NURS 2130 Pediatrics Final 2020 | NURS2130 Pediatrics Final

NURS 2130 Pediatrics Final 2020 1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the ...

NURS 2130 Pediatrics Final 2020 1. A 3-day postpartum client, who is not immune to rubella, is to receive the vaccine at discharge. Which of the following must the nurse include in her discharge teaching regarding the vaccine? a. The woman should not become pregnant for at least 4 weeks. b. The woman should pump and dump her breast milk for 1 week. c. The mother must wear a surgical mask when she cares for the baby. d. Passive antibodies transported across the placenta will protect the baby. 2. A patient, G2P1102, who delivered her baby 8 hours ago, now has a temperature of 100.2ºF. Which of the following is the appropriate nursing intervention at this time? a. Notify the doctor to get an order for acetaminophen. b. Request an infectious disease consult from the doctor. c. Provide the woman with cool compresses. d. Encourage intake of water and other fluids. 3. A breastfeeding woman has been counseled on how to prevent engorgement. Which of the following actions by the mother shows that the teaching was effective? a. She pumps her breasts after each feeding. b. She feeds her baby every 2 to 3 hours. c. She feeds her baby 10 minutes on each side. d. She supplements each feeding with formula. 4. The nurse in the obstetric clinic received a telephone call from a bottle feeding mother of a 3-day-old. The client states that her breasts are firm, red, and warm to the touch. Which of the following is the best action for the nurse to advise the client perform?
a. Intermittently apply ice packs to her axillae and breasts.
b. Apply lanolin to her breasts and nipples every 3 hours.
c. Express milk from the breasts every 3 hours.
d. Ask the primary health care provider to order a milk suppressant. 5. The nurse is caring for a breastfeeding mother who asks advice on foods that will provide both vitamin A and iron. Which of the following should the nurse recommend?
a. 1⁄2 cup raw celery dipped in 1 ounce cream cheese.
b. 8 ounce yogurt mixed with 1 medium banana.
c. 12 ounce strawberry milk shake.
d. 1 1⁄2 cup raw broccoli. 6. A breastfeeding mother states that she has sore nipples. In response to the complaint, the nurse assists with “latch on” and recommends that the mother do which of the following?
a. Use a nipple shield at each breastfeeding.
b. Cleanse the nipples with soap 3 times a day.
c. Rotate infant positions at each feed.
d. Bottle feed for 2 days then resume breastfeeding. 7. Which of the following statements is true about breastfeeding mothers as compared to bottle feeding mothers?
a. Breastfeeding mothers usually involute completely by 3 weeks postpartum.
b. Breastfeeding mothers have decreased incidence of diabetes mellitus later in life.
c. Breastfeeding mothers show higher levels of bone density after menopause.
d. Breastfeeding mothers are prone to fewer bouts of infection immediately
postpartum. 8. The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs during the early postpartum period?
a. Decreased urinary output.
b. Increased blood pressure.
c. Decreased blood volume.
d. Increased estrogen level. 9. During a home visit, the nurse assesses a client 2 weeks after delivery. Which of the following signs/symptoms should the nurse expect to see?
a. Diaphoresis.
b. Lochia alba.
c. Cracked nipples.
d. Hypertension. 10. The nurse is caring for a client who had a cesarean section under spinal anesthesia less than 2 hours ago. Which of the following nursing actions is appropriate at this time?
a. Elevate the head of the bed 60 degrees.
b. Report absence of bowel sounds to the physician.
c. Have her turn and deep breathe every 2 hours.
d. Assess for patellar hyperreflexia bilaterally. 11. The nurse is caring for a postpartum client who experienced a second-degree perineal laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
1. Apply an ice pack to the perineum.
2. Advise the woman to use a sitz bath after every voiding.
3. Advise the woman to sit on a pillow.
4. Teach the woman to insert nothing into her rectum. 12. A client, 2 days postoperative from a cesarean section, complains to the nurse that she has yet to have a bowel movement since the surgery. Which of the following responses by the nurse would be appropriate at this time?
1. “That is very concerning. I will request that your physician order an enema
for you.”
2. “Two days is not that bad. Some patients go four days or longer without a
movement.”
3. “You have been taking antibiotics through your intravenous. That is probably
why you are constipated.”
4. “Fluids and exercise often help to combat constipation. Take a stroll around the unit and drink lots of fluid.” 13. A client is 40 minutes postpartum from a forceps delivery of a 4500 gram neonate over a right mediolateral episiotomy. The client is at risk for each of the follow nursing diagnoses. Which of the diagnoses is highest priority at this time?

Ineffective breast feeding
Fluid Volume Deficit
Infection
Pain 14. A nurse is assessing a 1-day-postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon?
1. Fundus at the umbilicus.
2. Nodular breasts.
3. Pulse rate 60 bpm.
4. Pad saturation every 30 minutes. 15. A 1-day postpartum woman states, "I think I have a urinary tract infection. I have to go to the bathroom all the time." Which of the following actions should the nurse take? 1. Assure the woman that frequent urination is normal after delivery.
2. Obtain an order for a urine culture.
3. Assess the urine for cloudiness.
4. Ask the woman if she is prone to urinary tract infections. 16. Which of the following nursing interventions would be appropriate for the nurse to perform to achieve the client care goal: The client will not develop postpartum thrombophlebitis?
1. Encourage early ambulation.
2. Promote oral fluid intake.
3. Massage the legs of the client twice daily. 4. Provide the client with high-fiber foods. 17. A nurse is counseling a woman about postpartum blues. Which of the following should be included in the discussion?
1. The father may become sad and weepy.
2. Postpartum blues last about a week or two.
3. Medications are available to relieve the symptoms.
4. Very few women experience postpartum blues. 18. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 1 hour. How should the nurse document this finding?
1. Scant
2. Light
3. Heavy
4. Excessive 19. The perinatal nurse is caring for a woman in the immediate postbirth period. Assessment reveals that the woman is experiencing profuse bleeding. The most likely etiology for the bleeding is:

A. Uterine atony
B. Uterine inversion
C. Vaginal hematoma
D. Vaginal laceration 20. What woman is at greatest risk for early postpartum hemorrhage?

A. A primiparous woman (G 2 P 1 0 0 1) being prepared for an emergency cesarean birth for fetal distress
B. A woman with severe preeclampsia on magnesium sulfate whose labor is being induced
C. A multiparous woman (G 3 P 2 0 0 2) with an 8-hour labor
D. A primigravida in spontaneous labor with preterm twins 21. The first and most important nursing intervention when a nurse observes profuse postpartum bleeding is to:

A. Call the woman's primary health care provider
B. Administer the standing order for an oxytocic
C. Palpate the uterus and massage it if it is boggy
D. Assess maternal blood pressure and pulse for signs of hypovolemic shock 22. When caring for a postpartum woman experiencing hemorrhagic shock, the nurse recognizes that the most objective and least invasive assessment of adequate organ perfusion and oxygenation is:

A. Absence of cyanosis in the buccal mucosa
B. Cool, dry skin
C. Diminished restlessness
D. Urinary output of at least 30 ml/hr 23. The most effective and least expensive treatment of puerperal infection is prevention. What is important in this strategy?

A. Large doses of vitamin C during pregnancy
B. Prophylactic antibiotics
C. Strict aseptic technique, including handwashing, by all health care personnel
D. Limited protein and fat intake 24. One of the first symptoms of puerperal infection to assess for in the postpartum woman is:

A. Fatigue continuing for longer than 1 week
B. Pain with voiding
C. Profuse vaginal bleeding with ambulation
D. Temperature of 38° C (100.4° F) or higher on 2 successive days starting 24 hours after birth 25. The perinatal nurse assisting with establishing lactation is aware that acute mastitis can be minimized by:

A. Washing the nipples and breasts with mild soap and water once a day
B. Using proper breastfeeding techniques
C. Wearing a nipple shield for the first few days of breastfeeding
D. Wearing a supportive bra 24 hours a day 26. What infection is contracted mostly by first-time mothers who are breastfeeding?

A. Endometritis
B. Wound infections
C. Mastitis
D. Urinary tract infections 27. A nurse is collecting data from a client who is receiving magnesium sulfate. Which of the following findings should the nurse report to the provider? - absent deep tendon reflexes 28. A nurse is caring for a client who is 2 hr postpartum. The nurse locates the client's fundus 2 cm above the umbilicus, with displacement to the right of the midline, and notes it is boggy. The nurse should identify which of the following complications as the likely cause of these findings? - uterine bleeding 29. A nurse is caring for a client following a cesarean birth. Which of the following actions should the nurse take to decrease the client's risk of developing thrombophlebitis? - have the client ambulate several times a day 30. A nurse is reinforcing teaching about newborn umbilical cord care with a client who is postpartum. Which of the following statements should the nurse identify as an indication that the client understands the instructions? - I will report any drainage from my baby’s umbilical cord 31. A nurse is contributing to the plan of care for a client who has hyperemesis gravidarum. Which of the following interventions should the nurse recommend? - monitor input and output 32. A nurse is reviewing the medical record of a client who is at 26 weeks of gestation. Which of the following findings should the nurse identify as a risk factor for the development of preeclampsia? - iron deficiency anemia 33. A nurse is preparing to administer phytonadione to a newborn. The nurse should plan to administer this medication by which of the following routes? - intramuscular 34. A nurse is contributing to the plan of care for a client who has eclampsia. Which of the following interventions should the nurse identify and plan to include as the priority immediately following a seizure? - insert an indwelling urinary catheter 35. A nurse is reinforcing teaching with a new parent about the prevention of newborn abduction. Which of the following statements by the parent indicates an understanding of the teaching? - I will ask the nurse to take care of my baby in the nursery if I need to take a nap 36. A nurse is caring for a client who is planning to become pregnant. The client asks the nurse why folic acid supplements are necessary. The nurse should inform the client that the purpose of the folic acid supplement is to do which of the following? - prevents certain kind of defects 37. A nurse is reinforcing teaching about food sources that are high in folate with a group of women who are pregnant. Which of the following foods should the nurse recommend to this group as the best source of folate? - dried peas 38. A nurse is reinforcing teaching about car seat safety with a parent of a newborn. Which of the following statements should the nurse identify as an indication that the client understands the instructions? - If my baby rides in a car with no backseat the passenger airbag must be turned off 39. A nurse is planning to administer phytonadione (vitamin k) to a newborn. Which of the following actions should the nurse take? - Use the vastus lateralis as the injection site 40. A nurse is assisting in the care of a client during the active phase of labor. Which of the following actions should the nurse take to promote the client's comfort? - have the client perform relaxing breathing techniques 41. A nurse is caring for a client who is at 30 weeks of gestation. Which of the following findings should the nurse report to the provider? - prolonged decelerations of FHR 42. A nurse is caring for a newborn who is large for gestational age and is jittery. Which of the following actions should the nurse take first? - check the neworns blood glucose 43. A nurse in a prenatal clinic is caring for a client who is at 16 weeks of gestation and has a positive hepatitis B test result. Which of the following actions should the nurse take? - Explain to the client that she will receive the hepatitis B immune globulin immediately 44. A nurse is assisting with the care of a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. The client has a respiratory rate of 10/min. Which of the following medications should the nurse expect a charge nurse to administer to the client? - calcium gluconate 45. A nurse is contributing to the plan of care for a newborn who was circumcised with a plastic bell device. Which of the following actions should the nurse include in the plan? - Apply pressure with sterile gauze a bleeding occurs at the site 46. A nurse is reinforcing teaching with a client who has a new prescription for ferrous sulfate. Which of the following instructions should the nurse include? - increase your fluid intake with this medication 47. An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed:

A. Only if the newborn is in obvious distress
B. Once by the obstetrician, just after the birth
C. At least twice, 1 minute and 5 minutes after birth
D. Every 15 minutes during the newborn's first hour after birth 48. The nurse is assessing a newborn girl who is 2 hours old. What finding would warrant a call to the physician?

A. Blood glucose of 45 mg/dl using a Dextrostix
B. Heart rate of 160 beats/min after crying vigorously
C. A crepitant-like feeling when assessing the clavicles
D. Passage of a dark black-green substance from the rectum 49. The nurse administers vitamin K to the newborn for what reason?

A. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
B. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
C. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract.
D. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented. 50. The nurse is using the Ballard scale to determine the gestational age of a newborn. Which assessment finding is consistent with a gestational age of 40 weeks?

A. Flexed posture
B. Abundant lanugo
C. Smooth, pink skin with visible veins
D. Faint red marks on the soles of the feet 51. A newborn is jaundiced and is receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:

A. Apply an oil-based lotion to the newborn's skin to prevent dying and cracking
B. Limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea
C. Place eye shields over the newborn's closed eyes
D. Change the newborn's position every 4 hours 52. Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after:

A. The bleeding stops completely.
B. Yellow exudate forms over the glans.
C. The PlastiBell rim falls off.
D. The infant voids. 53. A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home?

A. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours.
B. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs.
C. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change.
D. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection. 54. An Apgar score of 10 at 1 minute after birth would indicate:

A. An infant having no difficulty adjusting to extrauterine life and needing no further testing
B. An infant in severe distress that needs resuscitation
C. A prediction of a future free of neurologic problems
D. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth 55. While completing a newborn assessment, the nurse should be aware that the most common birth injury is:

A. To the soft tissues
B. Caused by forceps gripping the head on delivery
C. Fracture of the humerus and femur
D. Fracture of the clavicle 56. The nurse tests the newborn's Babinski reflex by doing which of the following?

1. Touching the corner of the newborn's mouth or cheek
2. Changing the newborn's equilibrium
3. Placing a finger in the palm of the newborn's hand
4. Stroking the lateral sole from the heel upward and across the ball of the foot 57. A mother is beginning to experience nipple discomfort while breastfeeding. What would be the nurse's first priority in the plan of care?

1. Have the mother pump until the nipples heal and give breast milk from the bottle.
2. Remove the baby from the breast and reposition.
3. Give the mother a nipple shield to wear.
4. Have the mother breastfeed only from the nipple that is not injured. 58. A nurse is admitting an infant of a diabetic mother (IDM). At 1 hour of age, the nurse notices that the newborn is very jittery. Which action by the nurse is most appropriate?

1. Begin oxygen by nasal cannula.
2. Assess the newborn's blood glucose.
3. Place the newborn under a radiant warmer.
4. Initiate use of a cardiac/apnea monitor. 59. A newborn's temperature is 97.4F. What is the priority nursing intervention by the nurse?

1. Notify the health care provider immediately.
2. Take the newborn to the nursery and observe for two hours.
3. Reassess the temperature in four hours.
4. Wrap the newborn in two warm blankets and place a cap on the head. 60. A nurse is assessing a neonate born 12 hours ago and notes a yellow tint to the sclera. The nurse should read the medical record for what other assessment that is important to note at this time?

1. Blood glucose level
2. Blood type and Rh factor of both mother and newborn
3. Most recent infant blood pressure
4. Length of time membranes ruptured prior to delivery 61. The parents of a 28 weeks' gestation neonate ask the nurse, "Why does he have to be fed through a tube in his mouth?" What is the nurse's best response?

1. "It allows us to accurately determine the baby's intake since he is so small."
2. "The baby's sucking, swallowing, and breathing are not coordinated yet."
3. "The baby's stomach cannot digest formula at this time."
4. "It helps to prevent thrush, an infection that could affect the baby's mouth." 62. Which nursing diagnosis should have the highest priority for the nurse who is caring for a preterm newborn?

1. Ineffective Thermoregulation related to lack of subcutaneous fat
2. Grieving related to loss of "perfect delivery"
3. Imbalanced Nutrition: Less Than Body Requirements related to immature digestive system
4. Risk for Injury related to thin epidermis 63. The nurse is assigned to a baby receiving phototherapy. Which assessment warrants further investigation by the nurse?

1. Loose, green stools
2. Yellow tint to skin
3. Temperature 97.2F
4. Fine, red rash on trunk * Any temperate below 97.6F is considered hypothermia and requires immediate attention. 64. A baby's mother is HIV-positive. Which intervention is most important for the nurse to include when planning care for this newborn?

1. Encourage the mother to breastfeed.
2. Administer zidovudine (ZDV) after delivery.
3. Cuddle the baby as much as possible.
4. Place the baby's crib in a quiet corner of the nursery. 65. The nurse is preparing to initiate bottle-feeding in a preterm infant. In which situation would the nurse withhold the feeding and notify the health care provider?

1. Apical heart rate 120-130
2. Axillary temperature 97.2F-98.4F
3. Yellow tint to skin and sclera
4. Respiratory rate 62-68 * Any sustained respiratory rate greater than 60 breaths/minute increases the risk of aspiration in the infant, oral feedings should be withheld 66. When should bonding and integration of infant into family structure begin? - pregnancy 67. how long is dependent or taking-in phase? - 24-48 hrs postpartum 68. when does dependent-independent or taking hold phase begin? - 2-3 days and lasts 10 days to several days 69. a postpartum client is focused on personal needs, relying on others to assist, excited, talkative, needs to review birth experience w/ others...what phase of maternal role attachment is this? - taking-in phase 70. a postpartum client is focusing on baby care, wants to take charge, learn, and practice and is dealing w/ phy and emo discomforts ie: baby blues --what phase of maternal role attachment is this? - taking hold phase 71. A client is now focusing on family as a unit and resuming role of wife or individual. What phase of maternal role attachment is this? - letting go phase 72. what behaviors indicate lack of mom bonding w/ baby? - apathy when infant cries - disgust when infant stools or spits up - disappointment in infant, turns away - doesn't seek close proximity - does not talk about infant's unique feature - handles roughly, ignores infant, does not include infant in family context - perceives infant bx as uncooperative 73. what are signs of paternal adaptation and father/infant bond? - father does skin to skin, holds infant, eye contact, observes infant for features similar to his, talks, sings and reads to infant