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75問 • 2年前

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The nurse is caring for a newborn monitored with esophageal atresia. When reviewing the mother's history. Which would the nurse expect to find?

Maternal Polyhydramnios.

The nurse is caring for a 5 month old infant with a diagnosis of intussusception. The infants has periods of irritability during which the knees are brought to chest and the infants cries, alternating with periods of lethargy. Vital signs are stable and within age-appropriate limits. The physician ordered to give an enema. The parents ask the purpose of the enema. What is the nurse's most appropriate response?

The enema will help confirm the diagnosis and has a good chance of fixing the intussusception.

The nurse is caring for an infant newly diagnosed with Hirschsprung disease. What does the nurse understand about this infant's condition.

immediately obtain all vital signs with a quick head-to-toe assessment.

A nurse working in an emergency room of a large pediatric hospital receives a transfer call from a reporting nurse at a local community hospital. The nurse will soon receive a 4-month-old who has been diagnosed with an intussusception. The infant is described as very lethargic with the following vital signs, T 101.8°F (38.7°C), HR 181, BP 68/38. The reporting nurse states the infant's abdomen is very rigid. Which of the following is the most appropriate action for the receiving nurse

Prepare to get the infant ready for immediate surgical correction

The nurse is caring for an 2 month old male infant who has just been diagnosed with hirschsprung disease. The parents ask what they should expect. What is the nurse's best response?

Although your child will require surgery, there are different ways to manage the disease, depending on how much bowel is involved

The parents of a newborn diagnosed with cleft lip and palate ask the nurse when their child's lip and palate will most likely be repaired. What is the nurse's best response?

The lip is repaired first few weeks of life, but the palate is not usually repaired until the child is 18 months old.

The nurse is caring for an 8 week old infant being evaluated for pyloric stenosis. Which statement by the parent would be typical for a child with this diagnosis?

The baby is always hungry after vomiting so I refeed.

The nurse is caring for a newborn who has just been diagnosed with tracheoesophageal fistula and is scheduled for surgery. Which should the nurse expect to do in the preoperative period?

Administer intravenous fluids and antibiotics.

The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother states she is pregnant with a boy and wants to know if her new baby will likely have the disorder. What is the nurse's best response?

Genetics play a small role in Hirschsprung disease, so there is a chance the baby will develop it as well

The nurse knows that Nissen fundoplication involves which of the following procedure?

The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter.

The nurse is administering Prilosec (omeprazole) to a 6 months old child diagnosed with gastro-esophageal reflux (GER). The child's parents ask the nurse how the medication works.

Prilosec decreases stomach acid, so it will not be as irritating when your child spits up.

A 4-month-old is being admitted to the emergency department because of episodes of vomiting and diarrhea for 24 hours. The infant is fussy, and the anterior fontanel is sunken. The nurse notes the infant does not produce tears when crying. Which task will help confirm the diagnosis of dehydration

Analysis of Serum electrolytes

What is Retained placental fragments?

incomplete expulsion of the placenta

What is Perineal hematoma?

Localized collection of blood in loose connective tissue

What is uterine atony?

relaxation of the uterus due to loss of muscle tone

Second degree perineal lacerations involves vaginal mucous membrane, skin of perineum to the fourchettte.

False

Administration of oxytocin 50 "u" incorporated in the IV line is one of thee nursing management of uterine atony

False

Fundal massage stimulates uterine dilation

False

The causative agent of mastitis is streptococcus.

False

Clindamycin is a drug of choice for endometritis?

True

What type of trauma during labor and birth would lead to postpartum hemorrhage risk? 1 C-section 2 All of the above 3 Lacerations of the cervix 4 Forceps birth

Which of these cases could be diagnosed as postpartum hemorrhage after vaginal delivery?

Hypotension

Matching Type: Newborns

voiding possible

Matching Type: 3 mos of age

able to concentrate urine

Matching Type: 10 day of life

50% bladder capacity

Matching Type: 2 years of age

full maturity of bladder

During nephrotic syndrome in children, thromboembolism results from?

Increased clotting factors due to kidney failure

The nurse reviewing the patients' charts during the endorsement, which of the following clients will the nurse visit first?

A 1 year old child with BUN values of 31mg/dl

The assigned nurse in the recovery room received from operating room health personnel, a pediatric client who had undergone tonsillectomy. She should place the not fully awake client in what position?

Side-lying position

What is the flow rate in mL per hour if the doctor ordered 40 mEq KCL in 100 mL NS over 45 minutes?

133ml

The mother of a child with chronic asthma asked the nurse why her child's rib cage is round just like a barrel chest? What is the best response of the nurse?

Barrel chest is due to overinflation of air in the alveoli with CO2 trapping.

If the nursing diagnosis for pediatric client with LTB is ineffective airway clearance r/t edema and constrictction of the airway, what will be your priortizied nursing action?

Assess child's respiratory status effort and diminished breath sounds.

in children with bronchitis complaining of productive cough, it is important to raise the accumulated viscous sputum to relieve airway problem. what is the drug of choice indicated for this situation?

cough expectorant

A school age child has asthma which of the following can trigger asthma attack? 1. Inhalants 2. Air pollutants 3. Pollens 4. Viral agents

124

Mary a 7yo was diagnosed with primary complex. What are the first line of drugs for tuberculosis? 1. Isoniazid 2. Rifampin 3. Pyrazinamide 4. Ethambutol

1234

A school child complained of sudden onset of fever and was diagnosed with influenza. After 2 days, the client had inflammation of the muscle with muscle fatigue and weakness. What is the term used for this complication of influenza?

Myositis

In the different stages of LTB, which one will make the pedia client in danger causing the child to be int he life threatening situation?

Stage IV

what will be the effects of bronchospasm, inflammation and increased bronchial secretions to a pediatric client with asthma

These will reduce the size of airway lumen leading to acute respiratory distress.

A veteran is admitted to the hospital after sustaining a traumatic brain injury. A magnetic resonance image shows significant damage to the veteran's cerebellum. The damage would result in difficulty with which of the following functions

Coordination of movement

The basic cyclic pattern of inspiration and expiration are established by a respiratory center with the ____.

Medulla oblongata

Joshua received a golden retriever puppy for his birthday. He picked up the puppy and is surprised at how soft and fluffy the puppy's fur feels. What love of Joshua's cerebral cortex first processes the information about the feel of the puppy's fur?

Parietal lobe

A pregnant client admitted to the labor room arrived with a fetal heart rate (FHR) of 94 beats/minute and the umbilical cord protruding from the vagina. The client tells the nurse that her "water broke" before coming to the hospital. What is the appropriate nursing action?

Wrap the cord loosely in a sterile towel soaked with warm, sterile normal saline.

The nurse has collected the following data on a client in labor. The fetal heart rate (FHR) is 154 beats/min and is regular, and contractions have moderate intensity, occur every 5 minutes, and have a duration of 35 seconds. Using this information, what is the appropriate action for the nurse to take?

Continue to monitor the client.

The nurse is monitoring a client who is in the active phase of labor. The client has been experiencing contractions that are short, irregular, and weak. Which type of labor dystocia should the nurse document that the client is experiencing?

Hypotonic

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. What is the initial nursing action?

Turn the client on her side and administer oxygen by face mask at 8 to 10 L/min.

An ultrasound is performed on a client with suspected abruptio placentae, and the results indicate that a placental abruption is present. Which intervention should the nurse prepare the client for?

Delivery of the fetus

The nurse performs a vaginal assessment on a pregnant client in labor. On assessment, the nurse notes the presence of the umbilical cord protruding from the vagina. Which is the initial nursing action?

Place the client in Trendelenburg's position.

The nurse is preparing to care for a client with hypertonic labor. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. Which is the priority nursing intervention?

Provide pain relief measures.

The nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which is noted on the external monitor tracing during a contraction?

Variable decelerations

The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats/minute. Which nursing action is most appropriate?

Notify the health care provider (HCP).

The nurse is assisting a client undergoing induction of labor at 41 weeks of gestation. The client's contractions are moderate and occurring every 2 to 3 minutes, with a duration of 60 seconds. An internal fetal heart rate monitor is in place. The baseline fetal heart rate has been 120 to 122 beats/minute for the past hour. What is the priority nursing action?

Discontinue the infusion of oxytocin.

The nurse in a birthing room is monitoring a client with dysfunctional labor for signs of fetal or maternal compromise. Which assessment finding should alert the nurse to a compromise?

Persistent nonreassuring fetal heart rate

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client admitted for premature rupture of the membranes. Gestational age of the fetus is determined to be 37 weeks. Which prescription should the nurse question?

Perform a vaginal examination every shift.

The nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse should monitor the client closely for the risk of uterine rupture if which occurred?

Forceps delivery

The nurse is caring for a client in labor and prepares to auscultate the fetal heart rate (FHR) by using a Doppler ultrasound device. Which action should the nurse take to determine fetal heart sounds accurately?

Palpating the maternal radial pulse while listening to the FHR

The nurse prepares a plan of care for the client with preeclampsia and documents that if the client progresses from preeclampsia to eclampsia, the nurse should take which first action?

Clear and maintain an open airway.

During the intrapartum period, the nurse is caring for a client with sickle cell disease. The nurse ensures that the client receives adequate intravenous fluid intake and oxygen consumption to achieve which outcome?

Prevent dehydration and hypoxemia.

The nurse is preparing to care for a client in labor. The health care provider has prescribed an intravenous (IV) infusion of oxytocin. The nurse ensures that which intervention is implemented before initiating the infusion?

Continuous electronic fetal monitoring

The nurse is caring for a client during the second stage of labor. On assessment, the nurse notes a slowing of the fetal heart rate and a loss of variability. Which is the initial nursing action?

Turn the client onto her side and give oxygen by face mask at 8 to 10 L/min.

An amniotomy is performed on a client in labor. On the amniotic fluid examination, the delivery room nurse should identify which findings as normal?

Pale straw in color, with flecks of vernix

The labor room nurse assists with the administration of a lumbar epidural block. How should the nurse check for the major side effect associated with this type of regional anesthesia?

Monitoring the mother's blood pressure

The nurse assists the health care provider to perform an amniotomy on a client in labor. Which is the priority nursing action after this procedure?

Assess the fetal heart rate.

The nurse is caring for a client in active labor. Which nursing intervention would be the best method to prevent fetal heart rate (FHR) decelerations?

Encourage an upright or side-lying maternal position.

Fetal distress is occurring with a woman in labor. As the nurse prepares her for a cesarean birth, what other intervention should the nurse implement?

Administer oxygen at 8 to 10 L/min via face mask.

A pregnant 39-week-gestation gravida 1, para 0 client arrives on the labor and delivery unit with signs and symptoms of active labor. The nurse reviews the client's prenatal record and discovers that she has had a positive group B streptococcus (GBS) laboratory report during her prenatal course. After performing a cervical exam, the nurse confirms that the cervix is dilated 6 cm and 90% effaced. Which should be the nurse's first action?

Call the health care provider (HCP) to obtain a prescription for intravenous antibiotic prophylaxis (IAP).

The nurse is caring for a client in the transition phase of the first stage of labor. The client is experiencing uterine contractions every 2 minutes and she cries out in pain with each contraction. What is the nurse's best interpretation of this client's behavior?

Fear of losing control

A pregnant 39-week-gestation client arrives at the labor and delivery unit in active labor. On confirmation of labor, the client reports a history of herpes simplex virus (HSV) to the nurse, who notes the presence of lesions on inspection of the client's perineum. Which should be the nurse's initial action?

Explain to the client why a cesarean delivery is necessary

After the spontaneous rupture of a laboring woman's membranes, the fetal heart rate drops to 85 beats/minute. Which should be the nurse's priority action?

Assess the vagina and cervix with a gloved hand.

On assessment of the fetal heart rate (FHR) of a laboring woman, the nurse discovers decelerations that have a gradual onset, last longer than 30 seconds, and return to the baseline rate with the completion of each contraction. The nurse plans care, knowing that this identifies which category of decelerations?

Periodic, early decelerations that indicate fetal head compression

The nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a contraction to begin before she infuses the medication into the intravenous line. Which is the nurse's most appropriate response?

Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication

If the ectopic pregnancy is not managed and the fertilized egg continues to grow in the fallopian tube, it can cause which of the following occurence? ● Shock ● Fainting ● Cause extreme lightheadedness ● The tube to rupture ● All of the choices are correct

All of the choices are correct

A student nurse is caring for a client with abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation?

Swelling of the calf in one leg

Disseminated intravascular coagulation (DIC) can occur in __________________. This happens because when the placenta becomes damaged and detaches from the uterine wall, large amounts of _____________ are released into mom’s circulation, leading to clot formation and then clotting factor depletion.

Abruptio placentae, thromboplastin

Which of the following patients are at risk for developing placenta previa? A 28 year old pregnant female with chronic hypertension. SELECT ALL THAT APPLY ● A 28 year old pregnant female with chronic hypertension. ● A 37 year old woman who is pregnant with her 7th child. ● A 20 year old pregnant female who is a cocaine user. ● A 25 year old female who is 36 weeks pregnant that has experienced trauma to abdomen.

A 37 year old woman who is pregnant with her 7th child. A 20 year old pregnant female who is a cocaine user.

A patient who is 28 weeks pregnant has partial placenta previa. The student nurse is providing her health education to the patient about the condition and self-care. Which statement of the patient requires the need to re-educate her?

“I may start to experience dark red bleeding with pain.”

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NCM 112 QUIZZES PERIOP

ユーザ名非公開 · 39問 · 1年前

NCM 112 QUIZZES PERIOP

39問 • 1年前