A primigravida arrives at the observation unit of the maternity unit because thinks is in labor. The
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nurse applies the external fetal heart monitor and determines that the fetal heart rate is 140
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beats/minute and the contractions are occurring irregularly every 10 to 15 minutes. What i;l i;l i;l i;l i;l i;l i;l i;l i;l i;l i;l i;l
assessment finding confirms to the nurse that the client is not labor at this time? - correct Answers ✔✔ -
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A primipara has delivered a stillborn fetus at 30 weeks gestation. To asses the parents in the grieving process
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which intervention is most for the nurse to implement ?
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A. explain the possible cause of the fetal demise
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B. Provide a time for the parents to hold their infant in privacy
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C. Encourage the parents to seek counseling within the next few weeks
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D. Assist the couple to request autopsy - correct Answers ✔✔ -B. provide a time for the parents to hold their
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infant in privacy
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What is the priority nursing assessment immediately following the birth of an infant with esophageal atresia
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and a tracheoesophageal (the) fistula ?
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A. body temperature
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B. level of pain
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C. time of first void
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D. number of vessels in the cord - correct Answers ✔✔ -A. body temperature
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What is the most important assessment for the nurse to conduct following the administration of epidural
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anesthesia to a client who is at 40-weeks gestation?
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A. Level of pain sensation
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B. Station of presenting part
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C. Variability of fetal heart rate
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A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer's Lactate 500 ml with
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magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the
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A mother of a 3-year-old boy has just given birth to a new baby girl. The little boy asks the nurse, "Why is
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my baby sister eating my mommy's breast?" How should the nurse respond? (Select all that apply)
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A. Explain that newborns get milk from their mothers in this way
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,B. Reassure the older brother that it does not hurt his mother
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C. Remind him that his mother breastfed him too
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D. Suggest that the baby can also drink from a bottle
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E. Clarify that breastfeeding is his mother's choice - correct Answers ✔✔ -A. Explain that newborns get milk
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from their mothers in this way
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B. Reassure the older brother that it does not hurt his mother
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C. Remind him that his mother breastfed him too
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The nurse is examining an infant for possible cryptorchidism. Which exam technique should be used?
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A. Place the infant in side-lying to facilitate the exam
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B. Hold the penis and retract the foreskin gently
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C. Cleanse the penis with an antiseptic-soaked pad
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D. Place the infant in warm room and use a calm approach - correct Answers ✔✔ -D. Place the infant in
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warm room and use a calm approach
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The nurse is planning care for a client at 30-weeks gestation who is experiencing preterm labor. What
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maternal prescription is most important in preventing this fetus from developing respiratory distress
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syndrome?
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A. Betamethasone (Celestone) 12 mg deep IM
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B. Butorphanol 1 mg IV push q2h PRN pain
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C. Ampicillin 1 Gram IV push q8h
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A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary
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retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery
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eyes, and a rash in the diaper area. What action is most important for the nurse to take?
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A. Auscultate the lungs for respiratory pneumonia.
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B. Draw blood to analyze for streptococcal infection
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C. Change to latex-free gloves when handling infant
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D. Apply zinc oxide to perineum with each diaper change - correct Answers ✔✔ -C. Change to latex-free
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gloves when handling infant
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The nurse is caring for a female client, a primigravida, with preeclampsia. Findings include +2 proteinuria, BP
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172/112 mmHg, facial and hand swelling, complaints of blurry vision and a severe frontal headache. Which
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medication should the nurse anticipate for this client?
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A client at 35-weeks gestation complains of a "pain whenever the baby moves." On assessment, the nurse
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notes the client's temperature to be 101.2F, with severe abdominal or uterine tenderness on palpation. The
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nurse knows that these findings are indicative of what condition?
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, A male infant with a 2-day history of fever and diarrhea is brought to a clinic by his mother who tells the
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nurse that the child refuses to drink anything. The nurse determines that the child has a weak cry with no
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tears. Which prescription is most important to implement?
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A. Provide a bottle of electrolyte solution
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B. Infuse normal saline intravenously
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C. Administer an antipyretic rectally
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A 6-month old child who had a cleft-lip repair has elbow restraints in place. What nursing intervention should
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the nurse plan to implement?
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A. remove restraints q4h for 30 minutes and place gloves on the child's hands
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B. record observations of the restraints q2h and ensure that they are in place at all times
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C. obtain the HCP advice as to when the restraints should be removed
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D. remove restraints one at a time to provide ROM exercises - correct Answers ✔✔ -D. remove restraints one
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at a time to provide ROM exercises
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A new mother calls the nurse stating that she wants to start feeding her 6-month-old child something besides
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breast milk, but is concerned that the infant is too young to start eating solid foods. How should the nurse
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respond?
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A. encourage the mother to schedule a developmental assessment of the infant
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B. advise the mother to wait at least another month before starting any solid foods
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C. instruct the mother to offer a few spoons of 2-3 pureed fruit at each meal
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D. reassure the mother that the infant is old enough to eat iron-fortified cereal - correct Answers ✔✔ -D.
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reassure the mother that the infant is old enough to eat iron-fortified cereal
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While caring for a laboring client on continuous fetal monitoring, the nurse notes a fetal heart rate pattern that
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falls and rises abruptly with a "V" shaped appearance. What action should the nurse take first?
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A. Prepare for a potential cesarean
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B. Allow the client to begin pushing
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C. Administer oxygen at 10/L by mask
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D. Change the maternal position - correct Answers ✔✔ -D. Change the maternal position
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A postpartum client who is Rh-negative refuses to receive Rho (D) immune globulin (RhoGam) after delivery
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of an infant who is Rh-positive. Which information should the nure provide this client?
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A. RhoGam is not necessary unless all her pregnancies are Rh-positive
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B. The R-positive factor from the fetus threatens her blood cells
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C. The mother should receive RhoGam when the baby is Rh-negative
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A 6-week-old infant diagnosed with pyloric stenosis has recently developed projectile vomiting. Which
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assessment finding indicates to the nurse that the infant is becoming dehydrated?
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A. Weak cry without any tears
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B. Bulging fontanel
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C. Visible peristaltic wave.
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