Maternal Newborn Nursing Questions, Exams of Nursing

Download Maternal Newborn Nursing Questions and more Exams Nursing in PDF only on Docsity! Maternal Newborn A nurse is caring for a client who has hyperemesis gravidarum and is receiving IV fluid replacement. Which of the following findings should the nurse report to the provider? a. BUN 25 mg/dL b. serum creatinine 0.8 mg/dL c. urine output of 280 mL w/ 8 hr d. urine negative for ketones A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which statement should the nurse include in the teaching? a. replace the diaphragm every 5 years b. leave the diaphragm in place for at least 6 hours after intercourse c. use an oil-based product as a lubricant when inserting the diaphragm d.insert the diaphragm when bladder is full A nurse is reviewing the med record of a client who is postpartum and has preeclampsia. Which lab results should the nurse report to the provider? a. Hct 39% b. serum albumin 4.5g/dL c. WBC 9000/mm3 d. platelets 50,000/mm3 A nurse is teaching a client about Rho(D) immune globulin. Which statement by the client indicates an understanding of the teaching? a. I will receive this med if my baby is Rh- b. I will receive this med when I'm in labor c. I will need a 2nd dose of this med when my baby is 6wks old d.I will need this med if I have an amniocentesis A nurse is assessing a client who is 30 weeks gestation during a routine prenatal visit. Which findings should the nurse report to the provider? a.swelling of the face b.varicose veins in the calves c.nonpitting 1+ ankle edema d.hyperpigmentation of the cheeks A nurse is developing a plan of care for a newborn who is to undergo phototherapy for hyperbilirubinemia. Which actions should the nurse include in the plan? a. feed the newborn 1oz of water q4hrs b. apply lotion to newborns skin 3x/day c. remove all clothing from newborn except diaper d. discontinue therapy if the newborn develops a rash A nurse is caring for a client who is 35 weeks gestation and is undergoing nonstress test that reveals a variable deceleration in the FHR. What action should the nurse take? a. give the client oj b. elevate the client's legs c. have the client change positions d. establish IV access A nurse is assessing a client who gave birth vaginally 12hrs ago and palpates her uterus to the right above the umbilicus. What interventions should the nurse perform? a. reassess the client in 2 hrs b. administer simethicone c. assist the client to empty her bladder d. instruct the client to lie on her right side A nurse is performing a routine assessment on a client who is 18 weeks gestation. What findings should the nurse expect? a. deep tendon reflexes 4+ b. fundal height 14cm c. urine protein 2+ d. FHR 152/min A nurse is teaching a new mother about steps the nurses will take to promote security and safety of the newborn. What statement should the nurse make? a. we will prevent unidentified visitors from entering the unit b. we will document the relationship of visitors in your medical record c. your baby will stay in the nursery while you are asleep d. staff members who take care of your baby will be wearing photo identification A nurse is assessing the newborn of a client who took a SSRI during pregnancy. What manifestations should the nurse identify as an indication of withdrawal from and SSRI? a. large for gestational age b. Hyperglycemia c. bradypnea d. vomiting A nurse in an antepartum clinic is providing care for a client who is 26 weeks gestation. Upon reviewing her medical record, what findings should the nurse report to the provider? a. 1-hr glucose tolerance test b. Hematocrit c. fundal height measurement d .FHR A nurse is caring for a client following an amniocentesis at 18 wks gestation. What finding should the nurse report to the provider as a potential complication? a. increased fetal movement b. leakage of fluid from the vag c. upper abd discomfort d. urinary frequency A nurse is caring for a client who is in active labor and has no cervical change in the last 4 hrs. Which statement should the nurse make? a. let me help you into a comfortable pushing position so you can begin bearing down b. going to call the doc to get a script for meds to ripen your cervix c. i will give you some IV pain med to strengthen your contractions d. your provider will insert an intrauterine pressure cath to monitor the strength of your contractions A nurse is caring for a client who is anemic at 32 wks gestation and is in preterm labor. The provider prescribed betamethasone 12 mg IM. What outcomes should the nurse expect? a. decrease uterine contractions b. increase in client's Hgb levels c. reduction in resp distress in NB d. increase production of antibodies in NB A nurse is teaching a client who is 10 wks gestation about nutrition during pregnancy. What statement by the client indicates an understanding of the teaching? a. increase my protein to 60 g/day b. i should drink 2 L of water/day c. increase my overall caloric intake by 300 calories d. take 600 mcg of folic acid each day A nurse is teaching a client who is in preterm labor about terbutaline. What statement by the client indicates an understanding of the teaching? a.i will get injections of the med once daily until my labor stops b.my blood sugar may be low while I am on this med c. i will have blood tests because my K+ might decrease d. My BP may increase while I'm on this med A nurse is creating a plan of care for a client who is postpartum and adheres to traditional Hispanic cultural beliefs. What cultural practices should the nurse include? a. protect the client's head and feet from cold air b. bathe the client within 12 hr following delivery c. ambulate the client within 24 hr of delivery d. offer the client a glass of milk with her first meal A nurse on a postpartum unit is caring for a client who is experiencing hypovolemic shock. After notifying the provider, what action should the nurse take next? a. massage the client's fundus b. insert an indwelling urinary catheter c. administer O2 at 10L/mind d. elevate the clients right hip A nurse is caring for a client who is at 36 wks gestation and has a prescription for amniocentesis. For which reason should the nurse prepare the client for an ultrasound? a. estimate fetal weight b. locate pocket of fluid c. determine multiparity d. prescreen for fetal anomalies A nurse is demonstrating to a client how to bathe her newborn. What order should the nurse perform the following actions? a.clean the NB diaper area b.wash the newborn's neck by lifting the NB chin c.wipe the NB eyes from the inner canthus outward d.cleanse the skin around the newborn's umbilical cord stump e.wash the NB legs and feet A nurse is assessing a newborn 12hrs after birth. What manifestation should the nurse report to the provider? a. Acrocyanosis b. transient strabismus c. jaundice d. caput succedaneum b. cover your baby with a light blanket while sleeping c. check the temp of the baby's bath water with your hand d. your baby can nap in her car seat during the day A nurse is caring for a postpartum client who is receiving heparin via a continuous IV infusion for thrombophlebitis in her left calf. What action should the nurse take? b. maintain the client on bedrest A nurse is instructing a client who is taking an oral contraceptive about danger signs to report to her provider. The nurse determines the client understands the teaching when the client states the need to report which? A.reduced menstrual flow B.Breast tenderness C. SOB D. Headaches. 2. A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider? B. 3.6 kg (8 lb) weight gain and is in her first trimester A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th week of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with? D. Orange Juice. A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity? A. Alpha-fetoprotein (AFP) B. lecithin/sphingomyelin (L/S) ratio C. Kleihauer-Betke test D. indirect Coombs' test. A nurse is teaching a client who is pregnant about the amniocentesis procedure. Which of the following statements should the nurse include in the teaching? C."You should empty your bladder prior to the procedure." A nurse is providing care for a client who is at 32 weeks of gestation and who has a placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe? A. Betamethasone A nurse is administering magnesium sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicates magnesium sulfate toxicity? SATA A. Respirations less than 12/min B. Urinary output less than 30 ml/hr. C. Hyperreflexic deep-tendon reflexes D. decreased level of consciousness E. Flushing and sweating A nursing is caring for a client who is receiving IV magnesium sulfate. Which of the following medications should the nurse anticipate administering if magnesium sulfate toxicity is suspected? D. calcium gluconate A nurse is reviewing a new prescription for ferrous sulfate with a client who is at 12 weeks of gestation. Which of the following statements by the client indicates understanding of the teaching? C. "I plan to drink more orange juice while taking this pill." A nurse in labor and delivery is providing care for a client who is in preterm labor at 32 weeks of gestation. Which of the following medications should the nurse anticipate the provider will prescribe to hasten fetal lung maturity? D. betamethasone A nurse is caring for a client who is receiving nifedipine for prevention of preterm labor. The nurse should monitor the client for which of the following manifestations? B. Dizziness Nurse is performing a vaginal examination on a client who is in labor and observes the umbilical cord protruding from the vagina. After calling for assistance, which of the following actions should the nurse take next? Apply internal upward pressure to the presenting part using two gloved fingers A nurse is planning care for a client who is two hours postpartum. Which of the following intervention should the nurse plan to implement during the taking hold phase of postpartum behavioral adjustment? Demonstrate to the client how to perform a newborn bath A nurse is teaching a client who is at 36 weeks of gestation and has a prescription for a non-stress test. Which should the nurse include in the teaching? You will be offered orange juice to drink during the test A nurse in a woman's health clinic is providing teaching about nutritional intake to a client who is at eight weeks of gestation. The nurse should instruct the client to increase her daily intake of which of the following nutrients Iron A nurse is caring for a client who is at 35 weeks of gestation and has placenta previa. Which of the following actions should the nurse take? Initiate continuous external fetal monitoring A nurse is assessing fetal heart tones for a client who is pregnant. The nurse has a term in the fetal position as left a simple anterior. To which of the following areas of the clients I have dementia the nurse supply the ultrasound transducer to assess the point of maximum intensity of the fetal heart Left lower quadrant Nursery for praying to administer azithromycin to a client who is at 16 weeks of gestation and has a positive chlamydia culture. The prescription states administer azithromycin 1 g orally now. Available is 250 mg tablets. How many tablets should the nurse administer? 4 A nurse is caring for a newborn who is undergoing photo therapy to treat hyperbilirubinemia. Which of the following actions should the nurse take? Cover the newborn under the photo light therapy The school nurse is providing teaching to an adolescent about Lebanon gestural contraception. Which of the following information should the nurse include in the teaching? You should take this medication within 72 hours following and protected sexual intercourse A nurse is providing teaching about family planning to a client who has a new prescription for a diaphragm. Which of the following statement sure the nurse include in the teaching? You should leave the diaphragm in place for at least 6 hours after intercourse The nurse is caring for a client who is at 22 weeks of gestation and reports concern about the bocce hyperpigmentation on her for head. What should the following action should the nurse take? Explain to the client this is an expected occurrence The nurse is teaching a client who is in preterm labor about terbutaline. Which of the following statements by the client indicates an understanding of the teaching?I will have blood test because my K+ might decrease A nurse is assessing a newborn of a client who took a SSRI her during pregnancy. Which of the following manifestation should the nurse identify as an indication of withdrawal from an SSRI? Vomiting I nurse is assessing a newborn who is 12 hours old. Which of the following manifestations requires intervention by the nurse? Sub sternal chest retractions while sleeping I nurse in the antepartum clinic is assessing a client adaptation to pregnancy. The client states that she is happy one minute and crying the next. The nurse should Interpret the clients statement as an indication of which of the following? Emotional liability I know it's on antepartum unit is caring for for clients. Go to the phone client shared the nurse identified as the priority? A client who is at 34 weeks of gestation reports epigastric pain A nurse is assessing a client who is at 30 weeks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider? Swelling of the face A nurse is providing discharge teaching to a client who has postpartum period for which of the following manifestation should the nurse instruct the client to monitor and report to the provider? Unilateral breast pain A nurse is teaching a new mother how to use a bulb syringe to suction her newborn secretions. Which of the following instruction should the nurse include? Stop sectioning when the new ones cry sounds clear A nurse is reviewing laboratory results of a newborn who is four hours old. Which of the following findings should the nurse report to the provider BilliRubin 9 mg/dL A nurse in a family planning clinic is caring for a client who request an oral contraceptive. Which of the following findings in the clients history show the nurse recognized as a contraindication to oral contraceptives. SATA Cholecystitis, hypertension, migraine headaches A nurse is teaching a postpartum client about steps the nurse will take to promote the security and safety of the clients newborn. Which of the following statement sure the nurse make? Staff members who take care of your baby will be wearing a photo identification badge nurse is reviewing the laboratory results for a client who is at 10 weeks of gestation period which of the following laboratory findings should the nurse report to the provider? Hemoglobin 10 g/dL A nurse is caring for a client who has preeclampsia and is receiving a continuous infusion of magnesium sulfate RV. Which of the following actions should the nurse take? Have calcium gluconate readily available A nurse is caring for a client who is in active labor and has had no cervical change in the last four hours. Which of the following statements are the nurse make? Your provider will insert an intrauterine pressure catheter to monitor the strength of your contractions Nurse is caring for a newborn who was transferred to the nursery 30 minutes after birth because of my respiratory distress. Which of the following actions should the nurse take first? Verify the newborns identification A nurse is assessing a newborn for manifestations of hypo glycemia. Which of the following findings should the nurse expect? Jitteriness And ours in a prenatal clinic is caring for a client who reports that her menstrual period is two weeks late. The client appears anxious and ask the nurse if she is pregnant. Which of the following responses should the nurse make? Can you can miss your period for several other reasons. Describe your typical menstrual cycle A nurse is caring for a client who is pregnant and is at the end of her first trimester. The nurse should place the Doppler ultrasound stethoscope in which of the following locations to begin assessing for the funeral heart tones? Just above the symphysis pubis nurse is preparing to perform Leopold's maneuvers for a client. Identify the sequence the nurse should follow. -palpate the fundus to identify the fetal part -determine the location of the fetal back -palpate for the fetal port presenting at the inlet -Identify the attitude of the head A nurse is performing a newborn assessment. Which of the following images should the nurse identify as an indication of spina bifida occulta? The picture of the dimpled area over the defect in the presence of a birthmark or hair pet over the area I nurse is caring for a client who is experiencing preterm labor at 29 weeks of gestation and has a prescription for betamethasone. Which of the following statements are the nurse make about the indication for medication administration? This medication stimulates been a Lung Maturity I nurse is caring for a client who is in labor and reports increasing rectal pressure. She is experiencing contractions 2 to 3 minutes apart, each lasting 80 to 90 seconds, and a vaginal examination reveals that her cervix is dilated to 9 cm. The nurse should identify that the client is in which of the following phases of labor? Transition A nurse is teaching a new pair in about newborn safety. Which of the following instruction should the nurse include in the teaching? You can share your room with your baby for the next few weeks A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? Absence of peristalsis A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? Apply topical analgesic cream to the site 1 hr prior to the procedure. A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? Epinephrine A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? "I should keep my child indoors when I mow the yard." A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? White rice A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? Hematocrit 28% A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? Perform a finger stick. A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? Petechiae on the lower extremities A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? Loud, harsh murmur A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? Implement seizure precautions for the infant. A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? Serum creatinine 3.0 mg/dL A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? Substernal retractions A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make? "Let's talk about some of the ways you have handled previous stressors in your life." A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? A. The nurse should identify this area of the client's abdomen as McBurney's point. This area of the RLQ located about 2/3rds of the way between the umbilicus and the client's antero superior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness. A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider? Hgb 8.5 g/dL A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make? "You can sign the consent form because you are married." A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? Cuts an outlined shape using scissors. A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control? Have a designated stethoscope in the infant's room A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take? Give morphine 0.05mg/kg IV A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings in an indication of early septic shock? Temperature 39.1° C (102.4° F) A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? Denies discomfort during assessment of injuries. A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? Mental confusion A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? SATA -Ankle clonus -Exaggerated stretch reflexes -Contractures A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Withhold the measles, mumps, and rubella (MMR) vaccine. A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? A unilateral rib hump A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? Dry, hacking cough A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? "Your daddy will be back after you eat." The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site. A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? Place the child in a side-lying position. A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? "I should secure the car seat using lower anchors and tethers instead of the seat belt." A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? Administer the immunization using a 24-gauge needle. A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? Screen the child's visitors for indications of infection. A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority? Tachypnea A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? "Give the infant a pacifier at bedtime." The nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect? Abdominal distension The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? The toddler received tobramycin during a hospitalization 2 weeks ago. A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take? Initiate droplet precautions for the child. A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? "Shake the medication prior to administration." A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? Oral rehydration solution A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? Administer epinephrine IM to the child. A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? Ensure the oxygen source is functioning in the childs room A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? "You should offer your child high-protein meals and snacks throughout the day." A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? "Allow the stent to drain into your infants diaper." A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? Decreased edema A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? A toddler who has a concussion and an episode of forceful vomiting. A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following finding to the provider? Restricted ability to move the toes. A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? Wheezes A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? Potassium Chloride A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? The child should be able to stand on the balls of their feet when sitting on the bike. A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? Great Toe A nurse is an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? Monitor the childs oxygen saturation A nurse in an emergency department is caring for a school-age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? Apply an antimicrobial ointment to the affected area. A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? "When your childs lesions are crusted, usually 6 days after they appear." A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistant asthma. Which of the following instructions should the nurse include? "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? SATA -Vomiting -Lethargy A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? Erythrocyte sedimentation rate 18 mm/hr A nurse is providing discharge teaching to the parents of a 3-month old infant following a cheiloplasty. Which of the following instructions should the nurse include? "Apply a thin layer of antibiotic ointment on the your babys suture line daily for the next 3 days." A nurse is discussion organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? Explore the parents feelings and wishes regarding organ donation. A nurse is caring for a client who is 26 wks gestation and has epilepsy. The nurse enters the room and observes the client having a seizure. After turning the client's head to one side, what action should the nurse take next? a. monitor the FHR b. assess uterine activity c. administer O2 via non-rebreather mask d. start a bolus of IV fluids A nurse is providing teaching about comfort measures to a client who is breastfeeding and is experiencing engorgement. What nonpharm measures should the nurse include in the teaching? a. use a breast binder to relieve the discomfort b. use cold compresses after each feeding c. apply a few drops of colostrum to the nipple following the feeding d. place breast shells inside your bra A nurse in a health clinic is reviewing contraceptive use with a group of adolescent clients. Which of the following statements by an adolescent reflects an understanding of the teaching? A."a water-soluble lubricant should be used w/ condoms." 3. A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching? D. "a change in the string length of my iUD is [not] expected." 4. A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? SATA B. irregular vaginal bleeding C. Weight gain D. Breast changes e. gingival hyperplasia. 5. A nurse in a clinic is teaching a client about her new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? SATA A. "Weight loss can occur." B. "You are protected against Stis." C. "You should increase your intake of calcium." D. "You should avoid taking antibiotics." E. "irregular vaginal spotting can occur." 1. A nurse in a clinic is caring for a group of female clients who are being evaluated for infertility. Which of the following clients should the nurse anticipate the provider will refer to a genetic counselor? A. A client whose sister has alopecia B. A client whose partner has von Willebrand disease 2. A nurse is caring for a couple who is being evaluated for infertility. Which of the following statements by the nurse indicates understanding of the infertility assessment process? C. "the man is the easiest to assess, and the provider will usually begin there." 3. A nurse in an infertility clinic is providing care to a couple who has been unable to conceive for 18 months. Which of the following data should be included in the assessment? SATA A. Occupation B. Menstrual history C. Childhood infectious diseases 4.A nurse in a clinic is caring for a client who is to be seen by the provider for a postoperative appointment following a salpingectomy due to an ectopic pregnancy. Which of the following statements by the client requires clarification? A. "It is good to know that I won't have a tubal pregnancy in the future." 5. A nurse is reviewing the health record of a client who is to undergo hysterosalpingography. Which of the following data alert the nurse that the client is at risk for a complication related to this procedure? VITAL SIGNS Temperature 37.2° C (98.9° f) BMI 40.3, HISTORY AND PHYSICAL employed as a radiology technician Allergy to shrimp tonsillectomy at age 18, LABORATORY FINDINGS Glucose 103 mg/dl Hgb 13.1 g/dl total cholesterol 265 mg/dl, MEDICATIONS rosuvastatin Magnesium oxide Mafenide acetate A. Vital signs B. History and physical C. laboratory findings D. Medications. 1. A nurse is caring for a client who is pregnant and states that her last menstrual period was April 1st. Which of the following is the client's estimated date of delivery? A. January 8 B. January 15 C. February 8 D. February 15 2. A nurse in a prenatal clinic is caring for a client who is in the first trimester of pregnancy. The client's health record includes this data: g3 t1 p0 a1 l1. How should the nurse interpret this information? SATA A. client has delivered one newborn at term. B. client has experienced no preterm labor. C. client has been through active labor. D. client has had two prior pregnancies. E. client has one living child. 3. A nurse is reviewing the health record of a client who is pregnant. The provider indicated the client exhibits probable signs of pregnancy. Which of the following findings should the nurse expect? A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? Serum potassium level 4.1 mEq/L A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurses priority? Disease process A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? FACES A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100mg/5mL. How many mL should the nurse administer to the infant per dose? 2 mL A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? Presence of strabismus A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first? Check the childs respiratory rate. A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? Provide the child with a book about adventure. A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? Have the adolescent sign a consent form for treatment. A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the childs respirations, which of the following actions should the nurse take next? Initiate IV access. A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? An 8-month-old who is not yet making babbling sounds. A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? "I will notify the doctor if I notice that my child is swallowing frequently." A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? Poor personal hygiene A nurse assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? Difficulty concentrating A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? "I should wear sandals as much as possible." A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? Deep respirations of 32/min A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? "Choose a waterproof sunscreen with a minimum SPF of 15." A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? "Brush the childs teeth after giving the medication." A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching? "Encourage the child to perform independent self-care." A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include? Initiate airborne precautions for the child. A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the bicep reflect. A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? "I will teach challenging academic subjects to students who have ADHD in the morning." A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? Palpate the dorsum of the childs feet A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take? Place the infant in a knee- chest position A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? 1⁄2 cup raisins A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? Sunken anterior fontanel A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan? Use a semipermeable transparent dressing to cover the site. A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching? "Mononucleosis is caused by an infection with the Epstein- Barr virus." A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? Recombinant growth hormone A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? Avoid palpating the abdomen when bathing the child before surgery. A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? "I will monitor my childs number of wet diapers." A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make? "Your baby might pull at their ears when they are teething." A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? For 24 hr following initiation of antimicrobial therapy A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? Expressed likes and dislikes A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurses priority? Episodes of vomiting A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? SATA -Increased temperature -Xerophthalmia -Cervical lymphadenopathy A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? Sodium 155 mEq/L A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? Increase fat content in the childs diet to 40% of total calories. A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? Dress the toddler in minimal clothing. A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? "Wait 3 days before taking a tub bath." A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? Nasal flaring A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching? "Award your child with a sticker when they sit on the potty chair." 4. A nurse is caring for a client who has a prescription for magnesium sulfate. The nurse should recognize that which of the following are contraindications for use of this medication? SATA A. fetal distress C. Vaginal bleeding D. Cervical dilation greater than 6 cm 5. A nurse is reviewing discharge teaching with a client who has premature rupture of membranes at 26 weeks of gestation. Which of the following instructions should the nurse include in the teaching? D. Keep a daily record of fetal kick counts.