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The nurse is providing preoperative teaching to a teenage client with appendicitis information should the nurse include about postoperative activity?

. A client is receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased? D. Contraction pattern.

17. One day after vaginal delivery of a full-term baby, a postpartum client’s white blood cell count is 15,000/mm3. What action should the nurse take first? A. Check the differential, since the WBC is normal for this client.

18. A client delivers a viable infant, but begins to have excessive uncontrolled vaginal bleeding after the IV Pitocin is infused. When notifying the healthcare provider of the client’s condition, what information is most important for the nurse to provide? A. Maternal blood pressure.

19. While obtaining the vital signs of a 10-year-old who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement? A. Inspect the posterior oropharynx.

20. During a routine clinic visit, the nurse determines that a 5-year-old boy’s blood pressure is 112/70. When calculating the child’s blood pressure percentile, the nurse adjusts the calculation for age and height. What actions should the nurse implement next? A. Compare the child’s blood pressure with readings from previous visits.

21. A neonate who has congenital adrenal hyperplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly? C. Offer information about ultrasonography and genotyping to determine sex assignment.

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22. A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child’s hair with permethrin (Nix) shampoo and calls his parents. What instruction should the nurse provide to the parents about treatment for head lice? A. Rewash the child’s hair following a 24-hour isolation period. B. Wash the child’s bed linens and clothing in hot soapy water. —- Maybe this C. Take the child to a hair salon for a shampoo and a shorter haircut. D. Dispose of the child’s brusches, combs, and others hair accessories.

23. During a 26-week gestation prenatal exam, a client reports occasional dizziness and lightheadness when she is lying down. What intervention is best for the nurse to recommend to this client. D. Elevate the head with two pillows while sleeping.

24. The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4 F, heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74. What action should the nurse implement? A. Document the vital signs in the record.

25. The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant? C. A sore throat last week

26. A 4-day postpartum client calls the clinic and reports that her nipples are so sore that she does not know if she can continue to breastfeed her infant. What instruction is best for the nurse to provide? C. Apply hot packs just before each feeding.

27. A loading dose of terbutaline (Bretine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1000 ml D5W. How many ml of the solution should the nurse administer? (Enter numeric value only)

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28. A newborn with myelomeningocele is admitted to the neonatal intensive care unit. Which preoperative nursing intervention should the nurse implement first? A. Place the infant on the abdomen to protect the sac.

29. An infant is placed in a radiant warmer immediately after birth. At one hour of age, the nurse finds the infant to be jittery, tachypneic, and hypotonic. What is the first action that the nurse should take? D. Determine the infant’s blood sugar level.

30. The mother of a 5-week-old tells the nurse that her baby has acne and asks if she can use her teenage son’s acne cream, benzoyl peroxide, on the baby’s face. Which answer should the nurse to provide? A. “ Your baby may be showing signs of a systemic disease and needs to be seen by a healthcare provider”

31. The nurse is providing preoperative teaching to a teenage client with appendicitis information should the nurse include about postoperative activity?

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D. Early ambulation after surgery will be encouraged to reduce complications and promote healing.

32. A 36-week primigravida is admitted to labor and delivery with severe abdominal pain and bright red vaginal bleeding. Her abdomen is rigid and tender to touch. The fetal heart rate (FHR) is 90 beats/minute, and the maternal heart rate is 120 beats/minute. What action should the nurse implement first? C. obtain written consent for an emergency cesarean section.

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34. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first? B. Contact the healthcare provider.

35. A 34-week primigravida with pregnancy induced hypertension (PIH) is receiving Ringer’s Lactate 500 ml with magnesium sulfate 20 grams at the rate of 3 grams/hour. How many ml/hour should the nurse program the infusion pump? (Enter numeric value only)

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36. The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby’s weight has triple compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer? D. “What food does your baby usually eat in a normal day?”

37. A 5-year-old child is admitted to the pediatric unit fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first? B. Initiate normal saline IV at 50ml/hr.

38. A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is this child likely to exhibit? C. Metabolic Alkalosis.

39. Artificial rupture of the membranes of a laboring client reveals meconium-stained fluid. What intervention has the greatest priority? D. Have a meconium aspirator available at delivery.

40. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for wich acid base alteration? C. Metabolic acidosis

41. The nurse is caring for a 5-year-old child with Reye’s syndrome. Which goal of treatment most clearly relates to caring for this child? A. Reduce cerebral edema and lower intracranial pressure.