PRACTICE Q's LIFESPAN S22 FINAL
A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest. B. Platelet infusion. C. Immediate cesarean delivery. D. Labor induction with oxytocin.
A. Activity limited to bed rest. A. Activity limited to bed rest Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client's bleeding.
A mother tells the nurse that she is very worried because her 2-year old child does not finish his meals. What should the nurse advise the mother? A. make the child seat with the family in the dining room until he finishes his meal B. provide a quiet environment for the child before meals C. do not give snacks to the child before meals D. put the child on a chair and feed him
Correct Answer C. Do not give snacks to the child before meals. If the child is hungry he/she is more likely to finish his meals. Therefore, the mother should be advised not to give snacks to the child. Set times for meals and snacks and try to stick to them. A child who skips a meal finds it reassuring to know when to expect the next one. Avoid offering snacks or pacifying hungry kids with cups of milk or juice right before a meal — this can diminish their appetite and decrease their willingness to try a new food being offered.
During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? A. At the beginning of each fetal movement. B. At the beginning of each contraction. C. After every three fetal movements D. At the end of fetal movement.
Correct Answer: A. At the beginning of each fetal movement An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR.
The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A. Change the client's position. B. Prepare for an emergency cesarean section. C. Check for placenta previa. D. Administer oxygen.
Correct Answer: A. Change the client's position. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client's position from supine to side-lying may immediately correct the problem.
While the client is in active labor with twins and the cervix is 5 cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? A. Note the fetal heart rate patterns. B. Notify the physician immediately. C. Administer oxygen at 6 liters by mask. D. Have the client pant-blow during the contractions.
Correct Answer: B. Notify the physician immediately. The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.
Which of the following is the best method for performing a physical examination on a toddler A. From head to toe B. Distally to proximally C. From abdomen to toes, the to head D. From least to most intrusive
Correct Answer: D. From least to most intrusive When examining a toddler or any small child, the best way to perform the exam is from least to most intrusive. Stay at the child's level as much as possible. Do not tower. Examine painful areas last-get general impression of overall attitude. Be honest. If something is going to hurt, tell them that in a calm fashion.
TRUE or FALSE: A small muscular ventricular septal defect has a high probability of self-closure, and these types of VSDs are found in the lower portion of the ventricular septum.* True False
TRUE
During a prenatal visit, you are assessing the fundal height. You find the fundus of the uterus to be right above the symphysis pubis. Based on this finding the patient is about how far along in her pregnancy?* A. 20 weeks B. 12 weeks C. 16 weeks D. 24 weeks
The answer is B. At about 12 weeks of pregnancy, the fundal height can be found right above the symphysis pubis.
You're assessing a patient's chart and find that the patient is 36 weeks pregnant. Where should you find the fundus of the uterus during your assessment of fundal height?* A. midway between the umbilicus and xiphoid process B. about 4 cm below the xiphoid process C. at the xiphoid process D. 5 cm above the umbilicus
The answer is C. At 36 weeks of pregnancy, the fundal height should be at the xiphoid process.
A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): A. Sometimes uses vibroacoustic stimulation. B. Is an invasive test; however, contractions are stimulated. C. Is considered to have a negative result if no late decelerations are observed with the contractions. D. Is more effective than nonstress test (NST) if the membranes have already been ruptured.
Correct Answer: C. Is considered to have a negative result if no late decelerations are observed with the contractions. No late decelerations indicate a positive CST result.
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? A. Turn the neonate every 6 hours B. Encourage the mother to discontinue breastfeeding. C. Notify the physician if the skin becomes bronze in color. D. Check the vital signs every 2 to 4 hours.
D. Check the vital signs every 2 to 4 hours.
Normal lochial findings in the first 24 hours post-delivery include: A. Bright red blood B. Large clots or tissue fragments C. A foul odor D. The complete absence of lochia
Correct Answer: A. Bright red blood Lochia should never contain large clots, tissue fragments, or membranes. A foul odor may signal infection, as may absence of lochia.
When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: A. Prevent seizures. B. Reduce blood pressure. C. Slow the process of labor. D. Increase diuresis.
Correct Answer: A. Prevent seizures The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper-stimulated neurologic system by interfering with signal transmission at the neuromuscular junction.
An adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: A. Return preovulatory basal body temperature. B. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of cycle. C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. D. Breast tenderness and mittelschmerz.
Correct Answer: C. 3 full days of elevated basal body temperature and clear, thin cervical mucus. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus.
You're caring for a newborn who has Tetralogy of Fallot with severe cyanosis. You anticipate the newborn will be started on ___________?* A: Indomethacin B. Diclofenac C. Celecoxib D. Alprostadil
The answer is D. Alprostadil, prostaglandin E, will keep the ductus arteriosus open after birth. This will help with keeping the oxygen levels up because it allows more blood to flow to the lungs that is oxygenated via the ductus arteriosus. Remember this usually closes shortly after birth, but in a patient with severe Tetralogy of Fallot this opening needs to stay opened until surgery can be performed.
Which type of diabetes mellitus (DM) most likely results from heterogenous risk factors, making it preventable? A. Type 1 B. Type 2 C. Type 1 and 2 D. Gestational diabetes
Correct Answer: B. Type 2 Type 2 DM is a complex disorder of various causes with social, behavioral, and environmental risk factors. The disorder may be prevented by encouraging lifestyle modification for children at risk. Hyperglycemia results when there is a relative lack of insulin compared to glucose in the blood. In type 2 diabetes mellitus, insulin resistance first leads to increased insulin production by the beta cells of the pancreas. When the beta cells are unable to produce enough insulin to maintain euglycemia, hyperglycemia results.
Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? A. Low room humidity B. Cold weight scale C. Cool incubator walls D. Cool room temperature
Correct Answer: C. Cools incubator walls A common source of radiant heat loss includes cool incubator walls and windows. Radiant heat loss constitutes the transfer of heat from an infant's warm skin, via infrared electromagnetic waves, to the cooler surrounding walls that absorb heat.
A female adult patient is taking a progestin-only oral contraceptive or mini pill. Progestin use may increase the patient's risk for: A. Endometriosis B. Female hypogonadism C. Premenstrual syndrome D. Tubal or ectopic pregnancy
Correct Answer: D. Tubal or ectopic pregnancy Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies, possibly because progestin slows ovum transport through the fallopian tubes.
During a prenatal visit a patient tells you her last menstrual period was May 21, 2016. Based on the Naegele's Rule, when is the estimated due date of her baby?* A. February 27, 2016 B. March 19. 2017 C. February 28, 2017 D. April 16, 2016
February 28, 2017
A 30 year old female is 25 weeks pregnant with twins. She has 5 living children. Four of the 5 children were born at 39 weeks gestation and one child was born at 27 weeks gestation. Two years ago she had a miscarriage at 10 weeks gestation. What is her GTPAL?* A. G=7, T=4, P=0, A=1, L=5 B. G=7, T=4, P=1, A=1, L=5 C. G=6, T=4, P=0, A=1, L=5 D. G=6, T=2, P=2, A=1, L=5
G=7, T=4, P=1, A=1, L=5
The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A. "Nausea and vomiting can be decreased if I eat a few crackers before rising." B. "If I start to leak colostrum, I should cleanse my nipples with soap and water." C. "If I have a vaginal discharge, I should wear nylon underwear." D. "Leg cramps can be alleviated if I put an ice pack on the area."
A. "Nausea and vomiting can be decreased if I eat a few crackers before rising."
A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta. B. The ultrasound identifies blood flow through the umbilical cord. C. The test will determine where to insert the needle. D. The ultrasound locates a pool of amniotic fluid.
B. The ultrasound identifies blood flow through the umbilical cord. Correct Answer: B. The ultrasound identifies blood flow through the umbilical cord. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.
The nurse is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn? A. uneven head shape B. respirations are irregular, abdominal, 30-60 bpm C. (+) Moro reflex D. heart rate is 80 bpm
Correct Answer D. Heart rate is 80 bpm Normal heart rate of the newborn is 120 to 160 bpm. The high heart rate (120 to 160 beats per minute) seen in newborn infants can be attributed to the high metabolic rate of activity to main breathing, feeding, and thermogenesis.
A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense: A. Around the pelvic girdle B. Around the pelvic girdle and in the upper arms C. Around the pelvic girdle and at the perineum D. At the perineum
Correct Answer: A. Around the pelvic girdle During most of the first stage of labor, pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage, pain spreads to the upper legs and perineum. The pain of early labor is referred to T10-T12 dermatomes such that the pain is felt in the lower abdomen, sacrum, and back. This pain is dull in character and is not always sensitive to opioid drugs.
The multigravida mother with a history of rapid labor who is in active labor calls out to the nurse, "The baby is coming!" Which of the following would be the nurse's first action? A. Inspect the perineum. B. Time the contractions. C. Auscultate the fetal heart rate. D. Contact the birth attendant.
Correct Answer: A. Inspect the perineum When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client's statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques.
While examining a 2-year-old child, Nurse Victoria sees that the anterior fontanel is open. She should: A. Notify the doctor B. Look for other signs of abuse C. Recognize this as a normal finding D. Ask about a family history of Tay-Sachs disease
Correct Answer: A. Notify the doctor Because the anterior fontanel normally closes between ages 12 and 18 months, the nurse should notify the doctor promptly of this finding. The fontanel can enlarge in the first few months of life, and the median age of closure is 13.8 months. By three months of age, the anterior fontanel is closed in 1 percent of infants; by 12 months, it is closed in 38 percent; and by 24 months, it is closed in 96 percent.
Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why should the nurse monitor the patient's fluid intake and output closely during oxytocin administration? A. Oxytocin causes water intoxication. B. Oxytocin causes excessive thirst. C. Oxytocin is toxic to the kidneys. D. Oxytocin has a diuretic effect.
Correct Answer: A. Oxytocin causes water intoxication. The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication, leading to seizures, coma, and death. In addition, oxytocin may cause water intoxication via an antidiuretic hormone-like activity when administered in excessive doses with electrolyte-free solution.
While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client's fundus to: A. Prevent uterine inversion. B. Promote uterine involution. C. Hasten the puerperium period. D. Determine the size of the fundus.
Correct Answer: A. Prevent uterine inversion Using both hands to assess the fundus is useful for preventing uterine inversion. The recent uterine inversion with placenta already separated from it may often be replaced by manually pushing up on the fundus with the palm and fingers in the direction of the long axis of the vagina.
The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? A. Risk for deficient fluid volume related to hemorrhage. B. Risk for infection related to the type of delivery. C. Pain related to the type of incision. D. Urinary retention related to periurethral edema.
Correct Answer: A. Risk for deficient fluid volume related to hemorrhage Hemorrhage jeopardizes the client's oxygen supply — the first priority among human physiological needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over-diagnoses of Risk for Infection, Pain, and Urinary retention.
For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? A. The membranes must rupture. B. The fetus must be at 0 station. C. The cervix must be dilated fully. D. The patient must receive anesthesia.
Correct Answer: A. The membranes must rupture. Internal fetal heart rate monitoring uses an electronic transducer connected directly to the fetal skin. A wire electrode is attached to the fetal scalp or other body parts through the cervical opening and is connected to the monitor. Internal EFM can be applied only after the patient's membranes have ruptured when the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm.
In diagnosing seizure disorder, which of the following is the most beneficial? A. Skull radiographs B. EEG C. Brain scan D. Lumbar puncture
Correct Answer: B. EEG The EEG recognizes abnormal electrical activity in the brain. The pattern of multiple spikes can assist in the diagnosis of particular seizure disorders. Electroencephalography (EEG) is a biomarker for epilepsy. Focal or generalized epileptiform discharges constitute the EEG hallmark of seizure activity. Frequently EEG is obtained as a risk-stratification tool for a patient with a seizure of possibility of seizures.
When developing a plan of care for a male adolescent, the nurse considers the child's psychosocial needs. During adolescence, psychosocial development focuses on: A. Becoming industrious B. Establishing an identity C. Achieving intimacy D. Developing initiative
Correct Answer: B. Establishing an identity According to Erikson, the primary psychosocial task during adolescence is to establish a personal identity confusion. The adolescent attempts to establish a group identity by seeking acceptance and approval from peers and strives to attain a personal identity by becoming more independent from the family.
A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? A. Every 5 minutes. B. Every 15 minutes. C. Every 30 minutes. D. Every 60 minutes.
Correct Answer: B. Every 15 minutes During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary.
Will is being assessed by Nurse Lucas for possible intussusception. Which of the following would be least likely to provide valuable information? A. Abdominal palpation B. Family history C. Pain pattern D. Stool inspection
Correct Answer: B. Family history Because intussusception is not believed to have familial tendencies, obtaining a family history would provide the least amount of information. The causes of intussusception are not clearly known. About 90% of cases of intussusception in children arise from an unknown cause. They can include infections, anatomical factors, and altered motility.
A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient? A. Knowledge deficit B. Fluid volume deficit C. Anticipatory grieving D. Pain
Correct Answer: B. Fluid volume deficit If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Blood volume expands during pregnancy, and a considerable portion of the weight of a pregnant woman is retained water.
Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? A. Applying cold to limit edema during the first 12 to 24 hours. B. Instructing the client to use two or more peri pads to cushion the area. C. Instructing the client on the use of sitz baths if ordered. D. Instructing the client about the importance of perineal (Kegel) exercises.
Correct Answer: B. Instructing the client to use two or more peri pads to cushion the area Using two or more peripads would do little to reduce the pain or promote perineal healing. A fourth-degree perineal laceration is the injury to the perineum involving the anal sphincter complex and anorectal mucosa.
After 3 days of breastfeeding, a postpartum patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: A. Apply warm compresses to her nipples just before feeding. B. Lubricate her nipples with expressed milk before feeding. C. Dry her nipples with a soft towel after feeding. D. Apply soap directly to her nipples, and then rinse.
Correct Answer: B. Lubricate her nipples with expressed milk before feeding Measures that help relieve nipple soreness in a breastfeeding patient include lubricating the nipples with a few drops of expressed milk before feedings, applying ice compresses just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the nipples.
What is an appropriate indicator for performing a contraction stress test? A. Increased fetal movement and small for gestational age. B. Maternal diabetes mellitus and postmaturity. C. Adolescent pregnancy and poor prenatal care. D. History of preterm labor and intrauterine growth restriction.
Correct Answer: B. Maternal diabetes mellitus and postmaturity. The contraction stress test helps predict how the baby will do during labor. The test triggers contractions and registers how the baby's heart reacts. A normal heartbeat is a good sign that the baby will be healthy during labor.
A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? A. Placing the client in bed to begin fetal monitoring. B. Preparing for immediate delivery. C. Checking for ruptured membranes. D. Providing comfort measures.
Correct Answer: B. Preparing for immediate delivery. This question requires an understanding of station as part of the intrapartum assessment process. Based on the client's assessment findings, this client is ready for delivery, which is the nurse's top priority.
Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? A. Excessive vaginal bleeding B. Rigid, board-like abdomen C. Tetanic uterine contractions D. Premature rupture of membranes
Correct Answer: B. Rigid, board-like abdomen The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.
Hannah's child is scheduled for surgery due to myelomeningocele; the primary reason for surgical repair is which of the following? A. To prevent hydrocephalus B. To reduce the risk of infection C. To correct the neurologic defect D. To prevent seizure disorders
Correct Answer: B. To reduce the risk of infection Surgical closure decreases the risk of infection stemming from damage to the fragile sac, which can lead to meningitis. Prenatal surgery was proven to be more effective than postnatal surgery in lowering the occurrence of future complications.
The Foley Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition? A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle
Correct Answer: B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy The defects associated with tetralogy of Fallot include ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy. The exact embryological process that contributes to the development of tetralogy of Fallot still is unknown, but an association that had been observed is an anterior and cephalad deviation of the infundibular septum that results in a misaligned ventricular septal defect, with an overriding aortic root causing a subsequent right ventricular outflow obstruction.
Janae has a seizure disorder; which of the following would be the lowest priority when caring for her? A. Observing and taking down data on all seizures B. Assuring safety and protection from injuring C. Assessing for signs and symptoms of increased intracranial pressure (ICP) D. Educating the family about anticonvulsant therapy
Correct Answer: C. Assessing for signs and symptoms of increased intracranial pressure (ICP) Signs and symptoms of increased intracranial pressure (ICP) are not associated with seizure activity and therefore would be the lowest priority. A sudden alteration in consciousness with associated motor movements is the common description of a convulsive seizure. For generalized seizures with associated motor movements, the convulsion typically has a stiffening or tonic phase followed by clonic movements - rhythmic phased motor movements.
The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day. B. Wearing a supportive brassiere with nipple shields. C. Breastfeeding the neonate at frequent intervals. D. Decreasing fluid intake for the first 24 to 48 hours.
Correct Answer: C. Breastfeeding the neonate at frequent intervals Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate's and mother's needs.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? A. Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking. B. Hold the infant's head firmly against the breast until he latches onto the nipple. C. Encourage the mother to stop feeding for a few minutes and comfort the infant. D. Provide a formula for the infant until he becomes calm, and then offer the breast again.
Correct Answer: C. Encourage the mother to stop feeding for a few minutes and comfort the infant. The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often more successful.
A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? A. Altered nutrition, less than body requirements for lactation. B. Alteration in comfort related to nausea and abdominal distention. C. Impaired bowel motility related to pain medication and immobility. D. Fatigue related to cesarean delivery and physical care demands of infant.
Correct Answer: C. Impaired bowel motility related to pain medication and immobility Impaired bowel motility caused by surgical anesthesia, pain medication, and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.
Preferred nurses at the Nurseslabs Medical Center are about to perform a procedure related to a genitourinary (GU) problem to a group of pediatric patients. Which of the following groups would find it especially extra stressful? A. Infants B. Toddlers C. Preschoolers D. School-age children
Correct Answer: C. Preschoolers In general, preschoolers have more fears because of their fantasies, contributing to fears of the simplest procedures. Castration fears are also prominent at this age and may be heightened by procedures related to GU problems. The human brain is wired to alert us to and protect us from danger. Back in the day, that could mean a panther or wolf attack—so some trepidation around furry creatures is clearly in order. While babies and toddlers are usually scared of animals, too, things get turned up a notch when an active imagination kicks in at this age, explains Dr. Chansky.
A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? A. Proteinuria, headaches, vaginal bleeding B. Headaches, double vision, vaginal bleeding C. Proteinuria, headaches, double vision D. Proteinuria, double vision, uterine contractions
Correct Answer: C. Proteinuria, headaches, double vision A patient with pregnancy-induced hypertension complains of a headache, double vision, and sudden weight gain. A urine specimen reveals proteinuria.
Veronica's parents were told that their daughter needs ribavirin (Virazole). This drug is used to treat which of the following? A. Cystic fibrosis B. Otitis media C. Respiratory syncytial virus (RSV) D. Bronchitis
Correct Answer: C. Respiratory syncytial virus (RSV) Ribavirin is an antiviral medication used for treating RSV infection and for children with RSV who are compromised (such as children with bronchopulmonary dysplasia or heart disease). There is a single antiviral medication approved for use against RSV in the United States, ribavirin. It is a nucleoside analog with application in several RNA viruses, and it shows in vitro activity against RSV and may be administered in aerosolized form.
Appropriate intervention is vital for many children with heart disease in order to go on to live active, full lives. Which of the following outlines an effective nursing intervention to decrease cardiac demands and minimize cardiac workload? A. Feeding the infant over long periods B. Allowing the infant to have her way to avoid conflict C. Scheduling care to provide for uninterrupted rest periods D. Developing and implementing a consistent care plan
Correct Answer: C. Scheduling care to provide for uninterrupted rest periods Organizing nursing care to provide for uninterrupted periods of sleep reduces cardiac demand. Allow for rest periods between care; disturb only when necessary for care and procedures. This promotes rest and conserves energy.
The nurse is assessing a 9-month-old boy for a well-baby check-up. Which of the following observations would be of most concern? A. The baby cannot say "mama" when he wants his mother. B. The mother has not given him finger foods. C. The child does not sit unsupported. D. The baby cries whenever the mother goes out.
Correct Answer: C. The child does not sit unsupported. Over 90% percent of babies can sit unsupported by nine months. At 4 months, a baby typically can hold his/her head steady without support, and at 6 months, he/she begins to sit with a little help. At 9 months he/she sits well without support, and gets in and out of a sitting position but may require help.
Nurse Henry admits a child with suspected type 1 DM; Which of the following questions should the nurse ask the parents? A. "Does the child complain of headache?" B. "How much exercise does the child get?" C. "Has the child's number and type of bowel movements changed?" D. "Has the child experienced nocturia or bedwetting?" E. "How much candy and sweets does your child take daily?"
Correct Answer: D. "Has the child experienced nocturia or bedwetting?" Bedwetting in children who have previously stayed dry at night is often an early sign of diabetes. Type 1 diabetes is a disease when the pancreas that produces insulin and helps get sugars (glucose) into the cells does not produce insulin. As most children with type 1 diabetes are otherwise healthy, history and physical health is usually limited to the assessment of pertinent diabetes care.
A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseated." C. "This test will help to determine whether the baby has Down syndrome or a neural tube defect." D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."
Correct Answer: D. "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.
A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first? A. Pad the side rails. B. Place a pillow under the left buttock. C. Insert a padded tongue blade into the mouth. D. Maintain a patent airway.
Correct Answer: D. Maintain a patent airway The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.
The nurse answers a call bell and finds a frightened mother whose child, the patient, is having a seizure. Which of these actions should the nurse take? A. The nurse should insert a padded tongue blade in the patient's mouth to prevent the child from swallowing or choking on his tongue. B. The nurse should help the mother restrain the child to prevent him from injuring himself. C. The nurse should call the operator to page for seizure assistance. D. The nurse should clear the area and position the client safely.
Correct Answer: D. The nurse should clear the area and position the client safely. The primary role of the nurse when a patient has a seizure is to protect the patient from harming him or herself. Support head, place on soft area or assist to the floor if out of bed. Supporting the extremities lessens the risk of physical injury when the patient lacks voluntary muscle control.
A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? A. Active phase B. Latent phase C. Expulsive phase D. Transitional phase
Correct Answer: D. Transitional phase The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient.
The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? A. Active phase B. Complete phase C. Latent phase D. Transitional phase
Correct Answer: D. Transitional phase The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds.
While feeding a 3-month-old infant, who has Tetralogy of Fallot, you notice the infant's skin begins to have a bluish tint and the breathing rate has increased. Your immediate nursing action is to?* A. Continue feeding the infant and place the infant on oxygen. B. Stop feeding the infant and provide suction. C. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen. D. Assess the infant's heart rate and rhythm.
The answer is C. The patient is experiencing a "tet spell". This is where during any type of activity like feeding, crying, playing etc. the child's heart (due to Tetralogy of Fallot) is unable to maintain proper oxygen levels in the blood (these activities place extra work on the heart and it can't keep up).
As the nurse you know which statements are TRUE about Tetralogy of Fallot? Select all that apply:* A. "Tetralogy of Fallot is a cyanotic heart defect." B. "In this condition the heart has to work harder to pump blood to the lungs, which cause the right ventricle to work harder and enlarge." C. "Tetralogy of Fallot is treated with only palliative surgery." D. "Many patients with this condition will experience clubbing of the nails."
The answers are A, B, and D. Option C is wrong because this condition can be treated with both palliative surgery (used to help alleviate symptoms until the child is old enough for complete repair) and complete repair. All the other options are correct.
