Exam 3

Question 1

The nurse measures the frequency of a laboring woman’s contractions by noting:

How long the patient states the contractions last.

The time between the end of one contraction and the beginning of the next.

The time between the beginning and the end of one contraction.

The time between the beginning of one contraction and the beginning of the next.

Answer 1

The time between the beginning of one contraction and the beginning of the next.

Question 2

The relaxation phase between contractions is important because the:

Laboring woman needs to rest.

Uterine muscles fatigue without relaxation.

Contractions can interfere with fetal oxygenation.

Infant progresses toward delivery at these times.

Answer 2

Contractions can interfere with fetal oxygenation

Question 3

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse instructs the woman that the beginning of true labor is indicated by:

Contractions that are relieved by walking.

Discomfort in the abdomen and groin.

A decrease in vaginal discharge.

Regular contractions becoming more frequent and intense.

Answer 3

Regular contractions becoming more frequent and intense.

Question 4

The nurse caring for a woman in the first stage of labor reminds the patient that contractions during this stage of labor:

Get the infant positioned for delivery.

Push the infant into the vagina.

Dilate and efface the cervix.

Get the mother prepared for true labor.

Answer 4

Dilate and efface the cervix

Question 5

The nurse explains that the function of contractions during the second stage of labor is to:

Align the infant into the proper position for delivery.

Dilate and efface the cervix.

Push the infant out of the mother’s body.

Separate the placenta from the uterine wall.

Answer 5

C. Push the infant out of the mother’s body

Question 6

The nurse explains that the third stage of labor ends with:

Full cervical dilation.

Expulsion of the placenta and membranes.

Birth of the infant.

Engagement of the head.

Answer 6

Expulsion of the placenta and membranes

Question 7

During the fourth stage of labor, the nurse encourages the mother to void, because a full bladder may:

Interfere with cervical dilation.

Obstruct progress of the infant through the birth canal.

Obstruct the passage of the placenta.

Predispose the mother to uterine hemorrhage.

Answer 7

Predispose the mother to uterine hemorrhage

Question 8

The nurse observes on the fetal monitor a pattern of a 15 beat increase in the fetal heart rate that lasts 15 to 20 seconds. The nurse knows that this pattern is indicative of:
A. Well oxygenated fetus.
B. Compression of the umbilical cord.
C. Compression of the fetal head.
D. Uteroplacental insufficiency

Answer 8

A. Well oxygenated fetus

Question 9

One hour postdelivery the nurse notes the new mother has saturated three perineal pads. The nurse should:
A. Check the fundus for position and firmness.
B. Report to the doctor immediately.
C. Change the pads and chart the time.
D. Time how long it takes to soak one pad.

Answer 9

A. Check the fundus for position and firmness.

Question 10

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. The nurse’s initial action is to:
A. Stop the oxytocin infusion.
B. Increase the intravenous flow rate.
C. Reposition the woman to her side.
D. Start oxygen via nasal cannula.

Answer 10

C. Reposition the woman to her side.

Question 11

To relieve perineal bruising and edema following delivery the nurse should

Place an ice pack on the area for 12 hours.

Place a warm pack on the perineal area for 24 hours.

Administer aspirin to relieve inflammation.

Change the perineal pad frequently.

Answer 11

Place an ice pack on the area for 12 hours.

Question 12

At 1 and 5 minutes of life, a newborn’s apgar score is 9. The nurse understands that a score of 9 indicates this newborn:
A. Will require resuscitation.
B. May have physical disabilities.
C. Will have above average intelligence.
D. Is in stable condition.

Answer 12

D. Is in stable condition

Question 13

The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. The most appropriate nursing diagnosis is:

Pain related to increasing frequency and intensity of contractions.

Fear related to the probable need for cesarean delivery.

Dysuria related to prolonged labor and decreased intake.

Risk for injury related to hemorrhage.

Answer 13

Risk for injury related to hemorrhage

Question 14

The nurse caring for a patient who is not certain if she is in true labor will attempt to stimulate cervical effacement and intensity contractions in the patients by:
A. Offering the patient warm fluids to drink.
B. Helping the patient to ambulate in room.
C. Seating the patient upright in a straight backed chair.
D. Positioning the patient on her right side.

Answer 14

B. Helping the patient to ambulate in room.

Question 15

When late decelerations occur, the nurse should:
A. Reposition the patient to supine.
B. Decrease flow of intravenous (IV) fluids.
C. Increase oxygen to 10L/minute.
D. Prepare to increase oxytocin drip.

Answer 15

C. Increase oxygen to 10 L/minute.

Question 16

The nurse takes into consideration that the primary concern in the initial care of the newborn is maintaining:
A. Fluid intake.
B. Feeding schedule.
C. Thermoregulation.
D. Parental bonding.

Answer 16

C. Thermoregulation

Question 17

A nurse instructs a woman’s labor coach to comfort her by firmly pressing on her lower back. What is this technique?
A. Sacral pressure
B. Distraction
C. Effleurage
D. Conscious relaxation

Answer 17

A. Sacral pressure

Question 18

A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction?
A. Use slow paced breathing.
B. Hold her breath and push.
C. Blow in short breaths
D. Use rapid paced breathing

Answer 18

C. Blow in short breaths

Question 19

Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify?
A. Hypertension
B. Anxiety
C. Anoxia
D. Hyperventilation

Answer 19

D. Hyperventilation

Question 20

A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor?
A. It can cause medication given at later stages to be ineffective.
B. It will have no complications for the mother or infant.
C. It may result in respiratory depression to the newborn.
D. It will speed up labor and increase pain.

Answer 20

C. It may result in respiratory depression to the newborn.

Question 21

A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent?
a. Nausea and vomiting
b. Vomiting and aspiration
c. Abdominal cramping
d. Intestinal obstruction

Answer 21

B. Vomiting and aspiration

Question 22

What assessment should be taken immediately after the anesthesiologist administers an epidural block to a laboring woman?
a. Bladder for distention
b. Blood pressure
c. Sensation in the lower extremities
d. Intravenous fluid flow rate

Answer 22

B. Blood pressure

Question 23

A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia?
a. Reduced fetal heart rate
b. Long, intense contractions
c. Sudden leg cramps
d. Bladder distention

Answer 23

D. Bladder distention

Question 24

Which narcotic antagonist is used to reverse narcotic induced respiratory depression?
a. Hydroxyzine (Vistaril)
b. Phenobarbital
c. Naloxone (Narcan)
d. Nitrous oxide

Answer 24

C. Naloxone (Narcan)

Question 25

An 18 year old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, “Please give me something for the pain. I can’t take the pain!” What is the priority nursing diagnosis?
a. Pain related to uterine contractions
b. Knowledge deficit related to the birth experience
c. Ineffective coping related to inadequate preparation for labor
d. Risk for injury related to lack of prenatal care

Answer 25

A. Pain related to uterine contractions

Question 26

The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management?
a. Slow abdominal breathing
b. Guided relaxation
c. Listening to music
d. Massage

Answer 26

D. Massage

Question 27

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?

Frequently asking for ice chips

Facial grimacing

Changing positions in bed

Covering her face with her hands

Answer 27

Facial grimacing

Question 28

When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate?
a. Urinary retention
b. Severe lower back pain
c. A shorter labor process
d. Nausea

Answer 28

B. Severe lower back pain

Question 29

What nursing assessment should be reported immediately after an amniotomy?
a. Fetal heart rate is regular at 154 beats/min.
b. Amniotic fluid is clear with flecks of vernix.
c. Amniotic fluid is watery and pale green.
d. Maternal temperature is 37.8 C.

Answer 29

C. Amniotic fluid is watery and pale green.

Question 30

What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?
a. Warm compresses to the perineum
b. Cold pack to the perineum
c. Warm sitz bath
d. Elevation of hips to prevent edema

Answer 30

B. Cold pack to the perineum

Question 31

After several hours of labor, a nursing assessment reveals that a woman’s cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered?
a. Normal
b. Hypotonic
c. Hypertonic
d. False

Answer 31

B. Hypotonic

Question 32

An infant is delivered with the use of forceps. What should the nurse assess for in the newborn?
a. Loss of hair from contact with forceps
b. Sacral hematoma
c. Facial asymmetry
d. Shoulder dislocation

Answer 32

C. Facial asymmetry

Question 33

A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The nurse responds, This condition will resolve itself in a few days. What is the cause?
a. Prolonged pressure against the partially dilated cervix
b. Small leak of fluid through the posterior fontanelle
c. Pressure of the forceps during delivery
d. The effect of the vacuum extractor

Answer 33

The effect of the vacuum extractor

Question 34

A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor won’t induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the lowest Bishop score the patient should have prior to induction?
a. 6
b. 8
c. 10
d. 12

Answer 34

6

Question 35

The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor?
a. Get an order for an intravenous narcotic.
b. Notify the anesthesiologist for an epidural block.
c. Stay and breathe with her during contractions.
d. Tell her to bear with it because she is close to delivery.

Answer 35

Stay and breathe with her during contractions.

Question 36

A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response?
a. The fundus is not assessed until the second postoperative day.
b. The fundus is assessed by walking fingers from the side of the uterus to the midline.
c. The fundus is assessed only if large clots appear in lochia.
d. The fundus is assessed only once every shift.

Answer 36

b. The fundus is assessed by walking fingers from the side of the uterus to the midline.

Question 37

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis?
a. Anxiety related to the development of postpartum complications
b. Ineffective individual coping related to unfamiliarity with procedures
c. Risk for ineffective parenting related to emergency cesarean section
d. Grieving related to loss of expected birth experience

Answer 37

d. Grieving related to loss of expected birth experience

Question 38

A pregnant woman’s membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do?
a. Report any increase in fetal activity.
b. Notify her obstetrician if she has a temperature above 37.8 C (100 F).
c. Massage her breasts to promote uterine relaxation.
d. Rest in a side-lying Trendelenburg position with hips elevated.

Answer 38

Notify her obstetrician if she has a temperature above 37.8 C (100 F).

Question 39

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action?
a. Give the pain remedy.
b. Notify the charge nurse immediately.
c. Turn the patient to her back and flex her knees.
d. Suggest that the coach give her a back rub.

Answer 39

Notify the charge nurse immediately.

Question 40

What does the nurse explain is used to soften the cervix with a cervical ripening agent?
a. Prostaglandin gel insertion
b. Intravenous oxytocin
c. Warm saline douches
d. Nipple stimulation

Answer 40

Prostaglandin gel insertion

Question 41

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration?
a. Prevent infection.
b. Increase fetal lung maturity.
c. Increase blood flow from placenta.
d. Relax the cervix.

Answer 41

Increase fetal lung maturity.

Question 42

What sign(s) of infection should the nurse assess for after an amniotomy? (Select 1 that applies.)
a. Oral temperature of 37 C (99.8 F)
b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute
c. Flecks of vernix in the amniotic fluid
d. Low back pain
e. Edematous labia

Answer 42

Increase of fetal heart rate (FHR) from 160 to 174 beats/minute

Question 43

What are the rationales for labor induction? (Select 2 that apply.)
a. Placenta previa
b. Prolapse of cord
c. High station of fetus
d. Maternal diabetes
e. Placental insufficiency

Answer 43

Maternal diabetes
Placental insufficiency

Question 44

In planning teaching to parents of a child with Legg-Calvé-Perthes disease about the long-term effects of this disease, the nurse would include that:
a. there are no long-term effects.
b. the disease is self-limited and requires no long-term treatment.
c. degenerative arthritis may develop later in life.
d. there is risk of osteogenic sarcoma in adulthood.

Answer 44

degenerative arthritis may develop later in life.

Question 45

The nurse caring for a child in Buck’s skin traction will keep the:
a. child in high-Fowler’s position.
b. child pulled up in bed.
c. child’s heel on the bed surface.
d. child’s feet against the foot of the bed.

Answer 45

child pulled up in bed.

Question 46

The nurse reviewing the characteristics of Ewing’s sarcoma would point out that:
a. amputation is the accepted treatment.
b. the disease is sensitive to radiation and chemotherapy.
c. metastasis is rare.
d. the disease is more prevalent among toddlers and preschoolers.

Answer 46

the disease is sensitive to radiation and chemotherapy.

Question 47

The nurse caring for a child with Duchenne’s muscular dystrophy notes a characteristic manifestation, which is that the child:
a. ambulates by holding onto furniture.
b. exhibits atrophy of the calf muscles.
c. falls frequently and is clumsy.
d. has delayed fine-motor development.

Answer 47

falls frequently and is clumsy.

Question 48

The nurse is providing instructions about how to treat a sprained ankle. The nurse will recognize the need for additional teaching when the mother states:
a. “Apply warm compresses to the ankle for the first 24 hours.”
b. “Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off.”
c. “Wrap the ankle in an Ace bandage for support.”
d. “Keep the leg elevated when sitting.”

Answer 48

Apply warm compresses to the ankle for the first 24 hours.”

Question 49

The parent of a child with osteomyelitis asks why his child is in so much pain. The nurse’s response will be based on the understanding that the pain of osteomyelitis is caused by:
a. the pressure of inelastic bone.
b. purulent drainage in the bone marrow.
c. the cast applied on the extremity.
d. circulatory congestion of the skin.

Answer 49

purulent drainage in the bone marrow.

Question 50

A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. The nurse responds that antibiotic therapy will probably last for:
a. 2 weeks.
b. 6 weeks.
c. 2 months.
d. 3 months.

Answer 50

6 weeks.

Question 51

A nurse assessing a preadolescent child for scoliosis would:
a. ask the child to bend forward at the waist, and would observe the child’s back for asymmetry.
b. observe the gait while the child is walking forward heel to toe.
c. have the child flex the knees and look for uneven knee height.
d. look at the child’s shoulders and hips while fully clothed.

Answer 51

ask the child to bend forward at the waist, and would observe the child’s back for asymmetry.

Question 52

The observation that may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs is:
a. red, green, and yellow bruises on his body.
b. bruises are dispersed on his head, arms, and legs.
c. a broken arm last year, and the child being described as accident-prone.
d. the mother is very anxious for her son to get medical attention.

Answer 52

red, green, and yellow bruises on his body.

Question 53

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. The nursing diagnosis that takes highest priority for this child is:
a. pain resulting from tissue trauma.
b. high risk for impaired skin integrity resulting from immobility.
c. altered growth and development related to separation from family.
d. altered urinary elimination related to immobility and traction.

Answer 53

pain resulting from tissue trauma.

Question 54

The nurse explains that the child’s fracture heals more rapidly than the adult’s because the child’s bones:
a. are less porous than adult bone.
b. are covered by a thicker periosteum.
c. are not affected by bone overgrowth.
d. have faster callus formation.

Answer 54

have faster callus formation.

Question 55

On entering the room of a child in Buck’s traction the nurse makes all of the following observations. The observation that requires nursing intervention is the:
a. child’s heels are placed firmly against the foot of the bed.
b. head of bed is elevated 20 degrees.
c. weights are hanging freely.
d. ropes are on pulleys.

Answer 55

child’s heels are placed firmly against the foot of the bed.

Question 56

The nurse considers what factor(s) that may trigger abuse in a parent? Select all that apply.
A. Being abused as a child
b. Low self-esteem
c. Substance abuse
d. Overwhelming responsibility
e. Knowledge deficit relative to child care

Answer 56

a. Being abused as a child
b. Low self-esteem
c. Substance abuse
d. Overwhelming responsibility
e. Knowledge deficit relative to child care

Question 57

The initial intervention that the nurse would suggest to the parents of a child experiencing laryngeal spasm is to:
a. take the child outside in the cool air.
b. bring the child directly to the emergency department.
c. take the child to the bathroom and turn on a hot shower.
d. have the child drink plenty of fluids

Answer 57

take the child to the bathroom and turn on a hot shower.

Question 58

The nurse would observe a child for frequent swallowing following a tonsillectomy and adenoidectomy (T&A) because this is indicative of:
a. bleeding from the surgical site.
b. pain at the incision area.
c. sore throat from postnasal drip.
d. potential vomiting.

Answer 58

bleeding from the surgical site.

Question 59

The best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy is:
a. a Popsicle.
b. chocolate milk.
c. orange juice.
d. cola drink.

Answer 59

a Popsicle.

Question 60

The nurse caring for a child experiencing an acute asthma attack would:
a. offer plenty of fluids, particularly carbonated beverages.
b. place the child in a humidified cool mist tent with oxygen.
c. administer sedatives as ordered to decrease anxiety.
d. position the child with arms resting on the overbed table.

Answer 60

position the child with arms resting on the overbed table.

Question 61

The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. The nurse’s response is based on the understanding that with CF:
a. only one parent carries the CF gene.
b. both parents are carriers of the CF gene.
c. the inheritance pattern is multifactorial.
d. the result is probably a genetic mutation.

Answer 61

both parents are carriers of the CF gene.

Question 62

To facilitate digestion and absorption of nutrients, the nurse teaches the child with cystic fibrosis that she needs to take:
a. pancreatic enzymes.
b. water-soluble minerals.
c. fat-soluble vitamins.
d. salt supplements.

Answer 62

pancreatic enzymes.

Question 63

The nurse would advise a mother to clear the nostrils when her infant has a cold by:
a. clearing the nasal passages after the infant has a feeding.
b. using over-the-counter nose drops to clear passages.
c. removing nasal secretions with a bulb syringe.
d. instilling saline nose drops after clearing away secretions.

Answer 63

removing nasal secretions with a bulb syringe.

Question 64

The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is sweating profusely. The nurse recognizes these symptoms as:
a. severe asthma attack.
b. allergic response to theophylline.
c. onset of bronchitis.
d. drug toxicity.

Answer 64

drug toxicity.

Question 65

The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). Significant information would include:
a. wrapping the infant snugly for rest periods.
b. positioning the infant prone for sleep.
c. sitting the infant up in an infant seat.
d. placing infants on their backs or sides for sleep.

Answer 65

placing infants on their backs or sides for sleep.

Question 66

The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder to prevent:
a. discoloration of tooth enamel.
b. halitosis.
c. irritation of oral membranes.
d. candidiasis.

Answer 66

candidiasis.

Question 67

The nurse would suggest to the parents of an asthmatic child to encourage participation in which sport(s)? Select 3 that apply.
a. Swimming
b. Gymnastics
c. Baseball
d. Cross-country skiing
e. Distance running

Answer 67

Swimming
Gymnastics
Baseball

Question 68

A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse implement? (Select 3 that apply.)
a. Maintain strict bed rest.
b. Consider age.
c. Assess developmental level.
d. Implement light play activities.
e. Provide hypnotic medication as ordered.

Answer 68

Consider age.
Assess developmental level.
Implement light play activities.

Question 69

The nurse explains that a ventricular septal defect will allow:
a. blood to shunt left to right, causing increased pulmonary flow and no cyanosis.
b. blood to shunt right to left, causing decreased pulmonary flow and cyanosis.
c. no shunting because of high pressure in the left ventricle.
d. increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume.

Answer 69

blood to shunt left to right, causing increased pulmonary flow and no cyanosis.

Question 70

The assessment that would lead the nurse to suspect that a newborn infant has a ventricular septal defect is:
a. a loud, harsh murmur with a systolic tremor.
b. cyanosis when crying.
c. blood pressure higher in the arms than in the legs.
d. a machinery-like murmur.

Answer 70

a loud, harsh murmur with a systolic tremor.

Question 71

When a father asks why his child with tetralogy of Fallot seems to favor a squatting position, the nurse would explain that squatting:
a. increases the return of venous blood back to the heart.
b. decreases arterial blood flow away from the heart.
c. is a common resting position when a child is tachycardic.
d. increases the workload of the heart.

Answer 71

increases the return of venous blood back to the heart.

Question 72

A child develops carditis from rheumatic fever. The nurse knows that the areas of the heart affected by carditis are the:
a. coronary arteries.
b. heart muscle and the mitral valve.
c. aortic and pulmonic valves.
d. contractility of the ventricles.

Answer 72

heart muscle and the mitral valve.

Question 73

The comment made by a parent of a 1-month-old that would alert the nurse about the presence of a congenital heart defect is:
a. “He is always hungry.”
b. “He tires out during feedings.”
c. “He is fussy for several hours every day.”
d. “He sleeps all the time.”

Answer 73

“He tires out during feedings.”

Question 74

The nurse is caring for a child with a diagnosis of Kawasaki disease. The child’s parent asks the nurse, “How does Kawasaki disease affect my child’s heart and blood vessels?” The nurse’s response is based on the understanding that:
a. inflammation weakens blood vessels, leading to aneurysm.
b. increased lipid levels lead to the development of atherosclerosis.
c. untreated disease causes mitral valve stenosis.
d. altered blood flow increases cardiac workload with resulting heart failure.

Answer 74

inflammation weakens blood vessels, leading to aneurysm.

Question 75

A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever?
a. Subcutaneous nodules and fever
b. Painful, tender joints and carditis
c. Erythema marginatum and arthralgia
d. Chorea and elevated sedimentation rate

Answer 75

Painful, tender joints and carditis

Question 76

An infant with congestive heart failure is receiving digoxin (Lanoxin). The nurse recognizes a sign of digoxin toxicity, which is:
a. restlessness.
b. decreased respiratory rate.
c. increased urinary output.
d. vomiting.

Answer 76

vomiting.

Question 77

How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the child’s weakness and fatigue? Select 4 that apply.

A. Feeding more frequently with smaller feedings
b. Using a soft nipple with enlarged holes
c. Holding and cuddling the child during feeding
d. Substituting glucose water for formula
e. Offering high-caloric formula

Answer 77

Feeding more frequently with smaller feedings

Using a soft nipple with enlarged holes

Holding and cuddling the child during feeding

Offering high-caloric formula

Question 78

The nurse uses a diagram to illustrate what four structural heart anomalies that comprise tetralogy of Fallot? Select the four that apply

A. Hypertrophied right ventricle
b. Patent ductus arteriosus
c. Ventral septal defect
d. Narrowing of pulmonary artery
e. Dextroposition of aorta

Answer 78

Hypertrophied right ventricle

Patent ductus arteriosus

Narrowing of pulmonary artery

Dextroposition of aorta

Question 79

The nurse explains that which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? Select 3 that apply.

A. Atrial septal defects (ASDs)
b. Tetralogy of Fallot
c. Dextroposition of aorta
d. Patent ductus arteriosus
e. Ventricular septal defects (VSDs)

Answer 79

Atrial septal defects (ASDs)
Patent ductus arteriosus
Ventricular septal defects (VSDs)

Question 80

When teaching the parents of a young child about iron deficiency anemia, the nurse would tell them that a rich source of iron is:

a. an egg white.
b. cream of Wheat.
c. a banana.
d. a carrot.

Answer 80

cream of Wheat.

Question 81

The nurse would instruct the parent to give ferrous sulfate drops to the child:

a. with milk.
b. with orange juice.
c. with water.
d. on a full stomach.

Answer 81

with orange juice.

Question 82

The nurse would teach the parents of a child with a low platelet count to avoid:

a. ibuprofen.
b. aspirin.
c. caffeine.
d. prednisone.

Answer 82

aspirin.

Question 83

A child who is receiving a transfusion should be closely assessed for:

a. fever.
b. lethargy.
c. jaundice.
d. bradycardia.

Answer 83

fever.

Question 84

On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. The priority nursing intervention is:

a. assessing neurological status.
b. inserting an intravenous line.
c. monitoring vital signs during platelet transfusions.
d. providing family education about how to prevent bleeding.

Answer 84

assessing neurological status.

Question 85

A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. The nurse recognizes that the type of crisis the child is most likely experiencing is:

a. aplastic.
b. hyperhemolytic.
c. vaso-occlusive.
d. splenic sequestration.

Answer 85

vaso-occlusive.

Question 86

The statement made by a parent indicating understanding of health maintenance of a child with sickle cell disease is:

a. “I should give my child a daily iron supplement.”
b. “It is important for my child to drink plenty of fluids.”
c. “He needs to wear protective equipment if he plays contact sports.”
d. “He shouldn’t receive any immunizations until he is older.”

Answer 86

“It is important for my child to drink plenty of fluids.”

Question 87

A child has just been diagnosed with acute lymphoblastic leukemia. The nurse is aware that the result of an overproduction of immature white blood cells in the bone marrow is:

a. decreased T-cell production.
b. decreased hemoglobin.
c. increased blood clotting.
d. increased susceptibility to infection.

Answer 87

increased susceptibility to infection.

Question 88

When the child receiving a transfusion complains of back pain and itching, the nurse’s initial action would be to:

a. notify the charge nurse.
b. disconnect intravenous lines immediately.
c. give diphenhydramine (Benadryl).
d. clamp off blood and keep line open with normal saline.

Answer 88

clamp off blood and keep line open with normal saline.

Question 89

When dealing with a preschool-age child with a life-threatening illness, the nurse should remember that at this age the child’s concept of death includes:

a. that it is final.
b. only a fear of separation from her parents.
c. that a person becomes alive again soon after death.
d. an understanding based on simple logic.

Answer 89

that a person becomes alive again soon after death.

Question 90

The nurse finds an adolescent with Hodgkin’s disease crying. The adolescent says, “I am so scared.” The most appropriate nursing response to this comment is:

a. “I understand how you must feel.”
b. “You shouldn’t feel that way.”
c. “Is this the strongest feeling you’ve had today?”
d. “Tell me what’s got you scared.”

Answer 90

“Tell me what’s got you scared.”

Question 91

What are the classic symptoms of thalassemia major (Cooley’s anemia)? Select all that apply.

a. Hepatomegaly
b. Jaundice
c. Protruding teeth
d. Pathological fractures
e. Cardiac failure

Answer 91

Hepatomegaly
Jaundice
Protruding teeth
Pathological fractures
Cardiac failure