RECALLS 8 - NP2

SITUATION: Nurse Jihyo monitors Momo, a pregnant woman on her 24th week of pregnancy, who is being screened for pregnancy-induced hypertension (PIH). Momo's BP pre-pregnancy is at 120/80 mmHg. No trace of proteinuria or edema is present.

--

Nurse Jihyo further evaluates Momo. When BP was taken at 9:00 am, the reading was at 130/80 mmHg. The nurse knows that the physician may confirm that Momo is developing PIH when which criterion is satisfied?

A. BP is at 130/90 mmHg at 12nn.

B. A BP reading is read to be 140/90 at 10:30 am

C. 30/15 mmHg is added to the baseline BP at 4:00 pm.

D. BP is at 90/60 mmHg at 11:00 pm.

C. 30/15 mmHg is added to the baseline BP at 4:00 pm.

increase of 30/15 from baseline after 6 hours

if no baseline, ≥ 140/90

Momo asks Nurse Jihyo to explain the reason why PIH occurs. Nurse Jihyo's most appropriate answer would be:

a. "An increase in blood volume to support the growing child caused an increased pressure in the arteries causing damage to the walls. This led to the blood vessels in the body to suddenly tighten up or get narrower, thus causing the blood pressure to shoot up."

b. "Blood volume is increased by 40-50% in pregnancy, which usually peaks at the 2nd trimester due to an increase in plasma volume. That caused an increase in pressure in the endothelial lining of the arteries eventually leading to vasospasm. Hypertension occurs due to the narrowing of the blood vessels due to the spasms."

c. "The precise etiology revolves around aberrations in vascular homeostasis, with dysregulation of endothelial function and vascular tone modulation being paramount. This intricate cascade encompasses the intricate dance between vasoconstriction-promoting factors and vasodilation-mediating substances, leading to an imbalance favoring heightened vascular resistance and augmented systemic arterial pressure."

d. "I am not sure if I am allowed to give details about that diagnosis. I will ask your physician to explain it to you instead."

A. "An increase in blood volume to support the growing child caused an increased pressure in the arteries causing damage to the walls. This led to the blood vessels in the body to suddenly tighten up or get narrower, thus causing the blood pressure to shoot up."

SITUATION: Nurse Jihyo monitors Momo, a pregnant woman on her 24th week of pregnancy, who is being screened for pregnancy-induced hypertension (PIH). Momo's BP pre-pregnancy is at 120/80 mmHg. No trace of proteinuria or edema is present.

--

The nurse further assesses Momo for any other signs while she interviews her in the clinic as she documents the findings in Momo's chart. Which statement from Momo would she record as possible evidence that Momo is developing pre-eclampsia instead?

A. "I'm struggling to slip on my bedroom slippers because my feet are so puffy at night."

B. "My mom taught me a lot of things about being pregnant, but she never warned me that I would always feel so tired."

C. "I've been having the desire to really take care of how I look like these past few weeks."

D. "The puffy feet are tolerable, but the swollen hands and wrists are not."

D. "The puffy feet are tolerable, but the swollen hands and wrists are not."

pedal edema = normal

edema in hands and wrists = pre-eclampsia

SITUATION: Nurse Jihyo monitors Momo, a pregnant woman on her 24th week of pregnancy, who is being screened for pregnancy-induced hypertension (PIH). Momo's BP pre-pregnancy is at 120/80 mmHg. No trace of proteinuria or edema is present.

--

Eventually, Momo's physician ordered magnesium sulfate to be infused on piggyback with a loading dose of 5 g to be infused slowly over 30 minutes and a maintaining dose of 2 g/hr. Which of the following symptoms, when observed by Nurse Jihyo, would warrant her to discontinue the drug and notify the physician?

A. An RR of 16 breaths per minute.

B. Urine output of 12 cc/hr.

C. BP 110/80.

D. DTR of 2+

B. Urine output of 12 cc/hr.

SITUATION: Nurse Jihyo monitors Momo, a pregnant woman on her 24th week of pregnancy, who is being screened for pregnancy-induced hypertension (PIH). Momo's BP pre-pregnancy is at 120/80 mmHg. No trace of proteinuria or edema is present.

--

In case toxicity occurs, what emergency item must Nurse Jihyo prepare at bedside?

A. Protamine sulfate

B. Atropine sulfate

C. Kalcinate

D. Vitamin

C. Kalcinate

aka calcium gluconate

SITUATION: Developmental milestones Nurse Athena works at Northeastern Medical Hospital where she attends to a number of pediatric patients. One of her functions is to assess physical growth and developmental milestones.

--

A 12-month-old child was brought to Nurse Athena's attention. She first interviews the client's mother on the child's physical growth. Which of the following statements from the mother would be a cause for further assessment?

A. "My child weighed 2800 g when she was born. She weighed 8.4 kg when I checked yesterday morning."

B. "The soft spot at the back of her head can be easily pressed."

C. "When she walks, her abdomen and buttocks appear to stick out prominently."

D. "She has 6 teeth now."

B. "The soft spot at the back of her head can be easily pressed."

posterior = 2-3 months closed / 6-8 weeks

,ay be hydrocephalus or hypothyroidism

lordosis is normal

SITUATION: Developmental milestones Nurse Athena works at Northeastern Medical Hospital where she attends to a number of pediatric patients. One of her functions is to assess physical growth and developmental milestones.

--

Another mother asks the client about "cruising," a term that she had heard a physician talk about during her child's last routine check-up. Nurse Athena explains that it is the ability of a child to walk while holding onto furniture or with both hands held. At what month would Nurse Athena expect a child able to do this?

A. 6 months

B. 8 months

C. 4 months

D. 11 months

D. 11 months

4 months = less head lag

6 months = sit w/ back support

8 months = sit w/o support

SITUATION: Developmental milestones Nurse Athena works at Northeastern Medical Hospital where she attends to a number of pediatric patients. One of her functions is to assess physical growth and developmental milestones.

--

Nurse Athena observes 4 children in the waiting area. Which of them would be the best example of a child who has developed object permanence?

A. A 10-month-old child looking for his rubber ball that had fallen to the floor.

B. A 4-month-old child who anticipates feeding when she sees her mother.

C. A 7-month-old child who cries when another nurse attempts to take his heart rate.

D. A 3-month-old child who can recognize familiar objects, like her feeding bottle.

A. A 10-month-old child looking for his rubber ball that had fallen to the floor.

SITUATION: Developmental milestones Nurse Athena works at Northeastern Medical Hospital where she attends to a number of pediatric patients. One of her functions is to assess physical growth and developmental milestones.

--

A child during the stage of toddlerhood also displays major features of growth and development. At what age can a child begin to creep up the stairs?

A. 8 months

B. 9 months

C. 10 months

D. 15 months

D. 15 months

8-9 months = stand + holding on

10 months = stand securely

11 months = cruising

toddlerhood = more than 1 year

SITUATION: Developmental milestones Nurse Athena works at Northeastern Medical Hospital where she attends to a number of pediatric patients. One of her functions is to assess physical growth and developmental milestones.

--

Nurse Athena knows that a child at this age is able to imitate the sounds that he hears from the people and environment around him.

A. 3 months

B. 4 months

C. 5 months

D. 6 months

D. 6 months

3 months = squeals to show pleasure / chuckles / coos/ babbles

4 months = consonants + laughs aloud

5 months = cooing + mixed w/ consonants

SITUATION: Barbie, a 25-year-old, grand multiparous woman, had undergone normal spontaneous vaginal delivery. She has lost 750 mL of blood. Nurse Greta, along with the physician and the other members of the healthcare team, are rapidly intervening to prevent further blood loss.

--

There are several factors that can contribute to the presence of postpartum hemorrhage. Which risk factor most likely predisposed Barbie to this complication?

A. Advanced maternal age

B. Multiple gestation

C. A rapid birth

D. Delivering a macrosomic baby

B. Multiple gestation

SITUATION: Barbie, a 25-year-old, grand multiparous woman, had undergone normal spontaneous vaginal delivery. She has lost 750 mL of blood. Nurse Greta, along with the physician and the other members of the healthcare team, are rapidly intervening to prevent further blood loss.

--

In the event of postpartum hemorrhage, which independent nursing intervention would Nurse Greta do first to control the bleeding?

A. Administer oxytocin via IM on the left deltoid muscle.

B. Perform Crede's maneuver.

C. Attempt fundal massage.

D. Do controlled cord traction after the signs of placental expulsion take place.

C. Attempt fundal massage.

SITUATION: Barbie, a 25-year-old, grand multiparous woman, had undergone normal spontaneous vaginal delivery. She has lost 750 mL of blood. Nurse Greta, along with the physician and the other members of the healthcare team, are rapidly intervening to prevent further blood loss.

--

Once the bleeding was controlled, Barbie started to ask Nurse Greta about the process by which the reproductive organs, such as the uterus, return to their prepregnant state. This is termed as?

A. Involution

B. Diuresis

C. Lactation

D. Subinvolution

A. Involution

by 10 days postpartum = uterus can't be palpated abdominally

6-8 weeks

SITUATION: Barbie, a 25-year-old, grand multiparous woman, had undergone normal spontaneous vaginal delivery. She has lost 750 mL of blood. Nurse Greta, along with the physician and the other members of the healthcare team, are rapidly intervening to prevent further blood loss.

--

Nurse Greta reassesses Barbie's uterine fundus. At which part of the abdomen will she begin to palpate?

A. At the sides

B. On the symphysis pubis

C. At the umbilicus

D. Near the groin

C. At the umbilicus

SITUATION: Barbie, a 25-year-old, grand multiparous woman, had undergone normal spontaneous vaginal delivery. She has lost 750 mL of blood. Nurse Greta, along with the physician and the other members of the healthcare team, are rapidly intervening to prevent further blood loss.

--

It is now Barbie's 10th postpartum day. Where will Nurse Greta be able to palpate the uterus?

A. 5 fingerbreadths above the umbilicus

B. 5 fingerbreadths below the umbilicus

C. At the level of the umbilicus

D. The uterus is no longer palpable.

D. The uterus is no longer palpable.

SITUATION: Makani, 28 years of age, is pregnant with her third child. She is currently 27 weeks into her pregnancy. It was revealed that her first pregnancy abruptly ended due to unknown causes at 6 weeks of gestation. Her second child weighed 11 lbs at birth and was born 39 weeks AOG.

--

Nurse Alex was asked by her senior nurse to determine Makani's obstetric history. Which of the following answers from Nurse Alex would require no further teaching?

A. G3 T1 P1 A1 L1 M0

B. G3 T1 P2 A1 L1 M0

C. G3 T2 P1 A1 L2 M0

D. G3 T2 P1 A2 L1 M0

G3 T1 P0 A1 L1 M0

SITUATION: Makani, 28 years of age, is pregnant with her third child. She is currently 27 weeks into her pregnancy. It was revealed that her first pregnancy abruptly ended due to unknown causes at 6 weeks of gestation. Her second child weighed 11 lbs at birth and was born 39 weeks AOG.

--

Due to the presence of multiple risk factors based on Makani's history, the attending OB-GYNE requested for her to be screened for the presence of gestational diabetes mellitus. Nurse Alex knows that the test is called?

A. Urine Glucose Test

B. Continuous Glucose Monitoring

C. Oral Glucose Challenge Test

D. Capillary Blood Glucose Monitoring

C. Oral Glucose Challenge Test

NORMAL: < 140 mg/dL

18. Makani tells Nurse Alex that she heard from a family friend that the test will consider her to possibly have GDM if her blood glucose level reaches a certain number and that another test will need to be done. Nurse Alex agrees and explains that the test Makani is referring to is the "Three Hour Glucose Tolerance Test." Nurse Alex correctly describes this test if she states that?

a. "Fasting blood sugar will be obtained, then you will be asked to drink an oral 100g glucose solution. Afterwards, urine will be collected at 1, 2, and 3 hours later to be checked for the presence of glucose. You will be diagnosed with GDM if two of the four samples are abnormal."

b. "Once your fasting blood sugar levels have been obtained, you will be asked to take an oral 100g glucose solution. Venous blood will be taken at 1, 2, and 3 hours later. A diagnosis of GDM is determined if two out of four samples fall within an abnormal value."

c. "You are to receive a 50g oral glucose solution. An hour later, blood will be taken from a vein in your arm and will be used to measure the blood sugar level. If it reaches a value of 140 mg/dL, you will be diagnosed with gestational diabetes."

d. "After your hands are clean, a lancet will be used to prick the side of a fingertip. The blood sample will be placed on a test strip. The results will be read by a glucometer. If the results indicate a value of 140 mg/dL, a diagnosis of gestational diabetes is made."

B.

1. FBS

2. Oral 100g glucose sol'n

3. Venous blood will be taken at:

1 hour ≤ 180

2 hours ≤ 155

3 hours ≤ 140

(+) GDM = 2 out of 4 AbN values

SITUATION: Makani, 28 years of age, is pregnant with her third child. She is currently 27 weeks into her pregnancy. It was revealed that her first pregnancy abruptly ended due to unknown causes at 6 weeks of gestation. Her second child weighed 11 lbs at birth and was born 39 weeks AOG.

--

Makani is diagnosed with GDM. What would be Nurse Alex's most appropriate health teaching regarding lifestyle modifications?

A. "You will need to intake metformin in order to maintain normal blood glucose levels."

B. "Your carbohydrate intake will need to be increased due to heightened energy requirements."

C. "Insulin will need to be decreased to allow more glucose uptake."

D. "No special diet will be ordered for you, but make sure that your food is healthy and balanced."

D. "No special diet will be ordered for you, but make sure that your food is healthy and balanced."

SITUATION: Makani, 28 years of age, is pregnant with her third child. She is currently 27 weeks into her pregnancy. It was revealed that her first pregnancy abruptly ended due to unknown causes at 6 weeks of gestation. Her second child weighed 11 lbs at birth and was born 39 weeks AOG.

--

A few months later, glycosylated hemoglobin was ordered and revealed a result of 10%. What statement made by Nurse Alex while she is providing health education will necessitate the need for an intervention by her senior nurse?

A. "Glycosylated hemoglobin measures how well you have controlled your blood glucose over the past 120 days."

B. "A result of 10% indicates that you have too much sugar in your blood. May I ask if you were able to follow through with your balanced diet?"

C. "This test is known as the gold standard for the measurement of your glycemic control."

D. "The upper normal level of glycosylated hemoglobin is 8%."

D. "The upper normal level of glycosylated hemoglobin is 8%."

NORMAL = 4-6%

SITUATION: Jieun, a 30-year-old woman who is at 20 weeks AOG, comes to the clinic for routine prenatal ultrasound. She is accompanied by her husband, Jongsuk. Upon assessment, the couple was devastated to hear when it was detected that their baby has bilateral talipes equinovarus.

--

Nurse Jang Man-wol attends to the pair. The couple expresses feelings of anxiety and guilt upon learning of their child's condition. What would be Nurse Man-wol's best intervention?

A. Provide health teaching regarding the condition.

B. Ask the couple if they would like to speak to the hospital's chaplain.

C. Discuss the problem with the couple and the feelings that they currently have.

D. Introduce them to a support group of parents who have children with the same condition.

C. Discuss the problem with the couple and the feelings that they currently have.

clubfoot

SITUATION: Jieun, a 30-year-old woman who is at 20 weeks AOG, comes to the clinic for routine prenatal ultrasound. She is accompanied by her husband, Jongsuk. Upon assessment, the couple was devastated to hear when it was detected that their baby has bilateral talipes equinovarus.

--

Jieun, with enough guidance from her attending physician and from Nurse Man-wol, delivers the child safely at term. Which of the following assessment findings placed in the infant's birth history indicates the true presence of bilateral talipes equinovarus?

A. The infant was born in a footling breech position.

B. The heels are drawn in and both the feet are turned inward.

C. The defect cannot be determined via ultrasonography.

D. The deformity can always be corrected via cast.

B. The heels are drawn in and both the feet are turned inward.

D. The deformity can be corrected via OSTEOTOMY / EXTERNAL FIXATION

SITUATION: Jieun, a 30-year-old woman who is at 20 weeks AOG, comes to the clinic for routine prenatal ultrasound. She is accompanied by her husband, Jongsuk. Upon assessment, the couple was devastated to hear when it was detected that their baby has bilateral talipes equinovarus.

--

After the child's birth, which of the following should Nurse Man-wol not do when giving instructions to Jieun and Jongsuk? Select all that apply.

I. Explain the situation in a brief, easy-to-understand, manner.

II. Avoid the parents entirely to allow them to grieve the child's condition.

III. Keep the infant's feet covered at all times.

IV. Be prepared to answer multiple questions at many different times.

V. Tell the parents that the child's deformity could be worse.

A. 2, 3, 4, 5

B. 1, 4

C. 2, 3, 5

D. 2, 4, 5

C. 2, 3, 5

SITUATION: Jieun, a 30-year-old woman who is at 20 weeks AOG, comes to the clinic for routine prenatal ultrasound. She is accompanied by her husband, Jongsuk. Upon assessment, the couple was devastated to hear when it was detected that their baby has bilateral talipes equinovarus.

--

Jieun and Jongsuk's child was placed on a cast during the first month of his life in an attempt to achieve maximum correction. Nurse Man-wol then provided them with health information on cast care. Which of the following statements from the couple indicate that they understood the teaching?

A. "The petals on the edge of the cast can be removed after 24 hours."

B. "We will frequently check the temperature and the color of our child's toes on the casted leg."

C. "It is alright to insert a soft, padded object to scratch our child's skin under the cast."

D. "We can use a hair dryer set to the hottest setting to help the cast dry faster."

B. "We will frequently check the temperature and the color of our child's toes on the casted leg."

TO PREVENT COMPARTMENT SYNDROME

A. "The petals on the edge of the cast can be removed after 24 hours."

Petals protect skin from rough edges

D. "We can use a hair dryer set to the hottest setting to help the cast dry faster."

coldest setting

SITUATION: Jieun, a 30-year-old woman who is at 20 weeks AOG, comes to the clinic for routine prenatal ultrasound. She is accompanied by her husband, Jongsuk. Upon assessment, the couple was devastated to hear when it was detected that their baby has bilateral talipes equinovarus.

--

Nurse Man-wol is about to discharge Jieun and Jongsuk's child. She will need to provide additional information if the parents state that:

A. "Our baby will need a series of casts to fix his feet."

B. "If there is a hot spot or any color change in our child's toes under the cast, we should immediately call the clinic."

C. "The cast should not prevent us from carrying the child."

D. "We should use pillows to elevate our child's feet while he sleeps."

D. "We should use pillows to elevate our child's feet while he sleeps."

increases SIDS

SITUATION: Jhemherline, a 38-year-old woman, with obstetric history of G7P6, decides to undergo a female sterilization procedure called tubal ligation. Six weeks later after her procedure, she was rushed to the emergency room due to sharp, stabbing pain at the left lower quadrant of her abdomen. Scant vaginal spotting is also present. Jhemherline's husband, Jhowel, recalls to the nurse that they had sexual intercourse two nights before her wife underwent tubal ligation.

--

The nurse immediately acquires the client's history. Which of the following information, aside from a surgical history of tubal ligation, would she consider to be significant? Select all that apply.

I. History of IUD use

II. Number of sexual partners

III. Past history of sexually transmitted infection

IV. Last menstrual period

V. Cesarean section

A. 1, 2, 3, 4

B. 1, 2, 3, 5

C. 1, 3, 4, 5

D. All of the above

A. 1, 2, 3, 4

ECTOPIC PREGNANCY

Anything that damages/scars FT:

Previous PID

CAUSE:

Chlamydia

Gonorrhea

Postpartum endometritis

Postabortal uterine infections

Previous Ectopic Pregnancy

Previous BTL

Previous Tubal or Pelvic Surgeries

Maternal Smoking at the time of conception

SITUATION: Jhemherline, a 38-year-old woman, with obstetric history of G7P6, decides to undergo a female sterilization procedure called tubal ligation. Six weeks later after her procedure, she was rushed to the emergency room due to sharp, stabbing pain at the left lower quadrant of her abdomen. Scant vaginal spotting is also present. Jhemherline's husband, Jhowel, recalls to the nurse that they had sexual intercourse two nights before her wife underwent tubal ligation.

--

Jhemherline was diagnosed with a ruptured ectopic pregnancy. Which of the following priority interventions would the nurse anticipate for Jhemherline?

A. Strict bed rest without bathroom privileges

B. Administration of an enema

C. Immediate surgery

D. Advise having small frequent feedings with a few sips of water.

C. Immediate surgery

salphingectomy

salphingostomy

SITUATION: Jhemherline, a 38-year-old woman, with obstetric history of G7P6, decides to undergo a female sterilization procedure called tubal ligation. Six weeks later after her procedure, she was rushed to the emergency room due to sharp, stabbing pain at the left lower quadrant of her abdomen. Scant vaginal spotting is also present. Jhemherline's husband, Jhowel, recalls to the nurse that they had sexual intercourse two nights before her wife underwent tubal ligation.

--

Aside from monitoring Jhemherline's blood pressure while preparing her for surgery, which of the following would the nurse also assess?

A. Hemoglobin and hematocrit

B. Presence of uterine cramping

C. Abdominal distention

D. Pulse rate

D. Pulse rate

SITUATION: Jhemherline, a 38-year-old woman, with obstetric history of G7P6, decides to undergo a female sterilization procedure called tubal ligation. Six weeks later after her procedure, she was rushed to the emergency room due to sharp, stabbing pain at the left lower quadrant of her abdomen. Scant vaginal spotting is also present. Jhemherline's husband, Jhowel, recalls to the nurse that they had sexual intercourse two nights before her wife underwent tubal ligation.

--

The nurse notices a bluish discoloration on the area around Jhemerline's umbilical region. She knows that this is due to internal hemorrhage. The nurse correctly identifies this as?

A. Cullen's sign

B. Battle's sign

C. Grey-Turner's sign

D. Calkin's sign

A. Cullen's sign

B. Battle's sign

head trauma > bruising in mastoid process

C. Grey-Turner's sign

intraabdominal hemorrhage > flank ecchymosis

D. Calkin's sign

separation of placenta

SITUATION: Jhemherline, a 38-year-old woman, with obstetric history of G7P6, decides to undergo a female sterilization procedure called tubal ligation. Six weeks later after her procedure, she was rushed to the emergency room due to sharp, stabbing pain at the left lower quadrant of her abdomen. Scant vaginal spotting is also present. Jhemherline's husband, Jhowel, recalls to the nurse that they had sexual intercourse two nights before her wife underwent tubal ligation.

--

Jhemerline's surgery went well, and she was receiving discharge instructions from the nurse. Which of the following complications, if stated by Jhemerline, would require the need for additional teaching?

A. Bleeding

B. Fever

C. Pain

D. Dizziness

D. Dizziness

not a post op complication

The period between 12 months to 36 months truly is a wonderful time in the growth and development of a child. Erikson, a German American psychoanalyst, describes this phase as the period where children first learn to be independent individuals who are capable of making their own decisions in life. However, he did also note that experiencing shame is also integral in molding the human experience. What is the corresponding counterpart of this phase under the Cognitive Developmental Theory of American psychologist, Lawrence Kohlberg?

A. Pre-operational

B. Preconventional

C. Conventional

D. Post-conventional

B. Preconventional

PIAGET

Sensorimotor

Pre-Operational

Concrete Operational

Formal Operational

KOHLBERG

Pre-Conventional = 1-6

Conventional = 6-12

Post-Conventional = 12 up

SITUATION: You are a student nurse who is currently reviewing for the upcoming November 2023 Nurse Licensure Exam. Because of your aspirations of not only passing, but also making it to the roster of the top 10, you decide to thoroughly go over the developmental theories in pediatric nursing. The following questions apply.

--

You observe that a child is afraid of getting vaccine shots from the nurse at the barangay health center as he states that his mother said that "worms will come crawling out of the wound." You correctly assume that the age of the child is around?

A. 0-1 years old

B. 12-18 years old

C. 3-6 years old

D. 1-3 years old

C. 3-6 years old

magical thinking = preschool

SITUATION: You are a student nurse who is currently reviewing for the upcoming November 2023 Nurse Licensure Exam. Because of your aspirations of not only passing, but also making it to the roster of the top 10, you decide to thoroughly go over the developmental theories in pediatric nursing. The following questions apply.

--

Two 4-year-old girls are playing with different dolls. You notice that they are sharing and offering their dolls to each other. What type of play are the two girls exhibiting?

A. Solitary

B. Cooperative

C. Competitive

D. Parallel

B. Cooperative

INFANT = SOLITARY

TODDLER = PARALLEL

PRE-SCHOOL = COOPERATIVE

SCHOOL = COMPETITIVE

SITUATION: You are a student nurse who is currently reviewing for the upcoming November 2023 Nurse Licensure Exam. Because of your aspirations of not only passing, but also making it to the roster of the top 10, you decide to thoroughly go over the developmental theories in pediatric nursing. The following questions apply.

--

Your nephew appears to love his mother so much that he follows her wherever she goes. You also observe that the child gets angry with his father when he kisses the mother on the cheek. What Freudian concept is this known as?

A. Elektra complex

B. Edziewao complex

C. Oedipus complex

D. Simple complex

C. Oedipus complex

A 2-year-old-child goes into a well-known toy store with his father. The child asks the father to buy a giant, remote-controlled dinosaur for him. The father tells his child that he couldn't because they still have to pay for their electric bill. Which reaction from the child would be most likely observed?

a. The child will tell his father that it's alright, since he has too many toys in their house.

b. The child will understand his father and simply drop the conversation.

c. The child will tell his father that he knows that his father didn't bring enough money to buy the dinosaur anyway.

d. The child will insist that he wants the toy and will throw temper tantrums while crying.

D. The child will insist that he wants the toy and will throw temper tantrums while crying.

SITUATION: Nurse Louiegy is to discuss to his second-year students as part of their lecture in Maternal and Child Health Nursing. For today's topic, he was to focus on endometriosis.

--

Nurse Louiegy first provides an anatomical review of the female reproductive system as a start of his lecture. He asks his students to identify which bodily organ produces estrogen which is the?

A. Hypothalamus

B. Anterior pituitary gland

C. Ovaries

D. Testes

C. Ovaries

SITUATION: Nurse Louiegy is to discuss to his second-year students as part of their lecture in Maternal and Child Health Nursing. For today's topic, he was to focus on endometriosis.

--

A student from the class asked what symptoms patients with endometriosis usually have. Nurse Louiegy correctly answers:

A. Amenorrhea and dyspareunia

B. Dysmenorrhea and subfertility

C. Fever and headache

D. Dizziness and amenorrhea

B. Dysmenorrhea and subfertility

SITUATION: Nurse Louiegy is to discuss to his second-year students as part of their lecture in Maternal and Child Health Nursing. For today's topic, he was to focus on endometriosis.

--

Nurse Louiegy asks his students to ponder on how endometriosis can interfere with fertility. Nurse Louiegy does not need to further clarify his lecture if his students state that?

A. Endometrial implants obstruct both of the fallopian tubes.

B. The ovaries stopped producing estrogen and progesterone.

C. Pressure on the pituitary gland leads to decreased FSH levels.

D. The uterine cervix becomes increasingly inflamed and swollen.

A. Endometrial implants obstruct both of the fallopian tubes.

SITUATION: Nurse Louiegy is to discuss to his second-year students as part of their lecture in Maternal and Child Health Nursing. For today's topic, he was to focus on endometriosis.

--

To further the discussion, Nurse Louiegy explains that endometriosis occurs when functional endometrial tissues are implanted in the pelvis outside of the uterine cavity. All of the following organs may be affected by endometriosis, except?

A. Ovaries

B. Fallopian tubes

C. Bowel and bladder

D. Pericardium

D. Pericardium

SITUATION: Nurse Louiegy is to discuss to his second-year students as part of their lecture in Maternal and Child Health Nursing. For today's topic, he was to focus on endometriosis.

--

Before the lecture ended, a student wanted to clarify to Nurse Louiegy as to whether endometriosis and endometritis are different conditions. The most appropriate answer that Nurse Louiegy can give is that:

A. "Yes, they are different. Endometritis is an infection of the uterine lining that usually occurs after prolonged rupture of membranes. Endometriosis is the presence of endometrial tissue outside of the uterus."

B. "Yes, they are different. Endometritis is the presence of endometrial tissue outside of the uterus. Endometriosis is an infection of the uterine lining that usually occurs after prolonged rupture of membranes."

C. "No, they are the same. These terms can be used interchangeably."

D. "No, they are the same. Did you not

A. "Yes, they are different. Endometritis is an infection of the uterine lining that usually occurs after prolonged rupture of membranes. Endometriosis is the presence of endometrial tissue outside of the uterus."

SITUATION: Cervical insufficiency is the premature dilatation of the cervix. Due to this, the cervix is unable to hold the fetus inside the uterus. Hwasa, a 43-year-old woman at 20 weeks AOG, is rushed to the hospital after having discharges of pink-tinged vaginal fluid and increased pelvic pressure. Upon inspection of the physician, Hwasa is 2 cm dilated.

--

There are a number of risk factors on why cervical insufficiency occurs. Hwasa's nurse will determine that she understood them when she enumerates the following factors. Select all that apply.

I. Adolescent mother

II. Advanced maternal age

III. Congenital structural defects

IV. Cervical trauma

A. 1, 3, 4

B. 2, 3, 4

C. 1, 2, 4

D. None of the above

B. 2, 3, 4

SITUATION: Cervical insufficiency is the premature dilatation of the cervix. Due to this, the cervix is unable to hold the fetus inside the uterus. Hwasa, a 43-year-old woman at 20 weeks AOG, is rushed to the hospital after having discharges of pink-tinged vaginal fluid and increased pelvic pressure. Upon inspection of the physician, Hwasa is 2 cm dilated.

--

The nurse reviews her own knowledge regarding cervical insufficiency. Which of the following signs and symptoms apply?

i. Occurs in the first trimester

ii. Cervical length is shortened

iii. Dilation is painless and bloodless

iv. Symptoms may be minimal

A. 1, 2, 3

B. 1, 3, 4

C. 2, 3, 4

D. All of the above

C. 2, 3, 4

2ND TRIMESTER, NOT 1ST

PAINLESS D/T LOW PAIN RECEPTORS

SITUATION: Cervical insufficiency is the premature dilatation of the cervix. Due to this, the cervix is unable to hold the fetus inside the uterus. Hwasa, a 43-year-old woman at 20 weeks AOG, is rushed to the hospital after having discharges of pink-tinged vaginal fluid and increased pelvic pressure. Upon inspection of the physician, Hwasa is 2 cm dilated.

--

Hwasa asks about the possible intervention for her condition as she has been informed by the physician that she is at risk for an abortion if nothing was done. The nurse is aware that the procedure performed for cervical insufficiency is called?

A. Dilation and curettage

B. Colporrhaphy

C. Shirodkar technique

D. Episiotomy

C. Shirodkar technique

CERVICAL CERCLAGE

1. SHIRODKAR = SUTURING OF CERVIX = CS

2. MCDONALD'S = TYING OF CERVIX = NSD

SITUATION: Cervical insufficiency is the premature dilatation of the cervix. Due to this, the cervix is unable to hold the fetus inside the uterus. Hwasa, a 43-year-old woman at 20 weeks AOG, is rushed to the hospital after having discharges of pink-tinged vaginal fluid and increased pelvic pressure. Upon inspection of the physician, Hwasa is 2 cm dilated.

--

Cerclage placement was successfully done for Hwasa. The nurse is now preparing her by providing discharge instructions. Which statement made by Hwasa indicates that the nurse will need to provide further instruction?

A. "Prenatal visits should now be more frequent."

B. "I can have nothing in my vagina until term."

C. "I should immediately call the clinic if I am leaking fluid, have bleeding, or have any contractions."

D. "I can have sex again next week."

D. "I can have sex again next week."

SITUATION: Cervical insufficiency is the premature dilatation of the cervix. Due to this, the cervix is unable to hold the fetus inside the uterus. Hwasa, a 43-year-old woman at 20 weeks AOG, is rushed to the hospital after having discharges of pink-tinged vaginal fluid and increased pelvic pressure. Upon inspection of the physician, Hwasa is 2 cm dilated.

--

Hwasa reached 37 weeks of gestation. She calls the clinic due to irregular contractions and are occurring every 5 to 7 minutes. Which response by the nurse is the most appropriate?

A. "Get to the hospital to have the cerclage removed to prevent your cervix from injury and to allow birth to progress."

B. "Wait until the frequency of your contractions occur every 1-2 minutes and are harder in intensity."

C. "Are you worried about your child?"

D. "The cerclage will be in place while you are to have a cesarean section."

A. "Get to the hospital to have the cerclage removed to prevent your cervix from injury and to allow birth to progress."

SITUATION: Nurse Lovejoy is assessing a pregnant client who is currently in the third trimester of her pregnancy at 30 weeks of gestation. She was admitted to the maternity unit due to a suspected diagnosis of placenta previa.

--

Which of the following assessment findings will Nurse Lovejoy least likely expect from the client if placenta previa is present?

A. Painless, bright red vaginal bleeding

B. Absence of abdominal pain

C. Soft abdomen

D. Uterine tenderness

D. Uterine tenderness

SITUATION: Nurse Lovejoy is assessing a pregnant client who is currently in the third trimester of her pregnancy at 30 weeks of gestation. She was admitted to the maternity unit due to a suspected diagnosis of placenta previa.

--

Nurse Lovejoy provides instructions on the cause of vaginal bleeding. She determines that the teaching was effective when the client states that the bleeding occurs due to which of the following?

A. Clotting factors are diminished

B. The fetus was large for gestational age

C. Increased platelet levels

D. The maternal sinuses were exposed

D. The maternal sinuses were exposed

Maternal sinuses are large blood vessels in the uterus that can bleed if they become exposed during pregnancy or childbirth.

SITUATION: Nurse Lovejoy is assessing a pregnant client who is currently in the third trimester of her pregnancy at 30 weeks of gestation. She was admitted to the maternity unit due to a suspected diagnosis of placenta previa.

--

Nurse Lovejoy prepares the client for admission. In reviewing the attending physician's prescription orders, which of the following would she question?

A. Prepare the client for ultrasound.

B. Prepare to draw hemoglobin and hematocrit blood samples.

C. Obtain equipment for manual pelvic examination.

D. Obtain equipment for external electronic fetal heart rate monitoring.

C. Obtain equipment for manual pelvic examination.

do not put anything into the vagina

SITUATION: Nurse Lovejoy is assessing a pregnant client who is currently in the third trimester of her pregnancy at 30 weeks of gestation. She was admitted to the maternity unit due to a suspected diagnosis of placenta previa.

--

A diagnosis of partial placenta previa was determined. Nurse Lovejoy reiterates the importance of learning about the condition and self-care measures. Which statement made by the patient would require no further teaching?

A. "Another ultrasound will be conducted at 32 weeks to reassess the placenta's location."

B. "I can have sexual intercourse and douche throughout my pregnancy."

C. "Dark red bleeding with pain is expected."

D. "My uterus should be rigid."

A. "Another ultrasound will be conducted at 32 weeks to reassess the placenta's location."

dark red bleeding w/ pain = abruptio placenta

soft abdomen not rigid

SITUATION: Nurse Lovejoy is assessing a pregnant client who is currently in the third trimester of her pregnancy at 30 weeks of gestation. She was admitted to the maternity unit due to a suspected diagnosis of placenta previa.

--

The client has successfully delivered the infant following the pregnancy with placenta previa. Nurse Lovejoy reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa

A. Infection

B. Chronic hypertension

C. Hemorrhage

D. Disseminated intravascular coagulation

C. Hemorrhage

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

During her shift, a 20-year-old woman approached her and asked what could possibly indicate that she is pregnant. She is correct if she said that:

A. Increased hyperplasia and hypertrophy of the breasts

B. Vaginal atrophy

C. Decrease in respiratory tidal volume

D. Increase in hemoglobin

A. Increased hyperplasia and hypertrophy of the breasts

Increase in TV

Pseudoanemia = d/t high plasma

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

Another patient of Nurse Alyssa would like to know her estimated date of confinement. She then told the nurse that her last menstrual period was three months ago on 11/21. Using the Nagele's Rule, the nurse would be correct if she said that the patient's EDC is:

A. 8/28

B. 1/28

C. 8/15

D. 1/15

A. 8/28

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

Jennie is at 20-week gestation and she is the next in line for the nurse's assessment. At which of the following would Nurse Alyssa expect to feel the patient's uterine height?

A. Two finger-breadths above the symphysis pubis

B. Halfway between the symphysis pubis and the umbilicus

C. At the umbilicus

D. Two finger-breadths above the umbilicus

C. At the umbilicus

A. 13 weeks

B. 16 weeks

D. 22 weeks

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

Which of the following would Nurse Alyssa conclude that that fundal height is the most accurate?

A. A pregnant client with uterine fibroids

B. A pregnant client who is obese

C. A pregnant client with polyhydramnios

D. A pregnant client who is experiencing fetal movement

D. A pregnant client who is experiencing fetal movement

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

While Nurse Alyssa is reviewing the laboratory results of a prenatal patient, which of the following should she question?

A. Hematocrit of 36.5%

B. WBC 7,000/mm3

C. Pap smear: Negative, HPV changes noted

D. Urine pH 7.4

C. Pap smear: Negative, HPV changes noted

A Pap smear with negative results but noted HPV changes might require further evaluation depending on the specific HPV strain

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

A newly pregnant woman comes to the outpatient department and talks to Nurse Alyssa regarding her anxiety about the entirety of her pregnancy. Which of the following should the nurse prioritize to teach to the newly pregnant woman?

A. Sexual relations with her spouse

B. Fetal growth and development

C. Labor and delivery options

D. Completion of preparations for the baby

B. Fetal growth and development

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

During the first 36 weeks of Pocari's pregnancy, she discussed to the nurse that she wanted to travel by air. For which possible complication should the nurse warn teach Pocari?

A. Preterm labor

B. Deep vein thrombosis

C. Spontaneous miscarriage

D. Nausea and vomiting

B. Deep vein thrombosis

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

Sweet comes to the OPD complaining of hemorrhoid pain. Which is the first intervention that the nurse should do?

A. Steroid-based cream

B. Diet modification

C. Surgery

D. Oral medications

B. Diet modification

high fiber diet

inc OFI

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

Which of the following medical conditions would most likely be a risk factor during pregnancy?

I. Diabetes

II. Previous pregnancy

III. Controlled chronic HTN

IV. Anemia

V. Hemorrhage with a previous pregnancy

A. 1, 2, 4, 5

B. 2, 3, 4, 5

C. 1, 2, 3, 4

D. 1, 3, 4, 5

D. 1, 3, 4, 5

SITUATION: Nurse Alyssa is a newly registered nurse working in the outpatient department of Pateros Medical Center. She is assigned to assist and care for pregnant woment. The following questions apply.

--

While teaching a group of newly pregnant women, Nurse Alyssa told them that the suggested weight gain for women who is in the ideal weight range is?

A. Less than 15 lb

B. 15-25 lb

C. 25-35 lb

D. 35-45 lb

C. 25-35 lb

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

After the delivery of a baby boy, nurse Dianne palpated for the uterine fundus which she found to be halfway located between symphysis pubis and umbilicus. What should the nurse do?

A. Immediately begin to massage the uterus

B. Document the findings

C. Assess for bladder distention

D. Monitor the client closely for increased vaginal bleeding

B. Document the findings

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

The patient of Nurse Dianne is crying because her stomach still looks like she is pregnant. Nurse Dianne explained that the muscles in the abdomen separate and:

A. Regain tone within the first week after birth

B. Regain pregnancy tone with exercise

C. Remain permanently separated giving the abdomen a slight bulge

D. Regain tone as the client loses the weight gained during the pregnancy

B. Regain pregnancy tone with exercise

pelvic tilt

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Which assessment of nurse Dianne should she be alerted of Sizzy's attachment to her baby boy?

A. Asking the licensed practical nurse (LPN) about how to change her infant's diaper

B. Comparing her baby's nose to her brother's nose

C. Calling the baby by name

D. Repeatedly telling her husband that she wanted a girl

D. Repeatedly telling her husband that she wanted a girl

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Nurse Dianne is aware that parenteral engrossment is occurring if she observed the father:

A. Talking to his newborn from across the room.

B. Discussing the similarity between his ears and the newborn's ears.

C. Expressing feelings of frustration when the infant cries.

D. Being hesitant to touch his newborn.

B. Discussing the similarity between his ears and the newborn's ears.

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Ella is a multiparous patient and was observed by nurse Dianne to be caressing her abdomen. The nurse asked Ella if she is in pain, and she answered that she feels like she is having menstrual cramps. What should the nurse do?

A. Offer a warm blanket for her abdomen.

B. Encourage her to lie on her stomach until the cramping stops.

C. Instruct the client to avoid ambulation while having pain.

D. Check her lochia flow, as pain can sometimes precede hemorrhage.

B. Encourage her to lie on her stomach until the cramping stops.

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Which of the following vaccines can safely be given by Nurse Dianne to her pregnant patient?

A. Rubella

B. Varicella

C. Hepatitis B

D. Mumps

C. Hepatitis B

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Basha, a pregnant woman admitted to the OB ward, notified Nurse Dianne that she has white, cottage-cheese-like vaginal discharge, itching, and redness. Which of the following should she anticipate to be prescribed?

A. Metronidazole (Flagyl®) 250 mg twice daily for 1 week

B. Butoconazole (Gynazole®) 2 g once

C. Imidazole vaginal cream daily for 1 week.

D. Fluconazole (Diflucan®) 150 mg by mouth once

C. Imidazole vaginal cream daily for 1 week.

A. Metronidazole (Flagyl®) 250 mg twice daily for 1 week

BACTERIAL VAGINOSIS

B. Butoconazole (Gynazole®) 2 g once

FETAL MALFORMATIONS

D. Fluconazole (Diflucan®) 150 mg by mouth once

NOT SAFE FOR PREG.

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Which of the following should nurse Dianne question upon admitting a 28 week pregnant woman experiencing congestive heart failure?

A. Furosemide (Lasix®) 40 mg IV bid

B. Captopril (Capoten®) 25 mg PO daily

C. Digoxin (Lanoxin®) 0.125 mg IV daily

D. Metoprolol sustained release (Toprol XL®) 50 mg PO daily

B. Captopril (Capoten®) 25 mg PO daily

ACE = 2nd trimester

oligohydramnios

IUFD

congenital structural defects

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

One patient of Nurse Dianne is currently pregnant and is diagnosed to have severe pre-eclampsia. She is prescribed MgSO4 IV. Nurse Dianne knows that the therapeutic level of magnesium is?

A. 2 mg/dL

B. 10 mg/dL

C. 6 mg/dL

D. 0.5 mg/dL

C. 6 mg/dL

4.8-8.4 mg/dL

SITUATION: Nurse Dianne is assigned in the OB ward to care for patients who have just given birth. The following questions apply.

--

Nurse Dianne knows that the Magnesium Sulfate is effective if she notes that:

A. An increase in blood pressure.

B. An increase in urine output.

C. A decrease in platelet count.

D. An increase in hematocrit.

B. An increase in urine output.

SITUATION: Nurse Pamella is assigned to take care of the newborn patients in the hospital. She is handling different newborn patients with various conditions. The following questions apply.

--

The father of the patient approached Nurse Pamella saying that her baby's hands and feet are bluish in color. Nurse Pamella is correct if she does:

A. Immediately stimulating the infant to cry.

B. Explaining to the father that this is an expected finding in a newborn.

C. Assessing the newborn's temperature.

D. Assessing the newborn's cardiac status.

B. Explaining to the father that this is an expected finding in a newborn.

SITUATION: Nurse Pamella is assigned to take care of the newborn patients in the hospital. She is handling different newborn patients with various conditions. The following questions apply.

--

While nurse Pamella is assessing a baby delivered 8 hours ago, she got an axillary temperature of 97 degrees fahrenheit. What should nurse Pamella do?

A. Document the findings.

B. Feed the infant warmed formula.

C. Call the health-care provider to report the findings.

D. Place the infant under a radiant warmer.

D. Place the infant under a radiant warmer.

36.1 = hypothermia

SITUATION: Nurse Pamella is assigned to take care of the newborn patients in the hospital. She is handling different newborn patients with various conditions. The following questions apply.

--

How should Nurse Pamella assess the anterior fontanel of a newborn?

A. Laying the infant on his or her back.

B. Placing the infant in a sitting position.

C. Stimulating the infant to cry.

D. Palpating over the infant's occipital bone.

B. Placing the infant in a sitting position.

SITUATION: Nurse Pamella is assigned to take care of the newborn patients in the hospital. She is handling different newborn patients with various conditions. The following questions apply.

--

Nurse Pamella is caring for a preterm baby with RDS. what intervention should Nurse Pamella do to enhance the respiratory status of the baby?

A. Monitoring blood glucose levels every 4 hours.

B. Cooling all inspired gases.

C. Weighing the infant every other day.

D. Positioning the infant in a prone position.

D. Positioning the infant in a prone position.

Prone positioning helps improve lung expansion and gas exchange in preterm infants with RDS. It allows for better ventilation and drainage of secretions, ultimately improving the baby's respiratory status.

prone = more weight in the lungs = less expansion in babies (d/t heart, liver, stomach)

SITUATION: Nurse Pamella is assigned to take care of the newborn patients in the hospital. She is handling different newborn patients with various conditions. The following questions apply.

--

While nurse Pamella is caring for Junjun, a 6-hour-old full-term newborn, he suddenly showed signs of respiratory distress. Nurse Pamella reviewed the chart of Junjun and suspected that Junjun aspirated meconium when which of the following is noted?

A. 1-hour precipitous labor, small for gestational age infant

B. 40-hour labor, green-stained amniotic fluid

C. Forceps delivery, shoulder dystocia

D. Planned cesarean birth

B. 40-hour labor, green-stained amniotic fluid

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

While assessing a child diagnosed with acute pericarditis, the nurse would note which of the following?

A. Bilateral lower extremity pain

B. Pain on expiration

C. Pleural friction rub

D. Pericardial friction rub

D. Pericardial friction rub

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

The nurse just got the ECG tracing of her 2-year-old patient with heart failure secondary to a congenital heart defect. She noted the PR interval is 0.26 seconds, the QRS is 0.08 seconds, and the QT is 0.28. The ventricular rate is 126 bpm. How should the nurse interpret this ECG tracing?

A. Sinus bradycardia.

B. Sinus rhythm with a bundle branch block.

C. Sinus rhythm with a first-degree AV block.

D. Sinus tachycardia with a first-degree AV block.

C. Sinus rhythm with a first-degree AV block.

80-130 normal

prolonged PR interval

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

A pediatric patient of the nurse with CHF is receiving digoxin therapy. Which of the following laboratory results is of utmost importance to the nurse before she administers digoxin?

A. Serum potassium levels

B. Serum magnesium levels

C. Serum sodium levels

D. Serum chloride levels

A. Serum potassium levels

hypokalemia = inc. digoxin toxicity

cardiac dysrhythmias

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

Of the 4 patients of the nurse, to which of the following is ECG not important?

A. A 4-year-old with tachycardia

B. A 3-year-old with bradycardia

C. A 10-year-old with an irregular pulse

D. An infant with a splitting of the S2 heart sound only when the infant takes a deep breath

D. An infant with a splitting of the S2 heart sound only when the infant takes a deep breath

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

While the nurse is teaching the relative of the pediatric patient about hypoxemia, she asks the nurse which of the following signs or symptoms would have them bring the patient to the ER immediately?

A. Weight loss or gain

B. Excessive crying

C. Dehydration and respiratory infection

D. Not achieving developmental milestones

C. Dehydration and respiratory infection

hypoxemia + DHN = no O2

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

The nurse is correct when she identifies that she should monitor her patient with congenital heart disease for the complication of:

A. Congestive heart failure and pulmonary hypotension

B. Congestive heart failure and hypoxemia

C. Hypoxemia and pulmonary hypotension

D. Pulmonary hypotension and cyanosis

B. Congestive heart failure and hypoxemia

pulmonary hyPERtension not hypo

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

For which disease would the nurse notify the patient if he develops tachycardia, edema, dyspnea, orthopnea, and crackles?

A. Right-sided heart failure

B. Rheumatic fever

C. Kawasaki disease

D. Left-sided heart failure

D. Left-sided heart failure

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

The parent is concerned when the physician told the parent that her child is diagnosed with rheumatic fever and has a heart murmur. The nurse explains that heart murmurs occur due to the defect in?

A. Heart valve

B. Heart vessel

C. Heart chamber

D. Heart conduction

A. Heart valve

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

A patient of the nurse developed an enlarged liver secondary to infectious endocarditis. Which cardiac condition should the patient continuously be assessed for?

A. Dysrhythmia

B. Right-sided heart failure

C. Myocardial infarction (MI)

D. Tetralogy of Fallot

B. Right-sided heart failure

SITUATION: The nurse is caring for pediatric patients with different cardiovascular disorders. The following questions apply.

--

The nurse should always be ready for doing CPR in case a patient with cardiac condition goes into arrest. If ever it is needed, which of the following is the correct compression-to-ventilation ratio to be used in pedia patients?

A. 30:2

B. 15:2

C. 30:1

D. 15:1

A. 30:2

SITUATION: Nurse Lucas is assigned in the pediatric wing of the hospital he is working. He is tasked to care for pediatric patients with respiratory disorders. The following questions apply.

--

Maui is a 4-year-old patient of Nurse Lucas. He is currently experiencing respiratory distress. Which of the following signs and symptoms should nurse Lucas observe to confirm that Maui is indeed experiencing respiratory distress?

A. Diaphoresis, restlessness, tachypnea, and anorexia

B. Pallor, coughing, wheezing, and confusion

C. Retractions, grunting, cyanosis, and bradycardia

D. Agitation, decreased level of consciousness, diarrhea, tachypnea

C. Retractions, grunting, cyanosis, and bradycardia

severe respiratory distress

anorexia = nutrititional / electrolyte imbalance

pallor = circulation / moderate resp. distress

D. Agitation, decreased level of consciousness, diarrhea, tachypnea = moderate resp. distress

SITUATION: Nurse Lucas is assigned in the pediatric wing of the hospital he is working. He is tasked to care for pediatric patients with respiratory disorders. The following questions apply.

--

Which nursing diagnosis should be the priority if patient Maui is experiencing respiratory distress?

A. Ineffective breathing pattern

B. Anxiety

C. Risk for deficient fluid volume

D. Deficient knowledge

A. Ineffective breathing pattern

SITUATION: Nurse Lucas is assigned in the pediatric wing of the hospital he is working. He is tasked to care for pediatric patients with respiratory disorders. The following questions apply.

--

A patient of Nurse Lucas is diagnosed to have acute laryngotracheobronchitis (LTB). Which of the following should indicate that the patient will be having a respiratory failure?

A. Restlessness and irritability

B. Retractions of the accessory chest muscles

C. Decreased inspiratory breath sounds

D. Hoarseness

C. Decreased inspiratory breath sounds

stridor

SITUATION: Nurse Lucas is assigned in the pediatric wing of the hospital he is working. He is tasked to care for pediatric patients with respiratory disorders. The following questions apply.

--

Nurse Lucas is caring for a patient with asthma. The physician ordered oxygen via facemask. Which should nurse Lucas instruct the parents of the patient to avoid while their child is on oxygen therapy?

A. Plastic blocks and handheld toys

B. Electronic educational toys and books

C. Cotton-filled toys and clothing

D. Synthetic toys and clothing

D. Synthetic toys and clothing

might cause static friction

SITUATION: Nurse Lucas is assigned in the pediatric wing of the hospital he is working. He is tasked to care for pediatric patients with respiratory disorders. The following questions apply.

--

Nurse Lucas is about to perform Chest Physiotherapy to a 5 years old patient diagnosed with cystic fibrosis. When should Nurse Lucas plan to perform this procedure?

A. Before performing postural drainage

B. One hour before meals

C. Before a nebulized aerosol treatment

D. After suctioning the upper respiratory tract

B. One hour before meals

or 2-3 hours after meals

SITUATION: The nurse in the community is assessing the well-being of the children. The following questions apply.

--

Knowing the appropriate growth and development for each age, the nurse is correct when he identifies the appropriate infant's weight is:

A. The baby's weight has tripled in the first 6 months of life

B. The baby's weight has doubled in the first year of life

C. The baby's weight has doubled in the first 6 months of life and tripled in the first year

D. The baby's weight has doubled in the first 6 months and doubled again in the next 6 months

C. The baby's weight has doubled in the first 6 months of life and tripled in the first year

SITUATION: The nurse in the community is assessing the well-being of the children. The following questions apply.

--

The parent of the 3-month-old baby asked the nurse which motor skill should she observe her baby doing?

A. Bangs objects held in hand

B. Begins to grab objects using a pincer grasp

C. Grabs objects using a palmar grasp

D. Looks and plays with own fingers

D. Looks and plays with own fingers

A. Bangs objects held in hand

B. Begins to grab objects using a pincer grasp

10 months

C. Grabs objects using a palmar grasp

6 months

SITUATION: The nurse in the community is assessing the well-being of the children. The following questions apply.

--

Which intervention is the most appropriate for providing tactile stimulation to a 10-month-old baby?

A. Caress the child while diaper changing

B. Let the child squash and mash food while sitting in a high chair

C. Give the child a soft squeeze toy

D. Swaddle the child at nap time

B. Let the child squash and mash food while sitting in a high chair

SITUATION: The nurse in the community is assessing the well-being of the children. The following questions apply.

--

An 8-month-old baby, developing appropriately, is crying and is being held by the mother. The nurse, with the knowledge of Erikson's theory, would be correct if she identified that the baby is in which stage of Erikson's theory of development?

A. Punishment versus obedience orientation

B. Oral stage

C. Initiative versus guilt

D. Trust versus mistrust

D. Trust versus mistrust

SITUATION: The nurse in the community is assessing the well-being of the children. The following questions apply.

--

The nurse is preparing to perform a head-to-toe assessment on a child who is presented to her by her parents due to nausea and vomiting. How should the nurse prepare for this?

A. Preparing for a physical examination based on the child's developmental age

B. Making sure the parents are present

C. Using a firm tone to settle the child down for the examination

D. Waiting until the child is ready to cooperate

A. Preparing for a physical examination based on the child's developmental age

SITUATION: Nurse Carina is a pediatric nurse assigned to care for patients with problems in endocrine system. The following questions apply.

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Nurse Carina knows that the risk for cardiovascular disease for patients with type 1 diabetes is decreased by:

A. Exercising at least 30 minutes every day.

B. Eating a diet that is low in fat and high in protein.

C. Maintaining optimal management of blood sugar levels.

D. Having a cardiac workup at each visit for diabetes.

C. Maintaining optimal management of blood sugar levels.

SITUATION: Nurse Carina is a pediatric nurse assigned to care for patients with problems in endocrine system. The following questions apply.

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The nurse knows that the importance of administering metformin to a pediatric patient at risk of developing Diabetes is:

A. Delay the development of type 2 diabetes mellitus in high-risk children.

B. Restore fertility in adolescent females.

C. Reduce blood sugars in children who have type 1 diabetes mellitus.

D. Restore renal function in children who have type 1 diabetes mellitus.

A. Delay the development of type 2 diabetes mellitus in high-risk children.

SITUATION: Nurse Carina is a pediatric nurse assigned to care for patients with problems in endocrine system. The following questions apply.

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The parents of child newly diagnosed with type 1 diabetes asked the nurse what the importance of counting the intake of the child's carbohydrate is:

A. Lower blood glucose levels.

B. Supply energy for growth and development.

C. Provide consistent glucose to prevent hypoglycemia.

D. Attain metabolic control of glucose and lipid levels.

D. Attain metabolic control of glucose and lipid levels.

SITUATION: Nurse Carina is a pediatric nurse assigned to care for patients with problems in endocrine system. The following questions apply.

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Which of the following laboratory should nurse Carina monitor for a patient diagnosed with long term success in controlling diabetes type 1?

A. Hemoglobin A1c levels

B. Blood insulin levels

C. Blood glucose levels

D. Urinary glucose levels

A. Hemoglobin A1c levels

SITUATION: Nurse Carina is a pediatric nurse assigned to care for patients with problems in endocrine system. The following questions apply.

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A patient of Nurse Carina suddenly becomes disoriented during an activity in the ward after lunch. What should nurse Carina obtain first knowing that the patient has a history of type 1 diabetes?

A. Blood sugar

B. Temperature

C. Morning insulin dose

D. Urine ketones

A. Blood sugar