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    Exam Review

    1. A nurse is caring for a client who is 36 hr postpartum. Exhibits After reviewing the information in the client's medical record, which of the following complications pose a greater risk for the client? The complication that poses the greatest risk for the client is ▾ hemorrhage as evidenced by their ▾ amount of lochia
      Dropdown 1:
      Option 1: mastitis
      Option 2: endometritis
      Option 3: hemorrhage
      Dropdown 2:
      Option 1: amount of lochia
      Option 2: temperature
      Option 3: breast findings
    2. A nurse is caring for a 2 month old infant who has had projectile vomiting for several days and is admitted to the pediatric unit. The infant's mucous membranes are dry and his anterior fontanel is depressed. Diagnostic results from his ultrasound shows that the infant has pyloric stenosis, Which of the following priority actions should the nurse take?
      A)Plan to administer a plain water enema and maintain contact precautions.
      B)Monitor the infant for dehydration and electrolyte imbalance
      C)Measure the infant's head circumference and weigh the infant.
      D)Offer the infant small, frequent feedings of thickened liquids
    3. A nurse in labor and delivery is caring for a client. Following delivery of the placenta, the nurse examines the umbilical cord. Which of the following vessels should the nurse expect to observe in the umbilical cord?
      A)One artery and one vein
      B)Two veins and one artery
      C)Two arteries and one vein
      D)Two arteries and two veins
    4. A nurse is planning discharge teaching for a postpartum client, Which of the following information should the nurse include for the client experiencing constipation?
      A)Laxatives are contraindicated for postpartum clients.
      B)Stay hydrated throughout the day
      C)Daily enemas are needed to relieve constipation
      D)Avoid fiber-rich foods, as they can worsen constipation.
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    Exam Review

    1. A nurse is providing care to an infant who has tetralogy of Fallot. The infant's caregiver reports increased irritability and a bluish discoloration of the infant's oral mucous membranes. Which of the following interventions is the nurse's priority?
      A)Consoling the child
      B)Administering morphine
      C)Providing supplemental oxygen
      D)Placing the child in a knee-to-chest position
    2. A nurse is caring for an infant diagnosed with tetralogy of Fallot. The infant's caregiver asks the nurse to explain this diagnosis. Which of the following is an accurate statement about this condition?
      A)"Tetralogy of Fallot is a group of four heart defects that impact circulation of blood in your child's body. These are pulmonary stenosis, ventricular septal defect, right ventricular hypertrophy, and an overriding aorta.
      B)"Tetralogy of Fallot is a heart defect that impacts circulation in your child's body due to the atypical placement of the mitral valve."
      C)"Tetralogy of Fallot is a group of three heart defects that impact the circulation of blood in your child's body. These are aortic stenosis, atrial septal defect, and left ventricular hypertrophy."
      D)"Tetralogy of Fallot is a heart defect that impacts the circulation in your child's body due to an opening between the atria, causing mixing of oxygenated and deoxygenated blood
    3. A nurse is assessing a client who is post-op tonsillectomy. Which of the following assessments would be a priority for the RN to intervene?
      A)Child has a fever, decreased urine output and is refusing oral liquids.
      B)Parent states her child is in a lot of pain.
      C)Nurse notes enlarged lymph nodes in cervical area (neck)
      D)Nurse notes that child is swallowing frequently.
    4. A nurse is reviewing charts for clients who have a diagnosis of placental abruption. Which of the following clients needs an emergent cesarean section?
      A)A client who is at 38 weeks of gestation, has a fetal demise and is hemorrhaging and has a cervix dilated at 1 cm
      B)A client who is at 37 weeks of gestation, has a blood pressure of 116/58 mm Hg a pulse of 72/min, and has a category Il fetal heart tracing with cervical dilation at
      C)A client who is at 32 weeks of gestation, has a blood pressure of 138/86 mm Hg, and a heart rate of 77/min with a category I fetal heart tracing
      D)A client who is at 39 weeks of gestation, has a blood pressure of 124/88 mm Hg and a pulse of 88/min with a fetal demise
    Page 2 of 9

    Exam Review

    1. A nurse is caring for a male infant who has stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings?
      A)Inguinal hernia
      B)Tracheoesophageal fistula
      C)Hypertrophic pyloric stenosis
      D)Intussusception
    2. A nurse is caring for a client who is in labor. Exhibits Which of the following actions should the nurse take? Select (3) options.(SATA)
      A)Administer an antipyretic
      B)Elevate the fetal presenting part.
      C)Reposition the client on their side.
      D)Discontinue the oxytocin infusion.
      E)Remove the epidural catheter.
      F)increase the rate of IV fluids
    3. A nurse is caring for an 11-year-old client who presents with abdominal pain and possible appendicitis, Which of the following manifestations should the nurse expect?
      A)Pain in both quadrants of the upper abdomen
      B)Pain in the left lower quadrant of the abdomen
      C)Pain in the right upper quadrant of the abdomen
      D)Pain in the right lower quadrant of the abdomen
    4. A nurse is reviewing the medical record of a client who gave birth 2 hours ago. Which of the following findings increases the client's risk for a postpartum hemorrhage?
      A)Moderate lochia rubra
      B)First degree perineal laceration
      C)Bloggy uterus
      D)Singleton pregnancy
    Page 3 of 9

    Exam Review

    1. A nurse is caring for a client who had a vaginal birth yesterday, is not breastfeeding and had no perineal lacerations. The client was given ibuprofen 1 hr ago. Which of the following outcomes should the nurse identity as an indication that the medication achieved the desired effect?
      A)Decrease in amount of lochia and passage of clots.
      B)Decrease in milk production.
      C)Decrease in swelling in the extremities
      D)Decrease in discomfort.
    2. A nurse is caring for a 6 year old client who has congestive heart failure and is taking digoxin daily. The client refused breakfast and is complaining of nausea a a and weakness. W Which of the following actions should the nurse take first?
      A)Request a dietitian consult.
      B)Check the client's vital signs.
      C)Request an order for an antiemetic
      D)Suggest that the client rests before eating the meal.
    3. A nurse is providing care for an infant who has heart failure and is being discharged from the hospital. When providing discharge education, which of the following clinical manifestations should the nurse ensure caregivers are able to identify as signs of worsening heart failure?
      A)Stridor, diuresis, and increased work of feeding
      B)Bradycardia, rapid weight gain, and irritability
      C)Tachypnea and diaphoresis with feeding, poor weight gain, and irritability
      D)Abdominal pain, poor appetite, and cough
    4. A nurse is providing teaching to a client who has asthma and a new prescription for inhaled beclomethasone. Which of the following instructions should the nurse provide?
      A)Check the pulse after medication administration.
      B)Take the medication with meals.
      C)Limit caffeine intake.
      D)Rinse the mouth after administration.
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    Exam Review

    1. A nurse in an urgent care center is caring for a client who is having an acute asthma exacerbation. Which of the following actions is the nurse's highest priority?
      A)Administering nebulized albuterol
      B)Providing immediate rest for the client
      C)Positioning the client in high-Fowler's
      D)Initiating oxygen therapy
    2. A nurse is caring for a client who is 4 hr postpartum following a vaginal birth. The client has saturated a perineal pad within 10 min. Which of the following actions should the nurse take first?
      A)Prepare to administer a prescribed oxytocic preparation.
      B)Massage the client's fundus.
      C)Assess client's blood pressure.
      D)Assess the bladder for distention.
    3. A nurse is caring for an adolescent who has heart failure and a prescription for digoxin 125 mcg PO daily. Available is digoxin PO 0.25 mg/tablet. How many tablets should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
    4. A nurse is assessing a newborn. Which of the following should the nurse understand is a clinical manifestation of pyloric stenosis?
      A)Absent bowel sounds
      B)Increased sodium levels
      C)Golf ball-sized mass over the left quadrant
      D)Projectile vomiting after feedings
    Page 5 of 9

    Exam Review

    1. A nurse is assessing an infant in the cardiology clinic. Which of the following sets of clinical manifestations is consistent with a ventricular septal defect?
      A)Cyanosis, fatigue with feeds and diminished breath sounds
      B)Cyanosis, murmur, and weight loss
      C)Murmur, tachypnea and wheezing
      D)Murmur, tachycardia and fatigue with feeds
    2. Using the given diagram, match each letter with the correct graph. Note: Each category must have at least 1 response option selected.
      ABCD
      Late decelerations✓
      Uterine Contractions✓
      Variable decelerations✓
      Early decelerations✓
    3. Which finding would the nurse expect as a normal finding when assessing a postpartum client's uterus after delivery?
      A)Displaced to the left
      B)Above the umbilicus
      C)Soft and boggy located midway between the symphysis pubis and the umbilicus
      D)Firm and midline
    4. A nurse is providing discharge teaching to a client who has asthma and a new prescription for fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the client to report to the provider?
      A)Dry oral mucous membranes
      B)Sedation
      C)Increased appetite
      D)White coating in the mouth
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