Peds/ maternity
A couple comes to the family planning clinic and asks about sterilization procedures. Which question by the nurse helps determine whether this method of family planning is appropriate?
"Do you plan to have any other children?"
The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?
"I need to take my child's rectal temperature daily."
The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a parent indicates the need for further teaching?
"I understand that I need to leave the scabicide on for 4 hours before washing it off."
The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?
"I will avoid immunizations and dental hygiene treatments for my child."
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."
The client at 28 weeks' gestation is Rh negative and Coombs antibody negative. The nurse determines that the client understands what the nurse has taught her about Rh sensitization when the client makes which statement?
"I will tell the nurse at the hospital that I had an Rh shot during pregnancy."
The nursing instructor asks a nursing student to describe the process of quickening. Which statement indicates an understanding of this term?
"It is the fetal movement that is felt by the mother."
The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching?
"PKU primarily affects the gastrointestinal system."
The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need for further teaching?
"The child does not experience pain at the primary tumor site."
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."
The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.
- A delay in growth may occur after a burn injury. - An immature immune system presents an increased risk of infection for infants and young children. - Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.
The nurse is checking a client's record for probable signs of pregnancy. Which are the probable signs of pregnancy that the nurse would note? Select all that apply.
- Ballottement - Chadwick's sign - Uterine enlargement - Braxton Hicks contractions
The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply.
- Firm, nontender, irregular mass in the abdomen - Urinary frequency or retention from compression on the bladder
The nurse working in a prenatal clinic reviews a client's chart and notes that the primary health care provider documents that the client has a gynecoid pelvis. The nurse plans care understanding that which findings are characteristic of this type of pelvis? Select all that apply.
- Round shape - Diagonal conjugate measures 12.5 cm to 13 cm - Blunt, somewhat widely separated ischial spines
The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which would be included in the list? Select all that apply.
- Siblings may also need treatment. - Grooming items such as combs and brushes should not be shared. - Launder all the bedding and clothing in hot water and dry on high heat. - Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits.
During a prenatal visit, the nurse checks the fetal heart rate (FHR) of a client in the third trimester of pregnancy. The nurse determines that the FHR is normal if which heart rate is noted?
150 beats per minute
A pregnant client asks the nurse in the clinic when she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal movements will be noted between which weeks of gestation?
16 and 20 weeks' gestation
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 would expect which finding?
26 cm
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 primary 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 topical corticosteroid is prescribed by the primary health care provider for a child with atopic dermatitis (eczema). Which instruction would the nurse give the parent about applying the cream?
Apply a thin layer of cream and rub it into the area thoroughly.
A primary health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?
Checks the amount of urine output
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
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
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 would the nurse tell the child?
Drink a half a cup of orange juice before soccer practice.
The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention would be incorporated into the plan of care?
Encourage quiet play activities.
The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse would instruct the mother to take which action?
Encourage the child to drink liquids.
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 reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching?
Fluid overload
An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings would the nurse expect to note?
Fruity breath odor and decreasing level of consciousness
The nurse is collecting data from a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks, and she tells the nurse that she does not have a history of any type of abortion or fetal demise. The nurse would document which as the GTPAL for this client?
G = 2, T = 1, P = 0, A = 0, L = 1
The nurse is collecting data from a client who is pregnant with triplets. The client also has a 3-year-old child who was born at 39 weeks' gestation. The nurse would document which gravida and para status on this client?
Gravida II, para I
The nurse is preparing to administer beractant to a premature infant who has respiratory distress syndrome. The nurse plans to administer the medication by which route?
Intratracheal
The nurse is reinforcing teaching to a pregnant woman about the physiological effects and hormonal changes that occur during pregnancy. The woman asks the nurse about the purpose of estrogen. The nurse bases the response on which purpose of estrogen?
It stimulates uterine development to provide an environment for the fetus and stimulates the breasts to prepare for lactation.
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, 2022. Using Nägele's rule, the nurse determines the estimated date of birth is which date?
July 27, 2023
The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?
Notify the registered nurse (RN).
A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and would question which intervention that is written in the plan?
Palpate the abdomen for a mass.
The nurse is reinforcing discharge instructions to the parents of a 2-year-old child who had an orchiopexy procedure done to treat cryptorchidism. The nurse would determine the parents understood the discharge instructions if they state which play activity is best for the child after this procedure?
Playing with clay
The client asks the nurse about the purpose of the placenta. The nurse plans to respond to the client knowing which about the placenta?
Provides an exchange of nutrients and waste products between the mother and the fetus
The nurse notes that a 6-year-old child does not recognize that objects exist when the objects are outside of the visual field. Based on this observation, which action would the nurse take?
Report the observation to the primary health care provider.
A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions. The nurse determines that the client is experiencing Braxton Hicks contractions. Based on this finding, which nursing action is appropriate?
Tell the client that these are common and they may occur throughout the pregnancy.
The client is undergoing an amniocentesis at 16 weeks' gestation to detect the presence of biochemical or chromosomal abnormalities. Which instructions would the nurse reinforce to the client?
The bladder must be full during the examination.
The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching?
The mother administered the iron with milk.
The nurse is describing the process of fetal circulation to a client during a prenatal visit. The nurse would tell the client that fetal circulation consists of which components?
Two umbilical arteries and one umbilical vein
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 would make?
Where fertilization occurs
The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?
White sacs attached to the hair shafts in the occipital area
