1. A nurse is caring for a client who is prescribed Rho immune globulin standard dose IM (Rhogam). The nurse should understand the action of this medication as which of the following?
Rhogam prevents the formation of Rh antibodies in mothers who are Rh negative
1. Fetal movement that is noted by the mother is a very important assessment factor to determine fetal well- being. If the nurse is to ask the client if she has “felt her baby move”, when is the best time for a primigravid client to note the first fetal activity?
18 – 20 weeks.
1. The nurse is palpating the uterus of a client who is 20 weeks pregnant to measure fundal height. Identify where the nurse will find the uterine fundus?
At or near the umbilicus
1. A woman asks the nurse: “What protects my baby’s umbilical cord from being pinched while the baby’s inside”. The nurse’s best response is?
“Your baby’s umbilical cord is surrounded by connective tissue called Wharton’s Jelly, which prevents compression of the blood vessels and ensures continued nourishment and oxygen to your baby.”
1. A 20 year -old client calls the clinic to report that she has found a lump in her breast. The nurse’s best response to her is which of the following?
“Many women have benign lumps and bumps in their breasts. However to make sure that it is benign, you should come in for an examination by your physician”
Activity is an important component of prenatal teaching. Activity that is considered safe for a client that states she does not participate in any activity or exercise program at this time would be?
Walking
During her annual gynecologic check up a 17 year-old woman states that recently she has been experiencing cramping and pain during her menstrual periods. The nurse would document this complaint as?
Dysmenorrhea
Prenatal testing is done to identify health issues that may interfere with the developing fetus. Within the first trimester what lab tests are normally obtained? (select all that apply)
Blood type and Rh factor
Complete blood count (CBC)
HIV
The normal parameter of Fetal heart tones is 110 – 160 and can be heard by a doppler as early as?
10-12 weeks gestation
A common discomfort of pregnancy can be managed by changing nutritional intake and some OTC medications. In reviewing information with the patient after her first prenatal visit the nurse is confident that this woman understand the management of constipation when she makes which of the following statements?
“In addition to increasing my dietary fiber, I can use fiber supplements, drink more water and increase my activity if I have no restrictions”
At 32 weeks of pregnancy a woman experiences preterm labor. Although tocolytics are administered and she is placed on bed rest, she continues to experience regular contractions and her cervix is beginning to dilate and efface. What additional medication should be considered to assist the development of the fetus?
Betamethasone
A 30 week gestational age pregnant client presents to the labor suite with complaints of contractions and pressure. What medications can the nurse expect the provider to order for administration? (select all that apply)
Magnesium sulfate
Terbutaline (Brethine)
Betamethasone
Hormonal shifts in pregnancy and the physiological changes that occur affect every body system. As the nurse, which of the following symptoms or presentation would you consider abnormal?
Headaches occurring in the third trimester
A women with the diagnosis of hyperemesis gravidarum requires hospitalization. In addition to her need to be hospitalized what else is significant?
She has vomiting severe and persistent enough to cause weight loss, dehydration and electrolyte imbalance.
A woman is 39 weeks gestation with severe abdominal pain that remains constant is being admitted to the labor and delivery unit. She suddenly experiences increased contraction frequency of every 1 to 2 minutes, has dark red vaginal bleeding and a tense rigid abdomen. What should the nurse suspect at this time?
Placenta abruption
Magnesium sulfate is given to a pregnant client with pre-eclampsia and eclampsia for which of the following reasons?
Prevent and treat seizures
A nurse is caring for a client who has a possible ectopic pregnancy at 8 weeks gestation. Which of the following manifestations should the nurse expect to identify as consistent with this diagnosis?
Unilateral abdominal pain
A woman who is 32 weeks pregnant is informed by the nurse that a danger sign of pregnancy could be which of the following?
changes in the pattern of fetal activity
A nurse instructs a 20 year old female college student about oral contraceptives. After the teaching session, the nurse confirms that the client understands the information when she makes which of the following statements?
Oral contraceptives should be taken the same time each day.
A 34 week pregnant woman is experiencing preterm labor. The nurse will provide the following interventions for her client? (select all that apply)
Obtain a urine specimen
Place on a fetal monitor
IV therapy of Lactated Ringers with a 500 ml bolus of fluid
A client with a gestational age of 32 weeks arrives at the clinic for a routine prenatal visit. In identifying fetal well-being, the nurse knows she must measure fundal height, fetal heart tones and fetal movement. The nurse finds the fundal height to be 28 cm and fetal heart tones at 115 bpm, and mother relates that fetal movement has slowed. What may the nurse conclude with this finding?
Possible IUGR and the nurse should identify risk factors and notify the physician.
A client who is 32 weeks pregnant is being monitored in the Antepartum unit for pregnancy induced hypertension (gestational hypertension). She suddenly complains of continuous abdominal pain and vaginal bleeding. Which of the following nursing interventions should be included in the care of this client? (select all that apply)
Evaluate fetal heart tones
Evaluate vital signs
Monitor the amount of vaginal bleeding
The clinic nurse reviews the complete blood count results of a 30-year-old woman who is now 33 weeks’ gestation. The patient’s hemoglobin value is 11.2 g/dL and her hematocrit is 38%. How does the clinic nurse interpret these findings?
normal pregnancy values for the third trimester.
A married couple is discussing alternatives for pregnancy prevention and has asked about fertility awareness methods. (Natural family planning, FAM’s) What is the nurse’s most appropriate response?
“They can be effective for many couples, but they require motivation.”
The student nurse is learning that is is recommended to screen for domestic violence in the first prenatal visit for all clients. The instructor has explained how to communicate and ask questions that are personal, so which question would be the best stated for the student nurse to ask?
“This is something that we ask everyone. Do you feel safe in your current living environment and relationships?”
The prenatal clinic nurse meets with a 30-year-old woman who is experiencing her first pregnancy. The patient’s quadruple marker screen result is positive or abnormal at 17 weeks of gestation and her provider recommends an amniocentesis. The nurse explains that the patient needs a referral to one of the following.
Genetics counselor/specialist.
Management of primary dysmenorrhea often requires a multifaceted approach. What is the optimal pharmacological therapy for pain relief when caring for a client with this condition?
Non-steroidal anti- inflammatory drugs (NSAIDS)
Screening at 24 weeks gestation reveals that a pregnant woman has gestational diabetes mellitus (GDM). In planning her care the nurse and the woman mutually agree that an expected outcome is to prevent injury to the fetus as a result of GDM. What does the nurse identify as the greatest risk for the fetus?
Macrosomia
The nurse caring for a pregnant client knows that her health teaching regarding fetal circulation has been effective when the client reports that she has been sleeping in what position?
In a side-lying position
A woman is at 14 weeks gestation. The nurse would expect to palpate the fundus at which level?
Slightly above the symphysis pubis
Which of the following signs and symptoms should a woman report immediately to her health care provider? Choose all that apply:
Rupture of membranes
Vaginal bleeding
Headaches that do not respond to usual therapy.
A woman’s obstetrical history indicates that she is pregnant for the 4th time and all of her children from previous pregnancies are living. One was born at 39 weeks of gestation, twins were born at 34 weeks of gestation, and another child was born at 35 weeks of gestation. What is her gravidity and parity using the GTPAL system?
4-1-2-0-4
Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman in her second trimester?
Increased pulse rate
A woman arrives at the clinic for a pregnancy test. The first day of her last menstrual period (LMP) was February 14. Her expected date of birth (EDB) would be?
November 21
A pregnant client at 32 weeks gestation has mild pre-eclampsia. She is discharged home with instructions to remain on bedrest. She should also be instructed to call her provider if she experiences which of the following symptoms? (select all that apply)
Blurred vision
Headache not relieved with over the counter medication
Epigastric pain
Intrauterine growth restriction is the result of poor placental perfusion. What pregnancy risk factors may contribute to intrauterine growth restriction? (select all that apply)
Drug abuse
Hypertension
Smoking
A 25-year-old single female comes to the gynecologist’s office for a follow-up visit related to her abnormal Papanicolaou (Pap) smear. The test revealed that the client has human papillomavirus (HPV). The client asks, “What is that? Can you get rid of it?” What is your best response?
“HPV stands for ‘human papillomavirus.’ It is a sexually transmitted infection (STI) that may lead to cervical cancer.”
The amniotic fluid has many functions and we know that amniotic fluid is necessary for fetal well- being. Please select the purpose of the fluid for fetal well -being. Select all that apply.
permits free movement of the baby
cushioning of the baby from minor trauma
temperature control
A pregnant woman experiencing nausea and vomiting. What action can she take?
eat small, frequent meals (every 2 to 3 hours)
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? (select all that apply)
Client has had two prior pregnancies
Client has one living child
Client has delivered one newborn at term
A nurse in a clinic is teaching a client of childbearing age about recommended folic acid supplements. Which of the following defects can occur in the fetus or neonate as a result of folic acid deficiency?
Neural tube defects
A nurse 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?
Calcium gluconate
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 of the following?
Shortness of breath
A client in the prenatal clinic is complaining of episodes of dizziness when sitting up after lying supine for some time. Which response by the nurse explains this change during pregnancy?
“This is due to the weight of the uterus on the vena cava.”
A nurse is reviewing a prescription for ferrous sulfate (iron supplementation) with a client who is at 12 weeks gestation. Which of the following statements by the client indicates understanding of the teaching?
“I plan to drink more orange juice while taking this pill.”
As a nurse working in a prenatal clinic it is important to obtain both maternal and fetal assessments. While obtaining fetal assessments, which of the following should the nurse complete for fetal well-being?
Fetal heart tones, Fetal movement, and Fundal height
A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis?
Painless red vaginal bleeding
A nurse is completing a health history for a client who is at 6 weeks of gestation. The client informs the nurse that she smokes one pack of cigarettes per day. The nurse should advise the client that smoking places the client’s newborn at risk for which of the following complications?
Intrauterine growth restriction
A nurse is admitting a client who has severe preeclampsia at 35 weeks of gestation and is reviewing the provider’s orders. Which of the following orders requires clarification?
Ambulate twice daily.
A student nurse asks the faculty about the importance of preconception counseling. Which response by the faculty is best?
“It is the best time to find any conditions that could have a negative effect on a pregnancy.”
rasmussen maternal child exam 1 quizlet
maternal child exam 2
maternal child final exam
maternal and child health nursing exam 2
maternal child final exam rasmussen
a nurse is preparing to perform a venipuncture to collect a blood sample from an infant
nur2513 exam 2
nur2633 exam 3
A nurse is caring for a child during a tonic-clonic seizure. Which of the following actions should the nurse take? (select all that apply)
A. Clear the areas of hard objects
B. Firmly hold the child’s arms to one side
C. Place a pillow under the child’s head
D. Insert a tongue blade into the child’s mouth
E. Loosen tight clothing around the child’s neck
ANS A, C, E
Clear the areas of hart object
Place a pillow under the child’s head
Loosen tight clothing around the child’s neck
A nurse is preparing to perform a venipuncture to collect a blood sample from an infant. Which of the following restrains should the nurse use for the procedure?
A. Elbow
B. Mitten
C. Jacket
D. Mummy
ANS D
Mummy
A nurse is teaching a parent of a preschool-age child about management of night terrors. Which of the following instructions should the nurse include?
A. Take the child to the parent’s bed to resume sleep
B. Allow the child to fall asleep with the television on
C. Remain uninvolved until the child awakens
D. Schedule professional counseling for the child
ANS C
Remain uninvolved until the child awakens
A nurse is assessing a toddler who is 8 hr postoperative following a cardiac catheterization procedure. Which of the following findings should the nurse report to the provider?
A. Weak pedal pulses distal to the site
B. Bilateral cool extremities
C. Serum glucose 90
D. Blood pressure 102/58
ANS B
Bilateral cool extremities
A nurse is providing education about dietary modifications to the parent of a school age child
who has glomerulonephritis. Which of the following information should the nurse include in the
teaching?
A. Increase the child calcium intake
B. Decrease the Child’s sodium intake
C. Increase the child’s intake of carbohydrates
D. Decrease the child’s fat intake
ANS B
Decrease the child’s sodium intake
A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure
disorder. The nurse should teach the parents to take which of the following actions during a
seizure?
A. Minimize movement of the limbs
B. Insert a tongue blade between the teeth
C. Clear the area of hard object
D. Place the child in a prone position
ANS C
Clear the area of hard objects
A nurse is assessing an adolescent who has type 1 diabetes mellitus. Which of the following findings is the nurse’s priority?
A. HbA1C 11.5%
B. cholesterol 189 mg/dL
C. Preprandial blood glucose 124 mg/dL
D. Glycosuria
ANS A
HbA1C 11.5%
A nurse is providing anticipatory guidance to a parent of a 1- month-old infant. The nurse should include that it is recommended to start this series of which of the following immunization first?
A. Varicella
B. measles, mumps, rubella
C. Inactivated poliovirus
D. Hepatitis A tetra
ANS C
Inactivated poliovirus
A nurse is reviewing the laboratory report of a toddler who has hemolytic uremic syndrome. Which of the following findings should the nurse expect?
A. Creatinine 0.3 mg/dL
B. Hgb 18 g/dL
C. Urine casts absent
D. BUN 28 mg/dL
ANS D
BUN 28
A nurse is caring for a school-age child who is experiencing a sickle cell crisis. Which of the
following actions should the nurse take?
A. Administer furosemide IV twice per day.
B. Apply warm compresses to the affected areas
C. Decrease the child’s fluid intake
D. Initiate contact precautions.
ANS B
Apply warm compresses to the affected area
A nurse is assessing a 6-month-old infant who has respiratory syncytial virus. The nurse should
immediately report which of the followings finding to the provider?
A. Rhinorrhea
B. Tachypnea
C. Pharyngitis
D. Coughing
ANS B
Tachypnea
All others are expected findings
A nurse is planning to teach an adolescent who is lactose intolerant about dietary guidelines. Which of the following instructions should the nurse include in the teaching?
A. You can drink milk on an empty stomach.
B. You should consume flavored yogurt instead of plain yogurt.
C. You can tolerate plain milk better than chocolate milk.
D. You can replace milk with nondairy source of calcium
ANS D
You can replace milk with nondairy source of calcium
A nurse on a pediatric intensive care unit is caring for a toddler who weighs 12 kg (26.5 Ib) and
is postoperative following open heart surgery. Which of the following findings should the
nurse report to the provider?
A. Skin temperature 36C (96.8 F)
B. Pedal and posterior tibial pulses of 2+
C. Urine output of 15 mL in the last 2 hr
D. Drainage from the chest tube of 22 mL in the last hour
ANS C
Urine output of 15 mL in the last 2 hours
A nurse is providing dietary teaching to a parent of a 10-month-old infant who has
phenylketonuria. Which of the following responses by the parent indicate an understanding of the teaching?
A. My daughter can’t drink orange juice
B. I will steam carrots and cut them into small pieces for her
C. I should ensure my daughter eats one ounce of meat every day
D. I will switch her to whole milk now that she is old enough
ANS B
I will steam carrots and cut them into small pieces for her
avoid foods high in protein
A nurse is providing teaching to the parent of a preschool-age child who has celiac disease.
which of the following instructions should the nurse include?
A. Your child will be on a gluten-free diet for the rest of her life.”
B. Your child will need to follow a low-protein diet temporarily.”
C. You should place your child on a high-fiber diet when she has an exacerbation.”
D. You should replace white flour with wheat flour when preparing meals for your child.”
ANS A
Your child will be on a gluten-free diet for the rest of her life.
A nurse is administering albuterol by metered dose inhaler for a preschool-age child who is
experiencing an asthma exacerbation. Which of the following findings should the nurse report to the provider?
A. Respiratory rate 24 /min
B. Peak flow rate of 80% (normal 80 to 100)
C. Intercostal retractions
D. Elevated heart rate
ANS D
Elevated heart rate
A nurse is caring for a school-age child who is 1 hr postoperative following it tonsillectomy. Which of the following actions should the nurse take? (Select all that apply.)
A. Administer an analgesic to the child on a scheduled basis.
B. Observe the child for frequent swallowing
C. Provide cranberry juice to the child
D. Maintain the child in a supine position
E. Discourage the child from coughing
ANS A, B, E
Administer an analgesic to the child on a scheduled basis
Observe the child for frequent swallowing
Discouraging the child from coughing
A nurse is caring for a school-age child who has heart failure. Which of the following findings should the nurse expect?
A. Tachycardia
B. Weight loss
C. Cyanosis
D. Dyspnea
E. Bounding peripheral pulses
ANS A, C, D
Tachycardia
Cyanosis
Dyspnea
A nurse is in the emergency department assessing a toddler who has a head injury. Which of the following findings should the nurse report to the provider?
A. GCS 15
B. RR 25
C. Vomiting
D. Negative babinski reflex
ANS C
Vomiting
A nurse caring for a toddler who is in the terminal stage of neuroblastoma. The parents ask, how can we help our child now? Which of the following responses by the nurse is appropriate?
A. Talk to your child about the meaning of death.”
B. Encourage your child’s friends to visit.”
C. Stay close to your child.”
D. Change your child’s schedule every day.”
ANS C
Stay close to your child
A nurse is preparing to administer cephalexin 24 mg/kg PO to a child who has otitis media and weighs 22 kg (48.5 lb). Available is cephalexin solution 250 mg/5 mL. How many mL should the nurse administer?
Round to the nearest whole number.
11 mL
During a well-baby visit, the parent of a 2- week-old newborn tells the nurse, “My baby always
keeps her head tilt to the right side. The nurse should further assess which of the following areas?
A. Sternocleidomastoid muscle
B. Posterior fontanel
C. Trapezius muscle
D. Cervical vertebrae
ANS A
Sternocleidomastoid muscle
A nurse is caring for a single mother of a 6-month-old infant. During a well-baby visit, the mother expresses feeling “inexperience” in caring for the baby. The nurse should recommend which of the
following community resources?
A. Respite childcare
B. Parent management training
C. Support group for postpartum depression
D. Parent enhancement center
ANS D
Parent enhancement center
A nurse is admitting an infant who has GERD. Which of the following is the priority assessment finding?
A. Regurgitation
B. Wheezing
C. Excessive crying
D. Weight loss
ANS B
Wheezing
A nurse is caring for an infant who has severe dehydration. Which of the following clinical findings should the nurse expect?
A. Capillary refill 3 seconds
B. Rapid respirations
C. Bradycardia
D. Warm extremities
ANS B
Rapid respirations
A nurse is teaching a group of female adolescents about healthy eating. Which of the following instructions should the nurse include in the teaching?
A. Consume 1,500 to 1,700 calories per day
B. Decrease your vitamin D intake once you start to menstruate
C. Increase the amount of iron intake
D. Limit your sodium intake to 3,000 grams per day
ANS C
Increase the amount of iron intake
A nurse is preparing to administer an immunization to a 3 month old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
A. Provide a pacifier coated with an oral sucrose solution prior to the injections
B. Inject the immunizations into the deltoid muscle
C. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injection
D. Use a 20G needle for the injection
ANS A
Provide a pacifier coated with oral sucrose solution prior to the injections
A nurse is caring for a child who has impetigo contagiosa that developed in the hospital. Which of the following actions should the nurse take?
A. Report the disease to the state health department
B. Administer amphotericin B
C. Initiate contact isolation precautions
D. Apply antimicrobial ointment
ANS C
Initiate contact isolation precautions
A nurse is providing discharge teaching to the parents of a school-age child who has cystic fibrosis. Which of the following responses by the parents indicate an understanding of the teaching?
A. I will limit my child’s daily fluid intake
B. I will restrict the amount of sodium in my child’s diet
C. I will give my child pancreatic enzymes with snacks and meals
D. I will prepare low-fat meals with limited protein for my child
ANS C
I will give my child pancreatic enzymes with snacks and meals
A nurse is caring for a 4-year-old child who has meningitis and is receiving gentamicin. Which of
the following laboratory values should the nurse report to the provider?
A. Creatinine 1.4 mg/dL (0.3 to 0.7)
B. Creatinine 0.3 mg/dL (Normal range)
C. BUN 6 mg/dL (5 to 18 normal range)
D. BUN 12 mg/dL (5 to 18 normal range)
ANS A
Creatinine 1.4 mg/dL
Crt 0.3 to 0.7
BUN 15-18
A nurse is providing teaching to the parent of a school-age child who has ADHD and a new
prescription for methylphenidate. The nurse should explain that this medication will have which of the
following therapeutic effects?
A. Promoting rest
B. Improving appetite
C. Reducing anxiety
D. Increasing focus
ANS D
Increases focus
A nurse is teaching an adolescent how to manage his cystic fibrosis. which of the following statements by the adolescent indicates an understanding of the teaching?
A. I will take fewer enzymes when I eat high-fiber foods
B. I will be excused from physical education classes
C. I will limit my calcium intake to prevent kidney stones
D. I will increase my intake of vitamin D
ANS D
I will increase my intake of vitamin D
A nurse in a provider’s office is caring for a preschool-age child who might have acute epiglottitis. which of the following actions should the nurse take?
A. Examine the oral mucosa using a tongue depressor
B. Obtain a sterile throat culture
C. Provide humidified oxygen via nasal cannula
D. Allow the child to sit in a comfortable position
ANS C
Provide humidified oxygen via nasal cannula
A nurse is providing teaching to the parents of a child who has impetigo. Which of the following
instructions should the nurse include in the teaching?
A. Administer as acyclovir PO two times per day.
B. Soak hair brushes in boiling water for 10 minutes
C. Apply bactericidal ointment to lesions.
D. Seals soft toys in a plastic bag for 14 days
ANS C
Apply antibacterial ointment to lesions
A nurse is preparing to perform a venipuncture to collect a blood sample from an infant. Which of
the following restraints should the nurse plan to use for this procedure?
A. Mummy
B. Mitten
C. Jacket
D. Elbow
ANS A
Mummy
A nurse is reviewing the laboratory report of a school age child who has rheumatic fever. Which of the following laboratory findings should the nurse expect?
A. Decreased BUN
B. Increased antistreptolysin O titer (ASO)
C. Increased immunoglobulin G (IgG)
D. Decreased erythrocyte sedimentation rate (ESR)
ANS B
Increased antistreptolysin O titer
A nurses administering an opioid to an adolescent who is in sickle cell crisis. Which statement is true regarding opioid pain management?
A. Oral opioid doses should be larger than parenteral doses
B. Oral opioids should not be combined with other types of pain relievers.
C. Opioid doses should be titrated until sedation occurs
D. Opioid doses should be used for mild pain
ANS A
Oral opioid doses should be larger than parenteral doses