopathy (DIC). The nurse should monitor this client for which symptom of this complication?v
Oozing from injection sites
A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever?
Pastia's sign
The nurse is assisting in caring for a client in labor. Which data collection finding by the nurse places the client at risk for uterine rupture?
Shoulder dystocia
Which action, if noted in the new mother, indicates the need for further data collection by the nurse for signs of postpartum depression?
The mother constantly complains of tiredness and fatigue.
The nurse is caring for a client diagnosed with preeclampsia. Which statement by the client suggests the need for further teaching regarding possible complications of preeclampsia?
"I should expect that my urine output will decrease."
The nurse is reinforcing instructions to the mother of an infant about postcircumcision care. The nurse determines that teaching has been effective when the mother states which?
"I will observe for signs of bleeding with each diaper change."
The nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse should make which response to the mother?
"In 3 weeks"
A client is scheduled for an amniocentesis and tells the nurse, "I'm not sure I should have this test done." Which response by the nurse is appropriate?
"Tell me what concerns you have."
A child with croup is placed in a cool-mist tent. The mother asks if the child may have her security blanket inside the tent. Which is the most appropriate response by the nurse?
"The child may have the security blanket inside the tent."
The nurse is reinforcing instructions to the mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother?
"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?
"The symptoms increase in severity after the rash appears."
The clinic nurse is reinforcing instructions to an adolescent with type 1 diabetes about administration of insulin. Which statements by the adolescent indicate the need for further teaching? Select all that apply.
1."I should give my injections only in my thighs 3."I should place any unopened insulin vials in the freezer."
The nurse working in a prenatal clinic receives a telephone call from a client at 22 weeks of gestation. The client reports some vaginal discharge and has started to experience menstrual-like cramps and diarrhea. Which responses by the nurse indicate an understanding of the implications of the client's signs/symptoms? Select all that apply.
1."Lie on your left side for an hour and try to drink some fluids." 2."It is important that you urinate frequently to keep your bladder empty." 4."Palpate for contractions and call back if there are more than four contractions in the next hour." 5."Can you identify what you ate and drank, what medications you took, and your activity during the past 24 hours?"
The nurse is reviewing the record of a client who has just been told that a pregnancy test is positive. Which probable signs of pregnancy refer to the softening of the uterus and related structures? Select all that apply.
1.Hegar's sign. 3.Goodell's sign 5.McDonald's sign
The nurse and a mother are discussing care of her child's iron deficiency anemia. The nurse should suggest including which foods in the child's diet that are highest in iron? Select all that apply.
1.Spinach 2.Apricots 3.Raisins
The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply.
2."I'm chilly but my baby's forehead is sweaty." 4."I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." 5."My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."
A prenatal client with severe abdominal pain is admitted to the labor and birthing department. Which data indicate to the nurse the presence of concealed bleeding? Select all that apply.
2.Boardlike abdomen 4.Increase in fundal height
The nurse is reviewing the record of a newborn infant and notes that the primary health care provider has documented the presence of a cephalhematoma. Based on this documentation, the nurse expects to observe which indications on data collection of the infant? Select all that apply.
4.Edema caused from bleeding below the brain's periosteum 5.Develops 24 to 48 hours following birth and may take 2 to 3 weeks to resolve
The nurse is reviewing the record of a client who has just been told that her pregnancy test is positive. The nurse notes that the health care provider has documented the presence of Goodell's sign. The nurse determines that this sign is indicative of which change that occurs with pregnancy?
A softening of the cervix
A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted?
Capillary refill is less than 2 seconds.
The nurse is asked to assist the primary health care provider in performing Leopold's maneuvers on a client. Which nursing intervention should be implemented before this procedure is performed?
Have the client empty her bladder.
A client in the postpartum unit complains of sudden, sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?
Prepare to administer oxygen at 8 to 10 L by tight face mask.
A client has just experienced a precipitate delivery. The nurse observes that the mother is lying quietly in bed and touches the infant only briefly and occasionally. How should the nurse be most therapeutic in this situation?
Provide support to the mother.
The pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects the client will indicate that which medication is prescribed?
Subcutaneous administration of heparin sodium 5000 units daily
The nurse is assisting in developing goals for the postpartum client who is at risk for infection. Which goal would be appropriate?
The client will be able to identify measures to prevent infection.
The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse should make which response to the mother?
"Have the child perform simple isometric exercises during this time."
A pregnant client tells the nurse that she has been experiencing pain as a result of hemorrhoids. Which statement by the client identifies the need for further teaching regarding the hemorrhoids?
"Hemorrhoids are caused solely by the changes in hormones during pregnancy. They will go away within a day or two after the baby is born."
A postpartum client is getting ready for discharge. The nurse suspects that the client needs further teaching related to breastfeeding when she makes which statement?
"I don't need birth control because I will be breastfeeding."
A postpartum nurse is reinforcing instructions to a mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the need for further teaching?
"I need to bathe my newborn after a feeding."
The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?
"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."
A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings should the nurse expect to observe? Select all that apply.
1.Ascites 2.Anorexia 4.Proteinuria 6.Periorbital and facial edema
A client is admitted to the hospital and is in the first stage of labor. She tells you that her "bag of waters" broke. Which assessments of the amniotic fluid are considered to be normal? Select all that apply.
1.Clear fluid 4.White flecks in the amniotic fluid 5.Presence of glucose and protein in the amniotic fluid
The advantages of using spinal anesthesia for delivery of a fetus include which reasons? Select all that apply.
1.Ease of administration 2.Absence of fetal hypoxia 3.Immediate onset of anesthesia
A 10-month-old child presents to the clinic with irritability, rubbing and pulling at the right ear, and a temperature of 102.4° F. The primary health care provider diagnoses the child with acute otitis media (OM) of the right ear, prescribes broad-spectrum antibiotics, and provides instructions to the parent, who verbalizes an understanding of the treatment plan. The parent later asks the nurse how to prevent future episodes of OM. Which instructions should the nurse reinforce in parent teaching? Select all that apply.
1.Ensure the child is not exposed to smoke 3.Have the child remain in a sitting position while awake. 5.Consider avoiding individuals with upper respiratory infections.
The nurse is caring for a 3-year-old child with suspected bacterial meningitis. Which signs and symptoms should the nurse expect to find during the initial data collection? Select all that apply.
1.Fever 3.Irritability 5.Nuchal rigidity
The nurse is collecting data from a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body areas, knowing that venous congestion is commonly noted in which areas? Select all that apply.
1.Legs 2.Vulva
A delivery room nurse collects data on a mother who just delivered a healthy newborn infant. The nurse checks the uterus to determine if the placenta has detached. Which findings indicate to the nurse that placental detachment has occurred? Select all that apply.
1.Lengthening of the umbilical cord 3.Sudden gush of dark blood from the vagina 4.Appearance of fetal membranes at the introitus
A client has had a midline episiotomy. In relation to clients with other types of episiotomies, the nurse anticipates that the client will generally experience which findings? Select all that apply.
1.Less pain 2.Less blood loss 4.More likely to extend with birth of LGA infant
Which nursing interventions should be implemented for a newborn receiving phototherapy for hyperbilirubinemia? Select all that apply.
1.Monitor the temperature frequently. 2.Protect the eyes with an opaque mask. 5.Monitor and document the number and consistency of stools.
The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply.
1.Our child will eventually grow out of this condition 3.It is not necessary to avoid individuals with the common cold.
During an initial prenatal visit, the nurse notes that the primary health care provider documents that the client is experiencing iron deficiency anemia. Which client data support this finding? Select all that apply.
1.Reports of fatigue 2.Pink mucous membranes
The nurse is preparing a list of self-care instructions for a postpartum client who has been diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.
1.Rest during the acute phase. 2.Wear a supportive, nonunderwire bra. 3.Maintain a fluid intake of at least 3000 mL. 4.Continue to breastfeed if the breasts are not too sore.
The nurse is reading the primary health care provider's (PHCP) documentation regarding a pregnant client and notes that the PHCP has documented that the client has a platypelloid pelvic shape. The nurse recognizes which characteristics to be present in the platypelloid pelvis? Select all that apply.
1.Shallow depth 2.Wide suprapubic arch 4.Compatible with vaginal delivery 5.Flattened anteroposteriorly and wide transversely
The nurse reviews the client's health record and notes that based on Leopold's maneuvers, the fetus is in a cephalic presentation. Which findings while performing Leopold's maneuvers support the identification of a cephalic presentation? Select all that apply.
1.Small parts are located on the left side of the uterus. 2.Small parts are located on the right side of the uterus. 5.A soft, irregular non-ballottable shape is located just above the symphysis pubis.
The nurse is reviewing the health care record of a newborn admitted to the nursery; the newborn is suspected of having an imperforate anus. The nurse understands that which documented findings are associated with this disorder? Select all that apply.
1.Stenosis of the anorectal canal 2.Failure to pass meconium stool 3.The presence of stool in the vagina 4.The presence of an anal membrane
The nurse in the newborn nursery is assisting in monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings, if noted in the newborn, should alert the nurse to the possibility of this syndrome? Select all that apply.
1.Tachypnea 2.Retractions 4.Nasal flaring
The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.
1.The 6-month old with bronchopulmonary dysplasia 4.The 1-year-old client taking corticosteroids
The nurse is reviewing the health care record of a pregnant client at 16 weeks of gestation. Which assessment findings are most likely present at this time? Select all that apply.
3.Fetal heart tones can be heard by Doppler. 4.Braxton Hicks contractions may be felt by the mother. 5.The fundus is located midway between the symphysis pubis and the umbilicus.
The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the primary health care provider? Select all that apply.
3."Could you please come assess the child as soon as possible?" 4."I am concerned that the child is bleeding from the surgical sites." 5."Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." 6."Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy."
The nurse is assisting in caring for a newborn whose mother is Rh negative. Which is important for the nurse to include when planning the newborn's care?
Ask about the newborn's blood type and direct Coombs.
A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting with care for the newborn, which should be the priority concern?
Aspiration
A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?
Assess for any bleeding on the dressing.
A pregnant woman reports to the health care clinic complaining of loss of appetite, weight loss, and fatigue. Following an assessment, tuberculosis is suspected. A sputum culture is obtained and identifies the Mycobacterium tuberculosis in the sputum. The nurse reinforces instructions to the client regarding therapeutic management of tuberculosis. Which statement is included in therapeutic management?
Isoniazid plus rifampin will be required for a total of 9 months.
The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease?
It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.
The nurse is reviewing the health record of a pregnant client at 16 weeks' gestation. The nurse should expect to document that the fundus of the uterus is located at which area?
Midway between the symphysis pubis and the umbilicus
The nurse is caring for a neonate with fetal alcohol syndrome (FAS). The nurse includes which priority intervention in the plan of care for this newborn?
Monitor neonate response to feedings and the weight gain pattern.
The nurse is reinforcing instructions to a pregnant client regarding measures that will strengthen the perineal floor muscles. Which should the nurse include in the instructions?
Perform Kegel exercises in 10 repetitions, three times per day.
The nurse is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. Based on this observation, the nurse should take which action?
Notify the registered nurse of the finding.
As a part of discharge teaching, a new mother has been provided with instructions about how to perform postpartum exercises. Which response by the client indicates that the client understands the instructions?
She should alternately contract and relax the muscles of the perineal area.
A breastfeeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which food should the nurse instruct the mother to avoid?
Soft cheeses
The nurse is teaching a pregnant client how to perform Kegel exercises. The nurse should tell the client that these exercises are for which purpose?
Strengthen the pelvic floor in preparation for delivery.
The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?
The harness needs to be removed to check the skin and for bathing.
The nurse is reviewing the criteria for early discharge of a newborn infant with a new mother. Which data, if noted in the infant, indicate that the criterion for early discharge has not been met?
The infant has evidence of significant jaundice.
The nurse is preparing to administer an injection of vitamin K to a newborn. When administering the injection, the nurse should select which injection site?
The lateral aspect of the middle third of the vastus lateralis muscle
The mother of a premature baby asks the nurse why the baby is receiving a caffeine-type medication. Which answer should the nurse give to the mother?
The medication primarily decreases the number of apnea occurrences.
A 1-year-old child is seen in the primary health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?
The mother states the child had purulent discharge from the ear last night.
The nurse is preparing to reinforce instructions to a pregnant client about nutrition. The nurse plans to include which instruction in this client's teaching plan?
The nutritional status of the mother significantly influences fetal growth and development.
The nurse is assigned to care for the client during the postpartum period. The client asks the nurse what the term involution means. Which description should the nurse give to the client?
The progressive descent of the uterus into the pelvic cavity, which occurs at a rate of approximately 1 cm/day
The nurse is caring for a client who had a cesarean section to deliver a nonviable fetus as a result of abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, "I lost my baby and now my wife! What am I going to do?" Which appropriately describes the situation?
The spouse lacks hope because of the loss of the baby and illness of his wife.
An elective cesarean delivery is being planned for a pregnant client. The nurse is reviewing the plans for the surgery with the client. A low transverse uterine incision will be used. The client asks the nurse to explain why this approach is being used. The nurse's response is based on which premise?
This incision allows a vaginal birth after cesarean (VBAC) to be possible in a subsequent pregnancy.
A parent calls the clinic nurse to schedule an appointment for her child's diphtheria, tetanus, and pertussis vaccination. The parent tells the nurse that her child had a swelling at the injection site and low-grade fever after the last diphtheria, tetanus, and pertussis (DTaP) vaccination. Which instructions should the nurse give to the parent to lessen this type of reaction to the upcoming vaccination?
To administer an appropriate dose of Tylenol 45 minutes before the appointment
The nurse reviews the results of a bilirubin level on a 2-day-old, jaundiced, term newborn. The results indicate a total bilirubin level of 7.2 mg/dL. The newborn's mother verbalizes concern over the bilirubin results. On which interpretation of the bilirubin result does the nurse base a response?
Within acceptable ranges
The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet?
rice
A client who has just been told that she is pregnant asks a clinic nurse when the fetus's heart will be developed and beating. The nurse tells the client that the fetal heart is beating at what gestational week?
week 5
The nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the priority in the plan of care?
wound care