NCLEX Questions: Nursing Quiz!
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A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse should identify which of the following is a manifestation of peritonitis?
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Hyperactice bowel sounds
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Abdominal distention
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Bradycardia
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Polyuria
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NCLEX Questions: Nursing Quiz! focuses on assessing and planning nursing care for children with various health conditions. Topics include appendicitis, medication dosages, acute kidney injury, otitis media, cystic fibrosis, and SIDS prevention. Essential for nursing students preparing for practical pediatric care scenarios.
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- 2.
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weights 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Explanation
2.2 lb/1 kg = pt weight in lb/X kg
2.2 lb/1 kg = 75 lb/ X kg
X = 34
1.2 mg x 34 kg = 40Rate this question:
- 3.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129. Which of the following interventions should the nurse include in the plan?
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Administer ibuprofen to the child for a temperature greater than 38 C (101 F)
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Assess the child's blood pressure every 8 hr
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Weight the child weekly at various times of the day
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Initiate seizure precautions for the child
Correct Answer
A. Initiate seizure precautions for the childExplanation
A sodium level of 129 indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions in order to maintain the child's safety. In the oliguric phase of AKI the child will have decreased urine output and fluid retention. This can result in water intoxication which predisposes the child to neurologic alterations such as seizures. To ensure accurate evaluation of fluid balance the nurse should plan to weigh the child daily at the same time in the same clothing and using the same scale. A child who has AKI is often hypertensive due to fluid volume excess and the activation of the RAAS. To prevent complications such as hypertensive encephalopathy the nurse should assess the child's blood pressure every 4 to 6 hours. A child who has AKI can develop a fever due to infection. Because AKI is a contraindication to receiving medications that are nephrotoxic, such as NSAIDs, the nurse should use compensatory measures, such as turning a fan on in the room.Rate this question:
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- 4.
A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen which of the following actions should the nurse plan to reduce the toddler's temperature?
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Apply a cooling blanket to the toddler
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Dress the toddler in minimal clothing
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Give the toddler a tepid bath
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Administer diphenhydramine to the toddler
Correct Answer
A. Dress the toddler in minimal clothingExplanation
Applying a cooling blanket can cause shivering and discomfort which increases metabolic requirements and is not effective in reducing the toddler's temperature.
The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin reducing the child's temperature
A tepid bath is lukewarm which can cause discomfort to the toddler and is not effective in reducing fever
Diphenhydramine is an antipruritic rather than an antipyretic medicationRate this question:
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- 5.
A nurse is planning care for a preschooler who has CF. Which of the following interventions should the nurse include in the plan?
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Administer pancreatic enzymes 2 hours after meals
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Decrease pancreatic enzymes if steatorrhea develops
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Limit fluid intake to 750 mL per day
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Increase fat content in the child's diet to 40% of total calories
Correct Answer
A. Increase fat content in the child's diet to 40% of total caloriesExplanation
The nurse should plan to administer pancreatic enzymes within 30 minutes of meals and snacks.
A child who has CF and develops steatorrhea or fatty stools needs to increase the intake of pancreatic enzymes.
The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration.
A child who has CF is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes.
The nurse should increase the child's fat intake to equal 40% of total caloric intake.Rate this question:
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- 6.
A nurse is providing anticipatory guidance to the parents of a 2-week-old infant about risk factors for sudden infant death syndrome (SIDS). Which of the following risk factors should the nurse include in the teaching?
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Covering the sleeping infant with a blanket
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Supine sleeping
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Maternal history of milk allergy
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Pacifier use during sleep
Correct Answer
A. Covering the sleeping infant with a blanketExplanation
The use of quilts or blankets to cover the sleeping infant increases the risk of SIDS due to the potential for suffocation. The nurse should recommend the parents dress the infant warmly and increase the temperature in the home.
Evidence-based practice indicates that supine sleeping is a protective factor against SIDS. Infants who sleep prone are at risk for SIDS due to the potential for oropharyngeal obstruction, ineffective thermal balance, decreased arousal state, and rebreathing of carbon dioxide
A milk allergy either the mother's or the infant's is not a risk factor for SIDS
Evidence-based practice indicates that pacifier use is a protective factor against SIDS. infants should use a pacifier at naptime and bedtime. Parents whose infants are breastfeeding should wait to have the infant use a pacifier until she is breastfeeding successfullyRate this question:
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- 7.
A nurse is teaching a school-age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?
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"Stay home from school for 1 week following the procedure."
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"Follow a diet that is low in fiber for 1 week."
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"Wait 3 days before taking a tub bath."
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"Apply a pressure dressing to the site for 3 days."
Correct Answer
A. "Wait 3 days before taking a tub bath."Explanation
The child can attend school the next day but he should avoid strenuous activities to prevent bleeding at the insertion site.
The child can resume his regular diet after the procedure.
The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water.
The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.Rate this question:
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- 8.
A nurse in an ED is caring for a school-age child who has appendicitis and rates his abdominal pain at 7 on a 0 to 10 scale. Which of the following actions should the nurse take?
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Instill a 500 mL tap water enema
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Give morphine 0.05 mg/kg IV
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Administer polyethlene glycol 1 g/kg PO
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Apply a heating pad to the child's abdomen
Correct Answer
A. Give morphine 0.05 mg/kg IVExplanation
Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix.
A pain level of 7 on a 0 to 10 scale is considered severe and the nurse should administer an analgesic medication for pain relief.
Administering laxatives accelerates bowel motility and increases the risk for perforation of the appendix
Applying heat to the child's abdomen increases the risk for perforation of the appendixRate this question:
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- 9.
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?
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Place the infant in a knee-chest position
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Administer a dose of meperidine IV
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Discontinue administration of IV fluids
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Apply oxygen at 2 L/min via nasal cannula
Correct Answer
A. Place the infant in a knee-chest positionExplanation
The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.
The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting
The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood which decreases the risk of CVA
The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brainRate this question:
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- 10.
A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan?
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Use sterile scissors to remove the dressing from the site
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Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use
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Access the site using a noncoring angled needle
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Use a semipermeable transparent dressing to cover the site
Correct Answer
A. Use a semipermeable transparent dressing to cover the siteExplanation
The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter.
The nurse should flush each lumen of the catheter with a heparin solution daily when not in use
The nurse should use a noncoring angled or straight needle when accessing an implanted port
The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infectionRate this question:
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- 11.
A nurse in an ED is caring for a school-age child who has sustained a superficial minor burn from fireworks on his forearm. Which of the following actions should the nurse take?
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Administer a tetanus toxoid if more than 1 year since prior dose
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Use an antimicrobial ointment on the affected area
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Leave the burn open to air
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Place an ice pack on the affected area
Correct Answer
A. Use an antimicrobial ointment on the affected areaExplanation
The nurse should administer a tetanus toxoid if it has been more than 5 years since the prior dose
The nurse should apply an antimicrobial ointment to the burned area to prevent infection
The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound
Applying ice to the affected area may impair circulation to the area and increase tissue damageRate this question:
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- 12.
A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority when making a room assignment?
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Length of stay
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Treatment schedule
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Disease process
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Self-care ability
Correct Answer
A. Disease processExplanation
It is important for the nurse to consider the child's anticipated length of stay because some client rooms may be larger and thus more comfortable for families during long hospitalizations; however this is not the nurse's priority consideration
It is important to consider the child's treatment schedule when making room assignments because children requiring frequent monitoring and treatments should be assigned to a room close to the nurse's station if possible but this is not the priority consideration
The transmission of infectious diseases is the greatest risk to this child and other children on the unit therefore the child's disease process is the nurse's priority consideration
It is important to consider the child's self care ability when making room assignments because children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station if possible but this is not the nurse's priority considerationRate this question:
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- 13.
A nurse is caring for a school-age child who has acute rheumatic fever. Which of the following actions should the nurse take?
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Limit the child's sodium intake
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Place a "no visitors" sign on the child's door
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Maintain the child on bed rest
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Avoid administering salicylates to the child
Correct Answer
A. Maintain the child on bed restExplanation
Rheumatic fever is an inflammatory disease resulting from an immune response that involves the heart, joints, skin and CNS. There is no indication or benefit to limiting the child's sodium intake.
Rheumatic fever is not contagious to others. Unless requested by parents or child it is not necessary to restrict visitors
The nurse should maintain the child on bed rest as well as limit the child's activity during the acute phase of rheumatic fever to assist with the prevention of cardiac damage
The nurse should administer salicylates to the child who has acute rheumatic fever to decrease fever and discomfort and help to control the inflammatory processRate this question:
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- 14.
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take?
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Place the child in a room with positive-pressure airflow
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Place the child in a room with negative-pressure airflow
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Initiate contact precautions for the child
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Initiate droplet precautions for the child
Correct Answer
A. Initiate droplet precautions for the childExplanation
The nurse should place the child who has undergone an allogeneic hematopoietic stem cell transplant in a room with positive-pressure airflow to reduce the risk of disease transmission to the child
The nurse should place a child who has an airborne infection such as measles or varicella into a room with negative-pressure airflow
The nurse should initiate contact precautions for a child who has an illness that can be transmitted by direct contact or contact with the child's items, such as hepatitis A and rotavirus
The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talksRate this question:
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- 15.
A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect?
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Resists having an axillary temperature taken
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Exhibits withdrawal behaviors when her parent leaves
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Has multiple bruises on her knees
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Poor personal hygeine
Correct Answer
A. Poor personal hygeineExplanation
The toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Not a finding indicative of physical neglect
Separation anxiety is an expected finding for a toddler. The child of this age can become fearful and exhibit regressive behaviors when left alone with strangers and separated from her parents. Not indicative of physical neglect
The 18 month old toddler has accomplished the gross motor skills of standing and walking and has begun to try to run but falls easily and can have bruises on her knees. No indication of physical neglect
Poor personal hygiene in a toddler is a potential indication of physical neglect. Because toddlers are still dependent on their parents help with hygiene needs, poor personal hygiene indicates a lack of supervisionRate this question:
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- 16.
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first?
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Skin breakdown
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Hypotension
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Hyperpyrexia
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Tachypnea
Correct Answer
A. TachypneaExplanation
Toddlers who have gastroenteritis and are dehydrated are at increased risk for skin breakdown because of changes in circulation and loss of skin elasticity. The nurse should address another finding first.
Toddlers who have gastroenteritis and are dehydrated may exhibit hypotension because of reduced blood volume. Nurse should address another finding first
Toddlers who have gastroenteritis and are dehydrated may exhibit hyperpyrexia or fever which is caused by the effect of fluid volume depletion on the hypothalamus. Address another finding first
When using the airway, breathing, circulation approach to client care the first finding the nurse should address is the toddler's tachypnea which results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosisRate this question:
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- 17.
A nurse is reviewing the laboratory report of a 6-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
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Hgb 8.5
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WBC 9500
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Prealbumin 18
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Platelets 300,000
Correct Answer
A. Hgb 8.5Explanation
The child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a Hgb level of 8.5 is below the expected reference range for a 6-year-old child and should be reported to the provider.Rate this question:
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- 18.
A nurse in a health clinic is reviewing contraceptive use with a group of adolescent clients. Which of the following statements by an adolescent reflects and understanding of the teaching?
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"A water-soluble lubricant should be used with condoms."
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"A diaphragm should be removed 2 hours after intercourse."
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"Oral contraceptives can worsen a case of acne."
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"A contraceptive patch is replaced once a month."
Correct Answer
A. "A water-soluble lubricant should be used with condoms."Explanation
Condoms are used with water-soluble lubricants. A diaphragm should be removed no sooner than 6 hours and no later than 24 hours after intercourse. Acne is reduced when taking oral contraceptives. Contraceptive patches are placed once a week.Rate this question:
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- 19.
A 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?
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Reduced menstrual flow
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Breast tenderness
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Shortness of breath
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Headaches
Correct Answer
A. Shortness of breathExplanation
Reduced menstrual flow is a common adverse effect of oral contraceptives and usually subsides after a few months of use. Breast tenderness is a common adverse effect of oral contraceptives and usually subsides after a few months of use. Shortness of breath can indicate a pulmonary embolus or myocardial infarction and should be reported to the provider immediately. Headaches are a common adverse effect of oral contraceptives and usually subside after a few months of use.Rate this question:
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- 20.
A nurse in an obstetrical clinic is teaching a client about using an IUD for contraception. Which of the following statements by the client indicates an understanding of the teaching?
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"An IUD should be replaced annually during a pelvic exam."
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"I cannot get an IUD until after I've had a child."
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"I should plan on regaining fertility 5 months after the IUD is removed."
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"I will check to be sure the strings of the IUD are still present after my periods."
Correct Answer
A. "I will check to be sure the strings of the IUD are still present after my periods."Explanation
An IUD will be replaced every 3 to 5 years dependent upon the type of IUD used. Clients do not have to have given birth prior to the insertion of an IUD. It will be necessary for the client to have a negative pregnancy test prior to insertion of the IUD. Fertility will resume immediately following removal of the IUD. The client should check for presence of IUD strings following each menstruation to ensure the device is still present. A change in length of strings should be reported to the provider.Rate this question:
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- 21.
A nurse is teaching a client about potential adverse effects of implantable progestins. Which of the following adverse effects should the nurse include? Select all that apply.
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Tinnitus
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Irregular vaginal bleeding
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Weight gain
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Breast changes
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Gingival hyperplasia
Correct Answer(s)
A. Irregular vaginal bleeding
A. Weight gain
A. Breast changesExplanation
Tinnitus is not an adverse effect of implantable progestins. Irregular vaginal bleeding is a potential adverse effect of implantable progestins. Weight gain is a potential adverse effect of implantable progestins. Breast changes are a potential adverse effect of implantable progestins. Gingival hyperplasia is not a potential adverse effect of implantable progestins.Rate this question:
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- 22.
A nurse in a clinic is teaching a client about her new prescription for medroxyprogesterone. Which of the following information should the nurse include in the teaching? Select all that apply.
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"Weight loss can occur."
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"You are protected against STIs."
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"You should increase your intake of calcium."
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"You should avoid taking antibiotics."
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"Irregular vaginal spotting can occur."
Correct Answer(s)
A. "You should increase your intake of calcium."
A. "Irregular vaginal spotting can occur."Explanation
Weight gain can occur when taking this medication. This med does not provide protection against STIs. Clients should take calcium and vitamin D to prevent loss of bone density, which can occur when taking this medication. Antibiotics are not contraindicated. This medication can cause irregular vaginal bleeding.Rate this question:
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- 23.
A nurse is teaching a group of women who are pregnant about measures to relieve backache during pregnancy. Which of the following measures should the nurse include in the teaching? Select all that apply.
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Avoid any lifting
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Perform Kegel exercises twice a day
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Perform the pelvic rock exercise every day
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Use proper body mechanics
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Avoid constrictive clothing
Correct Answer(s)
A. Perform the pelvic rock exercise every day
A. Use proper body mechanicsExplanation
Lifting may be done by using the legs rather than the back. Kegel exercises are done to strengthen the perineal muscles and do not relieve backache. The pelvic rock or tilt exercise stretches the muscles of the lower back and helps relieve lower back pain. The use of proper body mechanics prevents back injury due to the incorrect use of muscles when lifting. Avoiding constrictive clothing helps prevent UTIs, vaginal infx, varicosities, and edema of the lower extremities.Rate this question:
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- 24.
A nurse is caring for a client who is pregnant and reviewing signs of complications the client should promptly report to the provider. Which of the following complications should the nurse include in the teaching?
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Vaginal bleeding
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Swelling of the ankles
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Heartburn after eating
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Lightheadedness when lying on back
Correct Answer
A. Vaginal bleedingExplanation
Vaginal bleeding indicates a potential complication of the placenta such as placenta previa. The nurse should instruct the client to notify the provider immediately. Swelling of the ankles is a common occurrence during pregnancy and can be relieved by sitting with the legs elevated. Heartburn occurs during pregnancy due to pressure on the stomach by the enlarging uterus. It can be relieved by eating small meals. Supine hypotension can be experienced by the client who feels lightheaded or faint when lying on her back. The nurse should instruct the client about the side-lying position to remove pressure of the uterus on the vena cava.Rate this question:
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- 25.
A client who is at 7 weeks gestation is experiencing n/v in the morning. Which of the following information should the nurse include in the teaching?
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Eat crackers or plain toast before getting out of bed
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Awaken during the night to eat a snack
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Skip breakfast and eat lunch after nausea has subsided
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Eat a large evening meal
Correct Answer
A. Eat crackers or plain toast before getting out of bedExplanation
N/V during the first trimester might be relieved by eating crackers or plain toast 30-60 min to rising in the morning. Eating during the night can cause heartburn and dose not relieve n/v during the first trimester. Instruct the client to avoid an empty stomach for prolonged periods of time to reduce n/v. Eating a large meal can cause heartburn and does not relieve n/v in the morning.Rate this question:
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- 26.
A nurse is teaching a client who is at 6 weeks of gestation about common discomforts of pregnancy. Which of the following findings should the nurse include in the teaching? Select all that apply.
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Breast tenderness
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Urinary frequency
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Epistaxis
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Dysuria
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Epigastric pain
Correct Answer
A. Breast tendernessExplanation
Breast tenderness is a common discomfort occurring during the 1st trimester. Urinary frequency too. Epistaxis too. Dysuria is a complication that might occur during pregnancy. The nurse should instruct the client to report this finding to the provider. Epigastric pain is a clinical finding of pregnancy-induced hypertension. The nurse should instruct the client to report this finding to the provider.Rate this question:
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- 27.
A client who is at 8 weeks of gestation tells the nurse that she isn't sure she is happy about being pregnant. Which of the following responses should the nurse make?
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"I will inform the provider that you are having these feelings."
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"It is normal to have these feelings during the first few months of pregnancy."
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"You should be happy that you are going to bring new life into the world."
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"I am going to make an appointment with the counselor for you to discuss these thoughts."
Correct Answer
A. "I will inform the provider that you are having these feelings."Explanation
This is a nontherapeutic response by the nurse and does not acknowledge the client's concerns. Feelings of ambivalence about pregnancy are normal during the first trimester. The others are nontherapeutic.Rate this question:
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- 28.
A nurse in a prenatal clinic is providing education to a client who is in the 8th week of gestation. The client states that she does not like milk. Which of the following foods should the nurse recommend as a good source of calcium?
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Dark green leafy vegetables
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Deep red or orange vegetables
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White breads and rice
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Meat, poultry, fish
Correct Answer
A. Dark green leafy vegetablesExplanation
Good sources of calcium for bone and teeth formation include low-oxalate, dark green leafy vegetables, such as kale, artichokes, turnip greens. Deep red or orange vegetables are good sources of vitamins C and A. White breads and rice do not contain high levels of calcium. Meat, poultry, and fish are sources of protein but do not contain high levels of calcium.Rate this question:
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- 29.
A nurse in a prenatal clinic is caring for four clients. Which of the following clients' weight gain should the nurse report to the provider?
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1.8 kg (4 lb) weight gain and is in her 1st trimester
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3.6 kg (8 lb) weight gain and is in her 1st trimester
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6.8 kg (15 lb) weight gain and is in her 2nd trimester
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11.3 kg (25 lb) weight gain and is in her 3rd trimester
Correct Answer
A. 3.6 kg (8 lb) weight gain and is in her 1st trimesterExplanation
1.8 kg is appropriate for client in 1st trimester. The nurse should be concerned about this client because she has exceeded the expected 3-4 lb weight gain in the first trimester. 6.8 kg (15 lb) weight gain and is in her 2nd trimester. 11.3 kg (25 lb) weight gain and is in her 3rd trimester - within recommended weight gain.Rate this question:
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- 30.
A nurse in a clinic is teaching the 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?
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Iron deficiency anemia
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Poor bone formation
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Macrosomic fetus
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Neural tube defects
Correct Answer
A. Neural tube defectsExplanation
Iron deficiency anemia is the result of a lack of iron-rich dietary sources, such as meat, chicken, and fish. Ca deficiency can result in poor bone and teeth formation. Maternal obesity can lead to a macrosomic fetus. Neural tube defects are caused by folic acid deficiency. Food sources of folic acid include fresh green leafy vegetables, liver, peanuts, cereals, and whole-grain breads.Rate this question:
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- 31.
A nurse is reviewing a new prescription for iron supplements with a client who is in the 8th week of gestation and has iron deficiency anemia. Which of the following beverages should the nurse instruct the client to take the iron supplements with?
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Ice water
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Low-fat or whole milk
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Tea or coffee
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Orange juice
Correct Answer
A. Orange juiceExplanation
Water does not promote absorption of iron, but drinking water can prevent constipation which is an adverse effect of iron supplements. Milk and calcium interferes with iron absorption. Caffeine in tea and coffee can interfere with iron absorption. The client should consume no more than 200 mg/day because it increases the risk of spontaneous abortion or fetal intrauterine growth restriction. Orange juice contains vitamin C which aids in the absorption of iron.Rate this question:
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- 32.
A nurse is reviewing findings of a client's biophysical profile (BPP). The nurse should expect which of the following variables to be included in this test? Select all that apply.
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Fetal weight
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Fetal breathing movement
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Fetal tone
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Fetal position
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Amniotic fluid volume
Correct Answer
A. Amniotic fluid volumeExplanation
Fetal weight and fetal position are not one of the variables included in the BPP. Fetal breathing movements, fetal tone, and amniotic fluid volume are included in the BPP.Rate this question:
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- 33.
A nurse is caring for a client who is in preterm labor and is scheduled to undergo an amniocentesis. The nurse should evaluate which of the following tests to assess fetal lung maturity?
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Alpha-fetoprotein (AFP)
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Lecithin/sphingomyelin (L/S) ratio
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Kleihauer-Betke test
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Indirect Coombs' test
Correct Answer
A. Lecithin/sphingomyelin (L/S) ratioExplanation
AFP is a test to assess for fetal neural tube defects or chromosome disorders. A test of the L/S ratio is done as a part of an amniocentesis to determine fetal lung maturity. Kleihauer-Betke test is used to verify that fetal blood is present during a percutaneous umbilical blood sampling procedure. An indirect Coombs' test detects Rh antibodies in the mother's blood.Rate this question:
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- 34.
A nurse caring for a client who is pregnant and undergoing a nonstress test. The client asks why the nurse is using an acoustic vibration device. Which of the following responses should the nurse make?
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"It is used to stimulate uterine contractions."
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"It will decrease the incidence of uterine contractions."
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"It lulls the fetus to sleep."
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"It awakens a sleeping fetus."
Correct Answer
A. "It awakens a sleeping fetus."Explanation
The acoustic vibration device does not stimulate the uterus. It has no effect on the uterine muscles. It stimulates a sleeping fetus. The acoustic vibration device is activated for 3 seconds on the maternal abdomen over the fetal head to awaken a sleeping fetus.Rate this question:
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- 35.
A nurse in the ED is caring for a client who reports abrupt, sharp, right-sided lower quadrant abdominal pain and bright red vaginal bleeding. The client states she missed one menstrual cycle and cannot be pregnant because she has an IUD. The nurse should suspect which of the following?
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Missed abortion
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Ectopic pregnancy
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Severe preeclampsia
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Hydatidiform mole
Correct Answer
A. Ectopic pregnancyExplanation
A client who experienced a missed abortion would report brownish discharge and no pain. Manifestations of an ectopic pregnancy include unilateral lower quadrant pain with or without bleeding. Use of an IUD is a risk factor associated with this condition. A client who has severe preeclampsia does not have vaginal bleeding and presents with right upper quadrant epigastric pain. A client who has a hydatidiform mole usually has dark brown vaginal bleeding in the 2nd trimester that is not accompanied by abdominal pain.Rate this question:
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- 36.
A nurse is providing care for a client who is diagnosed with a marginal abruptio placentae. The nurse is aware that which of the following findings are risk factors for developing the condition? Select all taht apply.
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Fetal position
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Blunt abdominal trauma
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Cocaine use
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Maternal age
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Cigarette smoking
Correct Answer(s)
A. Blunt abdominal trauma
A. Cocaine use
A. Cigarette smokingExplanation
Fetal position is not a risk factor associated with abruptio placentae. Blunt abdominal trauma is a risk factor for this. Cocaine use is a risk factor too. Maternal age is not. Cigarette smoking is associated risk.Rate this question:
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- 37.
A nurse is providing care for a client who is at 32 weeks of gestation and who has placenta previa. The nurse notes that the client is actively bleeding. Which of the following types of medications should the nurse anticipate the provider will prescribe?
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Betamethasone
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Indomethacin
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Nifedipine
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Methylergonovine
Correct Answer
A. BetamethasoneExplanation
Betamethasone is given to promote lung maturity if delivery is anticipated. Indomethacin is prescribed for the client in preterm labor. Nifedipine is prescribed for the client in preterm labor. Methylergonovine is prescribed for the client experiencing postpartum hemorrhage.Rate this question:
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- 38.
A nurse at an antepartum clinic is caring for a client who is at 4 months of gestation. The client reports continued nausea and vomiting and a scant, prune-colored discharge. She has experienced no weight loss and has a fundal height larger than expected. Which of the following complications should the nurse suspect?
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Hyperemesis gravidarum
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Threatened abortion
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Hydatidiform mole
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Preterm labor
Correct Answer
A. Hydatidiform moleExplanation
A client who has hyperemesis gravidarum will have weight loss and signs of dehydration. A client who has a threatened abortion would be in the 1st trimester and report spotting to moderate bleeding with no enlarged uterus. A client who has a hydatidiform mole exhibits increased fundal height inconsistent with the week of gestation and excessive n/v due to elevated hCG levels. Scant, dark discharge occurs in the 2nd trimester. Preterm labor presents prior to 37 weeks of gestation and is accompanied by pink-stained vaginal discharge and uterine contractions that become more regular.Rate this question:
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- 39.
A nurse is caring for a client who has a diagnosis of ruptured ectopic pregnancy. Which of the following findings is seen with this condition?
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No alteration in menses
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Transvaginal US indicating a fetus in the uterus
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Serum progesterone greater than the expected reference range
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Report of severe shoulder pain
Correct Answer
A. Report of severe shoulder painExplanation
A client experiencing a ruptured ectopic pregnancy has delayed, scant, or irregular menses. TV US would indicate an empty uterus in the client who has ruptured ectopic pregnancy. A serum progesterone level lower than the expected reference range is an indication of ectopic pregnancy. A client's report of severe shoulder pain is a finding associated with a ruptured ectopic pregnancy due to the presence of blood in the abdominal cavity, which irritates the diaphragm and phrenic nerve.Rate this question:
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- 40.
A nurse is admitting a client who is in labor and has HIV. Which of the following interventions should the nurse identify as contraindicated for this client? Select all that apply.
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Episiotomy
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Oxytocin infusion
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Forceps
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Cesarean birth
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Internal fetal monitoring
Correct Answer(s)
A. Episiotomy
A. Forceps
A. Internal fetal monitoringExplanation
An episiotomy should be avoided for a client who is HIV-positive due to the risk of maternal blood exposure. Oxytocin infusion is not contraindicated for this client. The use of forceps during delivery should be avoided due to risk of fetal bleeding. Cesarean birth is not contraindicated for this client. Internal fetal monitoring should be avoided due to the risk of bleeding.Rate this question:
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- 41.
A nurse in an antepartum clinic is assessing a client who has a TORCH infection. Which of the following findings should the nurse expect? Select all that apply.
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Joint pain
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Malaise
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Rash
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Urinary frequency
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Tender lymph nodes
Correct Answer(s)
A. Joint pain
A. Malaise
A. Rash
A. Tender lymph nodesExplanation
TORCH infx are flu-like in presentation, such as joint pain, malaise, rash, and tender lymph nodes.Rate this question:
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- 42.
A nurse is caring for a client who has gonorrhea. Which of the following medications should the nurse anticipate the provider will prescribe?
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Ceftriaxone
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Fluconazole
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Metronidazole
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Zidovudine
Correct Answer
A. CeftriaxoneExplanation
Ceftriaxone IM or doxycycline PO x 7 days is prescribed for the treatment of gonorrhea. Fluconazole is used to treat candidasis. Metronidazole is used in the treatment of bacterial vaginosis and trichomoniasis. Zidovudine is used to treat HIV/AIDS.Rate this question:
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- 43.
A nurse is caring for a client in labor. The nurse should identify that which of the following infections can be treated during labor or immediately following birth? Select all that apply.
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Gonorrhea
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Chlamydia
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HIV
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Group B streptococcus beta-hemolytic
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TORCH infection
Correct Answer(s)
A. Gonorrhea
A. Chlamydia
A. HIV
A. Group B streptococcus beta-hemolyticExplanation
Erythromycin is administered to the infant immediately following delivery to prevent Neisseria gonorrhoeae. Erythromycin is administered to the infant immediately following delivery to prevent chlamydia. Retrovir is prescribed to a client in labor who is HIV-positive. Penicillin G or ampicillin may be prescribed to treat positive GBS. A TORCH infection can be treated during pregnancy depending upon the infection.Rate this question:
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- 44.
A nurse is caring for a client who is at 14 weeks gestation and has hyperemesis gravidarum. The nurse should identify that which of the following are risk factors for the client? Select all that apply.
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Obesity
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Multifetal pregnancy
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Maternal age greater than 40
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Migraine headaches
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Oligohydramnios
Correct Answer(s)
A. Obesity
A. Multifetal pregnancy
A. Migraine headachesExplanation
Obesity, multifetal pregnancy, and migraine headache are risk factors for hyperemesis gravidarum. Maternal age less than 30 is a risk factor for hyperemesis gravidarum. Oligohydramnios is not a risk factor for hyperemesis gravidarum.Rate this question:
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- 45.
A nurse is caring for a client who has suspected hyperemesis gravidarum and is reviewing the client's lab reports. Which of the following is a manifestation of this condition?
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Hgb 12.2 g/dL
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Urine ketones present
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Alanine aminotransferase 20 IU/L
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Serum glucose 114 mg/dL
Correct Answer
A. Urine ketones presentExplanation
Altered hematocrit is a manifestation of hyperemesis gravidarum due to the hemoconcentration that occurs with dehydration. The presence of ketones in the urine is associated with the breakdown of fats that occurs in a client who has hyperemesis gravidarum. Alanine aminotransferase 20 IU/L. Liver enzymes are elevated in a client who has hyperemesis gravidarum. This finding is within the expected reference range. Decreased serum glucose is anticipated is anticipated in a client who has hyperemesis gradvidarum. This result is within the expected reference range.Rate this question:
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- 46.
A nurse is administering Mg Sulfate IV to a client who has severe preeclampsia for seizure prophylaxis. Which of the following indicated Mg Sulf toxicity? Select all that apply.
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Respirations less than 12/min
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Urinary output less than 30 mL/hr
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Hyperreflexic DTRs
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Decreased level of consciousness
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Flushing and sweating
Correct Answer(s)
A. Respirations less than 12/min
A. Urinary output less than 30 mL/hr
A. Decreased level of consciousnessExplanation
A respiratory rate of less than 12/min, urinary output less than 30 mL/hr, decreased level of consciousness is a sign of Mg tox. The absence of patellar deep-tendon reflexes is a sign of Mg toxicity. Flushing and sweating are adverse effects of Mg but not signs of toxicity.Rate this question:
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- 47.
A nurse is caring for a client who is receiving IV Mg. Which of the following medications should the nurse anticipate administering if Mg toxicity is suspected?
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Nifedipine
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Pyridoxine
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Ferrous sulfate
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Calcium gluconate
Correct Answer
A. Calcium gluconateExplanation
Nifedipine is an antihypertensive medication that can be administered to women who have gestational hypertension. Pyridoxine (vitamin B6) is a vitamin supplement prescribed for clients who have hyperemesis gravidarum. Ferrous sulfate is a medication used in the treatment of iron deficiency anemia. Calcium gluconate is the antidote for Mg.Rate this question:
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Mar 21, 2023Quiz Edited by
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May 02, 2018Quiz Created by
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