CARE OF MOTHER & CHILD (100 ITEMS)

Valerie, 5 years old with an intelligence quotient of 65 is admitted to the community pediatric hospital for evaluation. When planning care, nurse Neil should keep in mind that Valerie is:

Mildly retarded but educable

The nurse is assessing a client who is 6 hours PP after delivering a full-term healthy infant. The client complains to the nurse of feelings of faintness and dizziness. Which of the following nursing actions would be most appropriate?

Instruct the mother to request help when getting out of bed

What type of milk is present in the breasts 7 to 10 days PP?

Transitional milk

Which of the following is the best method for performing a physical examination on Cheng, 2 years and 10 months old:

From least to most intrusive

Which of the following circumstances is most likely to cause uterine atony and lead to PP hemorrhage?

Urine retention

A nurse is developing a plan of care for a PP woman with a small vulvar hematoma. The nurse includes which specific intervention in the plan during the first 12 hours following the delivery of this client?

Prepare an ice pack for application to the area.

A nurse is providing instructions to a mother who has been diagnosed with mastitis. Which of the following statements if made by the mother indicates a need for further teaching?

I need to stop breastfeeding until this condition resolves.

A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which of the following signs, if noted in the mother, would be an early sign of excessive blood loss?

An increase in the pulse from 88 to 102 BPM

Nurse Maria is administering a medication using the intraosseous route to a Lito who is admitted at the Pediatric ward. Intraosseous drug administration is typically used when a child such as Lito, is:

Critically ill and under age 3

Select all of the physiological maternal changes that occur during the PP period. I. Cervical involution ceases immediately II. Vaginal distention decreases slowly III. Fundus begins to descend into the pelvis after 24 hours IV. Cardiac output decreases with resultant tachycardia in the first 24 hours V. Digestive processes slow immediately

I and III

Nurse Evan answers a call bell and finds a frightened mother, Mrs. Nelia, whose child, the patient, is having a seizure. Which of these actions should nurse Evan take?

The nurse should clear the area and position the client safely.

A nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. When the nurse locates the fundus, she notes that the uterus feels soft and boggy. Which of the following nursing interventions would be most appropriate initially?

Massage the fundus until it is firm

A PP nurse is assessing a mother who delivered a healthy newborn infant by C-section. The nurse is assessing for signs and symptoms of superficial venous thrombosis. Which of the following signs or symptoms would the nurse note if superficial venous thrombosis were present?

Enlarged, hardened veins

Nurse Sevilla is aware that the most common assessment finding in a child like Grace with ulcerative colitis is:

Profuse diarrhea

Methergine or pitocin are prescribed for a client with PP hemorrhage. Before administering the medication(s), the nurse contacts the health provider who prescribed the medication(s) in which of the following conditions is documented in the client’s medical history?

Peripheral vascular disease

Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants. At what age is the diagnosis of SIDS most likely?

At I week to 1 year of age, peaking at 2 to 4 months

Ingrid, a female child, age 2 years and 3 months old, is brought to the emergency - trauma department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. Upon entering the examination room, Ingrid is crying and clinging to her mother. Which data should nurse Jeia obtain first?

Heart rate, respiratory rate, and blood pressure

A nurse is assessing a client in the 4th stage if labor and notes that the fundus is firm but that bleeding is excessive. The initial nursing action would be which of the following?

Notify the physician

The nurse is evaluating Cristine, a pediatric client with acute post streptococcal glomerulonephritis for signs of improvement. Which finding typically is the earliest sign of improvement?

Increased urine output

What should be the initial bolus of crystalloid fluid replacement for Francis, a pediatric patient in shock?

20 ml/kg

Jason, a 1-year and 3-months-old child weighing 26 lb (11.8 kg) is admitted for traction to treat his congenital hip dislocation. When preparing the client’s room, nurse Rein anticipates using which traction system?

Bryant’s traction

In order to decrease the likelihood of bradyarrhythmias in children during endotracheal intubation, succinylcholine (Anectine) is used with which of the following agents?

Atropine sulfate

Baby Ernesto , who is suspected to have rheumatic fever, is admitted at the Children’s Unit of a Provincial hospital. In obtaining his history, nurse Monica considers which information to be most essential ?

A recent episode of pharyngitis

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy and how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, should begin by telling this woman that:

The expected weight loss immediately after birth averages about 11 to 13 pounds

Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours postpartum?

Pain in left calf with dorsiflexion of left foot

.In administering an intramuscular injection to Baby Joseph, nurse Andy who is in charge should use which site?

Rectus femoris

Nurse Kathlenn is assessing a newborn who had undergone vaginal delivery. Which of the following findings is least likely to be observed in a normal newborn?

heart rate is 80 bpm

On which of the postpartum days can Mrs. Nelia Richards expect lochia serosa?

Days 3 to 10 PP

A PP nurse is providing instructions to a woman after delivery of a healthy newborn infant. The nurse instructs the mother that she should expect normal bowel elimination to return:

3 days PP

When performing a postpartum check, the nurse should:

Assist the woman into a lateral position with upper leg flexed forward to facilitate the examination of her perineum

Josefa, a female child, who is 6-years old, is brought to the health center for a routine check-up. To assess the Josefa’s vision, nurse Neil should ask:

“How are you doing in school?”

Mariane, a mother tells nurse Bianca that she is very worried because Pepita, her 2-year old child does not finish her meals. What should nurse Bianca advise Mariane?

do not give snacks to the child before meals

In developing a care plan for Mr. Neil Moleta, an adolescent client, nurse Francis considers the psychosocial needs of Neil. Francis should focus on what psychosocial development of Neil:

Establishing an identity

A new mother received epidural anesthesia during labor and had a forceps delivery after pushing 2 hours. At 6 hours PP, her systolic blood pressure has dropped 20 points, her diastolic BP has dropped 10 points, and her pulse is 120 beats per minute. The client is anxious and restless. On further assessment, a vulvar hematoma is verified. After notifying the health care provider, the nurse immediately plans to

Prepare the client for surgery

How does nurse Gayle appropriately administer Mycostatin suspension in her infant client like Angel?

Swab Mycostatin on the affected areas

During a well-baby check-up, Ariella asks nurse Shamcey when she should start giving Baby Pia solid foods. Nurse Shamcey, should instruct her to introduce which solid food first?

Rice cereal

A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered?

Activated partial thromboplastin time

Nurse Venus is teaching a group of parents a topic on otitis media. When discussing why children are predisposed to this health problem, Venus should mention the importance of which anatomical feature?

Eustachian tubes

Which of the following is most likely associated with a cerebrovascular accident (CVA) resulting from congenital heart disease?

Polycythemia

Buck’s traction with a 10 lb. weight is securing a patient’s leg while the client is waiting for surgery to repair a hip fracture. It is important to check circulationsensation-movement:

every 4 hours.

In developing a plan care for Marilen, a hospitalized child, nurse Pacis knows that the child in this age group is most likely to view illness as a punishment rather than rewards?

Preschool age

Ellaine, is using bronchodilators for her asthma. The side effects of these drugs that nurse Jhonila need to monitor this patient for include:

tachycardia, nausea, vomiting, heart palpitations, inability to sleep, restlessness, and seizures.

Which of the following factors might result in a decreased supply of breastmilk in a PP mother

Supplemental feedings with formula

When performing a PP assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which of the following nursing actions is most appropriate?

Notify the physician

Joseph, age 12, had a lumbar puncture to examine the cerobrospinal fluid to determine if bacterial infection is present. The best position to keep her in after the said procedure is:

Supine for several hours, to prevent a headache.

A nurse is preparing to perform a fundal assessment on a postpartum client. The initial nursing action in performing this assessment is which of the following?

Ask the mother to urinate and empty her bladder

Methergine or pitocin is prescribed for a woman to treat PP hemorrhage. Before administration of these medications, the priority nursing assessment is to check the:

Blood pressure

Which of the following would be inappropriate when administering chemotherapy to a child like Kristine?

Observing the child for 10 minutes to note for signs of anaphylaxis

At the community AYRH facility, nurse Neil Moletaleads an adolescent health information group and expands into other areas of discussion. He is aware that these young individuals are trying to find out “who they are,” and discussion often focuses on which directions they want to take in school and life, as well as peer relationships. According to Erik Erikson, this stage is known as:

identity vs. role confusion.

A postpartum nurse is taking the vital signs of a woman who delivered a healthy newborn infant 4 hours ago. The nurse notes that the mother’s temperature is 100.2*F. Which of the following actions would be most appropriate?

Increase hydration by encouraging oral fluids

Which of the following blood study results would nurse Angelica expect as most likely when caring for Angela, a child with iron deficiency anemia?

Decreased mean corpuscular volume (MCV)

Which of the following situations increase the risk of lead poisoning in children?

playing in the park with heavy traffic and with many vehicles passing by

The nurse examines a woman one hour after birth. The woman’s fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse’s initial action would be to:

Massage her fundus

Which type of lochia should nurse Moleta expect to find in Mrs. Real, a client on 2 days PP?

Lochia rubra

Dr. Gallardo, prescribes corticosteroids to her pediatric client, Shane with nephrotic syndrome. What is the primary purpose of administering corticosteroids to her client?

To decrease proteinuria

A PP client is being treated for DVT. The nurse understands that the client’s response to treatment will be evaluated by regularly assessing the client for:

Hematuria, ecchymosis, and epistaxis

Which of the following findings would be expected when assessing the postpartum client?

Fundus 1 cm above the umbilicus 1 hour postpartum

Which of the following physiological responses is considered normal in the early postpartum period?

Rapid diuresis

Nurie, a mother of an 11 1/2 -month-old girl, Maria, is in the center for her daughter’s scheduled EPI. She expresses concern to nurse Jeia that Maria cannot yet walk. Nurse Lee correctly replies that, according to the Denver Developmental Screen, the median age for walking is:

12 months.

On the first PP night, a client requests that her baby be sent back to the nursery so she can get some sleep. The client is most likely in which of the following phases?

Taking-in phase

Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health?

Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?

Cervical laceration

Nurse Rolly should expect that Pauline, a 3-year-old child to be able to perform which action?

Ride a tricycle

After expulsion of the placenta in a client who has six living children, an infusion of lactated ringer’s solution with 10 units of pitocin is ordered. The nurse understands that this is indicated for this client because:

Multigravidas are at increased risk for uterine atony

Which of the following complications is most likely responsible for a delayed postpartum hemorrhage?

Uterine subinvolution

Alden, a 12-year-old boy has fractured his arm because of a fall from his bicycle. After the injury has been casted, nurse Neil knows it is most important to perform all of the following assessments on the area distal to the injury except:

skin integrity

An inborn error of metabolism that causes premature destruction of RBC?

Glucose-6-phosphate dehydrogenase deficiency

Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching?

The client should avoid getting pregnant for 3 months after the vaccine

When assessing Lito’s cultural background, nurse Maria who is in charge should keep in mind that Lito’s:

Behavioral patterns are passed from one generation to the next

When performing a physical examination to Danaya, an infant, nurse Hagorn notes abnormally low-set ears. This finding is associated with:

Renal anomalies

How should nurse Enriquez prepare a suspension before administration?

By shaking it so that all the drug particles are dispersed uniformly

The nurse is assessing the lochia on a 1 day PP patient. The nurse notes that the lochia is red and has a foul-smelling odor. The nurse determines that this assessment finding is:

Indicates the presence of infection

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be:

Soft, non-tender; colostrum is present

While examining Gericko, who is a 2-year-old child, nurse Tamares in charge sees that the anterior fontanel is open. Nurse Tamares should:

Notify the doctor

.Jonnalyn, a child is diagnosed with Wilms’ tumor. During assessment, nurse Mary Jho in charge expects to detect:

An abdominal mass

Which of the following organisms is responsible for the development of rheumatic fever?

Group A β-hemolytic streptococcus

Basilio, a kid with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, Nurse Bermas anticipates that the physician will order which laboratory or diagnostic test?

Total protein

Which of the following changes best described the insulin needs of a client with type 1 diabetes who has just delivered an infant vaginally without complications?

Decrease

Which measure would be least effective in preventing postpartum hemorrhage?

Massage the fundus every hour for the first 24 hours following birth

A nurse is caring for a PP woman who has received epidural anesthesia and is monitoring the woman for the presence of a vulva hematoma. Which of the following assessment findings would best indicate the presence of a hematoma?

Changes in vital signs

Nurse Nelson is assessing Baby Jano, 9-month-old boy for a well-baby check up and consultation. Which of the following observations would be of most concern?

The child does not sit unsupported.

On completing a fundal assessment, the nurse notes the fundus is situated on the client’s left abdomen. Which of the following actions is appropriate?

Ask the client to empty her bladder

A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. I. Take the prescribed antibiotics until the soreness subsides. II. Wear supportive bra III. Avoid decompression of the breasts by breastfeeding or breast pump IV. Rest during the acute phase V. Continue to breastfeed if the breasts are not too sore.

II, IV, V

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to:

Assess for hypovolemia and notify the health care provider or the physician in charge

.Mr. and Mrs. Rivera, bring their baby to the center, seeking treatment for vomiting and diarrhea that lasted for 3 days. On assessment, nurse Moleta detects dry mucous membranes and lethargy. What other findings suggest a fluid volume deficit?on

A sunken fontanel

Which of the following interventions would be helpful to a breastfeeding mother who is experiencing engorged breasts?

Teaching how to express her breasts in a warm shower

Cara, 32 years old client is complaining of painful contractions, or afterpains, on postpartum day 2. Which of the following conditions could increase the severity of afterpains experienced by Cara?

Multiple gestation

Nurse Chay is drawing blood from the diabetic patient for a glycosylated hemoglobin test. She explains to the woman that the test is used to determine:

Glucose levels over the past several months.

.A nurse in a PP unit is instructing a mother regarding lochia and the amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed the need for:

Eight peripads per day

Nurse Alfred suspects that, Leila, a 4-years old client, is being neglected physically. To best assess the Leila’s nutritional status, Alfred should ask the parents of which question?

“What did your child eat for breakfast?”

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman’s vital signs:

Every 15 minutes during the first hour and then every 30 minutes for the next two hours

Mrs. Marione, mother of Imelda who is a 5-years old child asks nurse Moleta how to manage her child’s behaviour, who recently started wetting the pants after being completely toilet trained. Imleda just started attending nursery school 3 days a week. Which principle should guide Nurse Moleta’s response?

The child returns to a level of behavior that increases the sense of security

During the 3rd PP day, which of the following observations about the client would the nurse be most likely to make?

The client appears interested in learning about neonatal care

Faye, an adolescent patient has symptoms of meningitis: nuchal rigidity, fever, vomiting, and lethargy. The nurse knows to prepare for the following test

lumbar puncture.

Which of the following behaviors characterizes the PP mother, Mrs. Aliah Cruz who is in the taking-in phase?

Passive and dependant

When evaluating a severely depressed adolescent like Mary, 15 years old. Nurse Tetay knows that one indicator of a high risk for suicide is:

A preoccupation with death

The nurse is about the give a Type 2 diabetic her insulin before breakfast on her first day postpartum. Which of the following answers best describes insulin requirements immediately postpartum?

Lower than before she became pregnant

Perineal care is an important infection control measure. When evaluating a postpartum woman’s perineal care technique, the nurse would recognize the need for further instruction if the woman:

Uses the peribottle to rinse upward into her vagina

Jana, 12 years old, is brought to the center for evaluation for a suspected eating disorder. To best assess the effects of role and relationship patterns on the her nutritional intake, nurse Benjamin should ask:

“Do you like yourself physically?”

Sahaya, 13-years old, is 7 1/2 months pregnant. When teaching parenting skills to an adolescent client like Sahaya, nurse Amihan knows that which teaching strategy is least effective?

Providing age-appropriate reading materials