Exam Review

A 2-month-old infant is brought to the emergency room.Which factor should lead the RN to suspect that the child may have experienced abusive head trauma?
A)Sunken fontanels.
B)Retinal hemorrhage.
C)Large bruises on the body.
D)Laceration to the forearm.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel on a pediatric unit?
A)Weigh the diaper of an infant for output.
B)Assess the dressing of the infant that is two days post-operative.
C)Calculate the Morse Fall Scale for the preschool child.
D)Perform assessment of a child's developmental milestones.
A nurse in a provider's office is planning care for a client who has a new diagnosis of polycystic ovarian syndrome.The nurse should plan to monitor which of the following laboratory values?
A)Liver function.
B)Blood urea nitrogen (BUN).
C)Thyroid-stimulating hormone.
D)Serum glucose levels.
A newborn is admitted with a diagnosis of a spiral fracture of the right femur.The mother states the child received the injury when the baby fell off the changing table.Which would be the priority nursing intervention?
A)Call the child abuse hotline.
B)Educate the mother on safety.
C)Inform the mother to call the nurse for all diaper changes.
D)Complete the Morse Fall Scale.

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A nurse is caring for a newborn and assessing newborn reflexes.To elicit the Moro reflex, the nurse should take which of the following actions?
A)Perform a sharp hand clap near the infant.
B)Place a finger at the base of the newborn's toes.
C)Hold the newborn vertically allowing one foot to touch the table surface.
D)Turn the newborn's head quickly to one side.
An 18-hour-old infant with hyperbilirubinemia is placed under phototherapy bank lights.Which of the following is an appropriate intervention for this infant?
A)Expose as much of the infant's skin to the lights as possible.
B)Keep skin moisturized with lotion.
C)Keep eye shields on at all times, including when breastfeeding.
D)Tightly swaddle the infant in a blanket.
The nurse knows that which of the following is not a cause of mastitis?
A)Infrequent, inconsistent feedings.
B)Cracks or fissures of the nipples.
C)Gradual weaning of breastfeeding.
D)Engorgement from oversupply of milk.
A nurse is caring for a client who is experiencing menopausal symptoms and asks the nurse about menopausal hormone therapy (HT). The nurse should inform the client that HT is contraindicated due to which of the following findings in the client's medical history?
A)History of breast cancer.
B)Concurrent treatment for GERD.
C)History of dermatitis.
D)Multiple hospitalizations for COPD.

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The nurse is caring for a newborn born at 30 weeks' gestation.Which assessment finding should the nurse anticipate?
A)Plantar creases over the entire sole.
B)Flexion of all four extremities.
C)Abundance of subcutaneous fat deposits.
D)Lanugo covering most of the body.
A nurse is discharging a child who has sickle cell anemia after an acute crisis episode.Which of the following instructions should the nurse include in the teaching?
A)Restrict outdoor play activity to 1 hour per day.
B)Apply cold compresses when your child expresses pain.
C)Offer fluids to your child multiple times every day.
D)Monitor your child's temperature daily.
Which three assessment findings indicate that the breastfeeding client has achieved a proper latch?(SATA)
A)A slurping or clicking sound as the infant sucks.
B)Audible swallowing.
C)Infant's tongue cups under the breast with lips flanged.
D)The mother can see a rhythmic sucking pattern.
E)Dimpling of the infant's cheeks while sucking.
An infant has just undergone surgical repair of a myelomeningocele.What is the priority nursing intervention to perform immediately following the procedure?
A)Position the infant supine to protect the surgical site.
B)Monitor head circumference.
C)Monitor intake and output.
D)Maintain skin integrity.

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The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home.Which statement made by the parents suggests that additional education is necessary?
A)Playing on the backyard swings and running around outside are exercises our child will really enjoy.
B)Three to four times a day we will perform chest therapy and postural drainage on our child.
C)A high-protein, high-calorie diet may need to be supplemented with a high-calorie formula.
D)Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements.
Which assessment finding in a newborn places them at risk for physiological jaundice?
A)Acrocyanosis.
B)Mongolian spots.
C)Cephalohematoma.
D)Caput succedaneum.
A nurse is assessing a child who is in sickle cell crisis.Which of the following findings should the nurse expect?
A)Pain.
B)Constipation.
C)High fever.
D)Bradycardia.
After receiving instruction on the use of a diaphragm for contraception, which statement by the client indicates that they have understood the teaching?
A)Once I am fitted for the diaphragm it will always be the correct size.
B)This contraceptive can be used during menstruation.
C)I need to leave the diaphragm in for six hours after the last act of intercourse.
D)I can leave the diaphragm in for a day or two.

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The nurse is caring for a newborn diagnosed with patent ductus arteriosus (PD
A)Decreased urine output.
B)Bradycardia.
C)Cyanosis of the extremities.
D)A continuous "machinery-like" heart murmur.
When caring for a 13-year-old with muscular dystrophy receiving corticosteroids to slow disease progression, which of the following medication side effects would you assess for?
A)Weight gain.
B)Mood changes.
C)Chronic fatigue.
D)Osteoporosis.
A nurse is assessing a client 1 hour after delivery and notices a large amount of lochia rubra along with several small clots on the perineal pad.The client's fundus is firm and located at the umbilical level, in the midline.What action should the nurse take next?
A)Increase the frequency of fundal massage.
B)Document the findings and continue to monitor the client.
C)Notify the provider immediately.
D)Encourage the client to empty her bladder.
A nurse is caring for a client who is in labor and has an external fetal monitor.The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?
A)Umbilical cord compression.
B)Uteroplacental insufficiency.
C)Fetal head compression.
D)Maternal bradycardia.

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The nurse identifies the following assessment findings in a client who is 36 weeks' gestation.Which should be immediately reported to the provider?
A)Positive rubella serum antibody titer.
B)Blood pressure 144/94 mmHg in left arm.
C)Copious leukorrhea.
D)O negative blood type.
Which assessment findings would alert the nurse to an infant or child in heart failure?(SATA)
A)Difficulty feeding infant.
B)Wheezes or rales.
C)Edema in feet and legs.
D)Tachypnea.
A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck.When asked what happened, she states, "I walked into a door.”. What are the most appropriate interventions by the nurse?(SATA)
A)Interview the client privately.
B)Maintain a calm, caring, professional demeanor.
C)Ask the teen if she feels safe.
D)Contact the police.
Which of the following clients would the nurse report as a suspected abuse case?(SATA)
A)A 2-year-old with a large bruise on the forehead.
B)A 4-year-old with circular abrasions around the wrists.
C)A 10-year-old with a burn on the palm of the hand.
D)A 6-year-old with splash burns on the front torso.

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