Question: Which description of a stool is characteristic of intussusception?
Answer Options: Ribbon-like stools Hard stools positive for guaiac “Currant jelly” stools Loose, foul-smelling stools
Answer: “Currant jelly” stools
Question: The nurse is caring for a 10-month-old infant diagnosed with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should be included in the child’s care?
Answer Options: Administer antibiotics and discharge home. Administer cough syrup and place on supplemental oxygen. Encourage adequate nutritional intake, rest and monitor oxygen saturation. Encourage interactive play with other patients the same age.
Answer: Encourage adequate nutritional intake, rest and monitor oxygen saturation.
Question: The cheese-like, whitish substance that fuses with the epidermis and serves as a protective coating over the fetal skin is called:
Answer Options: vernix caseosa. surfactant. caput succedaneum. acrocyanosis.
Answer: vernix caseosa.
Question: A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-lb, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, “I’m bleeding a lot.” The most likely cause of after-birth hemorrhage in this woman is:
Answer Options: uterine atony. Retained placental fragments. unrepaired vaginal lacerations. Puerperal infection.
Answer: uterine atony.
Question: Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last action the nurse will consider is:
Answer Options: Pouring water from a squeeze bottle over the woman’s perineum while she sits on the toilet and tries to void. Placing oil of peppermint in a bedpan under the woman. Offering the patient analgesics. Emptying the patient’s bladder with a sterile straight catheter.
Answer: Emptying the patient’s bladder with sterile straight catheter.
Question: As relates to rubella vaccine, nurses should be aware of the following educational need for the patient:
Answer Options: breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. women should be made aware that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.
Answer: women should be made aware that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination.
Question: Post Partum Hemorrhage (PPH) may be sudden and result in rapid blood loss. The nurse must be alert to the symptoms of hemorrhage and hypovolemic shock and be prepared to act quickly to minimize blood loss. Astute assessment of circulatory status can be done with noninvasive monitoring. Please choose from the following the type of noninvasive assessments that the RN would perform:
Answer Options: Pulse oximetry Heart rate Arterial pulses Skin color, temperature, turgor Blood pressure Increase or decrease in reflexes
Answer: Pulse oximetry, Heart rate, Arterial pulses, Skin color, temperature, turgor, Blood pressure
Question: Medications that may be used to manage Post Partum Hemorrhage (PPH) include:
Answer Options: Pitocin Methergine Fluconazole Hemabate Magnesium Sulfate
Answer: Pitocin, Methergine, Hemabate
Question: Babies are prone to losing body heat after birth. Nurses can prevent evaporative heat loss in the newborn by:
Answer Options: drying the baby immediately after birth and wrapping the baby in a dry warmed blanket. protecting the baby from drafts and keeping the baby away from air conditioning vents. keeping the baby away from outside walls and windows. using warmed scales to weigh the baby, warming stethoscopes, and the nurse’s hands before touching the baby.
Answer: drying the baby immediately after birth and wrapping the baby in a dry warmed blanket.
Question: A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to:
Answer Options: apply an oil-based lotion to the newborn’s skin to prevent drying and cracking. limit the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea. place eye shields over the newborn’s closed eyes. change the newborn’s position every 4 hours.
Answer: place eye shields over the newborn’s closed eyes.
Question: A baby is born and at 1 minute of age has an Apgar score of 7. What does the nurse know this score indicates which action:
Answer Options: An infant having no difficulty adjusting to extrauterine life and needing no further testing. An infant in severe distress who requires neonatal resuscitation. A prediction can be made to the mother that her baby will have a future free of neurologic problems. An infant should be given “blow by O2” to the face and should be assessed again at 5 minutes after birth.
Answer: An infant should be given “blow by O2” to the face and should be assessed again at 5 minutes after birth.
Question: The nurse administers IM Vitamin K to the newborn within the first hour of birth. Why is this medication given to the baby?
Answer Options: Most mothers have a diet deficient in vitamin K, which results in the infant’s being vitamin K deficient. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. The normal intestinal flora responsible for the synthesis of vitamin K is not present in the newborn’s intestinal tract at birth. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.
Answer: The normal intestinal flora responsible for the synthesis of vitamin K is not present in the newborn’s intestinal tract at birth.
Question: A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization, the infant is weighed. The birth weight is 4.26 kg (9 lbs, 6 ounces). The nurse’s most appropriate action is to:
Answer Options: leave the infant in the room with the mother and tell her you will be back in an hour. take the infant immediately to the nursery and tell the nurses there you will be back in an hour. perform a Ballard Gestational Age Assessment to determine whether the infant is large for gestational age. monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
Answer: monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.
Question: A premature infant with respiratory distress syndrome (RDS) receives pulmonary surfactant in the NICU. You are the nurse caring for the mother of this baby on the Post Partum floor. How will you explain the use of surfactant for her infant?
Answer Options: “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide, by improving respiratory compliance.” “The drug keeps your baby from requiring too much sedation.” “Surfactant is used to reduce episodes of periodic apnea.” “Your baby needs this medication to fight a possible respiratory tract infection.”
Answer: “Surfactant improves the ability of your baby’s lungs to exchange oxygen and carbon dioxide, by improving respiratory compliance.”
Question: Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:
Answer Options: showing signs of a low blood sugar. experiencing severe swings in blood pressure. trying to maintain a neutral thermal environment. breathing in a respiratory pattern common to premature infants.
Answer: breathing in a respiratory pattern common to premature infants.
Question: Human immunodeficiency virus (HIV) may be perinatally transmitted:
Answer Options: only in the third trimester from the maternal circulation. by a needlestick injury at birth from unsterile instruments. only through the ingestion of amniotic fluid. through the ingestion of breast milk from an infected mother.
Answer: through the ingestion of breast milk from an infected mother.
Question: Which infant would be more likely to have Rh incompatibility?
Answer Options: Infant of an Rh-negative mother and a father who is Rh positive. Infant who is Rh negative and whose mother is Rh negative. Infant of an Rh-negative mother and a father who is Rh negative. Infant who is Rh positive and whose mother is Rh positive.
Answer: Infant of an Rh-negative mother and a father who is Rh positive.
Question: A woman is in her 24th week of pregnancy. She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:
Answer Options: this is a normal respiratory change in pregnancy caused by elevated levels of estrogen. this is an abnormal cardiovascular change, and the nosebleeds are an ominous sign. the woman is a victim of domestic violence and is being hit in the face by her partner. the woman has been using cocaine intranasally.
Answer: this is a normal respiratory change in pregnancy caused by elevated levels of estrogen.