Multiple Choice
Identify the
choice that best completes the statement or answers the question.
|
|
|
1.
|
A licensed practical nurse (LPN) is assisting a
high school nurse in conducting a session with female adolescents regarding the menstrual cycle. The
LPN tells the adolescents that the normal duration of the menstrual cycle is about:
a. | 14 days | b. | 28 days | c. | 30
days | d. | 45 days |
|
|
|
2.
|
A nurse-midwife is conducting a session on the
process of fertilization with a group of nursing students. The nurse-midwife asks a nursing student
to identify the structure in which fertilization of an ovum takes place. The student answers
correctly by identifying which location?
a. | Fallopian tube | b. | Fundus of the uterus | c. | Ovary | d. | Corpus of the
uterus |
|
|
|
3.
|
A nurse is collecting data from a female client who
is suspected of having mittelschmerz. Which of the following would the nurse expect to note on data
collection of the client?
a. | Pain at the beginning of
menstruation | b. | Profuse vaginal
bleeding | c. | Sharp pain located on the right side of the
pelvis | d. | Pain that occurs during
intercourse |
|
|
|
4.
|
A client calls the physician’s office to
schedule an appointment because a home pregnancy test was performed and the results were positive.
The nurse determines that the home pregnancy test identified the presence of which of the following
in the urine?
a. | Estrogen | b. | Progesterone | c. | Human chorionic
gonadotropin (hCG) | d. | Follicle-stimulating hormone |
|
|
|
5.
|
A nurse is teaching a pregnant woman about the
physiological effects and hormone changes that occur in pregnancy. The woman asks the nurse about the
purpose of estrogen. The nurse bases the response on which of the following purposes of
estrogen?
a. | It maintains the uterine lining for
implantation. | b. | It stimulates
metabolism of glucose and converts the glucose to fat. | c. | It prevents the involution of the corpus luteum and maintains the production
of progesterone until the placenta is formed. | d. | It stimulates
uterine development to provide an environment for the fetus and stimulates the breasts to prepare for
lactation. |
|
|
|
6.
|
A nurse is reviewing the record of a pregnant
client and notes that the physician has documented the presence of Chadwick’s sign. The nurse
determines that the hormone responsible for the development of this sign is which of the
following?
a. | Human chorionic gonadotropin | b. | Estrogen | c. | Progesterone | d. | Prolactin |
|
|
|
7.
|
A nurse is reviewing the health care record of a
pregnant client at 16 weeks’ gestation. The nurse would expect documentation that the fundus of
the uterus is noted at which of the following areas?
a. | Midway between the symphysis pubis and the
umbilicus | b. | At the umbilicus | c. | Just above the symphysis pubis | d. | At the level of the xiphoid process |
|
|
|
8.
|
A nurse is collecting data from a client seen in
the health care clinic for a first prenatal visit. The nurse asks the client when the first day of
her last menstrual period was, and the client reports February 9, 2011. Using Nägele’s
rule, the nurse determines that the estimated date of confinement is:
a. | October 16, 2011 | b. | November 16, 2011 | c. | October 7,
2011 | d. | November 7, 2011 |
|
|
|
9.
|
A pregnant client is seen in the health care
clinic. During the prenatal visit the client informs the nurse that she is experiencing pain in the
calf when she walks. Which of the following would be the most appropriate nursing
action?
a. | Tell the client that this is normal during
pregnancy. | b. | Instruct the
client to avoid walking. | c. | Check for the
presence of Homans’ sign. | d. | Instruct the
client to elevate the legs consistently throughout the day. |
|
|
|
10.
|
A client in her second trimester of pregnancy is
seen at the health care clinic. The nurse collects data from the client and notes that the fetal
heart rate is 100 beats per minute. Which of the following nursing actions would be
appropriate?
a. | Document the findings. | b. | Inform the mother that everything is normal and
fine. | c. | Notify the physician. | d. | Instruct the mother to return to the clinic in 1 week for revaluation of the
fetal heart rate. |
|
|
|
11.
|
A nurse is caring for a pregnant client who has
herpes genitalis. The nurse provides instructions to the mother about modalities that may be
necessary to treat this condition. Which statement by the mother indicates an understanding of these
treatment measures?
a. | “I do not need to abstain from sexual
intercourse.” | b. | “I need to
use vaginal creams after the douche every day.” | c. | “I need to douche and perform a sitz bath three times a
day.” | d. | “It may be
necessary to have a cesarean section for delivery.” |
|
|
|
12.
|
A pregnant client tests positive for the hepatitis
B virus (HBV). The client asks the nurse if she will be able to breast-feed the baby as planned after
delivery. Which response by the nurse is appropriate?
a. | “You will not be able to breast-feed the baby
until 6 months after delivery.” | b. | “Breast-feeding is not a problem, and you will be able to breast-feed
immediately after delivery.” | c. | “Breast-feeding is allowed once the baby has been vaccinated with immune
globulin.” | d. | “Breast-feeding is not advised, and you should seriously consider
bottle-feeding the baby.” |
|
|
|
13.
|
A clinic nurse is collecting psychosocial data on a
client who has been told that she is pregnant. Which of the following findings would indicate to the
nurse that the client is at high risk for contracting human immunodeficiency virus
(HIV)?
a. | A history of intravenous (IV) drug
use | b. | A history of one sexual partner for the past 10
years | c. | No history of any sexually transmitted
diseases | d. | A significant other who is
heterosexual |
|
|
|
14.
|
A nurse in the prenatal clinic is taking a
nutritional history from a 16-year-old adolescent. Which statement by the adolescent would alert the
nurse to a potential psychosocial problem?
a. | “I only want to gain 10 pounds because I want to
have a small, petite baby.” | b. | “I will
continue drinking my afternoon milkshake.” | c. | “I don’t like dairy products.” | d. | “I’m not used to eating so much food but I will
try.” |
|
|
|
15.
|
A nurse in the prenatal clinic is conducting a
session about nutrition for a group of adolescents who are pregnant. The most appropriate measure to
teach the adolescents is which of the following?
a. | Avoid meals in fast-food
restaurants. | b. | Eliminate snacks
during the day. | c. | Monitor for
appropriate weight gain patterns. | d. | Eat only when
hungry. |
|
|
|
16.
|
A nurse is teaching a diabetic pregnant client
about nutrition and insulin needs during pregnancy. The nurse determines that the client understands
dietary and insulin needs if the client states that the second half of pregnancy may
require:
a. | Increased caloric intake | b. | Decreased caloric intake | c. | Increased
insulin | d. | Decreased insulin |
|
|
|
17.
|
A client in the prenatal clinic asks the nurse
about her delivery date. The client began her last menses on September 7, 2012, and ended the menses
on September 14, 2012. Using Nägele’s rule, the nurse would tell the client that the
estimated date of birth is which of the following?
a. | July 14, 2013 | b. | June 21, 2013 | c. | June 14,
2013 | d. | July 1, 2013 |
|
|
|
18.
|
A nurse is collecting data from a pregnant client
with a history of cardiac disease. The nurse is checking for venous congestion. The nurse inspects
which of the following areas, knowing that venous congestion is most commonly noted
here?
a. | Vulva | b. | Fingers | c. | Around the
eyes | d. | Around the
abdomen |
|
|
|
19.
|
A pregnant client is seen in the health care clinic
for a regular prenatal visit. The client tells the nurse that she is experiencing irregular
contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions.
Which of the following nursing actions would be appropriate?
a. | Instruct the client to maintain bedrest for the
remainder of the pregnancy. | b. | Instruct the
client that these are common and may occur throughout the pregnancy. | c. | Contact the physician. | d. | Call the maternity
unit and inform them that the client will be admitted in a prelabor
condition. |
|
|
|
20.
|
A nurse is caring for a pregnant client who was
diagnosed with acquired immunodeficiency syndrome (AIDS) and asks the nurse if she will be able to
breast-feed the infant after delivery. Which response by the nurse is appropriate?
a. | “Breast-feeding is
contraindicated.” | b. | “Breast-feeding is allowed as long as the mother is taking zidovudine
[AZT].” | c. | “Breast-feeding is allowed as long as the infant is not showing signs of
human immunodeficiency virus [HIV] infection.” | d. | “Breast-feeding is allowed as long as the infant receives an
immunization for HIV.” |
|
|
|
21.
|
A pregnant client asks the nurse in the clinic when
she will be able to start feeling the fetus move. The nurse responds by telling the mother that fetal
movements will be noted:
a. | Between 6 and 8 weeks’
gestation | b. | Between 8 and 10 weeks’
gestation | c. | Between 12 and 14 weeks’
gestation | d. | Between 16 and 20 weeks’
gestation |
|
|
|
22.
|
A blood glucose measurement is performed on a
pregnant client. The results indicate that her blood glucose is elevated. Which of the following
would the nurse anticipate to be prescribed for the mother?
a. | An oral hypoglycemic agent | b. | NPH insulin on a daily basis | c. | A 3-hour glucose tolerance test | d. | A sliding scale Regular insulin dose |
|
|
|
23.
|
A nurse is assisting in conducting a prepared
childbirth class and is instructing pregnant women about the method of effleurage. The nurse
instructs the women to perform the procedure by:
a. | Contracting and then consciously relaxing different
muscle groups | b. | Contracting an
area of the body such as an arm or leg and then concentrating on letting tension go from the rest of
the body | c. | Massaging the abdomen during contractions using both
hands in a circular motion | d. | Instructing the
significant other to stroke or massage a tightened muscle by the use of
touch |
|
|
|
24.
|
A nurse is assisting in planning care to meet the
emotional needs of a pregnant woman. Which of the following nursing interventions would be least
likely to assist in meeting her emotional needs?
a. | Providing an opportunity for the pregnant woman to
discuss the aspects of pregnancy | b. | Using a caring and
supportive approach when dealing with a pregnant woman | c. | Offering praise and reinforcement for compliance with treatment
therapies | d. | Providing the mother with pamphlets and booklets to read
about the pregnancy |
|
|
|
25.
|
A nonstress test is prescribed for a pregnant
client, and the client asks the nurse about the procedure. Which of the following information will
the nurse provide to the client?
a. | “The test is an invasive procedure and requires
that you sign an informed consent.” | b. | “The test
will take about 2 hours and will require close monitoring for 2 hours after the procedure is
completed.” | c. | “An
ultrasound transducer that records fetal heart activity is secured over the abdomen where the fetal
heart is heard most clearly.” | d. | “The fetus
is challenged by uterine contractions to obtain the necessary
information.” |
|
|
|
26.
|
A pregnant client who is anemic tells the nurse
that she is concerned about what her baby's condition will be following delivery. Which nursing
response would best support the client?
a. | "You will not have any problems if you follow all
the advice the doctor has given you." | b. | “Your baby
will need to spend a few days in the neonatal intensive care unit following
delivery." | c. | "Don't
worry about your baby; complications are rare." | d. | "The effects of anemia on your baby are difficult to predict, but
let's review your plan of care to ensure that you are providing the best nutrition and growth
potential." |
|
|
|
27.
|
During the intrapartum period, a nurse is caring
for a laboring client with sickle cell disease. The nurse ensures that the client receives
appropriate intravenous (IV) fluid intake and oxygen consumption to primarily:
a. | Stimulate the labor process. | b. | Avoid the necessity of a cesarean delivery. | c. | Prevent dehydration and hypoxemia. | d. | Eliminate the need for analgesic
administration. |
|
|
|
28.
|
A nurse in the labor room is assisting in caring
for a client in the active stage of labor. The nurse is told that the fetal patterns show a late
deceleration on the monitor strip. Based on this finding, the nurse prepares for which appropriate
nursing action?
a. | Placing the mother in a supine
position | b. | Documenting the findings and continuing to monitor the
fetal patterns | c. | Administering
oxygen via face mask | d. | Increasing the
rate of the intravenous (IV) oxytocin infusion |
|
|
|
29.
|
A licensed practical nurse (LPN) is assisting in
gathering data on a client who is scheduled for a cesarean delivery. Which of the following findings
would indicate a need to contact the registered nurse (RN)?
a. | Fetal heart rate of 180 beats per
minute | b. | White blood cell count of
12,000/mm3 | c. | Maternal pulse
rate of 85 beats per minute | d. | Hemoglobin of 11
g/dL |
|
|
|
30.
|
A nurse is monitoring a client in active labor and
notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes
that the fetal heart rate between contractions is 100 beats per minute. Which of the following
nursing actions is appropriate?
a. | Encourage the client’s coach to continue breathing
techniques. | b. | Encourage the
client to continue pushing with each contraction. | c. | Continue monitoring the fetal heart rate. | d. | Notify the registered nurse (RN). |
|
|
|
31.
|
A nurse is reviewing the record of a client in the
labor room and notes that the nurse-midwife has documented that the fetus is at minus one station.
The nurse determines that the fetal presenting part is
a. | 1 cm above the ischial spines | b. | 1 fingerbreadth below the symphysis pubis | c. | 1 inch below the coccyx | d. | 1 inch below the
iliac crest |
|
|
|
32.
|
A nurse is monitoring a client in labor whose
membranes rupture spontaneously. The initial nursing action is to:
a. | Take the client’s blood
pressure. | b. | Provide peripads to the
client. | c. | Note the amount, color, and odor of the amniotic
fluid. | d. | Determine the fetal heart
rate. |
|
|
|
33.
|
A nurse assisting in the labor room is preparing to
care for a client with hypertonic dysfunction. The nurse is told that the client is experiencing
uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority
nursing intervention in caring for the client is to:
a. | Monitor the oxytocin (Pitocin) infusion
closely. | b. | Provide pain relief measures. | c. | Prepare the client for an amniotomy. | d. | Promote ambulation every 30 minutes. |
|
|
|
34.
|
A nurse has assisted in developing a plan of care
for a client experiencing dystocia and includes several nursing interventions in the plan of care.
The nurse prioritizes the plan and selects which nursing intervention as the highest
priority?
a. | Keeping the significant other informed of the progress
of the labor | b. | Providing comfort
measures | c. | Monitoring fetal status | d. | Changing the client’s position
frequently |
|
|
|
35.
|
A nurse is assisting in preparing a plan of care
for a client who just delivered a dead fetus. The appropriate initial intervention in meeting the
emotional needs of the client and her spouse is which of the following?
a. | Encourage the client to talk about the dead
fetus. | b. | Allow the client and the spouse to hold the
baby. | c. | Allow family members to name the
baby. | d. | Gather data from the client and spouse about the
perception of the event. |
|
|
|
36.
|
A nurse is assisting in caring for a client with
abruptio placentae and is monitoring the client for disseminated intravascular coagulopathy (DIC).
Which of the following findings is least likely associated with DIC?
a. | Swelling of the calf of one
leg | b. | Prolonged clotting times | c. | Decreased platelet count | d. | Petechiae, oozing
from injection sites, and hematuria |
|
|
|
37.
|
A nurse is preparing to care for a woman in the
immediate postpartum period who has just delivered a healthy newborn. The nurse plans to take the
woman’s vital signs:
a. | Every 30 minutes during the first hour and then every
hour for the next 2 hours | b. | Every 15 minutes
during the first hour and then every 30 minutes for the next 2 hours | c. | Every hour for the first 2 hours and then every 4
hours | d. | Every 5 minutes for the first 30 minutes and then every
hour for the next 4 hours |
|
|
|
38.
|
A nurse is preparing to assist in performing a
fundal assessment on a postpartum client. The nurse understands that the initial nursing action when
performing this assessment is which of the following?
a. | Ask the client to turn onto her
side. | b. | Ask the client to lie flat on her back with her knees
and legs flat and straight. | c. | Ask the client to
urinate and empty her bladder. | d. | Massage the fundus
gently prior to determining the level of the fundus. |
|
|
|
39.
|
When performing a postpartum assessment on a
client, the licensed practical nurse (LPN) notes clots in the lochia. The LPN examines the clots and
notes that they are larger than 1 cm. Which of the following nursing actions is
appropriate?
a. | Document the findings. | b. | Notify the registered nurse (RN). | c. | Reassess the client in 2 hours. | d. | Encourage increased oral intake of
fluids. |
|
|
|
40.
|
A nurse is providing nutritional counseling to a
new mother who is breast-feeding her newborn. The nurse instructs the mother that her calorie intake
needs to increase by approximately:
a. | 100 calories per day | b. | 300 calories per day | c. | 500 calories per
day | d. | 1000 calories per
day |
|
|
|
41.
|
A nurse is providing instructions to the mother
following delivery regarding care of the episiotomy site to prevent infection. Which statement by the
mother indicates a need for further instructions?
a. | “I will wipe my perineum from front to back after
voiding and defecation.” | b. | “I will use
warm water or an irrigation device to rinse the perineum after
elimination.” | c. | “I will
change the perineum pads three times a day.” | d. | “I will take warm sitz baths three times a
day.” |
|
|
|
42.
|
A nurse is monitoring a new mother in the fourth
stage of labor for signs of hemorrhage. Which of the following signs, if noted in the mother, would
indicate an early sign of excessive blood loss and shock?
a. | A temperature of 100.4°
F | b. | A increase in the pulse rate from 88 to 102 beats per
minute | c. | An increase in the respiratory rate from 18 to 22
breaths per minute | d. | A blood pressure
change from 130/88 to 124/80 mm Hg |
|
|
|
43.
|
On the second postpartum day, a woman complains of
burning on urination, urgency, and frequency of urination. A urine sample is collected for
urinalysis, and the results indicate the presence of a urinary tract infection. The nurse instructs
the new mother regarding measures to take for the treatment of the infection. Which statement by the
mother indicates the need for further instructions?
a. | “My prescribed medication must be taken until it
is completed.” | b. | “My fluid
intake should be increased to at least 3000 mL daily.” | c. | “I should urinate frequently throughout the
day.” | d. | “Foods and
fluids that will increase urine alkalinity should be
consumed.” |
|
|
|
44.
|
A client in the postpartum unit complains of sudden
sharp chest pain. The nurse notes that the client is tachycardic and the respiratory rate is
elevated. The nurse suspects a pulmonary embolism. The initial nursing action would be which of the
following?
a. | Check the client’s blood
pressure. | b. | Prepare for the insertion of an intravenous (IV)
line. | c. | Prepare to administer oxygen at 8 to 10 L by tight face
mask. | d. | Prepare to administer morphine
sulfate. |
|
|
|
45.
|
A new mother is seen in the health care clinic 2
weeks after the birth of a healthy newborn. The mother says that she feels as though she has the flu
and complains of fatigue and aching muscles. On further data collection the nurse notes a localized
area of redness on the left breast, and the mother is diagnosed with mastitis. The mother asks the
nurse how the condition occurs. The appropriate nursing response is which of the
following?
a. | “The infection can occur at anytime during
breast-feeding.” | b. | “The
infection is most common for women who have breast-fed in the past.” | c. | “The infection usually involves both
breasts.” | d. | “The
infection usually is caused by wearing a supportive
bra.” |
|
|
|
46.
|
A nurse is caring for a client who delivered a
healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a
wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care
related to the infection. Which statement by the mother indicates the need for further
instructions?
a. | “I need to take the antibiotics as
prescribed.” | b. | “I need to
apply warm compresses to provide comfort.” | c. | “I need to take warm sitz baths to promote
healing.” | d. | “I need to
isolate my infant for 48 hours after starting the
antibiotics.” |
|
|
|
47.
|
A postpartum nurse has reinforced instructions to a
new mother on how to bathe her newborn. The nurse demonstrates the procedure to the mother and on the
following day asks the mother to perform the procedure. Which of the following observations, if made
by the nurse, indicates that the mother is performing the procedure correctly?
a. | The mother cleans the newborn’s ears and then
moves to the eyes and the face. | b. | The mother begins
to wash the newborn by starting with the eyes and face. | c. | The mother washes the arms, chest, and back followed by the neck, arms, and
face. | d. | The mother washes the entire newborn’s body and
then washes the eyes, face, and scalp. |
|
|
|
48.
|
A nurse in the delivery room is assisting with the
delivery of a newborn. The nurse prepares to prevent heat loss in the newborn due to conduction
by:
a. | Wrapping the newborn in a
blanket | b. | Closing the doors to the delivery
room | c. | Drying the newborn with a warm
blanket | d. | Warming the crib pad before placing the newborn in the
crib |
|
|
|
49.
|
The mother of a newborn calls the clinic and
reports to the nurse that when she was cleansing the newborn’s umbilical cord, the cord was
moist and discharge was noted. The appropriate nursing instruction to the mother is which of the
following?
a. | To increase the number of times that the cord is
cleansed per day | b. | To monitor the
cord for another 24 to 48 hours and to call the clinic if the discharge
continues | c. | To bring the infant to the
clinic | d. | That this is a normal
occurrence |
|
|
|
50.
|
A nurse is caring for a newborn following
circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which
of the following nursing actions would be appropriate?
a. | Document the findings. | b. | Notify the registered nurse (RN) immediately. | c. | Circle the amount of bloody drainage on the dressing and reassess in 30
minutes. | d. | Reinforce the
dressing. |
|
|
|
51.
|
A nurse in the newborn nursery is assisting in
monitoring a preterm newborn for respiratory distress syndrome (RDS). Which of the following findings
if noted in the newborn would alert the nurse to the possibility of this syndrome?
a. | Hypotension and bradycardia | b. | Tachypnea and retractions | c. | Acrocyanosis and grunting | d. | The presence of a barrel chest with
acrocyanosis |
|
|
|
52.
|
A postpartum nurse is providing instructions to the
mother of a breast-fed newborn who has hyperbilirubinemia. Which of the following instructions would
the nurse provide to the mother?
a. | Switch to bottle-feeding the baby during the period of
high bilirubin levels, and feed less frequently. | b. | Stop the breast-feedings and switch to bottle-feeding
permanently. | c. | Provide
bottled-water feedings between the breast-feeding sessions. | d. | Increase the frequency of the
breast-feeding. |
|
|
|
53.
|
A postpartum nurse is providing instructions to a
mother regarding how to provide a bath to the newborn. Which statement by the mother indicates the
need for further instructions?
a. | “I need to bathe my newborn after a
feeding.” | b. | “I need to
fill a clean basin or sink with 2 to 3 inches of water and then check the temperature using the
wrist.” | c. | “I will
never leave the newborn in the tub of water alone.” | d. | “I will gather all my supplies before I start bathing my
newborn.” |
|
|
|
54.
|
A nurse is caring for a client in labor. The nurse
reviews the physician’s orders and notes that the client has an order for butorphanol tartrate
(Stadol). The nurse understands that the action of this medication is to:
a. | Decrease pain. | b. | Increase uterine contractions. | c. | Decrease uterine contractions. | d. | Promote fetal lung maturity. |
|
|
|
55.
|
A nurse has an order to give a dose of
Rho(D) immune globulin (RhoGAM) to a client who has delivered an infant. The nurse
understands that this medication will prevent the next infant from experiencing which of the
following?
a. | Being affected by Rh
incompatibility | b. | Having Rh-positive
blood | c. | Developing perinatal
infection | d. | Experiencing high bilirubin
levels |
|
|
|
56.
|
A client experiencing preterm labor at 29
weeks’ gestation has been admitted to the hospital. The client has an order to receive
betamethasone. The nurse explains to the client that the medication will do which of the
following?
a. | Prevent spontaneous delivery | b. | Stop the uterine contractions | c. | Promote maturation of the fetal lungs | d. | Accelerate the growth rate of the fetus |
|
|
|
57.
|
A nurse is providing vaccine information to a
second-day postpartum client who received a rubella vaccine. The nurse reminds the client to avoid
which of the following after receiving this vaccine?
a. | Eating highly acidic foods for a
week | b. | Sustaining injury to the injection
site | c. | Having sexual relations for 2 to 3
months | d. | Becoming pregnant for 2 to 3
months |
|
|
|
58.
|
A licensed practical nurse (LPN) is assisting in
the care of a client who is receiving oxytocin (Pitocin) to induce labor. The LPN plans to notify the
registered nurse immediately if which of the following is noted?
a. | The client complains of
fatigue. | b. | The client becomes drowsy. | c. | There are early decelerations of fetal heart rate. | d. | The uterus becomes hyperstimulated. |
|
|
|
59.
|
A licensed practical nurse (LPN) is assisting in
the care of a pregnant teen-aged client with preeclampsia receiving magnesium sulfate. The LPN plans
to notify the registered nurse immediately if which sign of magnesium toxicity is
noted?
a. | Respiratory rate of 10 breaths per
minute | b. | Serum magnesium level of 5
mEq/L | c. | Proteinuria | d. | Hyperactive deep tendon reflexes |
|
|
|
60.
|
A nurse has a routine order to instill erythromycin
ointment (Ilotycin) into the eyes of a newborn. The nurse explains to the parents that the purpose of
the medication is to:
a. | Help the newborn to see more
clearly. | b. | Guard against infection acquired during intrauterine
life. | c. | Ensure the sterility of the conjunctiva in the
newborn. | d. | Protect the newborn from contracting an eye infection
from the birth process. |
|
|
|
61.
|
A licensed practical nurse (LPN) is caring for a
client in preterm labor who is receiving an infusion of ritodrine hydrochloride, when the client
suddenly begins to complain of shortness of breath. The LPN should take which action
first?
a. | Notify the registered nurse. | b. | Count the respiratory rate for at least 2 minutes. | c. | Bring a manual resuscitation bag to the bedside. | d. | Assist the client to lie down. |
|
|
|
62.
|
A licensed practical nurse (LPN) is assisting in
the care of a client in preterm labor who is being started on intravenous magnesium sulfate to stop
the contractions. The LPN checks to see that which of the following is available on the unit as an
antidote to magnesium sulfate?
a. | Magnesium oxide | b. | Vitamin K | c. | Aluminum
hydroxide | d. | Calcium gluconate |
|
|
|
63.
|
A nurse assisting in the care of a newborn has a
standing order to administer the hepatitis B vaccine to the infant. The nurse should plan to do which
of the following when carrying out this order?
a. | Spread the skin under the injection
site. | b. | Obtain written parental
consent. | c. | Use the dorsogluteal muscle. | d. | Select a 21-gauge, 1-inch needle. |
|
Multiple Response
Identify one
or more choices that best complete the statement or answer the question.
|
|
|
64.
|
A nurse in the newborn nursery is collecting data
on a neonate who was born of a mother addicted to cocaine. Which of the following would the nurse
expect to note in the neonate? Select all that apply.
|
|
|
65.
|
A clinic nurse is teaching a pregnant client about
the warning signs in pregnancy and prepares a list of the warning signs that indicate the need to
notify the physician. Which of the following would be included on the list? Select all that
apply.
|
|
|
66.
|
A nurse is monitoring a newborn who was born to a
drug-addicted mother. Which of the following findings would the nurse expect to note during data
collection for this newborn? Select all that apply.
|