A nurse is caring for a client diagnosed with acute rhinosinusitis. Which of the following instructions should the nurse provide to the client? Select all that apply.

The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back. Which parental statement indicates understanding of the procedure?

A client at 9-weeks gestation informs the nurse that she has reduced her alcohol intake but still consumes at least one alcoholic drink every evening before bedtime. What action should the nurse take?

During the second stage of labor, the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse anticipate performing to assist the healthcare provider?

The nurse is evaluating the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

The nurse is caring for a client who is 40-weeks gestation in active labor and has received epidural anesthesia. What is the most important assessment for the nurse to conduct following the administration of epidural anesthesia?

A client who experienced a severe postpartum hemorrhage following the vaginal birth of twins is transferred to the postpartum unit. The nurse knows that assessment for which complication is the highest priority for this client?

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse expect?

A client’s maternal serum alpha-fetoprotein level is elevated at 17 weeks. What condition should the nurse identify as the likely cause of this increase?

The nurse is educating parents on how to prevent recurrent otitis media in their infant. What advice should the nurse give?

The nurse is caring for a toddler with a large, unrepaired ventricular septal defect and heart failure. What assessment finding should the nurse anticipate?

On the first postpartum day, the nurse examines a new mother’s breasts. What condition is the nurse most likely to find?

During the admission procedure of a school-age child, the child states, “I’m going to have an operation.”. What is the best response for the nurse to provide to this child?

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse. Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

The client is awake and alert, interacting with parents at the bedside. She has thin, copious mucus from her nose and mouth and a cough. She took her bottle in 20 minutes, with no issues. The client’s monitor alarmed, oxygen saturation is 59%. She is cyanotic. The client was placed in a knee-to-chest position, and the rapid response team was called. What could be the potential cause of the client’s condition?

A woman is in the second stage of labor where the fetal head has just been born and the nurse observes the immediate retraction of the head against the perineum. What action should the nurse expect to perform to assist the healthcare provider?

A client at 38-weeks gestation reports experiencing severe abdominal pain. Upon palpation, the nurse notes that the abdomen is rigid. How should the nurse document the findings?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A parent rushes their pre-school age child to the emergency department with an asthma exacerbation. Which additional finding should alert the nurse that the child is in acute respiratory distress?

The nurse is providing information to a parent of a six-month old about vaccinations. Which statement made by the parent should the nurse recognize as understanding the information?

A 17-year-old student arrives at the emergency department (ED) complaining of severe abdominal pain and cramping that has worsened since the morning. Her mother suspects a urinary tract infection due to her daughter’s frequent and urgent urination, or possibly appendicitis. What signs would indicate that a healthy psychosocial adaptation is taking place? Select all that apply.

A patient in active labor is prescribed oxytocin 12 milliunits/min intravenously (IV). The IV bag contains 5 units of oxytocin in 500 mL of lactated Ringer’s solution. How many mL/hour should the nurse set the infusion pump to? (Enter numerical value only) .

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby. Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale. She was assisted to the bathroom where she voided 150 mL of clear yellow urine. Lochia rubra is moderate with small clots, no foul odor noted. The fundus is firm at the umbilicus. The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis. There is no pain, redness, or swelling in the calves. A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag. The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

A nurse is providing instructions to the parent of a 10-year-old child who has recently been diagnosed with type 1 diabetes mellitus (DM). The parent expresses a fear of needles and is unable to perform the procedure of administering subcutaneous insulin injections to the child. What action should the nurse take?