Exam Review

After assisting the provider with an amniotomy on a laboring client, what is the nurse's priority action?
A)
Adjust the intravenous fluid infusion rate.
B)
Provide a clean gown and linens for the client.
C)
Assess the fetal heart rate.
D)
Assist the client to wash the perineum.
Kawasaki syndrome is a diagnosis of exclusion. Treatment for this diagnosis may include IVIG and high dose aspirin therapy to prevent which condition?
A)
Chronic anemia.
B)
Cardiac arrhythmias.
C)
Acute respiratory distress.
D)
Coronary artery aneurysms.
A nurse has just received a shift report on their assigned labor clients. Which of the following clients should be seen first?
A)
A client with a fetal heart rate of 110 beats per minute with moderate variability and accelerations.
B)
A client with an epidural who is 7 cm dilated.
C)
A client with a blood pressure of 110/82 mmHg, heart rate of 80 beats per minute, and oxygen saturation of 98%.
D)
A client with a fetal heart rate baseline of 130s, minimal variability, and late decelerations.
The nurse is caring for a child admitted with nephrotic syndrome. Which of the following lab findings are characteristic of this syndrome? Select all that apply.
(SATA)
A)
Increased intracranial pressure.
B)
Hypoalbuminemia.
C)
Proteinuria.
D)
Glucosuria.
E)
Hyperlipidemia.
F)
Elevated erythrocyte sedimentation rate (ESR).

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Exam Review

When visiting a friend, you see an 18-month-old toddler pull a scalding cup of tea off a table onto himself. Your first action should be to:
A)
Apply butter to soothe the injured skin.
B)
Wrap him in a blanket and rush him to the nearest hospital.
C)
Remove his shirt and apply burn ointment.
D)
Pour cool water over the skin area where the coffee spilled.
When assessing the fundus in a postpartum client, which palpation method is recommended?
A)
Placing one hand on the fundus, one on the perineum.
B)
Palpating the fundus with only fingertip pressure.
C)
Placing one hand at the base of the uterus and one on the fundus.
D)
Resting both hands on the fundus.
The nurse is assessing a client who is 2 weeks postpartum. The nurse would be concerned about mastitis if which of the following were noted? Select all that apply.
(SATA)
A)
Urinary frequency.
B)
Flu-like symptoms.
C)
Unilateral breast tenderness.
D)
Unilateral breast erythema.
E)
Uterine tenderness.
F)
Bilateral breast firmness.
After delivery of the placenta, a client's uterus is slow to contract. Which of the following is a priority nursing intervention?
A)
Measure blood pressure hourly.
B)
Prepare to administer blood products as prescribed.
C)
Administer intravenous fluids.
D)
Initiate oxytocin infusion as prescribed.

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Exam Review

A nurse receives a call from a parent concerned their toddler ingested half of a bottle of ferrous sulfate vitamins. What should the nurse instruct the parent to do?
A)
Have the child take docusate sodium.
B)
Have the child drink orange juice.
C)
Induce vomiting to remove as much medication as possible.
D)
Contact the poison control center.
A nurse has just received a shift report on their assigned postpartum clients. Which of the following clients should be seen first?
A)
A client with a localized area of breast tenderness.
B)
A 4-hour post-op cesarean section client reporting a pain scale score of 3/10.
C)
A client with a moderate amount of dark red lochia.
D)
A client with uterine tenderness, foul-smelling lochia, and a new temperature of 102 degrees
After assisting the provider with an amniotomy on a laboring client, what is the nurse’s priority action?
A)
Adjust the intravenous fluid infusion rate.
B)
Provide a clean gown and linens for the client.
C)
Assess the fetal heart rate.
D)
Assist the client to wash the perineum.
A 2-year-old toddler is seen for croup (acute laryngotracheobronchitis). What observation would lead the nurse to suspect airway occlusion?
A)
The nasal discharge is increasing.
B)
The cough is becoming harsher.
C)
The respiratory rate is gradually increasing.
D)
The toddler states being tired and wanting to sleep.

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Exam Review

A client who gave birth 5 hours ago has completely saturated a perineal pad within 15 minutes. Which action by the nurse should be implemented first?
A)
Assess the fundus.
B)
Begin an IV infusion of Ringer's lactate solution.
C)
Assess vital signs.
D)
Notify the health care provider.
A laboring client is at 10 cm dilation. What would the nurse do next?
A)
Assess for the need for pain medication.
B)
Administer oxytocin.
C)
Be sure the client’s dinner has been ordered.
D)
Prepare for the second stage of labor.
A nurse notes that the fetus of a client in labor is in a vertex presentation at +1 station. The nurse knows this means the presenting part is at which vaginal exam location?
A)
The presenting part is 1 cm above the ischial spines.
B)
The presenting part is at the level of the ischial spines.
C)
The presenting part is 1 cm below the ischial spines.
D)
The presenting part is entering the pelvic inlet.
What information would the nurse document regarding a patient's reported allergies? Select all that apply.
A)
Family history of allergies.
B)
Type of allergic reaction.
C)
Medication names.
D)
Epi Pen use for allergic reactions.
E)
Date of allergic reaction.

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Exam Review

Which assessment on the third postpartum day would indicate to the nurse that a client is experiencing uterine subinvolution?
A)
The fundus is palpated 3 finger-breadths below the umbilicus after voiding.
B)
Uterine cramping is mild and resolved by NSAIDs.
C)
The fundus is palpated 2 finger-breadths above the pubic symphysis after voiding.
D)
The fundus is palpated at the umbilicus after voiding.
A client with sickle cell disease is in a vaso-occlusive crisis and reporting a severe headache with blurry vision. What intervention should the nurse perform first?
A)
Administer analgesic medication.
B)
Assess the client's neurological status.
C)
Increase the client's intravenous fluids.
D)
Administer 2 L of oxygen via nasal cannula.
A client who is now a G6 P6006 is 15 minutes postpartum from a normal vaginal delivery. The newborn weighed 10 lbs 13 ounces (4595 grams) at birth. Which of the following complications should the nurse monitor for in this client?
A)
Hemorrhage.
B)
Thrombosis.
C)
Seizures.
D)
Infection.
The nurse is caring for a client who had a cesarean section birth. Which of the following would be the most important assessment to make?
A)
If signs of infection are present at the incision site.
B)
If they plan to return to work postpartum.
C)
If signs of infection are present at the perineal site.
D)
If their breasts fill by the 1st postpartum day.

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Exam Review

A client who is in the transition phase reports the narcotic pain medication they last received 3 hours ago has worn off. The client asks if they can have another dose of the narcotic. How should the nurse respond to the request?
A)
"It is too early as the medication should be given only every 4 hours.”.
B)
"I will get permission from your health care provider.”.
C)
"Since it has been over 3 hours, you should be able to have more of the medication.”.
D)
"Your phase of labor makes giving another dose unsafe for the fetus.”
A toddler is being treated for acetaminophen toxicity after an accidental overdose. The nurse should prepare to administer which medication?
A)
Succimer.
B)
Atropine.
C)
Syrup of ipecac.
D)
Acetylcysteine.
A postpartum client has been diagnosed with postpartum depression. Which of the following symptoms would the nurse anticipate the client was exhibiting, aiding in the diagnosis?
A)
Insomnia.
B)
Intermittent crying in the first week postpartum, now resolved.
C)
Delusions.
D)
Induced vomiting.
If the fetal monitor demonstrates the following pattern, which action would the nurse perform first? (Click on paperclip if image is not showing).
A)
Prepare for vaginal delivery.
B)
Administer oxygen at 8 to 10 liters via nasal cannula.
C)
Turn the client or ask the client to turn on their side.
D)
Perform a vaginal exam to assess for the umbilical cord.

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