Week 5
The nurse palpates the abdomen of a pregnant patient and reports that the fetus lies in longitudinal position with cephalic presentation. Which observation enabled the nurse to report about the fetal position?
"I am worried a lot this time; I had a lot of problems in my last labor."
The parents of a 2-year-old child are watching the nurse administer the Denver II Development Screening Test to their child. They ask, "why did you make our child draw on paper? We don't let our child draw at home." Which is the best responses by the nurse?
"It lets us test the child's ability to perform tasks requiring the hands."
The nurse is assessing a couple as part of a prenatal interview. On assessment, the nurse finds that the patient has previously undergone uterine surgery for fibroids. What will the nurse tell the patient?
"You may need a cesarean to deliver the baby."
The first day of a client's last menstrual period was July 22. Which is the estimated date of birth?
April 29
Which would the nurse identify as a group of hospitalized toddlers' most important need?
Contact with their parents
The nurse is caring for a 24-hour-postpartum patient who had a cesarean birth with general anesthesia. The patient complains of abdominal discomfort and gas pains. What would be the most suitable nursing intervention in this situation?
Encourage the patient to use a rocking chair.
Identify the most important reason why medications used to treat acquired immunodeficiency syndrome (AIDS) become ineffective?
Missing doses of the prescribed medications
The nurse on the pediatric unit is observing the development skills of several 2-year-old children in the playroom. Which child would the nurse continue to evaluate?
One who exhibits echolalia when speaking
The nurse advises an alcoholic patient to stop consuming alcohol during pregnancy. The reason for this could be to prevent what?
Teratogenic effect in the fetus
Which type of prehension is exhibited by a 5-month-old infant?
The grasp is palmar
The nurse is assessing a pregnant patient who is gained 25kg in the third trimester of pregnancy. The nurse informs the patient that this weight gain is expected. What conditions would have led the nurse to consider this weight gain normal?
The patient has a pregnancy with multiple fetuses
After delivery, the primary health care provider (PHP) prescribes Rh immune globulin to a postpartum patient. The nurse asks the PHP. "What is the purpose of this medication?" Which is the best response by the PHP?
"It protects the patient's next baby from developing affected Rh incompatibility."
The nurse is assessing a patient who has an unplanned pregnancy, The patient says to the nurse, "My partner is not happy that I'm pregnant." What should be a relevant response by the nurse?
"Your partner should be given adequate time to adapt to the idea of having a baby."
The nurse is caring for a patient in labor with a history of sexual abuse. What interventions should the nurse preform while caring for the patient?
-Explain the need of the procedures. -Limit the number of invasive examinations. -Obtain the patient's permission to touch her.
The client reports difficulty in breathing. The nurse auscultates lung sounds and assesses the respiratory rate. Which is the purpose of the nurse's action?
Data collection
Which treatment would the nurse anticipate for an infant admitted with bronchiolitis caused by respiratory syncytial virus (RSV)?
Humidified cool air and adequate hydration
On examining a patient who gave birth 5 hours ago, the nurse finds that the patient has completely saturated a perineal pad within 15 minutes. What should be the nurses first action?
Massage the woman's fundus.
Which type of play do 2-year-old toddlers engage in?
Parallel
The primary health care provider has asked the nurse to administer varicella vaccine (Varivax) to a postpartum patient on the day of discharge from the hospital. What instruction does the nurse give the patient before administering the vaccine?
-"You must return for a second dose in 4 to 8 weeks." -"Use contraception for 1 month to avoid pregnancy."
Several 3-year-old girls in the daycare enter are having a tea party with their dolls. This is an example of which behavior?
Appropriate make-believe play
Which clinical finding is associated with high-dose lead exposure?
Blindness
Which ethnic group has a greater incidence of osteoporosis due to musculoskeletal differences?
Chinese Americans
A 2-year-old toddler is to have IV antibiotic therapy. Which action will the nurse take to prevent the child from pulling the IV line?
Cover the IV site with a protective device
Evidence-based care practices designed to support normal labor and birth recommended which practice during the immediate newborn period?
Encourage skin-to-skin contact of mother and baby.
A 13-year-old adolescent is found to have idiopathic scoliosis. Because exercise and avoidance of fatigue are essential components of care, which sport would the nurse suggest as the most therapeutic for this preadolescent?
Swimming
Upon assessment, the nurse suspects that a pregnant patient has potential complications during the early phase of labor. Which signs in the patient correspond to the nurses suspicion?
-Intrauterine pressure of 85 mm Hg -Uterine contractions lasting for 92 seconds -Relaxation between UCs lasting for 25 seconds
A pregnant patient calls the nurse on the tele[hone and states that she is having severe pain in her uterus. The patient also tells the nurse that she is worried about having early labor. Which actions are most appropriate for the nurse to preform in this situation?
-Suggest that the patient come to the hospital immediately. -Ask the patient to contact the primary health care provider (PHP). -Record the time of call and advice given to the patient in the patient's record
Which step of the nursing process is directly affected if the nurse does not make a nursing diagnosis?
Planning
Which toys would the nurse suggest to the parent of a 4-month-old infant to help promote the child's growth and development?
Soft squeeze toys
After reviewing the laboratory reports of a pregnant patient at term, the primary health care provider (PHP) advised the nurse to administered IV fluids to the patient. What is the reason for giving such advice?
Dehydration
The nurse is planning to administer a modified bacteria immunization to a preschool child. Which agent will be administered?
A vaccine
A client at the fertility clinic is being treated for hypertension and obesity and has lost 8lb (3.6kg) in the past month, and her blood pressure has decreased to 154/98 mmHg. She states she is using self control strategies to achieve these improvements. Which would be a therapeutic response by the nurse?
Acknowledging the client's achievement while encouraging continuation of her current program
In a child with lead poisoning, where is lead stored while remaining inert?
Bones
The nurse is caring for a newly admitted nulliparous patient in the ninth month of pregnancy. What should the nurse do to provide effective care?
Explain the various labor stages to the patient
During the first trimester of pregnancy, a patient reports nasal stuffiness and nose bleeding. What does the nurse identify as the probable reason?
High estrogen level
The nurse is caring for a patient during the fourth stage of labor. After assessment, the nurse finds that the patient lost 600mL of blood. The nurse also finds that the patient uterus is soft and relaxed. Which postpartum complication has the patient developed?
Postpartum hemorrhage
The nurse is teaching a birthing/prenatal class about breast-feeding. Which hormone stimulates the production of milk during lactation?
Prolactin
Which nursing intervention would the nurse direct toward a child admitted for acute glomerulonephritis?
Promoting diuresis
Which statement by the nurse is true about health promotion in infants and toddlers?
Remove grocery plastic bags from the home.
The nurse is assessing blood loss in a postpartum patient by observing the perineal pad. The nurse finds that 1.5cm of the pad is saturated. What patient clinical observation should the nurse infer from this finding?
Scanty bleeding