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    Exam Review

    1. A 34-week gestation multigravida comes to the clinic for her bimonthly appointment. Which assessment finding should the nurse report to the healthcare provider (HCP)?
      A)
      1+ edema on her lower extremities.
      B)
      Fundal height of 30 cm.
      C)
      Weight gain of 2 pounds (0.91 kg).
      D)
      Fetal heart rate of 110 beats/minute.
    2. Exhibits The nurse reviews the client's history and physical, the nurses' notes, and the flow sheet. Select the findings that will help the nurse determine what is causing the client's symptoms.
      (SATA)
      A)
      Rupture of membranes for 16 hours
      B)
      Normal spontaneous vaginal birth
      C)
      Breastfeeding 7 to 8 times a day for 10 minutes
      D)
      Discharge hemoglobin of 9.2 g/dL (92 g/L)
      E)
      Current vital signs
      F)
      Shopping yesterday for 5 hours
      G)
      Foul-smelling lochia rubra
    3. Exhibits For each assessment finding, click to indicate whether findings from this client's assessment are generally associated with mastitis, endometritis, or could be a sign of both conditions. Each row must have only one response option selected.
      MastitisEndometritisBoth mastitis and endometritis
      Pulse of 105 beats/minute✓
      Feeling chilled, achy, and fatigued✓
      Baby fed pumped breast milk✓
      Pain rating of 4 on a 0 to 10 scale✓
      Foul-smelling lochia rubra at 2 Weeks postpartum✓
      Temperature of 101.2° F (38.4°C)✓
    4. Exhibits Which education by the nurse will help resolve the issue for the client? Select all that apply.
      (SATA)
      A)
      Wear an underwire bra around the clock.
      B)
      Apply warm compresses to affected area before feeding.
      C)
      Pump breasts if feeding will be missed, due to absence from the infant.
      D)
      Pump breastmilk and feed it to infant instead of nursing.
      E)
      Finish antibiotics even if symptoms improve.
      F)
      Maintain activity due to the risk of blood clots with extra rest.
      G)
      Wash hands before handling the breast.
      H)
      Start infant on the unaffected side, so there is less pain when infant is the hungriest.
      I)
      Vary breastfeeding positions at each feeding.
    Page 1 of 11

    Exam Review

    1. Exhibits Choose the most likely options for the information missing from the statement by selecting from the list of options provided. The nurse knows that the mastitis in this scenario is most likely caused by▾ Plugged duct, as evidenced by▾ Firm, red, warm area on the right breast
      Dropdown 1:
      Option 1: Plugged duct
      Option 2: Breast abscess
      Option 3: Engorgement
      Option 4: Nipple trauma with cracked skin
      Dropdown 2:
      Option 1: Firm, red, warm area on the right breast
      Option 2: Pus draining from the nipple
      Option 3: Generalized swelling of the entire breast
      Option 4: Pain that worsens with cold compresses
    2. Exhibits The nurse determines the need to perform more of an assessment based on the client's symptoms. Based on the new assessment findings, choose the most likely options for the information missing from the statements by selecting from the lists of options provided. Based on the assessment findings, the priority diagnosis suspected is ▾ MastitisThis diagnosis places the client at risk of▾ Abscess
      Dropdown 1:
      Option 1: Mastitis
      Option 2: Engorgement
      Option 3: Blocked milk duct
      Option 4: Inflammatory breast cancer
      Dropdown 2:
      Option 1: Abscess
      Option 2: Breastfeeding intolerance
      Option 3: Nipple thrush
      Option 4: Postpartum hemorrhage
    3. Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.
      (SATA)
      A)
      After a feeding, the nipple is creased.
      B)
      The feelings of fatigue continue, but there are no chills, achiness, or dizziness.
      C)
      The infant continues to want to nurse all the time.
      D)
      The temperature taken at home is 99.0° F (37.2° C).
      E)
      Pain during feeding lasts for 10 of the 20 minutes of the feed.
      F)
      Pumping continues on the right side instead of breastfeeding on that side.
      G)
      The red area on her right breast has resolved.
      H)
      The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions.
    4. The parent of an 11-year-old client who has juvenile idiopathic arthritis tells the nurse, "I really don't want my child to become dependent on pain medication, so I only allow taking the medication when the pain is really bad." Which information is most important for the nurse to provide this parent?
      A)
      Giving pain medication around the clock helps control the pain.
      B)
      The use of hot baths can be used as an alternative for pain medication.
      C)
      The child should be encouraged to rest when experiencing pain.
      D)
      Encourage quiet activities such as watching television as a pain distracter.
    Page 2 of 11

    Exam Review

    1. The nurse is providing discharge instructions to the caregiver of an infant with recurrent otitis media. Which statement made by the caregiver should the nurse recognize as needing additional education about minimizing subsequent infections?
      A)
      Avoid any smoking inside the house.
      B)
      Give infant the full course of antibiotics.
      C)
      Schedule visit for pneumococcal vaccine.
      D)
      Instill benzocaine otic drops regularly.
    2. A child who weighs 25 kg receives a prescription for isoniazid 10 mg/kg/day by mouth once a day. The bottle is labeled "Isoniazid Oral Solution, USP 50 mg per 5 mL." How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
      Correct Answer:25 mL per dose
    3. The nurse is caring for a primigravida client who delivered vaginally 48-hours ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus positive. Which prescription should the nurse prepare to administer? Reference Range Hemoglobin [Pregnant female: greater than 11 g/dL (greater than 110 g/L)] Hematocrit [Pregnant female: greater than 33% (greater than 0.33 volume fraction)] Hepatitis B surface antigen [Negative] Rubella [Immune] Group B Streptococcus [Negative]
      A)
      Hepatitis B immunoglobulin.
      B)
      Rubella vaccination.
      C)
      Blood transfusion.
      D)
      Penicillin G potassium.
    4. Exhibits The nurse determines the client is in pain. Which pain scales would be appropriate for this client? Select all that apply.
      A)
      FLACC Postoperative Pain Scale
      B)
      Riley Infant Pain Scale
      C)
      Poker Chip Tool
      D)
      Visual Analog Scale
      E)
      Numeric
      F)
      FACES
    Page 3 of 11

    Exam Review

    1. Exhibits The nurse is reviewing the assessment data. Which are the 3 most likely reasons that the infant is crying?
      A)
      Hunger
      B)
      Opioid withdrawal
      C)
      Hemorrhage
      D)
      Separation anxiety
      E)
      Pain
      F)
      Hypovolemia
      G)
      Hypoxia
    2. Exhibits Which other assessment data would the nurse want to collect before implementing pain management strategies? Select all that apply.
      A)
      Blood type
      B)
      Parents religious affiliation
      C)
      Blood pressure
      D)
      Level of consciousness
      E)
      Hearing acuity
      F)
      Heart rate
      G)
      Deep tendon reflexes
    3. Exhibits Based on the FLACC score and the client's developmental level, mark which nurse actions would be appropriate, and which would not be appropriate. Each row must have one option selected.
      A)
      Ask the healthcare provider to prescribe a nonsteroidal antiinflammatory drug.
      B)
      Have one of the parents hold the baby.
      C)
      Perform guided imagery.
      D)
      Consult a child life specialist.
      E)
      Encourage the baby's mother to breastfeed the baby.
      F)
      Wait 1 hour, reassess, and give medication if the FLACC score remains elevated.
      G)
      Request a prescription for an opioid.
    4. Exhibits The nurse is reviewing the prescription and planning the appropriate pain management. Complete the following sentence by choosing from the lists of options. For best pain management, the nurse should give... of acetaminophen every 4 hours as scheduled.
      A)
      3.3 mL
      B)
      1.9 mL
      C)
      5.0 mL
      D)
      0.8 mL
    Page 4 of 11

    Exam Review

    1. An adolescent with pelvic inflammatory disease (PID) is admitted to the hospital after 14 days of taking levofloxacin 500 mg PO daily and metronidazole 500 mg IV piggy back (IVBP) twice daily (BID). She asks the nurse, "Why do I have to be in the hospital? Why can't I get my treatment at home?" Which purpose should the nurse provide that supports an effective outcome?
      A)
      Detection of early symptoms of Jarisch-Herxheimer reaction.
      B)
      Collection of serial anaerobic cultures of vaginal discharge.
      C)
      Implementation of contact precautions to prevent spread of infection.
      D)
      Administration of a supervised parenteral antibiotic protocol.
    2. A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, "I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?" Which information should the nurse provide?
      A)
      Describe genetic testing protocols.
      B)
      Sign up for group therapy sessions.
      C)
      Start a prenatal care plan as soon as possible.
      D)
      Discontinue the methadone right away.
    3. A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?
      A)
      Begin prescribed intravenous antibiotic administration.
      B)
      Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck.
      C)
      Obtain bedside trays for intubation or tracheotomy by the healthcare provider.
      D)
      Provide a nebulizer treatment with bronchodilators.
    4. The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?
      A)
      Folic acid.
      B)
      Iron.
      C)
      Vitamin D.
      D)
      Calcium.
    Page 5 of 11

    Exam Review

    1. Exhibits Review H and P, and nurse's note. Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.
      A)
      Avoid mentioning anything about the mother to the child.
      B)
      Develop a trusting relationship with the child.
      C)
      Notify the mother that social services will be notified if she does not visit regularly.
      D)
      Have the child sign a treatment contract stating he will participate in therapy.
      E)
      Ask the mother to bring a familiar object from home.
      F)
      Facilitate phone conversations between the child and his mother.
    2. An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?
      A)
      "We should be sure to start our daughter on birth control pills."
      B)
      "Sexual maturity differences between my daughter and her peers will disappear within a few years."
      C)
      "Our daughter will be on this hormone treatment the rest of her life."
      D)
      "We should encourage her to dress in clothing that suits her sexual maturity level."
    3. A client who is 37 weeks gestation comes to the women's health clinic reporting an excruciating headache. On examination, the nurse determines the client has an elevated blood pressure. Which action should the nurse implement next?
      A)
      Establish the frequency of headaches.
      B)
      Ask about a history of delivering large babies.
      C)
      Examine the client for pedal edema.
      D)
      Collect a urine sample to screen for protein.
    4. The nurse is giving instructions to the mother of a 10-year-old boy who is newly diagnosed with type 1 diabetes mellitus (DM). When attempting to teach the mother how to administer subcutaneous insulin injections to the child, the mother tells the nurse that she is afraid of needles and cannot perform the procedure. Which intervention should the nurse implement?
      A)
      Determine if the child can administer the insulin.
      B)
      Ask if the father can help with the injections.
      C)
      Assess the mother's parenting skills.
      D)
      Encourage the mother to handle the needles.
    Page 6 of 11