PEDI/MCH HESI review
Why should a woman of child bearing age take folic acid supplements? A. To prevent neural tube defects & orofacial clefts in the fetus B. To help prevent constipation C. To prevent the mother from developing HTN D. To prevent Rh compatibility.
Correct ANS: A
Alert PCP if there are fewer than 10 fetal kicks in a 2 consecutive 2hr period. TRUE OR FLASE
true
At 16 weeks the funds can be found 1/2 way between the symphysis pubis and umbilicus TRUE OR FALSE
true
At 20-22 weeks the fundus is approx. located at umbilicus TRUE OR FALSE
true
A 55yr old confides in the RN about his sexual function. What is the RN's best response? A. How often do you have sexual relations B. Please share with me more about your concerns C. You are still young and have nothing to worry about D. You should not have a decline in restore unit you
Correct ANS: B RN needs to establish trust
What is the role of amniotic fluid? SATA A. Surrounds cushions and protects fetus and allows for fetal movement B. Maintains body temperature of the fetus C. Contains fetal urine and is a measure of fetal kidney function
ALL are correct
A 14 month old boy is hospitalized with dehydration. He is unconsolable, screaming, and rejecting your physical contact. What best describes the infants response to you? A.Separation anxiety-PROTEST PHRASE B.Fear of injury and pain C.Separation anxiety-DESPAIR D.Loss of Control
A
A 2 year-old is scheduled to have a tonsilectomy. How would you educate the patient? A.Use picture books & puppets and repeat explanations. B.Provide a video and explain in clear terms. C.Engage in conversations about the procedure and encourage the child to express his or her thoughts. D.Describe the procedure as it is about to be performed.
A
A mother brings her 8 month old child in for a well visit. Which statement by the mother would raise concern for the infants safety and the mother would need to be re-educated? A."I love using the hot steam vaporizer when he has a cold." B."We have a gate at the stairs." C."Yesterday I threw away all of our house plants." D."He is still riding in a rear-facing car seat."
A
The reactive non stress test requires how many accelerations? A.2 or more lasting at least 15 seconds B.4 or more lasting at least 10 seconds C. 3 or more lasting at least 15 seconds
A
Which statement by the mother demonstrates her child is ready for toliet training? A."She is waking up dry from a nap for about a couple of weeks now." B."I'm still changing a wet diaper every 2 hours." C."She fusses when I sit her on the potty. What can I do?" D.None of the options are correct.
A
You are observing a 5 month old for developmental skills. Which of the following skills would concern you if the infant was not demonstrating? A.Follows objects with eyes B.Crawling C.Sitting with support D.Grasps objects
A
Which statements about the placenta is correct? SATA A. To provide exchange of nutrients and waste product between the fetus and mother B. It allows large particles to pass through to the fetus C. In the 3rd trimester it provides the fetus with passive immunity to certain diseases for the first few months after birth. D. Genetic testing can be done via CVS by week 4
A & C are correct. Large particles such as bacteria can't pass through the placenta but nutrients, medications, alcohol, antibodies, and viruses can pass through the placenta. Genetic testing can be done by week 10-12 via chorionic villus sampling (CVS).
A 15 year old, who is type 1 diabetic, reports that she almost "passes out" during gym class. What information would you assess from the teenager? A.Her eating habits prior to gym class. B.None of the options are correct. C.What type of form she needs to have filled out so she can be excused from gym class. D.How she takes her blood glucose after exercise.
A is correct It is very important to ask the teen when and what she eats before gym. Type 1 diabetics are encouraged to eat before physical activity to decrease the chances of hypoglycemia (which is what this teen is experiencing). She should take her blood glucose BEFORE exercise not AFTER. There is no need for her to be excused from gym class because exercise is essential for diabetics.
A 7 year old has been having vomiting with diarrhea for 3 days. How do you expect the child to present clinically? A.Tachycardia, dry mucous membranes, weight loss B.Sunken eyeballs and bradycardia C.Bradycardia, dry mucous membranes, absence of tears D.None of the options are correct.
A is correct The child should be experiencing dehydration and would present clinically with: Tachycardia, dry mucous membranes, weight loss, sunken eyes and/or fontanles, decreased urinary output
As the nurse, taking care of the patient who has been hospitalized for 3 days with dehydration, what abnormal finding would you report to the MD? A.Weight change of 100 lbs to 92 lbs and urinary output of less than 1 ml/kg/hr B.1-3 second skin turgor C.Weight change of 90 lbs to 93 lbs and dry mucous membranes D.Options A & C
A is correct The only correct option is: Weight change of 100 lbs to 92 lbs and urinary output of less than 1 ml/kg/hr. All the other answers are normal findings that do not cause concern.
A child is ordered by the doctor for ketone and glucose urine testing. The patient is to collect it at home. How would you instruct the patient to collect the specimen? A.Use the second voided urine for most accurate results. B.Cleanse the area with betadine. D.Demonstrate a clean catch techinque. E.Encourage the patient to consume at least 24 oz of water prior to the specimen collection.
A is correct The patient should use the second voided urine to ensure that the results are accurate. First voided urines tend to be concentrated and could effect results.
A mother brings her child in the office for a follow-up appointment and voices concern that her child has started urinating more than normal and is constantly thirsty & hungry. As the RN, you suspect? A.Diabetes Mellitus B.Tret's syndrome C.Hypoglyemia D.Phenylkentonuria
A is correct The symptoms the mother is reports are the classic 3 P's of diabetes: polyuria, polydipsia, polyphagia
You're patient is complaining of leg cramps what interventions would you tell her to do? A. Regular exercise like walking B. Dorsiflexing the foot of the affected leg C. Increase potassium intake D. Increase calcium intake
A,B,D
The RN is teaching a prenatal class about fetal circulation. Which statements should be included? A. The ductus arterioles allows blood to bypass the fetal lungs. B. One vein carries oxygenated blood from placenta to fetus C. The normal fetus heart beat is 160-170 during pregnancy. D. Two arteries carry deoxygenated blood and waste products away from the placenta E. Two veins carry blood that is high in carbon dioxide and other waste products away from the fetus to the placenta.
A,B,D are Correct The ductus arterioles allows blood to bypass the nonfunctioning fetal lungs. Oxygenated blood is transported to the fetus by one vein. The normal heart rate is 110-160. Two arteries carry deoxygenated blood and waste products from the fetus.
Which statement by a mother regarding her 15 month old requires further evaluation? A."I add honey to his oatmeal in the morning." B."He loves drinking juice from a bottle at night...it helps him sleep." C."I only buy whole milk, not skim or low fat." D."I avoid giving him seeds, popcorn, and raisins."
B
True or False: A child who is 11 months old and weighs 39.5 kg can ride in a forward facing upright position safety seat. True False
FALSE
What nursing intervention would you NOT include in the plan of care with a two-year old experiencing loss of control? A.Provide routines and rituals the 2-year old is familiar with. B.Distract the toddler from looking at pictures of parents placed at bedside. C.Anticipate temper tantrums D.Allow the two-year old to select if they want orange juice or milk for breakfast.
B
Average expected weight gain during pregnancy is 35-40 lbs TRUE OR FALSE
FALSE- 25-36lbs
In reference to fetal kicks which statement indicates the patient needs further education? A. I will record the number of kicks B. I need to lie flat to perform the procedure C. If I count fewer than 10 kicks in 2 hrs I should count again over the next 2hrs D. I should place my hand on the largest part of my abdomen and concentrate on the fetal movement to count the kicks
ANS: B The pt should be lying on her side or sit. The pt should alert the PCP if she feels fewer than 10 kicks over 2 consecutive 2 hr intervals
Rubella titer is less than 1:8 and the vaccine is prescribed to be administered before discharge what information should the nurse provide? A. Breast feeding needs to be stopped for 3 months B.pregnancy needs to be avoided for 1-3 months C. Vaccine is administered SUBCUT D. Exposure to immunosuppressed individuals needs to be avoided E. A hypersensitivity reaction can occur if the pt is allergic to eggs F. The area of the injection needs to be covered with a sterile gauze for 1 week.
ANS: B,C,D,E The live vaccine is not communicable in breast milk, breast feeding doesn't need to be stopped
The RN is providing instructions to a pregnant pt who is scheduled for an amniocentesis, what instruction should the nurse provide? A. Strict bed rest B. Hospitalization is necessary for 24 hrs after the procedure C. Informed consent needs to be signed D. A fever is expected because of trauma to the abdomen.
ANS: C This is an invasive procedure and needs consent, pt is instructed to rest but may resume light activity when cramping stops.
A non reactive contraction stress test is a .. A. Normal finding B. Abnormal C.high risk for fetal demise
ANS:A No late decelerations is a normal finding
A pt reports thin colorless vaginal discharge what should the RN say? A. Come to the clinic immediately B. It may be bothersome but this is normal C. Report to ED D. Use tampons but change them every 2 hrs.
ANS:B Leukorrhea begins during the 1st trimester many its notice thin colorless or yellow vaginal discharge throughout pregnancy, they may use panty liners but no tampons because of infection risk.
Which statements are true about fetal circulation? A. The umbilical cord should contain 2 arteries and 1 vein B. Arteries carry deoxygenated blood and waste products from the fetus C. Veins carry oxygenated blood to the fetus D. FHR is 160-170 beats per minute in the first trimester but slows to 110-160 beats per minute
All are correct
5. You're assessing a 4 year old with epiglottitis who just arrived to the pediatric clinic. The child is drooling and has a respiratory rate of 45 breaths per minute. In addition, the child is becoming increasingly apprehensive. Which findings below exhibited by the patient represents an acute upper airway obstruction that requires IMMEDIATE treatment? Select all that apply: A. Stridor B. Cyanosis C. Chest retractions D. Nasal flaring
All the answers are correct. All these findings represent an upper airway obstruction and require immediate treatment.
Pt is pregnant with twins and has a healthy 5yr old who was delivered at 38 weeks, no Hx of abortion or fetal demise. Using GTPAL what should the nurse see in the patients chart? A. G=3 T=2 P=0 A=0 L=1 B. G=2 T=1 P=0 A=0 L=1 C. G=1 T=1 P=1 A=0 L=1 D.G=2 T=0 P=0 A=0 L=1
B
Using Naegeles rule when is the expected delivery for October 19,2020 A. July 12,2021 B.july 26,2021 C. August 12 2021 D. August 26 2021
B
A 5 year old a has temperature of 103.6 'F and is brought into the emergency room by his mother. Which statement by the mother causes concern? A."I gave him a sponge bath to help with the fever." B."I administered Aspirin to help with the fever a few hours ago." C."I've tried to encourage fluid intake every hour." D."I re-took his temperature 30 minutes after I gave the medication and it was still high."
B is correct A child should never have aspirin, especially for a fever due to Reyes Syndrome.
You are going over insulin administration education with a patient's mother. Which statement by her raises concern? A."I ordered her a Medic-Alert bracelet yesterday." B."When she is sick I will hold her insulin." C."I always carry sugary items in case she has a hypoglemic attack." D."I will bring her in every 3 months for a glycosylate hemoglobin blood drawn."
B is correct When a diabetic is sick, they should never hold their insulin. This is because when the body is stressed or has an infection they are at a very high risk for hyperglycemia so it is essential they monitor their blood glucose closely and administered insulin as needed. All the other options are correct.
A 5 year-old patient is admitted with a broken left arm. His arm is immobilized. What nursing intervention is age appropriate for this child regarding his hospitalization? A.Discourage school friends from visiting the patient due to B.embarrassing the child because of his immobilized arm. C.Explain procedures in simplistic terms without diagrams. D.All the child to help with bathing, feeding, and changing bandages. E.Assess the 5 year old for questions about his appearance and the effects of how his injury will affect the future.
C
How many calories should the a pregnant pt increase to per day? A. 200 calories B.100 calories C.300 calories
C
Syphilis can lead to ..? A. HTN B. Spontaneous abortion & physical deformities C. Placenta abrevia D. Cold stress
Correct ANS B
The RN informs the Pt that she should be able to find out the sex of her fetus at 16 weeks because of which factor? A. The appearance of fetal external genitalia B fetal testes are descended into the scrotal sac C. The internal differences in males and females become apparent.
Correct ANS: A
When assessing fundal height what should you monitor for? A. Monitor for supine hypotension when placed in the supine position. B. Monitor for tachycardia C. Monitor for dehydration D. Monitor for bleeding
Correct ANS: A supine hypotension occurs as a result of pressure or uterus on the inferior vena cava when laying in a supine position.
Trichomoniasis is associated with..? SATA A. Premature rupture of membranes B. Postpartum endometritis C. Neonatal conjunctivitis
Correct ANS: A & B Chlamydia and gonorrhea are more closely r/t neonatal conjunctivitis
Which statements are considered as positive signs (diagnostic) A. FHR by doppler transducer B. Active fetal movements that are palpable by the examiner C. Outline of fetus via US D. Quickening
Correct ANS: A,B,C
Which statements are considered as probable s/s? A.Hegars sign ( compressibility & softening of lower uterine segment occurs week 6) B. Ballottement ( rebounding of fetus against examiners fingers on palpation) C.Chadwicks sign ( violet coloration of mucous membranes of Cervi, vagina, and vulva occurs week 6) D. Gooddell's sign (softening of cervix that occurs 2nd month) E. Palpable fetal movements by the examiner F. Outline of fetus via US
Correct ANS: A,B,C,D
Which statements are considered as presumptive s/s? A.quickening ( occurs at 16th-20th week of gestation) B. Pronounced nipples C. N/V D. Amenorrhea E. Fullness in breast F. Hegars sign G. Ballottement
Correct ANS: A,B,C,D,E
Which statements regarding pregnancy changes are true? A. During pregnancy the woman pulse rate may increase 10-15 beats per minute B. BP slightly increases in the second trimester then decreases in the 3rd trimester C. Respiratory rate remains the same or slightly increases
Correct ANS: A,C BP slightly decreases in the second trimester then increases in the third.
Which intervention is the BEST way to alleviate back pain for a pregnant woman from the list below? A. Breathing techniques to help relax the muscles B. Performing a pelvic tilt and conscious relaxation exercises C. Stretch out with a yoga wheel D. Take a bubble bath
Correct ANS: B
What statement should the RN make about a pregnant Pt w/ gynecoid pelvis? A. Your type of pelvis has a narrow pubic arch B. Your type of pelvis is the most favorable for labor & birth C. Your type of pelvis is a wide pelvis but has a short diameter D. You will need a C section
Correct ANS: B An android pelvis (resembling a males) is unfavorable because of the narrow pelvic planes. An anthropoid pelvis has an outlet that is adequate with a normal or moderately narrow pubic arch.
Couple ask about sterilization procedures. Which question by the RN should determine whether this method of family planning would be the most appropriate? A. Have you ever had surgery B. Do you plan to have any other children C. Do either of you have DM? D. Do either of you have HTN?
Correct ANS: B Reversal surgery is not always successful.
RN is doing an assessment and notes the FHR at 38 weeks is 174. What is the priority nursing action? A.document the finding B. Check the mothers heart rate C. Notify the OB D.Tell the client the heart rate is normal
Correct ANS: C If the FHR is less than 110 or more than 160 with the uterus at rest the fetus may be in distress.
The RN ask the student to describe the role of ductus venous. Which statement shows an understanding? A. It connects the pulmonary artery to the aorta B. Its an opening between the right & left atria C. It connects the umbilical artery to the inferior vena cava. D.it connects the umbilical vein to to inferior vena cava
Correct ANS: D Foramen vale is a temporary opening between the right and left atria. Ductus arteries joins the aorta and pulmonary artery
Why does the fertilized ovum stay in the Fallopian tube for 3 days? A. It promotes the fertilized ovums chance of survival B. It promotes the fertilized ovums exposure to estrogen & progesterone C.It promotes the fertilized ovums normal implantation in the top portion of the uterus D. It promotes the fertilized ovums exposure to latinizing hormone and follicle stimulating hormone.
Correct ANS:C
A patient with a history is diabetes is exhibiting sweating and slurred speech. What do you suspect is the cause? A.hypernaterima B.hyponaterima C.hyperglycemia D.hypoglycemia
D is correct These are the classic symptoms of hypoglycemia.
You check a patient's blood glucose with a glucometer and find it to read 99. How would you interpet this result? A.This is diabetic ketoacidosis and contact the doctor. B.This is hypoglyemia and encourage the patient to eat something with sugar. C.This is hyperglyemia and contact the doctor. D.This finding is normal and no further intervention is needed. E.A patient with a history is diabetes is exhibiting sweating and slurred speech.
D is correct This finding is normal. A normal blood sugar is 70 to 100.
3. When should a child receive the first dose of the Hepatitis B vaccine? A. Birth B. 2 months C. 4 months D. 6 months
The answer is A.
A 3 year old arrives to the ER. The child has a temperature of 102.4 'F, respiratory rate of 45, and is agitated. The child is diagnosed with epiglottitis. You note the child is sitting up, positioned forward with chin in the air and the tongue is protruding with the mouth open. Which nursing intervention below is NOT appropriate for this patient? A. Assist the patient in a supine position. B. Keep the child on the parent's lap during treatments. C. Keep the child nothing by mouth. D. Avoid taking a temperature on the patient orally.
The answer is A. Allow the child to be in a position that allows them to breathe and be comfortable. The child is in the tripod position, which is a common finding with epiglottis. Placing the child in the supine position is contraindicated because it impedes respiratory effort. A nursing goal is to keep the child calm (avoid things that cause the child to cry because this can affect the airway since the epiglottis is inflamed). So, keeping the child in the parent's lap during treatments is appropriate. In addition, NEVER place anything in the patient's mouth due to the risk of causing spasms which will further constrict the airway.
8. The nurse wants to assess the crawling reflex in a newborn. How is this reflex assessed? A. The nurse places the infant in the prone position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion. B. The nurse places the infant in the supine position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion. C. The nurse places the infant in the prone position and applies pressure with the hand to the neck. In response, the infant should attempt to move the arms and legs in a crawling like motion. D. The nurse places the infant in the supine position. In response, the infant should attempt to lift the head and move the arms and legs in a crawling like motion.
The answer is A: The nurse places the infant in the prone position and applies pressure with the hand to the sole of the foot. In response, the infant should attempt to push against the hand and move the arms and legs in a crawling like motion.
7. At what age does a child starting receiving a yearly flu vaccine? A. 12 months B. 6 months C. 2 months D. 24 months
The answer is B.
8. You're providing a free educational clinic to new moms about immunizations. You inform the attendees that the Measles, Mumps, and Rubella (MMR) vaccine is given? A. at 6 and 12 months B. 12 months and 4-6 years C. at 4 and 6 months D. at 2 and 12 months
The answer is B.
3. Regarding question 2, what is the recommended preventive administration schedule for this medication in preventing epiglottitis? A. 4, 6, 12-15 months and 4-6 years B. 2, 4, 6, 12-15 months C. 4, 6 months and 4-6 years D. 2 and 6 months
The answer is B. The Hib vaccine can prevent most cases of epiglottitis. Three or four doses are given, depending on the brand used. It is given at 2, 4, 6, and 12-15 months.
2. A mother calls the pediatric clinic to ask when her daughter will receive the Varicella vaccine. Your answer to her question is: A. at 2, 4, and 6 months B. at 12 months and 4-6 years C. at 6 and 12 months D. at 4 months and 4-6 years
The answer is B. The child will receive the Varicella vaccine at 12 months and 4-6 years of age.
4. A 12 month old receives a series of vaccinations which includes the Hepatitis A vaccine. When should the child receive the 2nd dose of this vaccine? A. in 3 months B. at the 18 month visit C. when the child is 4-6 years old D. in 2 months
The answer is B. The first dose of HepA is given at 12 months and then the second dose is given 6 months from that dose, which would be at the 18 month visit.
3. You note that when a finger is placed under the toes of a newborn, the toes will curl downward. This is known as the __________? A. Babinski reflex B. Plantar grasp reflex C. Tonic Neck reflex D. Step reflex
The answer is B. This is known as the plantar grasp reflex.
You're providing an in-service to a group of new labor and delivery nurse graduates about the pathophysiology of preeclampsia. Which statement by one of the group participants demonstrates they understood how this condition develops? A. "The basal arteries of the myometrium fail to widen to support blood flow to the placenta." B. "The placenta experiences ischemia because the spiral arteries of the uterus fail to reshape and increase in diameter." C. "The cardiovascular system of the mother fails to compensate for the increased blood flow from the fetus and placental ischemia occurs." D. "If the mother experience uncontrolled hypertension and proteinuria, it compromises blood flow to the placenta and leads to preeclampsia."
The answer is B. This is the only correct statement. When preeclampsia occurs it is because the spiral arteries of the uterus failed to widen in diameter due to poor trophoblast invasion during the beginning of the pregnancy. Overtime, this causes problems (usually after 20 weeks gestation) and the placenta experiences ischemia. When the placenta becomes ischemic is releases substances into mom's circulation that are very toxic to her endothelial cells, which causes all the signs and symptoms seen in preeclampsia. Severity varies in patients.
4. When the Moro Reflex is stimulated in an infant, the infant will _____________the arms with the palms of the hands turned ___________ and then move the arms ___________ the body. A. flex, upward, away from B. extend, upward, back to C. flex, downward, back to D. extend, downward, away from
The answer is B. When the Moro Reflex is stimulated in an infant, the infant will EXTEND the arms with the palms of the hand turned UPWARD and then move the arms BACK TO the body.
2. During a 2 month well visit with a patient and her mother you educate the parent on the most common cause of epiglottitis. You explain to the mother the most common cause of this condition is the _______________. In addition, you explain _________ can help prevent most cases of this condition? A. respiratory syncytial virus, palivizumab B. influenza virus, annual flu shot C. haemophilus influenzae type b, Hib vaccine D. rotavirus, RV vaccine
The answer is C. Most common cases of epiglottitis are caused by a bacteria that attacks the epiglottis called haemophilus influenza type B. The Hib vaccine can be given as prevention. Three to four doses are given (depending on the brand used) at 2, 4, 6 months, and 12-15 months.
1. Which statement is correct regarding the role of the epiglottis? A. This structure prevents food from entering the nasopharynx. B. The epiglottis helps with vocal cord vibration. C. After swallowing this structure moves downward to prevent swallowed contents from entering the trachea. D. The epiglottis is found in between the vocal folds.
The answer is C. Option A is wrong because this is the role of the uvula (NOT epiglottis). Option B is wrong because this is the role of the GLOTTIS (not epiglottis). Option D is where the glottis is found (not epiglottis). The epiglottis is found on the inside of the thyroid cartilage and is at the back of the tongue.
The nurse knows that preeclampsia tends to occur during what time in a pregnancy? A. before 20 weeks B. in the third trimester and postpartum C. after 20 weeks D. in the first and second trimester
The answer is C. Preeclampsia tends to occur AFTER 20 weeks gestation.
6. In a 3-month-old infant you assess the Babinski Reflex. What is the appropriate response in an infant at this age? A. The big toe plantar flexes and the other toes curl downward. B. All the toes curl downward. C. The big toe dorsiflexes and the other toes spread outward. D. The big toe plantar flexes and the other toes fan outward.
The answer is C. The Babinski reflex should disappear around 1 year of age. However, in an infant this age the big toe should dorsiflex (bend back) and the other toes spread outward.
5. When does the sucking reflex in an infant disappear and become voluntary? A. 6 months B. 2 months C. 4 months D. 12 months
The answer is C: 4 months. The sucking reflex in an infant will disappear and become a voluntary function at about 4 months of age.
5. Fill-in-the-blank: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the _________________ in mom's body, which injures organs. A. spiral arteries B. epithelial cells C. endothelial cells D. juxtaglomerular cells
The answer is C: The signs and symptoms of preeclampsia are mainly occurring because substances released by the ischemic placenta cause damage to the ENDOTHELIAL CELLS in mom's body, which injures organs.
11. How would the nurse check for clonus in a patient with preeclampsia? A. Assess the patellar and bicep tendon with a reflex hammer and grade the reaction. B. Assess for muscular rigidity by having the patient extend the arms and place resistance against the arms. C. Assess for beating of the foot when the foot is quickly dorsiflexed.
The answer is C: To check for clonus the nurse will have the patient dangle the leg and support the patient's lower leg. Then the nurse will quickly dorsiflex the foot. The nurse is assessing for bouncing or beating of the foot (hence the foot attempts to plantarflex). If the foot attempts to bounce or beat 3 or more times, it is positive for clonus.
6. A parent has a question about the Rotavirus vaccine and when it is administered. As the nurse you know that ________ doses are given, and the last dose is given at ________? A. 2; 6 months B. 3; 4 months C. 4; 4-6 years D. 3; 6 months
The answer is D.
8. A 5 year old with acute epiglottitis is intubated for airway management. As the nurse you know that all of the following can be prescribed as treatment for this condition EXCEPT? A. Intravenous fluids B. Antipyretics C. Corticosteroids D. Cough suppressants
The answer is D. A cough is usually absent in this condition, which is present in croup (laryngotracheobronchitis). Therefore, cough suppressants are not usually ordered for this condition because there is no cough.
2. Select the option below that best describes how to assess the palmar grasp reflex: A. Stroke the cheek of the infant and assess if the head turns toward the stimuli. B. Stroke the sole of the foot starting at the heel to the outward part of the foot and assess if the big toe bends back and the other toes spread out. C. Hold the infant upright with the legs and feet touching a surface and assess if the infant will move the legs in a stepping motion. D. Stroke the inside of the infant's hand with an object and assess if the hand closes around the object
The answer is D. Stroking the inside of the infant's hand with an object and assessing if the hand closes around the object helps assess the palmar grasp reflex.
7. You note when a 2-month-old is held upright with the legs and feet touching the surface, the infant will appear to be walking on the surface. This reflex is called the? A. Bauer Crawling Reflex B. Push-to-Walk Reflex C. Babinski Reflex D. Step Reflex
The answer is D. This is known as the step reflex.
1. During an assessment of an infant, you note that when the infant's head is turned to the right side, the leg and arm on the right side will extend, while the leg and arm on the left side will flex. You document this as what type of reflex? A. Rooting Reflex B. Sucking Reflex C. Moro Reflex D. Tonic Neck Reflex
The answer is D. When the infant's head is turned to a particular side, the leg and arm on that side will extend, while the leg and arm on the opposite side will flex.
8. Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have what medication on standby? A. Acetylcysteine B. Calcium carbonate C. Oxytocin D. Calcium gluconate
The answer is D: The antidote for Magnesium Sulfate is Calcium Gluconate. The nurse should have this on hand in case Magnesium toxicity occurs.
9. A 39 week pregnant patient is in labor. The patient has preeclampsia. The patient is receiving IV Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires you to notify the physician? A. Deep tendon reflex 4+ B. Respiratory rate of 13 breaths per minute C. Urinary output of 600 mL over 12 hours D. Clonus presenting in the lower extremitiesE. Patient reports flushing or feeling hot
The answer is E. The nurse should monitor for Magnesium Sulfate toxicity. Signs of this include: EARLY: flushing or feeling hot/warm, later on: decreased or absent reflexes (finding of 4+ Deep tendon reflex is considered HYPERreflexia), Respiratory rate less than 12 breaths per minute, Urinary output of less than 30 mL/hr, EKG changes.
10. In a patient with preeclampsia, what signs and symptoms indicate that the patient has a high risk of experiencing a seizure due to central nervous system irritability? Select all that apply: A. You note bouncing of the foot when it is quickly dorsiflexed. B. Patellar and bicep deep tendon reflexes are graded 4+. C. Platelet count 200,000 D. Patient reports a decrease in headache pain.
The answers are A and B. Option A indicates positive clonus and Option B is indicative of hyperreflexia. If these findings are present it demonstrates that the central nervous system is irritated and there is a high risk of potential seizure activity. Seizure precautions should be initiated and the physician notified.
12. A 37 week pregnant patient is admitted with severe preeclampsia. The patient begins to experiences a tonic-clonic seizure. Which of the following would the nurse AVOID during the seizure? A. Placing the patient in a supine position B. Holding down the patient's head to prevent injury C. Staying with the patient and activating the emergency response team D. Timing the seizure E. Providing 8 to 10 L of oxygen
The answers are A and B. The nurse would want to place the patient on their side (preferably the left-side...not supine) to help prevent the tongue from obstructing the airway, preventing aspiration, and improving blood flow to the placenta. In addition, the nurse would NOT want to restrain the patient, which can cause injury. Option C, D, and E are steps the nurse would want to take.
5. A 4 year old is scheduled for routine immunizations. As the nurse you know the physician will most likely order what vaccinations? A. DTaP (diphtheria, Tetanus, Pertussis) B. Polio C. Hepatitis B D. RV (Rotavirus) E. MMR (Measles, Mumps, Rubella) F. Hib (Haempophilus Influenzae Type B) G. Varicella
The answers are A, B, E, and G. The immunizations ordered at 4-6 years of age include: DTaP, Polio, MMR, and Varicella.
2. A patient is currently 34 weeks pregnant with her first baby. Which findings below could indicate the development of preeclampsia in this patient that would need to be reported to the physician? Select all that apply: A. 1600: blood pressure 144/100, 1700: blood pressure 120/80 B. 3+ dipstick urine protein C. 1 hour glucose tolerance test 90 mg/dL D. 0800: blood pressure 142/92, 1230: blood pressure: 144/98 E. <300 mg/dL 24-hour urine protein
The answers are B and D. Signs and symptoms of preeclampsia include: proteinuria (>1+ dipstick urine protein or >300 mg/dL 24 hour urine protein, hypertension >140/90...two reading at least 4-6 hours apart), swelling in face, eyes, extremities, headaches, vision changes, etc.
7. Select all the signs and symptoms that can present with epiglottitis? A. Slow onset B. Difficulty swallowing C. Drooling D. High Fever E. Barking cough F. Stridor G. Exudate on Tonsils H. Crackles
The answers are B, C, D, and F.
6. The parents of a 3 year old bring their child to the ER. The parents report the child suddenly developed a fever overnight and has had issues swallowing, which has led to excessive drooling. In addition, the parents explain that the child complains of sore throat, and it is hard to understand the child's speech because her voice is muffled. Based on this information, your next nursing actions will be? Select all that apply: A. Assess the child's temperature orally B. Obtain a throat culture C. Count the patient's respirations D. Assess the child's throat for tonsillar exudate E. Keep the child NPO
The answers are C and E. Based on the patient's signs and symptoms this may be a case of epiglottitis. Therefore, the nurse should NOT stick anything in the patient's mouth that could can a spasm (example: taking oral temperature, throat culture, using a tongue depressor etc.) and further block the airway.
1. During a routine pediatric visit, a 2 month old patient will need which of the following vaccines? A. MMR (Measles, Mumps, Rubella) B. Hepatitis A C. Hepatitis B D. DTaP (Diphtheria, Tetanus, Pertussis) E. Hib (Haemophilus Influenzae Type B) F. Varicella G. Polio H. RV (Rotavirus) I. PCV (Pneumococcal Conjugate Vaccine)
The answers are C, D, E, G, H, and I. At 2 months the patient should receive: DTaP, Hepatitis B, Hib, Polio, RV, and PCV.
6. Select all the risk factors below that increases a woman's risk for developing preeclampsia: A. Nulligravida B. Primigravida C. BMI 34 D. Pregnant with twins E. Maternal history of preeclampsia F. Age: 25-years-old G. History of Lupus and Diabetes
The answers are: B, C, D, E, and G. Risk factors for preeclampsia include: History of preeclampsia or family history, first pregnancy (primigravida), significant health history prior to pregnancy: diabetes, lupus, high blood pressure, kidney disease, Obese: BMI >30, having more than one baby (twins, triplets etc.), age (young <18 or advanced >35).
7. Your patient is 36 weeks pregnant with severe preeclampsia. The physician has ordered lab work to assess for HELLP Syndrome. Which findings on the patient's lab results correlate with HELLP Syndrome? A. Hemoglobin 12 g/dL B. Platelets 90,000 μL C. ALT 100 IU/L D. AST 90 IU/L E. Glucose 350 mg/dL F. Abnormal RBC peripheral smear
The answers are: B, C, D, and F. HELLP Syndrome causes of Hemolysis of RBCs (abnormal RBC peripheral smear), Elevated Liver enzymes (>70 IU/L for AST or ALT), Low Platelets (<100,000 μL ).
4. A 37-year-old female patient who is 36 weeks pregnant is diagnosed with mild preeclampsia. The nurse will include what information in the patient's education? Select all that apply: A. Report weight gain of >4 lbs in one week to physician B. Incorporate foods like eggs, nuts, fish, meat in your diet C. Follow a no salt diet D. Headache and vision changes are expected side effects of this condition and cause no reason for concern. E. Importance of monitoring urine protein at home F. Lying on left-side is recommended along with rest G. Report a decrease in fetal activity immediately
The answers are: B, E, F, and G. These options are topics the nurse wants to include in the patient's teaching with preeclampsia. Option A is wrong because the patient should report a weight gain of >2 lbs (NOT 4 lbs) in one week. Option C is wrong become it is no longer recommended the patient restrict salt in diet but limit it. Option D is wrong because a headache and vision changes are serious complications that may indicate the development of eclampsia, and the patient should report it immediately.
At 36 weeks, fundus is at diploid process TRUE OR FALSE
true
During 2nd and 3rd trimester fundal height in cm approx. equals fetal age in weeks + or - cm TRUE OR FALSE
true
Smoking during pregnancy can result in low birth weight, birth defects & still births TRUE OR FALSE
true
Substance abuse threatens normal fetal growth and successful completion of pregnancy. It places the pregnancy at risk for abrupt placentae ,fetal bradycardia. TRUE OR FALSE
true
