A. ).
A. ).
A. ). *. !.
A. ). *. !.
A. ).
A. ). *. !.
A. ). *. !.
A. ). *. !.
PART 1 1. Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor, and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? a. !o you have any chronic illness?" b. !o you have any aller#ies?" c. What is your e$pected due date?" d. Who %ill be %ith you durin# labor?" &. A patient is in the second sta#e of labor. !urin# this sta#e, ho% frequently should the nurse in char#e assess her uterine contractions? 'very ( minutes minutes *. 'very + minutes 'very 1( minutes !. 'very - minutes '. +. A patient is in last last trimester of pre#nancy pre#nancy.. urse /ane /ane should should instruct her to notify notify her primary health care provider immediately if she notices0 )lurred vision vision *. 2ncreased va#inal mucus emorrhoids !. 3hortness of breath on e$ertion '. 4. The nurse nurse in char#e is revie%in# revie%in# a patient5s patient5s prenatal prenatal history. history. Which findin# findin# indicates indicates a #enetic risk factor? The patient patient is &( years years old The patient has a child %ith cystic fibrosis The patient %a %as e$ e$posed to ru rubella at at ++- %e %eeks5 #estation The Th e pati tie ent ha has a his isto tory ry of pre prete term rm la lab bor at at +& +& %ee %eek ks5 #esta tattio ion n 6. (. A adult female female patient is usin# usin# the rhythm rhythm 7calendar8basal 7calendar8basal body temperature9 temperature9 method method of family plannin#. 2n this method, the unsafe period for se$ual intercourse is indicated by: Return preovulatory preovulatory basal basal body body temperature temperature )asa )a sall bod body y tem tempe pera ratu ture re in incr crea ease se of . .1 1 de# de#re rees es to .& de de#r #ree ees s on on the the &n &nd d or or +rd +rd da day y of of cycle + ful fulll day days s of of el elev evat ated ed ba basa sall bod body y tem tempe pera ratu ture re an and d cl clea earr, th thin in ce cerv rvic ical al mu mucu cus s )reast tenderness and mittelschmer; <. -. !urin# a nonstress nonstress test 73T9, 73T9, the electronic electronic tracin# displays displays a relatively relatively flat line for fetal movement, makin# it difficult to evaluate the fetal heart rate 76R9. To mark the strip, the nurse in char#e should instruct the client to push the control button at %hich time? At the be#innin# be#innin# of of each fetal fetal *. After every three fetal movements movement !. At the end of fetal movement At the be#innin# of each contraction '. =. When evaluatin# evaluatin# a client5s client5s kno%led#e kno%led#e of symptoms symptoms to report report durin# her pre#nancy pre#nancy,, %hich statement %ould indicate to the nurse in char#e that the client understands the information #iven to her? 25ll report increased increased frequency frequency of of urination." urination." 2ff 2 ha 2 have ve bl blur urre red d or do doub uble le vi visi sion on,, 2 sho shoul uld d ca call ll th the e cl clin inic ic im imme medi diat atel ely y." 2ff 2 fe 2 fee el ti tire red d afte terr re resti tin n#, 2 sh sho ould re rep port it im imme med dia iate tely ly.." ausea should be reported immediately." 6. >. When assessin# a client durin# durin# her first first prenatal prenatal visit, the nurse discovers discovers that that the client had a reduction mammoplasty. The mother indicates she %ants to breast8feed. What information should the nurse #ive to this mother re#ardin# breast8feedin# success? 2t5s contraindicate contraindicated d for you to to breast8feed breast8feed follo%in# follo%in# this type type of sur#ery sur#ery." ." 2 su supp ppor ortt you yourr com commi mitm tmen ent: t: ho ho% %ev ever er,, you you ma may y hav have e to to sup suppl plem emen entt eac each h fee feedi din# n# %i %ith th formula." o ou sho shoul uld d che check ck %i %ith th you yourr sur sur#e #eon on to de dete term rmin ine e %he %heth ther er br brea east st8f 8fee eedi din# n# %o %oul uld d be be possible." ou sh should be be ab able to to br breast8f 8fe eed %i %ith tho out di difficulty ty.." <. @. 6ollo%in# a precipitous delivery delivery,, e$amination e$amination of the the client5s va#ina va#ina reveals reveals a fourth8 de#ree laceration. Which of the follo%in# %ould be contraindicated %hen carin# for this client? Applyin# cold cold to limit edema edema durin# durin# the first first 1& to &4 &4 hours 2ns 2n str tru ucti tin n# th the cli clie ent to to us use t% t%o or or mo more peri rip pads to to cu cush shiion th the are area a 2nstructin# the cl client on on th the us use of of si sit; baths ifif or ordered 2nst 2n stru ruct ctin in# # th the e cl clie ient nt ab abou outt the the im impo port rtan ance ce of pe peri rine neal al 7 7e# e#el el99 e$e e$erc rcis ises es
A. ).
A. ). *.
A. ).
. 1. A client makes a routine visit to the prenatal clinic. Althou#h she5s 14 %eeks pre#nant, the si;e of her uterus appro$imates that in an 1>8 to &8%eek pre#nancy. !r. !ia; dia#noses #estational trophoblastic disease and orders ultrasono#raphy. The nurse e$pects ultrasono#raphy to reveal0 an empty #estational sac. *. a severely malformed fetus. #rapelike clusters. !. an e$trauterine pre#nancy. '. 11. After completin# a second va#inal e$amination of a client in labor, the nurse8mid%ife determines that the fetus is in the ri#ht occiput anterior position and at B1 station. )ased on these findin#s, the nurse8mid%ife kno%s that the fetal presentin# part is0 1 cm belo% the ischial spines. !. in no relationship to the ischial directly in line %ith the ischial spines. spines. 1 cm above the ischial spines. '. 1&. Which of the follo%in# %ould be inappropriate to assess in a mother %ho5s breast8 feedin#? The attachment of the baby to the *. Audible s%allo%in#. breast. !. The baby5s lips smackin# The mother5s comfort level %ith positionin# the baby.
'.
A. ).
A. ). *. !.
A. ). *. !.
A. ).
A. ).
A. ). *. !.
A. ).
A. ).
6. 1+. !urin# a prenatal visit at 4 months #estation, a pre#nant client asks %hether tests can be done to identify fetal abnormalities. )et%een 1> and 4 %eeks5 #estation, %hich procedure is used to detect fetal anomalies? Amniocentesis. *. 6etoscopy. *horionic villi samplin#. !. Cltrasound '. 14. A client, + %eeks pre#nant, is scheduled for a biophysical profile 7)PP9 to evaluate the health of her fetus. er )PP score is >. What does this score indicate? The fetus should be delivered %ithin &4 hours. The client should repeat the test in &4 hours. The fetus isn5t in distress at this time. The client should repeat the test in 1 %eek. 6. 1(. A client %ho5s +- %eeks pre#nant comes to the clinic for a prenatal checkup. To assess the client5s preparation for parentin#, the nurse mi#ht ask %hich question? Are you plannin# to have epidural anesthesia?" ave you be#un prenatal classes?" What chan#es have you made at home to #et ready for the baby?" *an you tell me about the meals you typically eat each day?" <. 1-. A client %ho5s admitted to labor and delivery has the follo%in# assessment findin#s0 #ravida & para 1, estimated 4 %eeks5 #estation, contractions & minutes apart, lastin# 4( seconds, verte$ D4 station. Which of the follo%in# %ould be the priority at this time? Placin# the client in bed to be#in *. *heckin# for ruptured membranes. fetal monitorin#. !. Providin# comfort measures. Preparin# for immediate delivery. '. 1=. urse Roy is carin# for a client in labor. The e$ternal fetal monitor sho%s a pattern of variable decelerations in fetal heart rate. What should the nurse do first? *han#e the client5s position. *. *heck for placenta previa. Prepare for emer#ency cesarean !. Administer o$y#en. section. '. 1>. The nurse in char#e is carin# for a postpartum client %ho had a va#inal delivery %ith a midline episiotomy. Which nursin# dia#nosis takes priority for this client? Risk for deficient fluid volume related to hemorrha#e Risk for infection related to the type of delivery Pain related to the type of incision Crinary retention related to periurethral edema 6. 1@. Which chan#e %ould the nurse identify as a pro#ressive physiolo#ical chan#e in postpartum period? Eactation *. Cterine involution Eochia !. !iuresis '. &. A +@8year8old at += %eeks5 #estation is admitted to the hospital %ith complaints of va#inal bleedin# follo%in# the use of cocaine 1 hour earlier. Which complication is most likely causin# the client5s complaint of va#inal bleedin#? Placenta previa *. 'ctopic pre#nancy Abruptio placentae !. 3pontaneous abortion
A. ). *. !.
A. ).
A. ).
A. ).
A. ). *. !.
A. ). *. !.
A. ).
A. ). '.
A. ).
A. ).
A. ).
'. &1. A client %ith type 1 diabetes mellitus %ho5s a multi#ravida visits the clinic at &= %eeks #estation. The nurse should instruct the client that for most pre#nant %omen %ith type 1 diabetes mellitus0 Weekly fetal movement counts are made by the mother. *ontraction stress testin# is performed %eekly. 2nduction of labor is be#un at +4 %eeks5 #estation. onstress testin# is performed %eekly until +& %eeks5 #estation 6. &&. When administerin# ma#nesium sulfate to a client %ith preeclampsia, the nurse understands that this dru# is #iven to0 Prevent sei;ures *. 3lo% the process of labor Reduce blood pressure !. 2ncrease dieresis '. &+. What5s the appro$imate time that the blastocyst spends travelin# to the uterus for implantation? & days *. 1 days = days !. 14 %eeks '. &4. After teachin# a pre#nant %oman %ho is in labor about the purpose of the episiotomy, %hich of the follo%in# purposes stated by the client %ould indicate to the nurse that the teachin# %as effective? 3hortens the second sta#e of labor *. Prevents perineal edema 'nlar#es the pelvic inlet !. 'nsures quick placenta delivery '. &(. A primi#ravida client at about +( %eeks #estation in active labor has had no prenatal care and admits to cocaine use durin# the pre#nancy. Which of the follo%in# persons must the nurse notify? ursin# unit mana#er so appropriate a#encies can be notified ead of the hospital5s security department *haplain in case the fetus dies in utero Physician %ho %ill attend the delivery of the infant 6. &-. When preparin# a teachin# plan for a client %ho is to receive a rubella vaccine durin# the postpartum period, the nurse in char#e should include %hich of the follo%in#? The vaccine prevents a future fetus from developin# con#enital anomalies Pre#nancy should be avoided for + months after the immuni;ation The client should avoid contact %ith children dia#nosed %ith rubella The inFection %ill provide immunity a#ainst the =8day measles. <. &=. A client %ith eclampsia be#ins to e$perience a sei;ure. Which of the follo%in# %ould the nurse in char#e do first? Pad the side rails *. 2nsert a padded ton#ue blade into Place a pillo% under the left buttock the mouth !. Gaintain a patent air%ay '. &>. While carin# for a multi#ravida client in early labor in a birthin# center, %hich of the follo%in# foods %ould be best if the client requests a snack? o#urt *. He#etable soup *ereal %ith milk !. Peanut butter cookies 6. &@. The multi#ravida mother %ith a history of rapid labor %ho us in active labor calls out to the nurse, The baby is comin#I" %hich of the follo%in# %ould be the nurse5s first action? 2nspect the perineum *. Auscultate the fetal heart rate Time the contractions !. *ontact the birth attendant '. +. While assessin# a primipara durin# the immediate postpartum period, the nurse in char#e plans to use both hands to assess the client5s fundus to0 Prevent uterine inversion *. asten the puerperium period Promote uterine involution !. !etermine the si;e of the fundus '. 6. Part & <. 1. A postpartum patient %as in labor for + hours and had ruptured membranes for &4 hours. 6or %hich of the follo%in# %ould the nurse be alert? 'ndometritis *. 3alpin#itis 'ndometriosis !. Pelvic thrombophlebitis '. &. A client at +- %eeks5 #estation is schedule for a routine ultrasound prior to an amniocentesis. After teachin# the client about the purpose for the ultrasound, %hich of the follo%in# client statements %ould indicate to the nurse in char#e that the client needs further instruction?
A. ). *. !. 6.
A. ). '. A. ). *. !. 6.
A. ). '.
A. ). *. !. 6.
A. ). '.
A. ). '.
A. ). *. !. 6.
A. ). '.
A. ). '. A. ). *. !.
The ultrasound %ill help to locate the placenta The ultrasound identifies blood flo% throu#h the umbilical cord The test %ill determine %here to insert the needle The ultrasound locates a pool of amniotic fluid +. While the postpartum client is receivin# herapin for thrombophlebitis, %hich of the follo%in# dru#s %ould the nurse Gica e$pect to administer if the client develops complications related to heparin therapy? *alcium #luconate *. Gethyle#onovine 7Gether#ine9 Protamine sulfate !. itrofurantoin 7macrodantin9 4. When carin# for a +8day8old neonate %ho is receivin# phototherapy to treat Faundice, the nurse in char#e %ould e$pect to do %hich of the follo%in#? Turn the neonate every - hours 'ncoura#e the mother to discontinue breast8feedin# otify the physician if the skin becomes bron;e in color *heck the vital si#ns every & to 4 hours (. A primi#ravida in active labor is about @ days post8term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse e$plains this type of anesthesia to the client, %hich of the follo%in# locations identified by the client as the area of relief %ould indicate to the nurse that the teachin# %as effective? )ack *. 6undus Abdomen !. Perineum -. The nurse is carin# for a primi#ravida at about & months and 1 %eek #estation. After e$plainin# self8care measures for common discomforts of pre#nancy, the nurse determines that the client understands the instructions %hen she says0 ausea and vomitin# can be decreased if 2 eat a fe% crackers before arisin#" 2f 2 start to leak colostrum, 2 should cleanse my nipples %ith soap and %ater" 2f 2 have a va#inal dischar#e, 2 should %ear nylon under%ear" Ee# cramps can be alleviated if 2 put an ice pack on the area" =. Thirty hours after delivery, the nurse in char#e plans dischar#e teachin# for the client about infant care. )y this time, the nurse e$pects that the phase of postpartal psycholo#ical adaptation that the client %ould be in %ould be termed %hich of the follo%in#? Takin# in *. Takin# hold Eettin# #o !. Resolution >. A pre#nant client is dia#nosed %ith partial placenta previa. 2n e$plainin# the dia#nosis, the nurse tells the client that the usual treatment for partial placenta previa is %hich of the follo%in#? Activity limited to bed rest *. 2mmediate cesarean delivery Platelet infusion !. Eabor induction %ith o$ytocin @. urse /ulia plans to instruct the postpartum client about methods to prevent breast en#or#ement. Which of the follo%in# measures %ould the nurse include in the teachin# plan? 6eedin# the neonate a ma$imum of ( minutes per side on the first day Wearin# a supportive brassiere %ith nipple shields )reast8feedin# the neonate at frequent intervals !ecreasin# fluid intake for the first &4 to 4> hours 1. When the nurse on duty accidentally bumps the bassinet, the neonate thro%s out its arms, hands opened, and be#ins to cry. The nurse interprets this reaction as indicative of %hich of the follo%in# refle$es? 3tartle refle$ *.
A. ).
A. ). *. !.
A. ). *. !.
A. ).
A. ). *. !.
A. ).
A. ).
A. ).
A. ). *. !.
A. ).
A. ). *. !.
6. 1+. Which of the follo%in# %ould the nurse 3andra most likely e$pect to find %hen assessin# a pre#nant client %ith abruption placenta? '$cessive va#inal bleedin# *. Titanic uterine contractions Ri#id, boardlike abdomen !. Premature rupture of membranes '. 14. While the client is in active labor %ith t%ins and the cervi$ is ( cm dilates, the nurse observes contractions occurrin# at a rate of every = to > minutes in a +8minute period. Which of the follo%in# %ould be the nurse5s most appropriate action? ote the fetal heart rate patterns otify the physician immediately Administer o$y#en at - liters by mask ave the client pant8blo% durin# the contractions 6. 1(. A client tells the nurse, 2 think my baby likes to hear me talk to him." When discussin# neonates and stimulation %ith sound, %hich of the follo%in# %ould the nurse include as a means to elicit the best response? i#h8pitched speech %ith tonal variations Eo%8pitched speech %ith a sameness of tone *ooin# sounds rather than %ords Repeated stimulation %ith loud sounds <. 1-. A +18year8old multipara is admitted to the birthin# room after initial e$amination reveals her cervi$ to be at > cm, completely effaced 71 J9, and at station. What phase of labor is she in? Active phase *. '$pulsive phase Eatent phase !. Transitional phase '. 1=. A pre#nant patient asks the nurse ate if she can take castor oil for her constipation. o% should the nurse respond? es, it produces no adverse effect." o, it can initiate premature uterine contractions." o, it can promote sodium retention." o, it can lead to increased absorption of fat8soluble vitamins." 6. 1>. A patient in her 14th %eek of pre#nancy has presented %ith abdominal crampin# and va#inal bleedin# for the past > hours. 3he has passed several cloth. What is the primary nursin# dia#nosis for this patient? no%led#e deficit *. Anticipatory #rievin# 6luid volume deficit !. Pain '. 1@. 2mmediately after a delivery, the nurse8mid%ife assesses the neonate5s head for si#ns of moldin#. Which factors determine the type of moldin#? 6etal body fle$ion or e$tension *. Gaternal and paternal ethnic Gaternal a#e, body frame, and back#rounds %ei#ht !. Gaternal parity and #ravidity '. &. 6or a patient in active labor, the nurse8mid%ife plans to use an internal electronic fetal monitorin# 7'6G9 device. What must occur before the internal '6G can be applied? The membranes must rupture *. The cervi$ must be dilated fully The fetus must be at station !. The patient must receive anesthesia '. &1. A primi#ravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first sta#e of labor. er pain is likely to be most intense0 Around the pelvic #irdle Around the pelvic #irdle and in the upper arms Around the pelvic #irdle and at the perineum At the perineum 6. &&. A female adult patient is takin# a pro#estin8only oral contraceptive, or minipill. Pro#estin use may increase the patient5s risk for0 'ndometriosis *. Premenstrual syndrome 6emale hypo#onadism !. Tubal or ectopic pre#nancy '. &+. A patient %ith pre#nancy8induced hypertension probably e$hibits %hich of the follo%in# symptoms? Proteinuria, headaches, va#inal bleedin# eadaches, double vision, va#inal bleedin# Proteinuria, headaches, double vision Proteinuria, double vision, uterine contractions 6. &4. )ecause cervical effacement and dilation are not pro#ressin# in a patient in labor, !r. 3mith orders 2.H. administration of o$ytocin 7Pitocin9. Why must the nurse monitor the patient5s fluid intake and output closely durin# o$ytocin administration?
A. ). *. !. <. A. ). '. A. ). '. A. ). '. A. ). *. !. 6. A. ). *. !. <. A. ). '. 6. A. ). *. !. <. A. ).
A. ).
A. ). A. ). *. !.
A. ). *. !.
K$yto$in causes %ater into$ication K$ytocin causes e$cessive thirst K$yto$in is to$ic to the kidneys K$yto$in has a diuretic effect &(. 6ive hours after birth, a neonate is transferred to the nursery, %here the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? Eo% room humidity *. *ools incubator %alls *old %ei#ht scale !. *ool room temperature &-. After administerin# bethanechol to a patient %ith urine retention, the nurse in char#e monitors the patient for adverse effects. Which is most likely to occur? !ecreased peristalsis *. !ry mucous membranes 2ncrease heart rate !. ausea and Homitin# &=. The nurse in char#e is carin# for a patient %ho is in the first sta#e of labor. What is the shortest but most difficult part of this sta#e? Active phase *. Eatent phase *omplete phase !. Transitional phase &>. After + days of breast8feedin#, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should su##est that she0 Apply %arm compresses to her nipples Fust before feedin#s Eubricate her nipples %ith e$pressed milk before feedin# !ry her nipples %ith a soft to%el after feedin#s Apply soap directly to her nipples, and then rinse &@. The nurse is developin# a teachin# plan for a patient %ho is > %eeks pre#nant. The nurse should tell the patient that she can e$pect to feel the fetus move at %hich time? )et%een 1 and 1& %eeks5 #estation )et%een 1- and & %eeks5 #estation )et%een &1 and &+ %eeks5 #estation )et%een &4 and &- %eeks5 #estation +. ormal lochial findin#s in the first &4 hours post8delivery include0 )ri#ht red blood *. A foul odor Ear#e clots or tissue fra#ments !. The complete absence of lochia PART 222 1. Which of the follo%in# %ould be inappropriate %hen administerin# chemotherapy to a child? Gonitorin# the child for both #eneral and specific adverse effects Kbservin# the child for 1 minutes to note for si#ns of anaphyla$is Administerin# medication throu#h a free8flo%in# intravenous line Assessin# for si#ns of infusion infiltration and irritation &. Which of the follo%in# is the best method for performin# a physical e$amination on a toddler 6rom head to toe *. 6rom abdomen to toes, the to head !istally to pro$imally !. 6rom least to most intrusive
'. 6. +. Which of the follo%in# or#anisms is responsible for the development of rheumatic fever? 3treptococcal pneumonia *.
A. ). *. !. A. ). *. !. A. ).
A. ). *. !.
A. ). *. !.
A. ).
A. ). *. !.
A. ).
A. ). *. !.
A. ).
A. ). *.
<. =. The nurse is assessin# a ne%born %ho had under#one va#inal delivery. Which of the follo%in# findin#s is least likely to be observed in a normal ne%born? uneven head shape respirations are irre#ular, abdominal, +8- bpm 7D9 moro refle$ heart rate is > bpm . >. Which of the follo%in# situations increase risk of lead poisonin# in children? playin# in the park %ith heavy traffic and %ith many vehicles passin# by playin# sand in the park playin# plastic balls %ith other children playin# %ith stuffed toys at home 2. @. An inborn error of metabolism that causes premature destruction of R)*? <-P! *. Phenylketonuria emocystinuria !. *eliac !isease '. 1. Which of the follo%in# blood study results %ould the nurse e$pect as most likely %hen carin# for the child %ith iron deficiency anemia? 2ncreased hemo#lobin ormal hematocrit !ecreased mean corpuscular volume 7G*H9 ormal total iron8bindin# capacity 7T2)*9 6. 11. The nurse ans%ers a call bell and finds a fri#htened mother %hose child, the patient, is havin# a sei;ure. Which of these actions should the nurse take? The nurse should insert a padded ton#ue blade in the patient5s mouth to prevent the child from s%allo%in# or chokin# on his ton#ue. The nurse should help the mother restrain the child to prevent him from inFurin# himself. The nurse should call the operator to pa#e for sei;ure assistance. The nurse should clear the area and position the client safely. <. 1&. At the community center, the nurse leads an adolescent health information #roup, %hich often e$pands into other areas of discussion. 3he kno%s that these youths are tryin# to find out %ho they are," and discussion often focuses on %hich directions they %ant to take in school and life, as %ell as peer relationships. Accordin# to 'rikson, this sta#e is kno%n as0 identity vs. role confusion. *. career e$perimentation. adolescent rebellion. !. relationship testin# '. 1+. The nurse is assessin# a @8month8old boy for a %ell8baby check up. Which of the follo%in# observations %ould be of most concern? The baby cannot say mama" %hen he %ants his mother. The mother has not #iven him fin#er foods. The child does not sit unsupported. The baby cries %henever the mother #oes out. 6. 14. *heska, the mother of an 118month8old #irl, *, is in the clinic for her dau#hter5s immuni;ations. 3he e$presses concern to the nurse that 3hannon cannot yet %alk. The nurse correctly replies that, accordin# to the !enver !evelopmental 3creen, the median a#e for %alkin# is0 1& months. *. 1 months. 1( months. !. 14 months. '. 1(. 3ally ent., a#e 1+, has had a lumbar puncture to e$amine the *36 to determine if bacterial infection e$ists. The best position to keep her in after the procedure is0 prone for t%o hours to prevent aspiration, should she vomit. semi8fo%ler5s so she can %atch TH for five hours and be entertained. supine for several hours, to prevent headache. on her ri#ht sides to encoura#e return of *36 6. 1-. )uck5s traction %ith a 1 lb. %ei#ht is securin# a patient5s le# %hile she is %aitin# for sur#ery to repair a hip fracture. 2t is important to check circulation8 sensation8movement0 every shift. *. every 4 hours. every day. !. every 1( minutes. '. 1=. *arol 3mith is usin# bronchodilators for asthma. The side effects of these dru#s that you need to monitor this patient for include0 tachycardia, nausea, vomitin#, heart palpitations, inability to sleep, restlessness, and sei;ures. tachycardia, headache, dyspnea, temp . 11 6, and %hee;in#. blurred vision, tachycardia, hypertension, headache, insomnia, and oli#uria.
!.
A. ).
A. ). *. !.
A. ).
A. ).
A. ).
A. ). *. !.
A. ). *.
A. ).
A. ).
A. ).
A. ).
A. ).
A. ).
restlessness, insomnia, blurred vision, hypertension, chest pain, and muscle %eakness. 6. 1>. The adolescent patient has symptoms of menin#itis0 nuchal ri#idity, fever, vomitin#, and lethar#y. The nurse kno%s to prepare for the follo%in# test0 blood culture. *. *AT scan. throat and ear culture. !. lumbar puncture. '. 1@. The nurse is dra%in# blood from the diabetic patient for a #lycosolated hemo#lobin test. 3he e$plains to the %oman that the test is used to determine0 the hi#hest #lucose level in the past %eek. her insulin level. #lucose levels over the past several months. her usual fastin# #lucose level. 6. &. The t%elve8year8old boy has fractured his arm because of a fall from his bike. After the inFury has been casted, the nurse kno%s it is most important to perform all of the follo%in# assessments on the area distal to the inFury e$cept0 capillary refill. *. fin#er movement radial and ulnar pulse. !. skin inte#rity '. 6. PART 4 <. 1. Andrea %ith suspected rheumatic fever is admitted to the pediatric unit. When obtainin# the child5s history, the nurse considers %hich information to be most important? A fever that started + days a#o *. A recent episode of pharyn#itis Eack of interest in food !. Homitin# for & days '. &. urse Ei;a is administerin# a medication via the intraosseous route to a child. 2ntraosseous dru# administration is typically used %hen a child is0 Cnder a#e + *. *ritically ill and under a#e + Kver a#e + !. *ritically ill and over a#e + '. +. When assessin# a child5s cultural back#round, the nurse in char#e should keep in mind that0 *ultural back#round usually has little bearin# on a family5s health practices Physical characteristics mark the child as part of a particular culture erita#e dictates a #roup5s shared values )ehavioral patterns are passed from one #eneration to the ne$t 6. 4. While e$aminin# a &8year8old child, the nurse in char#e sees that the anterior fontanel is open. The nurse should0 otify the doctor !. Ask about a family history of Tay8 Eook for other si#ns of abuse 3achs disease Reco#ni;e this as a normal findin# '. (. The nurse is a%are that the most common assessment findin# in a child %ith ulcerative colitis is0 2ntense abdominal cramps *. Anal fissures Profuse diarrhea !. Abdominal distention '. -. When administerin# an 2.G. inFection to an infant, the nurse in char#e should use %hich site? !eltoid *. Hentro#luteal !orso#luteal !. Hastus lateralis '. =. A child %ith a poor nutritional status and %ei#ht loss is at risk for a ne#ative nitro#en balance. To help dia#nose this problem, the nurse in char#e anticipates that the doctor %ill order %hich laboratory test? Total iron8bindin# capacity *. Total protein emo#lobin !. 3erum transferrin# '. >. When developin# a plan of care for a male adolescent, the nurse considers the child5s psychosocial needs. !urin# adolescence, psychosocial development focuses on0 )ecomin# industrious *. Achievin# intimacy 'stablishin# an identity !. !evelopin# initiative '. @. When developin# a plan care for a hospitali;ed child, nurse Gica kno%s that children in %hich a#e #roup are most likely to vie% illness as a punishment for misdeeds? 2nfancy *. 3chool a#e Preschool a#e !. Adolescence '. 1. urse Taylor suspects that a child, a#e 4, is bein# ne#lected physically. To best assess the child5s nutritional status, the nurse should ask the parents %hich question? as your child al%ays been so thin?" 2s your child a picky eater?"
*. !.
A. ). *. !.
A. ). *. !.
A. ). *. !.
A. ).
A. ).
A. ).
A. ). *. !.
A. ). A. ).
A. ).
A. ).
What did your child eat for breakfast?" !o you think your child eats enou#h?" 6. 11. A female child, a#e &, is brou#ht to the emer#ency department after in#estin# an unkno%n number of aspirin tablets about + minutes earlier. Kn enterin# the e$amination room, the child is cryin# and clin#in# to the mother. Which data should the nurse obtain first? eart rate, respiratory rate, and blood pressure Recent e$posure to communicable diseases umber of immuni;ations received ei#ht and %ei#ht <. 1&. A mother asks the nurse ho% to handle her (8year8old child, %ho recently started %ettin# the pants after bein# completely toilet trained. The child Fust started attendin# nursery school & days a %eek. Which principle should #uide the nurse5s response? The child for#ets previously learned skills The child e$periences #ro%th %hile re#ressin#, re#roupin#, and then pro#ressin# The parents may refer less mature behaviors The child returns to a level of behavior that increases the sense of security. . 1+. A female child, a#e -, is brou#ht to the health clinic for a routine checkup. To assess the child5s vision, the nurse should ask0 !o you have any problems seein# different colors?" !o you have trouble seein# at ni#ht?" !o you have problems %ith #lare?" o% are you doin# in school?" 2. 14. !urin# a %ell8baby visit, /enny asks the nurse %hen she should start #ivin# her infant solid foods. The nurse should instruct her to introduce %hich solid food first? Applesauce *. Rice cereal '## %hites !. o#urt '. 1(. To decrease the likelihood of bradyarrhythmias in children durin# endotracheal intubation, succinylcholine 7Anectine9 is used %ith %hich of the follo%in# a#ents? 'pinephrine 7Adrenalin9 *. Atropine sulfate 2soproterenol 72suprel9 !. Eidocaine hydrochloride 7Mylocaine9 '. 1-. A 1 year and &8month8old child %ei#hin# &- lb 711.> k#9 is admitted for traction to treat con#enital hip dislocation. When preparin# the patient5s room, the nurse anticipates usin# %hich traction system? )ryant5s traction *. Kverhead suspension traction )uck5s e$tension traction !. @8@ traction '. 1=. Gandy, a#e 1&, is = months pre#nant. When teachin# parentin# skills to an adolescent, the nurse kno%s that %hich teachin# strate#y is least effective? Providin# a one8on8one demonstration and requestin# a return demonstration, usin# a live infant model 2nitiatin# a teena#e parent support #roup %ith first B and B second8time mothers Csin# audiovisual aids that sho% discussions of feelin#s and skills Providin# a#e8appropriate readin# materials 6. 1>. When performin# a physical e$amination on an infant, the nurse in char#e notes abnormally lo%8set ears. This findin#s is associated %ith0 Kto#enous tetanus *. *on#enital heart defects Tracheoesopha#eal fistula !. Renal anomalies '. 1@. urse Raven should e$pect a +8year8old child to be able to perform %hich action? Ride a tricycle *. Roller8skates Tie the shoelaces !. /ump rope '. &. urse )etina is teachin# a #roup of parents about otitis media. When discussin# %hy children are predisposed to this disorder, the nurse should mention the si#nificance of %hich anatomical feature? 'ustachian tubes *. Tympanic membrane asopharyn$ !. '$ternal ear canal '. &1. The nurse is evaluatin# a female child %ith acute poststreptoccocal #lomerulonephritis for si#ns of improvement. Which findin# typically is the earliest si#n of improvement? 2ncreased urine output *. 2ncreased ener#y level 2ncreased appetite !. !ecreased diarrhea '. &&. !r. 3mith prescribes corticosteroids for a child %ith nephritic syndrome. What is the primary purpose of administerin# corticosteroids to this child?
A. ).
A. ). A. ). *. !.
A. ).
To increase blood pressure *. To decrease proteinuria To reduce inflammation !. To prevent infection '. &+. Parents brin# their infant to the clinic, seekin# treatment for vomitin# and diarrhea that has lasted for & days. Kn assessment, the nurse in char#e detects dry mucous membranes and lethar#y. What other findin#s su##ests a fluid volume deficit? A sunken fontanel *. 2ncreased blood pressure !ecreased pulse rate !. Eo% urine specific #ravity '. &4. o% should the nurse Gay prepare a suspension before administration? )y dilutin# it %ith normal saline solution )y dilutin# it %ith (J de$trose solution )y shakin# it so that all the dru# particles are dispersed uniformly )y crushin# remainin# particles %ith a mortar and pestle 6. &(. What should be the initial bolus of crystalloid fluid replacement for a pediatric patient in shock? & mlNk# *. + mlNk# 1 mlNk# !. 1( mlNk#
A. ). *. !.
A. ). *. !.
A. ). *. !.
A. ). *. !.
A. ). *. !.
'. &-. )ecky, a#e (, %ith intelli#ence quotient of -( is admitted to the hospital for evaluation. When plannin# care, the nurse should keep in mind that this child is0 Within the lo%er ran#e of normal intelli#ence Gildly retarded but educable Goderately retarded but trainable *ompletely dependent on others for care 6. &=. Gaureen, a#e 1&, is brou#ht to the clinic for evaluation for a suspected eatin# disorder. To best assess the effects of role and relationship patterns on the child5s nutritional intake, the nurse should ask0 What activities do you en#a#e in durin# the day?" !o you have any aller#ies to foods?" !o you like yourself physically?" What kinds of food do you like to eat?" <. &>. 3udden infant death syndrome 732!39 is one of the most common causes of death in infants. At %hat a#e is the dia#nosis of 32!3 most likely? At 1 to & years of a#e At 2 %eek to 1 year of a#e, peakin# at & to 4 months At - months to 1 year of a#e, peakin# at 1 months At - to > %eeks of a#e . &@. When evaluatin# a severely depressed adolescent, the nurse kno%s that one indicator of a hi#h risk for suicide is0 !epression '$cessive sleepiness A history of cocaine use A preoccupation %ith death 2. +. A child is dia#nosed %ith Wilms5 tumor. !urin# assessment, the nurse in char#e e$pects to detect0
