transitions exam 2
After a precipitous delivery, the nurse notes that the new mother is passive and only touches her newborn briefly with her fingertips. The nurse should do which to help the woman process what has happened?
Support the mother in her reaction to the newborn.
The nurse should monitor for which signs associated with respiratory distress syndrome (RDS) in a preterm newborn?
Tachypnea and retractions.
The nurse is assisting with caring for a client with abruptio placentae. While caring for the client, the nurse notes the client begins to develop signs of shock. The nurse should take which action first?
Turn the client on her side.
The nurse is the newborn nursery receives a telephone call to prepare for admission of a neonate born at 34 weeks gestation with Apgar scores of 1 and 4. When planning for the admission of this infant, which is the nurses highest priority?
Connecting the resuscitation bag to the oxygen outlet.
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.
Contact Airborne
Desmopressin acetate is prescribed for the treatment of diabetes insipidus. The nurse monitors the client after medication after medication administration for which therapeutic response?
Decreased urinary output.
A primigravida's membranes rupture spontaneously. Which action should the nurse take first?
Determine the fetal heart rate.
A client is taking Humulin NPH insulin daily every morning. The nurse reinforces instructions to the client and should tell the client that which is the most likely times for a hypoglycemic reaction to occur?
6-14 hours after administration.
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 client is admitted to the labor suite complaining of painless vaginal bleeding. The nurse assists with the examination of the client, knowing that which routine labor procedure is contraindicated?
A manual pelvic examination
The nurse is reinforcing instructions to a new mother about cord care and how to monitor for the presence of an infection. The nurse should tell the mother that which is a sign of infection?
A moist cord with discharge.
The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn infant after admission to the nursery. The nurse suspects fetal alcohol syndrome (FAS) and is aware that which of the following additional signs would be consistent with FAS?
Abnormal palmar creases
Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.
Frequent handwashing is important. The child should avoid exposures to other illnesses. Clean up body fluid spills with bleach solution (10:1 ration of water to bleach).
The homecare nurse visits a client recently diagnosed with diabetes mellitus wo is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should provide which information?
Refrigerate the insulin.
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 nurse manager is observing the actions of a nurse she is supervising. Which of the following actions by the nurse requires the nurse manager to intervene? Select all that apply.
Reviewing the health care record of a client assigned to another nurse. Making a copy of the clients most current laboratory results for the provider during rounds. Providing information about a clients condition to hospital clergy. Participating in walking rounds that involve the exchange of client-related information outside client's rooms.
The nurse is assigned to assist with caring for a client who has been admitted to the labor unit. The client is 9 cm dilated and is experiencing precipitous labor. What is the priority nursing action?
Keep the client in a side-lying position.
A child is diagnosed with scarlet fever. A nurse collects data regarding the child. Which of the following is a clinical manifestation of scarlet fever?
Pastia's sign.
The home care nurse visits a client at home who has been prescribed prednisone 5 mg orally daily. The nurse reinforces teaching for the client about the medication. Which statement made by the client indicates need for further teaching?
"I can take aspirin or my antihistamine if I need it."
A pregnant (HIV)-positive woman delivers a baby. The nurse provides guidance to help the client make decisions regarding newborn care. Which statement by the woman indicated the additional guidance needed?
"I will breastfeed especially for the first 6 weeks postpartum."
The nurse reviews measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching?
"I will have my child wear dark colored clothing so the tick will not be attracted to the colors."
The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?
"I will not let my child play with other children who have the flu unless they are taking acetaminophen."
A client ask 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 is monitoring a client receiving levothyroxine for hypothyroidism. Which findings indicate the presence of a side effect associated with this medication? Select all that apply.
Insomnia. Weight loss. Mild heat intolerance.
A 6-month-old infant receives a (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report 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 nurse witnesses and assistive personnel (AP) under her supervision reprimanding a client for not using the urinal properly. The AP threatens to put a diaper on the client if he doesn't use the urinal more carefully next time. Which of the following torts is the AP committing?
Assault.
The nurse is collecting data from a client who has been diagnosed with placentae previa. Which findings should the nurse expect to note? Select all that apply.
Bright red vaginal bleeding Soft, relaxed, nontender uterus
A nurse is reviewing a clients health care record and discovers that the clients DNR prescription has expired. The clients condition is not stable. Which of the following actions should the nurse take?
Call the provider to determine whether the prescription should be immediately reinstated.
A nurse is caring for a client who is scheduled for surgery. The client hands the nurse information about advanced directives and states, "here, I don't need this. I am too young to worry about life-sustaining measure and what I want done for me." Which of the following actions should the nurse take?
Contact client representative to talk with the client and offer additional information about the purpose of advances directives.
The nurse is assisgned to assist with caring for a client who is being admitted to the birthing center in early labor. During admission, which action should the nurse take initially?
Determine the maternal and fetal vital signs.
After birth the nurse prevent hypothermia as a result of evaporation by performing which action?
Drying the baby with a warm blanket,
Which findings indicate to the nurse that placental separation has occurred? Select all that apply
Lengthening of umbilical cord Sudden trickle or spurt of blood Fetal membranes are seen at the introitus
A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristics of chicken pox?
Macular rash on the trunk and scalp.
The nurse is assigned to assist with caring for a neonate born to a mother who is (HIV)-positive, The nurse understands that which should be included in the plan of care?
Maintaining standard precautions at all times while caring for the neonate.
The nurse is preparing to care for a newborn who is receiving phototherapy. Which measure should be implemented? Select all that apply.
Monitor the skin temp closely. Reposition the newborn every 2 hours. Cover the newborns eyes with shields or patches.
A nurse manager is providing information to the nurses on the unit about ensuring client rights. Which of the following regulations outlines the rights of individuals in health care settings?
Patient care partnership.
A client with diabetes mellitus visits a healthcare clinic. The clients diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 mg/dl to 200 mg/dl. Which medication added to the clients regimen, may have contributed to the hyperglycemia?
Prednisone.
The nurse is assigned to assist with caring for a client with abruptio placentae who is experiencing vaginal bleeding. The nurse collects data from the client, knowing that abruptio placentae is accompanied by which additional finding?
Uterine tenderness on palpation
A nurse is serving as a preceptor to a newly licensed nurse and is explaining the role of the nurse as advocate. Which of the following situations illustrates the advocacy role? (Select all that apply.)
Verifying that a client understands what is done during a cardiac catheterization Informing members of the health care team that a client has do-not-resuscitate status Reporting that a health team member on the previous shift did not provide care as prescribed
A newly licensed nurse is preparing to insert an IV catheter in a client. Which of the following sources should the nurse use to review the procedure and the standard at which it would be performed?
institutional policy and procedure manual.
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."
Glimepiride is prescribed for a client with diabetes mellitus. The nurse reinforces instructions for the client and tells the client to avoid which while taking this medication?
Alcohol.
The homecare nurse is visiting a client who was recently diagnosed with type 2 diabetes mellitus. The client, prescribed repaglinide and metformin, asks the nurse to explain these medications. The nurse should reinforce which instructions to the client? Select all that apply.
Diarrhea can occur secondary to metformin. The repaglinide is not taken is a meal is skipped. The repaglinide is taken 30 minutes before eating. Candy of another simple sugar is carried and used to treat mild hypoglycemia episodes.
A newborn has just been circumcised and is being discharged home in 2 hours. Which instructions should be provided by the nurse to the parents? Select all that apply.
Do not wash the penis with soap until the circumcision has healed, which takes 5-6 days. Change diapers every4 hours or more often to inspect the penis for drainage or infection. Monitor the circumcision; penis may appear reddened with small amount of bloody drainage shortly after the procedure.
The client who is being prepared for a cesarean delivery is brought to the delivery room. To maintain the optimal perfusion of oxygenated blood to the fetus, the nurse should place the client in which position?
Supine position with a wedge under the right hip.
Leopold's maneuvers will be performed on a pregnant client. The client ask the nurse about the procedure. Which information should the nurse provide to the client about Leopold's maneuvers?
The maneuvers are a systematic method for palpating the fetus through the maternal abdominal wall.
The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse knows that which is the most appropriate intervention?
The medication is withheld and the PHCP is called to question the prescription for the client.
A woman in active labor has contractions every 2 to 3 minutes that last for 45 seconds. The fetal heart rate between contractions is 100 beats per minute. On the basis of these findings, the priority nursing intervention is to:
Notify the RN immediately
A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about care of the child. Which instruction should the nurse provide to the parents?
Notify the physician if the child develops abdominal of left should pain.
The nurse is planning to reinforce instructions about cord care to a new mother. The nurse should plan to tell the mother about which cord care?
The process of keeping the cord clean and dry will decrease bacterial growth.
A nurse is caring for a toddler who is being treated in the emergency department following a head contusion for a fall. History reveals the toddler lives at home with only her mother. The child's discharge instructions include waking the child every hour to assess for indications of a possible head injury. In which of the following situations should the nurse intervene and attempt to prevent discharge?
The nurse smells alcohol on the mothers breath.
The nurse is caring for a client who is in labor. The nurse rechecks the client's blood pressure and notes that it has dropped. To decrease the incidence of supine hypotension the nurse should encourage the client to remain in which position?
Side-lying
The nurse is reinforcing teaching for a client regarding how to mix regular insulin and NPH insulin in the same syringe. Which action performed by the client indicates the need for further teaching?
Withdraws the NPH insulin first.
A pregnant woman has a positive history of genital herpes, but she has not had lesions during her pregnancy. The nurse plans to provide which information to the client?
"You will be evaluated at the time of delivery for herpetic genital tract lesions. If they are present, a cesarean delivery will be needed."
The nurse administers erythromycin ointment (0.5%) to the newborns eyes and the mother asks the nurse why this is done. The nurse should give which response to the client?
Prevents ophthalmia neonatorum from occurring after delivery to a neonate born to a woman with an untreated gonococcal infection.
The nurse is assigned to care for a client who is in early labor. When collecting data from the client, which should the nurse check first?
Baseline fetal heartrate.
The nurse is reinforcing measures regarding the care of the newborn with a mother. To bathe the newborn, the mother should be taught which intervention?
Begin with the eyes and face.
The nurse is caring for a post-term neonate immediately after admission to the nursery. The priority nursing action should be to monitor which clinical parameter?
Blood glucose level.
