Review for Maternity Hessi
2. A pregnant woman in the first trimester of pregnancy has hemoglobin of 8.6 mg/dl and a hematocrit of 25.1 %. What food should the nurse encourage this client to include in her diet?
3. The nurse is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the nurse withhold the drug?
· Respiratory rate of 22 breaths/min
· A large amount of lochia rubra
· Blood pressure 149/90
· Positive Homan’s sign
Note: The only contraindication that has this medicine is HBP, page 581 Matern…book.
4. The nurse is planning care for a 16-year-old, who has juvenile rheumatoid arthritis (JRA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?
· Begin a training program lifting weights and running
· Splint affected joints during activity
· Exercise in a swimming pool
· Perform passive range of motion exercises twice daily
Note: page 1710 MB (Maternity book)
5. A client receiving oxytocin (Pitocin) to augment early labor. Which assessment is most important for the nurse to obtain each time the infusion rate is increased?
· Pain level
· Blood pressure
· Infusion site
· Contraction pattern
Note: Page 508 MB
6. One day after vaginal delivery of a full term baby, a postpartum client’s white blood cell count is 15.000/mm. What action should the nurse take first?
· Check the differential, since the WBC is normal for this client
· Assess the client’s temperature, pulse, and respirations q4h
· Assess the client’s perineal area for signs of a perineal hematoma
· Notify the healthcare provider, since this finding is indicative of infection
Note: During the first 10 to 12 days after partum is between 20,000-25, 000
7. A neonate who has congenital adrenal hypoplasia (CAH) presents with ambiguous genitalia. What is the primary nursing consideration when supporting the parents of a child with this anomaly?
· Discuss the need for cortisol and aldosterone replacement therapy after discharge
· Support the parents in their decision to assign sex of their child according to their preference
· Offer information about ultrasonography and genotyping to determine sex assignment
· Explain that corrective surgical procedures consistent with sex assignment can be delayed
Note: page 776 MB
8. The nurse assessing a 9-year old boy who has been admitted to the hospital with possible acute postsreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant?
· Back pain for a few days
· A history of hypertension
· A sore throats last week
· Diuresis during the nights
Note: Page 1538 MB
9. A loading dose of terbutaline (Brethine) 250 mcg IV is prescribed for a client in preterm labor. Brethine 20 mg is added to 1,000 ml D W. How many ml of the solution should the nurse administer?
10. 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?
· Alert the neonatal team and prepare for neonatal resuscitation
· Notify the healthcare provider from the client’s bedside
· Obtain written consent for an emergency cesarean section
· Draw a blood sample for stat hemoglobin and hematocrit
Note: S&S of Abruption Placentae …page 366 collaborative cares MB
11. A laboring client’s membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. What intervention should the nurse implement first?
· Turn the client to her left side
· Contact the healthcare provider
· Assess the fetal heart rate
· Check the cervical dilation
Note: page 202 meconium and intrapartal period MB
12. A 5-year-old child is admitted to the pediatric unit with fever and pain secondary to a sickle cell crisis. Which intervention should the nurse implement first?
A. Obtain a culture of any sputum or wound drainage.
· Obtain a culture of any sputum or wound drainage
· Initiate normal saline IV at 50 ml/hr
· Administer a loading dose of penicillin IM
· Administer the initial dose of folic acid PO
Note: Therapeutic management page 1497 MB.
13. A child 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?
· Respiratory alkalosis
· Respiratory acidosis
· Metabolic alkalosis
· Metabolic acidosis
Note: In the book under Vomiting topic I did not find any but I know that when the people has frequent vomits it’s at risk for developing metabolic alkalosis related to the loss of hydrochloric acid.
14. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respiration. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration?
· Respiratory alkalosis
· Respiratory acidosis
· Metabolic acidosis
· Metabolic alkalosis
Note: page 1617 MB under ketoacidosis.
15. 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?
· Reduce cerebral edema and lower intracranial pressure
· Avert hypotension and septic shock
· Prevent cardiac arrhythmias and heart failure
· Promote kidney perfusion and normal blood pressure.
Note: Page 1581 MB under therapeutic and nursing care management.
16. A client whose labor is being augmented with an oxytocin(Pitocin) infusion requests an epidural for pain control. Findings of the last vaginal exam, performed 1 hour ago, were 3 cm cervical dilation, 60% effacement, and a 2-station. What action should the nurse implement first?
· Decrease the oxytocin infusion rate
· Determine current cervical dilation
· Request placement of the epidural
· Give a bolus of intravenous fluids
Note: page 413 MB
17. A child who received multiple blood transfusions after correction of a congenital heart defects is demonstrating muscular irritability and is oozing blood from the surgical incision. Which serum value is most important for the nurse before reporting to the healthcare provider?
· CO combining power
Note: Transfusions are in the page 1520 -1521, del unico electrolyte imbalance que habla es del K porque lo mas frecuente en las tranfusiones
Es hyperkalemia, pero en esta pregunta los s&s no concuerdan con la hyperkalemia y ademas tampoco es una de las opciones de respuesta, por otra parte nos dan el key word de que son varias tranfusiones en donde existe el riesgo que producto del anticoagulante citrate que contienen las tranfusiones y que se encarga de binde o combinarse con el Ca free, entonces este, el calcio este disminuido en sangre y produce estos sintomas.
18. A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chronic (sudden aimless movements of the arms and legs). Which information should the nurse to the parents?
· Muscle tension is decreased with fine motor skill projects, so these activities should be encouraged
· The chorea or movements are temporary and will eventually disappear
· Permanent life-style changes need to be made to promote safety in the home
· Consistent discipline is needed to help the child control the movements
Note: page 1474
19. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant, notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next?
· Measure the infant’s head to heel length
· Observe the infant for sunset eyes
· Palpate the anterior fontanel for tension and bulging
· Plot the measurement on the infant’s growth chart
Note: page 1595 MB
20. A 16-year-old gravida 1, para 0 client has just been admitted to the hospital with a diagnosis of eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include in this client’s nursing care plan?
· Keep airway equipment at the bedside.
· Allow liberal family visitation
· Monitor blood pressure, pulse, and respirations q4h
· Assess temperature q1h
Note: page 346
21. During a well-child visit for their child, one of the parent who has an autosomal dominant disorder tells the nurse, “We don’t plan on having any more children, since the next child is likely to inherit this disorder”. How should the nurse respond?
· Explain that the risk of inhering the disorder decrease by 50% with each child the couple has
· Acknowledge that the next that the next child will inherit the disorder since the first child did not
· Encourage the couple to reconsider their decision since the inheritance pattern may be sex-linked
· Confirm that there is a 50% chance of their future children inheriting the disorder
22. The nurse is caring for a one-year-old child following surgical correction of hypospadias. The nursing action has the highest priority?
· Monitor urinary output
· Auscultate bowel sounds
· Observe appearance of stool
· Record percent of diet eaten
23. Patient with Duchenne Disease. The nurse has to explain to the mother that:
This condition is inherited in an X-linked recessive chromosome pattern
24. Primipara patient. What is the pet to share time a, home that is not recommended?
25. An infant with letralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
· Administer morphine sulphate
· Start IV fluids
· Place the infant in a knee-chest position
· Provide 100% oxygen by face mask
Note: page 1465 (box) MB
26. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12 year old sibling at the child’s bedside. Which instruction best supports family?
· While waiting for the healthcare provider, only one visitor may stay with the child
· All of you should leave while the healthcare provider sutures the child’s forehead
· It is best if the sibling goes to the waiting room until the suturing is completed
· Please decide who will stay when the healthcare provider begins suturing
Note: Critical Thinking question
27. The parents of a 3 year-old boy who has Duchenne muscular dystrophy (DMD) ask “how can our son have this disease? We are wondering if we should have any more children” What information should the nurse provide these parents?
· This is an inherited X-linked recessive disorder, which primarly affects male children in the family
· The male infant had a viral infection that went unnoticed and iuntreated, so muscle damage was incurred
· The XXXX muscle groups of males can be impacted by a lack of the protein dystrophyn in the mother
· Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles
Note: page 1733 MB
28. A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
· Bilateral bronchial breath sounds
· Diaphragmatic respiration
· A resting respiratory rate of 35 breathe per minute
· Flaring of the nares
29. A two year old child with a heart failure(HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse obtains an apical heart rate of 128 bpm. What action should the nurse implement?
· Determine the pulse deficit
· Administer the schedule dose
· Calculate the safe dose range
· Review the serum digoxin level
Note: page 1460 MB
30. Which nursing intervention is most important to include in the plan of care for
for a child with acute glomerulonephritis?
· Encourage fluid intake
· Promote complete bed rest
· Weight the child daily
· Administer vitamin supplements
Note: page 1539 MB
31. A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When obtaining the nursing history which finding should the nurse expect to obtain?
· High blood cholesterol level on routine screening
· Increased thirst and urination
· A recent strep throat infection
· A recent DPT immunization
· A newborn yellow abdomen and chest
Assess bilirubin level
· Child HIV
· Percentile 97
Is in normal high level con respect a las caracteristicas del nino
· To confirm RDS in a newborn
Put baby in a room and calm the baby
Encourage the parents to help the baby with homework
· Watery vaginal white in the first trimester
· Palirizumab (synagis)
Is given to high risk baby
43. A child with leukemia is admitted for Chemotherapy and the nursing diagnosis " altered nutrion, less those body requirements related to anorexia, nausea and vomiting" is identified. Which intervention the nurse included in this child plan of care?
Allow the child to eat any food desired and tolerated.
44. 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 condition, what information is most important for the nurse to provide?
Maternal blood pressure
45. A new mother is having trouble breast feeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. What intervention would be most helpful to this mother?
Ask the mother to stop feeding, confront the infant, and then assist the mother to help the baby latch on.
46. A blind litter girld, 8 year sold was admitted to the hospital .....
Bring familiarly toys from home, such as bear,doll.
52. A pregnant woman with hypermesis gravidarium, what is the best nurse intervention.
Administered prescribed IV solution.