WorksheetsHealth Promotion And Maintenance
Total questions: 100
Worksheet time: 8hrs 20mins
The nurse is reviewing a client's health history during a primary care visit. Which of the following findings should the nurse identify as risk factors for developing hypertension? Select all that apply.
African American
DMII
Stress At Work
LDL 100
Smoking 1 pack of cigarettes daily
The client was diagnosed 6 months ago with hypertension and had a recent emergency department visit for a transient ischemic attack (TIA). The client's blood pressure today is 170/88 mm Hg. What teaching topic is a priority for the nurse to discuss with this client?
Decreasing Sodium intake
Decreasing stress level at work
Increasing activity level
Taking blood pressure medications as prescribed
An experienced nurse is mentoring a new registered nurse (RN) on the telemetry unit. The new RN is measuring orthostatic blood pressure (BP) for a client. Which situation would warrant intervention by the experienced nurse?
Nurse has client lie supine for 5-10 minutes prior to starting the procedure.
Nurse interprets a decrease in systolic BP by 10 mmhg as normal.
Nurse stars by measuring BP and HR with client standing.
Nurse takes BP and HR after standing at 1-3 minute intervals.
The nurse identifies which risk factors as contributing to the development of peripheral artery disease? Select all that apply.
Cigarette smoking
DMII
Hyperlipidemia
Oral Contraceptive
Prolonged standing
An experienced registered nurse (RN) is mentoring a new nurse in the telemetry unit. Which assessment technique by the new nurse requires intervention by the RN?
Nurse carefully auscultates for heart murmurs at Erb's point
Nurse palpates bilateral carotid arteries simultaneously to assess for symmetry
Nurse places client in semi-Fowler's position to assess for jugular venous distension
Nurse positions client supine to assess the point of maximal impulse
The nurse is providing community health screening. Which of the following clients should be referred to a health care provider for further evaluation?
30-year-old athlete with a heart rate of 50/min
45-year-old client with a body mass index of 35 kg/m2 and fingerstick glucose of 150 mg/dL (8.3 mmol/L)
55-year-old client missing all the hair on the lower legs and failing the pinprick test
80-year-old client with a blood pressure of 150/90 mm Hg
The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply.
I have been drinking alcohol almost daily since age 20
I have been overweight for as long as I can remember
I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year."
I know I eat too much fast food
I was a car mechanic for about 40 years and had my own garage.
A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply.
Perform the examination during a warm bath or shower
Perform the examination monthly on the same day
Report if one testis is slightly larger than the other
Report if there is a hard mass over the testis
Use both hands to feel each testis separately
The nurse is reviewing the history of four female clients. The nurse should recommend a Pap test to screen for cervical cancer in which client?
17-year-old who reports being sexually active for 2 years and uses condoms
26-year-old whose last Pap test screening at age 21 was negative
51-year-old who had a hysterectomy with cervix removal for benign reasons and whose previous Pap tests were negative
72-year-old with a history of regular Pap test screening whose previous Pap tests were negative
The nurse is caring for an adolescent newly diagnosed with a chlamydial infection. After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching? Select all that apply.
A long-term consequence of an untreated chlamydial infection is infertility.
I can resume sexual intercourse tomorrow, as I already received the antibiotic.
I can still spread the infection, even if I do not have any of the symptoms.
I should have screening yearly for chlamydia even if I do not have symptoms.
I will make sure my partner gets checked and treated to prevent reinfection.
The clinic nurse is reviewing the plan of care with a client who has phenylketonuria (PKU) and plans to become pregnant this year. Which statement from the client requires the nurse to intervene?
I will consume more high-protein, iron-rich foods, such as meat and eggs, before and during pregnancy.
I will use a special, low-phenylalanine formula for infant feeding if my baby is also diagnosed with PKU.
It would be beneficial for my partner and I to have genetic counseling even though he does not have PKU.
My baby will need to have adequate milk intake after birth to help ensure the screening test for PKU is accurate.
The nurse prepares a community education program about health promotion strategies for postmenopausal women. Which of the following teaching points are appropriate to include? Select all that apply.
Consider seeing a dietitian for help with healthy weight maintenance
Consult with a health care provider for cholesterol monitoring
Engage in a daily weight-bearing exercise regimen
Prioritize consumption of green, leafy vegetables and dairy products
Seek support to cope with any emotional symptoms
Which of these instructions is appropriate teaching for a 60-year-old woman? Select all that apply.
Consume adequate sources of calcium and vitamin D and take supplements
Increase intake of food sources of iron and take supplements
Observe for unilateral leg swelling when taking hormone replacement therapy (HRT)
Remain upright for 30 minutes when taking a bisphosphonate
Vaginal spotting after menopause is a common, insignificant sign of aging
The nurse is providing education to a client with a new prescription for progestin-only pills (POPs). Which statement about POPs is appropriate for the nurse to include?
If you begin vomiting any time within 24 hours of taking the pill, take an additional pill.
If you take your pill 3 or more hours after your usual time, use a backup contraceptive.
In your pill pack, there are 21 days of progestin pills and 7 days of inactive iron pills.
The use of POPs increases your risk of developing deep venous thrombosis.
The nurse reinforces education to a female client about the use of a cervical cap to prevent pregnancy. Which statement by the client indicates a need for further teaching?
I should apply spermicide to the cervical cap before inserting it.
I should not use the cervical cap while I am on my period.
I will remove and clean the cervical cap as soon as possible after intercourse.
It is okay for me to insert the cervical cap several hours before I have sex.
A 28-year-old client is seeking advice from the nurse about why she has not been able to conceive. The client is discouraged and states that she has been "trying to get pregnant for 4 months." Which statement by the nurse is best?
Adoption or surrogacy are options for those who are unable to conceive.
Consider talking to your health care provider about fertility-enhancing medications that can help you conceive more quickly.
There is no cause for concern unless you haven't been able to conceive for 1 year.
Using an over-the-counter urine ovulation detector kit to time sexual intercourse may improve your chances of conceiving.
The nurse is caring for a client with suspected pelvic inflammatory disease (PID). When the nurse is obtaining the client's health history, which of the following questions would provide pertinent data about the client's risk factors for PID? Select all that apply.
Are you currently taking oral contraceptives?
At what age did you experience your first menstrual cycle?
Do you engage in sexual intercourse with multiple partners?
Have you ever been diagnosed with a sexually transmitted infection?
Have you recently had an abortion or pelvic surgery?
The nurse educates a group of clients in the infertility clinic about risk factors contributing to infertility. Which factors should the nurse include in the teaching? Select all that apply.
BMI of 22 kg/m2
Endometriosis
Maternal age >35
Polycystic ovarian syndrome
Recurrent chlamydial infections
The nurse educator is completing a staff education conference about prenatal carrier screening. Which statement by a participant indicates a correct understanding of the genetic inheritance for cystic fibrosis?
Both parents must be carriers of the abnormal gene for offspring to have the disorder.
Female offspring are most often affected by the inheritance pattern of cystic fibrosis.
If the female partner is a carrier, only male offspring will have the disorder.
The inheritance pattern for cystic fibrosis does not skip generations.
The nurse is caring for several clients in a gynecology clinic. Which of the following clients are at increased risk for developing breast cancer? Select all that apply.
24-year-old client whose sister had breast cancer at age 38
32-year-old client with mutations of the breast cancer 1 and 2 (BRCA1, BRCA2) genes
45-year-old client whose menstrual period began at age 17
56-year-old client who is postmenopausal and gained 50 lb (22.7 kg) in the last 5 years
65-year-old client who has been taking estrogen and progestin pills for the last 15 years for vasomotor symptoms
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
Genital herpes and HIV
Gonorrhea and chlamydia
Human papillomavirus and syphilis
Yeast and trichomoniasis
A 14-year-old is seen in the sexually transmitted disease (STD) outpatient department and diagnosed with gonorrhea. The client tells the nurse of having sexual relations with only a 19-year-old partner. What is the best response by the nurse?
Has your partner been evaluated and treated by a health care provider?
I have to report your situation to local law enforcement.
One of your parents will need to consent to your treatment
You should use a condom when you have sex.
The family practice clinic nurse is conducting client intake histories. Which client findings or histories indicate a need for heightened concern that the client may have cancer? Select all that apply.
The 60-year-old client was just diagnosed with benign prostatic hyperplasia (BPH)
The client reports a mobile, golf ball–sized lesion under the skin over the right thigh that feels doughy
The client reports a nagging cough with hoarseness for the past 3 months
The female client who weighed 150 lb (68.0 kg) has lost 15 lb (6.8 kg) in 3 months without dieting
The male client reports a skin change on the breast that looks like an orange peel
The nurse is caring for a 50-year-old client in the clinic. The client's annual physical examination revealed a hemoglobin value of 10 g/dL (100 g/L) compared to 13 g/dL (130 g/L) a year ago. What should be the nurse's initial action?
Encourage intake of over-the-counter iron pills
Encourage intake of red meat and egg yolks
Facilitate a screening colonoscopy
Facilitate another blood test in 6 months
The clinic nurse is caring for a 51-year-old client whose sibling recently died from colorectal cancer (CRC). Which of the following client statements demonstrate a correct understanding of risk factors for CRC? Select all that apply.
Although I'm at increased risk due to age and family history, I can also do things to lower the risk.
Because my sibling had CRC, I will begin preventative screening at an earlier age.
I will eat less red meat and start including fruits and vegetables in my diet.
"I will join a support group to try to control my alcohol intake.
My sibling was very overweight, which increased the risk for colorectal cancer.
The nurse is caring for several clients in a women's health clinic. Based on the data collected, which client's history is most concerning for an increased risk of endometrial cancer?
40-year-old client who has been taking hormonal birth control pills for the past 10 years
45-year-old client who reports a history of an ectopic pregnancy with a ruptured ovary and two preterm births
47-year-old client with polycystic ovary syndrome, obesity, and a history of unsuccessful infertility treatments
60-year-old client who recently had a colposcopy after testing positive for a high-risk type of human papillomavirus
The nurse is teaching about cervical cancer prevention during a women's health conference. Which of the following factors should be taught as risks for cervical cancer? Select all that apply.
Human immunodeficiency virus (HIV)
Human papillomavirus (HPV)
Multiple sexual partners
Nulliparity
Sexual activity before age 18
The nurse is obtaining a client's health history during a routine physical and wellness examination. Which of the following statements by the client should cause the nurse to suspect potential Hodgkin lymphoma? Select all that apply.
For the past few weeks, I have noticed a pretty regular fever, but I do not have chills or feel bad.
I have had a lump in my underarm for several weeks. I have not thought much about it because it doesn't hurt.
My weight has gone down a lot in the past month. I have not changed my diet or exercise regimen, but it has been nice.
Recently, my skin has been very itchy. I have had allergies in the past, but this feels different.
Sometimes when I wake up, I find I have sweat so much while sleeping that I need to change the sheets.
During a screening clinic, the nurse performs a health assessment on several adult clients. Which finding by the nurse is most important to report to the primary health care provider?
Body mass index (BMI) of 23 kg/m2
Brownish skin thickening on the neck
Fasting total cholesterol of 180 mg/dL (4.7 mmol/L)
Round 3x3 mm pale pink mole
The home care nurse visits the house of an elderly client. Which assessment finding requires immediate intervention?
The client cannot remember what was done yesterday
The client has a painful red area on the buttocks
The client has new dependent edema of the feet
The client has strong, foul smelling urine
A client comes to the emergency department for the second time with shortness of breath and substernal pressure that radiates to the jaw. The nurse understands that angina pectoris may be precipitated by which of these factors? Select all that apply.
Amphetamine use
Cigarette smoking
Cold exposure
Deep sleep
Sexual intercourse
The nurse is caring for a client on the organ donation waiting list for cardiac transplantation. Which teaching topic is most important for the nurse to emphasize at this time?
Immunosuppressive therapy as a lifelong commitment
Importance of accurate daily weight monitoring
Importance of periodic endomyocardial biopsies
Maintenance of meticulous surgical incision care
A nurse cares for a frail, elderly client with osteoporosis in a nursing home. Which interventions are appropriate to include in the client's care plan to help prevent a hip fracture? Select all that apply.
Calcium supplements
Encourage bed rest
Use of full bed rails during the night
Vitamin D supplements
Weight-bearing exercises
A client newly diagnosed with osteomalacia is reviewing home care instructions with the nurse. Which statements indicate the need for further instruction? Select all that apply.
I will avoid foods high in calcium and phosphorus.
I will avoid going outside on sunny days.
I will decrease activity to prevent bone injury.
I will eat foods that are fortified with vitamin D.
I will use a cane to help me get around better.
The nurse is teaching about the importance of dietary fiber at a community health fair. Which health benefits of consuming a fiber-rich diet should the nurse include in the teaching plan? Select all that apply.
Helps prevent colorectal cancer
Improves glycemic control
Promotes weight loss
Reduces risk of vascular disease
Regulates bowel movements
The nurse assesses a client who has followed a vegan diet for several years. Which client statement indicates a potential nutritional deficiency?
I have had some visual disturbances while driving at night.
I have had trouble falling asleep over the past few months.
Scaly patches of skin are developing on my elbows and knees.
Sometimes my hands and feet get a tingling sensation.
The nurse is developing teaching materials for a client diagnosed with ulcerative colitis. The client will receive sulfasalazine. Which of the following instructions are included in the discharge teaching plan? Select all that apply.
Avoid small, frequent meals
Can have a cup of coffee with each meal
Eat a low-residue, high-protein, high-calorie diet
Increase fluid intake to at least 2000 mL/day
Medication should be continued even after the resolution of symptoms
A 78-year-old client recovering from a hip fracture tells the home health nurse, "I haven't had much of an appetite lately and have been really tired. I'm worried I'm not eating enough." Which question is the priority for the nurse to ask?
Are you able to prepare your own meals?
Are you feeling lonely or depressed?
Have you lost any weight unintentionally?
How many meals do you eat each day?
The nurse is caring for a young adult who is considering becoming pregnant. The client expresses concern, stating, "One of my parents has Huntington disease, and I am afraid my child will get it." How should the nurse respond?
Genetic counseling is recommended. You will receive a referral before you leave.
Huntington disease inheritance requires both biological parents to carry the gene.
There are other ways to grow your family. You should consider adoption.
This disease occurs spontaneously and is not likely to affect your children.
The clinic nurse is caring for an elderly client who is overweight and being treated for hypertension. What is most important for the nurse to emphasize to prevent a stroke (acute brain attack)?
Consume a low-fat, low-salt diet
Do not smoke cigarettes
Exercise and lose weight
Take prescribed antihypertensive medications
A nurse is caring for a postpartum client who has chosen to exclusively formula feed her newborn for medical reasons and is experiencing breast engorgement. What should the nurse teach regarding relief of breast engorgement?
Apply heat frequently to both breasts for 15-20 minutes
Manually express milk several times a day
Massage breasts from the base to the nipple 3 or 4 times a day
Use chilled, fresh cabbage leaves on breasts throughout the day
the graduate nurse (GN) receives report on a postpartum client with an Rh-negative blood type. Which statement by the GN regarding the Rh immune globulin injection requires the preceptor to provide further teaching?
Additional doses of Rh immune globulin may be required if excessive fetomaternal hemorrhage is suspected.
I should administer Rh immune globulin to the client within 72 hours after birth.
If the maternal antibody screen is negative, I will hold Rh immune globulin and contact the health care provider.
Rh immune globulin is not required if the newborn's blood type is Rh negative.
The nurse provides a follow-up phone call to a client who gave birth at a birthing center 5 days ago. Which statement by the client should the nurse be most concerned about?
I am really tired all of the time since giving birth.
I saw some bright red blood in my bowel movement yesterday.
My bleeding is like a really heavy period with some blood clots.
My hands feel tingly when I hold the baby for a long time.
Prior to hospital discharge, the nurse discusses sexuality after childbirth with a client who had an uncomplicated vaginal birth with no perineal lacerations. Which client statement requires further teaching?
i I should avoid resuming sexual intercourse until after my vaginal bleeding has stopped.
I should expect vaginal dryness and use water-soluble lubricants, especially if I'm breastfeeding.
I will begin using condoms to prevent pregnancy once menses returns.
I will try to feed my baby before my partner and I engage in sexual activity.
The nurse is teaching a postpartum client about breastfeeding. Which statement by the client indicates a correct understanding of teaching?
I will feed my baby for 5-10 minutes on each breast.
I will hold my baby on their back with the head turned toward my breast.
If I need to reposition my baby's latch, I will use my finger to break the suction first.
The baby's mouth should grasp only the nipple without the areola.
The nurse cares for a client who gave birth an hour ago to a 9-lb (4.1-kg) newborn. The client's lochia is heavy with large clots, and the fundus remains boggy after fundal massage and an oxytocin bolus. Which prescription from the health care provider should the nurse question? Click on the exhibit button for additional information.
BP: 168/95 MMHG HR: 98 / Min
Administer 0.2-mg methylergonovine IM
Administer 800-mcg misoprostol rectally
Collect a hemoglobin and hematocrit STAT
Initiate second IV line with 18-gauge needle
A pregnant client comes in for a routine first prenatal examination. According to the last menstrual period, the estimated gestational age is 12 weeks. Where would the nurse expect to palpate the uterine fundus in this client?
12 cm above the umbilicus
At the level of the umbilicus
Halfway between the symphysis pubis and the umbilicus
Just above the symphysis pubis
The nurse assesses a client at term gestation who reports having contractions for the last 2 hours. The client states, "I'm not sure, but I think my water broke." The nurse performs a nitrazine pH test, which turns blue. When documenting the results of the test, which client statement is most concerning to the nurse?
I did have sexual intercourse with my partner 1 hour before coming in today
I have noticed constant wetness in my panties since I thought my water broke.
It is difficult for me to tell if my water broke or if I just peed on myself a little bit.
With my last three pregnancies, my water never broke on its own.
The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.
Avoid intake of dairy products
Drink large amounts of fluid with meals
Eat several small meals each day
Eliminate fried, fatty foods
Lie down on the left side after meals
A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.
Desire for adoption planning services
Emotional response to the pregnancy
Family/social support systems
Nutritional habits and substance abuse
Plan for finishing high school
The nurse is teaching a client, gravida 1 para 0, at 8 weeks gestation about expected weight gain during pregnancy. The client's prepregnancy BMI is 21 kg/m2. Which statement by the client indicates an appropriate understanding about weight gain?
I should gain 10-15 lb (4.5-6.8 kg) during the first trimester."
I should gain a total of about 30 lb (13.6 kg) during my pregnancy.
I should gain no more than 0.5 lb (0.2 kg) per week during the third trimester.
If I gain <20 lb (9.1 kg) during pregnancy, it will be easier to lose weight postpartum.
A pregnant client arrives in the labor and delivery unit with mild contractions and brisk, painless vaginal bleeding. The client received no prenatal care and reports being "about 7-8 months." Which actions should the nurse anticipate? Select all that apply.
Blood draw for type and screen
Electronic fetal monitoring
Initiation of 2 large-bore IV catheters
Pad counts to assess bleeding
Vaginal examination for cervical dilation
The nurse is planning education for clients in group prenatal care who are entering the second trimester of pregnancy. Which of the following are appropriate for the nurse to include in second-trimester teaching? Select all that apply.
Anticipate light fetal movements around 16-20 weeks gestation
Expect to have an abdominal ultrasound for fetal anatomy evaluation
Gain about 1 lb (0.5 kg) per week if pre-pregnancy BMI was normal
Increase consumption of iron-rich foods like meat and dried fruit
Plan for gestational diabetes screening near the end of the second trimester
The nurse is counseling a pregnant client who is HIV positive. Which information is appropriate to discuss?
Infant should be exclusively breastfed for 6 months to receive maternal antibodies
Infant will not require treatment for HIV after birth
Prescribed antiretroviral therapy should be continued during pregnancy
Tetanus-diphtheria-pertussis vaccine should be avoided until after birth
Which meal should the nurse avoid for a pregnant client at 13 weeks gestation? Select all that apply
Baked chicken, turnip greens, peanut butter cookie, and grape juice
Baked swordfish, fries, baked apples, and fat-free milk
Chilled ham and cheese sandwich, broccoli, orange slices, and water
Fried liver and onions, pasteurized cheese squares, fresh fruit cup, and water
The nurse in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations are appropriate for this client? Select all that apply.
Consume dairy products with ferrous sulfate pills
Continue daily moderate-intensity exercises
Increase intake of raw fruits and vegetables
Limit intake of coffee to 3 cups per day
Take a stimulant laxative daily for a week
The nurse is providing nutrition counseling during a preconception visit to a client who does not eat green vegetables. In addition to a daily prenatal vitamin, which foods can the client add to the daily diet to decrease the risk of neural tube defects? Select all that apply.
Black beans and rice
Fortified breakfast cereal and milk
Medium baked sweet potato
Peanut butter on whole wheat toast
Raw carrots with cheese dip
The nurse is caring for a client in the first trimester during an initial prenatal clinic visit. Based on the information provided by the client, which factor places the client at an increased risk for preterm labor?
Age 25
Periodontal disease
Vegetarian diet
White ethnicity
The nurse is assessing a client at 36 weeks gestation during a routine prenatal visit. Which statement by the client should the nurse investigate first?
I am not sleeping as well due to cramps in my calves at night.
I have noticed less kicking movements as the baby grows bigger.
Over the last few weeks, I have not been able to wear any of my shoes.
Sometimes I feel short of breath after walking up a flight of stairs.
The graduate nurse (GN) and supervising nurse are preparing to follow-up with a client who had a spontaneous abortion at 6 weeks gestation at home. Which of the following statements by the GN are appropriate? Select all that apply.
Although the client is Rh negative, it is unnecessary to administer Rh immune globulin due to the client's early gestational age.
I will reinforce teaching with the client about abstaining from sexual intercourse for two weeks.
The client should call the health care provider for foul-smelling vaginal discharge, heavy vaginal bleeding, or severe pain.
The client should continue prenatal vitamins with iron and take ibuprofen as needed for pain.
To maintain perineal hygiene, the client should soak nightly in a bathtub and use mild soap.
A client suspects she is pregnant and comes for prenatal evaluation. Which assessment findings indicate definitive evidence (positive signs) of pregnancy? Select all that apply.
Cervical softening on examination
Fetal heart tones detected by Doppler device
Positive serum human chorionic gonadotropin test
Report of fetal movement felt by client
Visualization of fetus by ultrasound
A laboring client, gravida 3 para 2, is admitted to the labor unit reporting severe perineal pressure and urgently requesting pain relief. The client's cervix is 10 cm dilated and 100% effaced, with the fetal head at 0 station. Which pain management technique is most appropriate for this client's report of perineal pressure?
Epidural anesthesia
Hydrotherapy
IV narcotics
Pudendal nerve block
A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate?
Cervical lacerations
Inversion of the uterus
Uterine atony
Vaginal hematoma
A nurse is caring for a client following a forceps-assisted vaginal birth. The client reports severe vaginal pain and fullness. On assessment, the nurse notices a firm, midline uterine fundus. Lochia rubra is light. Which diagnosis should the nurse anticipate?
Cervical lacerations
Inversion of the uterus
Uterine atony
Vaginal hematoma
A laboring client at 35 weeks gestation comes to the labor and delivery unit with preterm rupture of membranes "about 18 hours ago." The client's group B Streptococcus status is unknown. What intervention is a priority for this client?
Administration of prophylactic antibiotics
Assessment of uterine contraction frequency
Collection of a clean-catch urine specimen
Vaginal examination to assess cervical dilation
A primigravid client in early labor is admitted and reports intense back pain with contractions. The fetal position is determined to be right occiput posterior. Which action by the nurse would be most helpful for alleviating the client's back pain during early labor?
Applying counterpressure to the client's sacrum during contractions
Encouraging the client to remain in bed during early labor
Positioning the client on the left side with pillows for support
Requesting that the nurse anesthetist administer epidural anesthesia
The nurse is caring for a client with gestational diabetes mellitus during the second stage of labor. After birth of the head, the nurse notes retraction of the fetal head against the maternal perineum. Which action should the nurse anticipate?
Administering a tocolytic
Initiating fundal pressure during a contraction
Obtaining the vacuum extractor
Pressing downward on the symphysis pubis
The nurse is admitting a client at 40 weeks gestation. The client is in active labor and reports intense pain in the lower back and sacral area during contractions. Based on these findings, the nurse should suspect the fetus is in which position?
The precepting nurse is supervising a new obstetric nurse performing a labor admission assessment on a client with suspected spontaneous rupture of membranes. Which action by the new nurse would cause the precepting nurse to intervene?
Documenting a positive nitrazine test result when the test strip turns blue
Donning nonsterile gloves and using soluble gel for vaginal examination
Palpating the client's abdomen before applying external fetal monitors
Providing the client with a variety of clear liquids to drink
A pregnant client admitted for induction of labor is receiving an oxytocin infusion. The baseline fetal heart rate is 140/min and the strip is shown in the exhibit. What is the nurse's best course of action? Click on the exhibit button for additional information.
Apply oxygen 10 L/min face mask
Continue to monitor the client
Discontinue oxytocin infusion
Notify the health care provider (HCP)
Following the precipitous birth of a term newborn, what is the best action by the nurse while awaiting expulsion of the placenta and arrival of the health care provider?
Clean the perineal area
Gently pull on the cord
Keep the infant warm
Massage the fundus
The nurse is caring for a client at 39 weeks gestation in active labor who is receiving an oxytocin infusion. The nurse notes persistent late decelerations on the fetal monitor. Which of the following actions should the nurse take? Select all that apply.
Administer oxygen via a nonrebreather face mask
Change maternal position to the left side
Discontinue the oxytocin infusion
Notify the health care provider
Perform a nitrazine test
A client in labor has reached 8 cm dilation, is fully effaced, and feels an urge to push. The nurse observes thick, blood-tinged mucus during the vaginal examination. What is the nurse's best action?
Administer prescribed IV meperidine for pain relief
Encourage client to bear down with spontaneous urges to push
Place client in the lithotomy position in preparation for birth
Provide encouragement and coaching in breathing techniques
The nurse is monitoring a neonate 1 hour after spontaneous vaginal delivery. Which of the following are expected findings? Select all that apply.
Capillary glucose of 60 mg/dL (3.3 mmol/L)
Holosystolic murmur auscultated at fourth intercostal space
Respirations of 56 breaths per minute
Single transverse crease across palm of the hand
White papules on bridge of the nose
The nurse is performing an assessment on a 39-week neonate an hour after a spontaneous vaginal delivery. What are common expected newborn findings? Select all that apply.
One artery and one vein in the umbilical cord
Plantar creases up the entire sole
Skin on the nose blanches to a yellowish hue
Toes fan outward when the lateral sole surface is stroked
White pearl-like cysts on gum margins
When assessing a preterm newborn for cold stress, a graduate nurse in the newborn nursery needs further teaching when stating the need to assess for which finding?
Irritability
Poor feeding
Shivering (Temblando)
Weak cry
The nurse is teaching a class of expectant parents about infant safety. Which statement by a class participant indicates a need for further instruction?
I will allow my baby to sleep with a pacifier.
I will dress my baby in a sleep sack to prevent my baby from getting cold.
I will make sure there is a firm mattress in the crib.
I will tie bumper pads to the sides of the crib to protect my baby's head.
A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2-hour-old newborn, which clinical finding requires the nurse to intervene?
Cyanosis of hands and feet
Heart rate of 165/min while crying
Jitteriness (Nerviosismo)
Respirations of 60/min
A nurse is teaching the parent how to care for a newly circumcised newborn. Which statement by the parent indicates that further teaching is needed?
Discharge and odor indicate infection of the circumcision site.
I will clean the area with alcohol-based wipes or soap water.
Infant crying during petrolatum gauze changes is expected.
The diaper should be changed at least every 4 hours.
A nurse is preparing to teach the parents of a newborn about newborn safety. Which instruction is appropriate for the nurse to include in the teaching plan?
Dress the newborn in a wearable blanket, such as a sleep sack, during sleep if an extra layer is needed.
Layer the newborn with jackets and blankets before securing the car seat harness.
Place the newborn in the prone position while sleeping.
Place the newborn's car seat facing forward.
The nurse is caring for a group of 1-day-old clients in the newborn nursery. Which finding requires immediate attention?
Abdominal breathing with 15-second pauses in a sleeping newborn
Apical pulse of 190/min in a newborn who is crying
Heart murmur in a newborn who is feeding appropriately
Respirations of 68/min with grunting in a newborn post cesarean birth
Which assessment findings would the nurse most likely expect to find in a male infant born at 28 weeks gestation? Select all that apply.
Abundant lanugo on shoulders and back
Deep creases and peeling skin on soles of feet
Flat areolae without palpable breast buds
Smooth, pink skin with visible veins
Testes completely descended into the scrotum
The nurse assesses a newborn with skin discoloration in the lumbar area, as shown in the exhibit. What would be an appropriate action for the nurse to complete? Click the exhibit button for additional information.
Assess the infant's hemoglobin, hematocrit, and platelet levels
Measure and document the size and location of the markings
Notify the health care provider of the markings immediately
Review the delivery record for evidence of a traumatic birth
The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia?
Decreased right hip adduction
Presence of extra gluteal folds on right side
Right leg longer than the left leg
Right pelvic tilt with lordosis
The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn?
Choose an infant carrier with a narrow seat
Place 2 diapers on the infant at all times
Swaddle the infant with hips flexed and abducted
Use an infant swing that keeps both legs straight
The nurse is performing well-child examinations in a pediatric clinic. Which finding requires further evaluation?
Bilateral bowlegs (genu varum) in a 15-month-old
Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant
Lateral curvature to the spine noted on examination of a 10-year-old girl
Presence of an S3 heart sound in a 2-year-old
The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply.
Dodgeball
Reading a book
Stationary bicycling
Swimming
Yoga
A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to recommend to the parents in order to prevent recurrence?
Exclusive breastfeeding
Not sending the child to day care
Preventing water from entering the ear
Smoking cessation by the parents
A nurse is planning to test the visual acuity of a 7-year-old. Which is the best way to test visual acuity in this child?
Have the child focus on a bright object and follow the target
Have the child view a set of cards one at a time
Position the child at a distance of 10 ft (3 m) from a chart
Shine a light into the child's eyes at a distance of 16 in (40.6 cm)
A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed? Select all that apply.
Haemophilus influenzae type b (Hib)
Hepatitis B (Hep B)
Measles, mumps, rubella (MMR)
Pneumococcal conjugate (PCV)
Varicella
Several 12-month-old infants are brought to the clinic for routine immunizations. Which situation would be most important for the nurse to clarify with the provider before administering the vaccination?
Haemophilus influenzae type b vaccine for client allergic to penicillin
Hepatitis A vaccine for a client with a "cold" and temperature of 99.0 F (37.2 C)
Pneumococcal vaccine for client with local swelling after last immunization
Varicella-zoster vaccine for client recently diagnosed with leukemia
The clinic nurse supervises a student nurse who is preparing to administer routine vaccinations to a child diagnosed with hemophilia. Which instructions should the clinic nurse provide to the student? Select all that apply.
Administer ibuprofen for pain relief
Administer vaccines via the subcutaneous route
Apply a warm compress to the injection site
Hold firm pressure on the site for 5 minutes
Massage the injection site to disperse the medication
A newborn has a large myelomeningocele. What nursing intervention is priority?
Assess the anus for muscle tone
Cover the area with a sterile, moist dressing
Measure the occipital frontal circumference
Place the newborn supine with the head of the bed elevated
The nurse is planning care for an 8-year-old client with mild cognitive impairment who is hospitalized for diagnostic testing. Which of the following interventions are appropriate to include in the plan of care? Select all that apply.
Consistently assign the same nurse and unlicensed assistive personnel to care for the client
Give direct procedural education and explanations to the parent rather than the client
Provide appropriate toys based on developmental level rather than chronological age
Reinforce parental limit-setting measures for preventing self-injurious behavior
Use a picture board to facilitate communication and promote understanding of procedures
The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia?
1-month-old infant born at term gestation who exclusively breastfeeds
2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula
3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk
6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal
The school nurse is teaching a class of 10-year-old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? Select all that apply.
Chew sugar-free gum
Drink fruit drinks/juices instead of sugary, carbonated beverages
Include milk, yogurt, and cheese in dietary intake
Minimize consumption of sweet, sticky foods
Rinse mouth with water after meals when brushing is not possible
The nurse is educating the parents of a 6-month-old about introducing solid foods into the infant's diet. Which parental statement indicates a need for further teaching?
I can introduce soft finger foods before my child has teeth.
I can offer a variety of foods within the first week of introducing solids.
I can prepare rice cereal with formula, breast milk, or water.
I can save money by preparing baby food at home instead of buying it.
The nurse is performing a physical examination on a 10-year-old client with abdominal discomfort. Which actions would be appropriate during the examination? Select all that apply.
Ask the accompanying parent to rate and describe the client's pain
Ask the client to describe the chief symptom
Conduct a head-to-toe assessment in the same manner as an adult assessment
Explain the outcome of the examination to the parent without the child present
Honor the client's request to be examined without a parent present
The nurse is teaching a class on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler?
½ cup orange juice
Dry, sweetened cereal
Raw carrot sticks
Slices of cheese
The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply.
Diets consisting of legumes as the only protein source are sufficient for growth.
It is important to feed your child fortified breads and cereals to help with iron intake.
Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake.
Try to pair foods high in iron with foods high in vitamin C to aid iron absorption.
Your child may require calcium and vitamin D supplementation due to lack of dairy intake.
