NUR 145 ( EXAM GINA )

A client at 37 weeks’ gestation arrives at the emergency department stating that

she has abdominal pain but no vaginal bleeding. The health care provider
diagnoses abruptio placenta. The client asks the nurse why it is so painful. What
should the nurse consider is the initial cause of the abdominal pain before
responding in language the client will understand? *

Concealed hemorrhage

A nurse in the birthing unit is caring for several clients. Which factor should the
nurse anticipate will increase the risk for hypotonic uterine dystocia? *

Twin gestation

When planning long-term care for a child with cerebral palsy (CP), it is important
for the nurse to consider that the: *

child should have genetic counseling before planning a family.

A nurse is obtaining the health history from a client with a diagnosis of a ruptured
tubal pregnancy. At what point in the pregnancy does the nurse expect the client
to state when the low abdominal pain and vaginal bleeding started? *

About the sixth week of pregnancy

To slow the progression of the curvature, the preadolescent with scoliosis is fitted
with a brace. How should the nurse respond to the parents’ questions about when
the brace will no longer be needed? *

After cessation of bone growth

A client is receiving magnesium sulfate therapy for severe preeclampsia. What

initial sign of toxicity should alert the nurse to intervene? *

Lack of the knee-jerk reflex

A nurse is caring for a client who is having a prolonged labor. The client is annoyed
and very concerned because her labor is deviating from what she perceives as
normal. After the nurse has acknowledged the client’s feelings, what is the next
best intervention? *

“I’ll rub your back, and you tell me if it helps.”

A client at 37 weeks’ gestation is admitted to the birthing unit from the

emergency department. She had arrived by ambulance following a motor vehicle
accident. Her vital signs are BP: 90/60; P: 108; R: 24. She is reporting sharp
abdominal pain. What is the priority nursing intervention at this time? *
Assess the amount of vaginal bleeding.

Prepare for a possible cesarean birth.

Draw blood for a type and crossmatch.

Apply an electronic fetal monitor.

The manifestations of hemolytic uremic syndrome (HUS) are due primarily to

which event? *

The swollen lining of the small blood vessels damages the red blood cells, which
are then removed by the spleen, leading to anemia.

The parent of a child with glomerulonephritis asks the nurse why the urine is such
a funny color. Which is the nurse’s best response? *

“There is blood in your child’s urine that causes it to be tea-colored.”

A client arrives at the hospital at 38 weeks’ gestation with profuse vaginal

bleeding. She states that it occurred suddenly without any contractions. Which
condition may the client be experiencing that requires immediate notification of
the health care provider? *

Placenta previa
A child has been admitted to the pediatric unit with a severe asthma attack. What
type of acid-base imbalance should the nurse expect the child to develop? *

Respiratory acidosis caused by impaired respirations and increased formation of

carbonic acid

Sonography of a primigravida who is at 15 weeks’ gestation reveals a twin

pregnancy. The nurse reviews with the client the risks of a multiple pregnancy that
were explained by the health care provider. Which condition does the client
identify that indicates the need for further instruction about complications
associated with a multiple gestation? *

Down syndrome

The parents of a 3-month-old ask why their baby will not have an operation to
correct a ventricular septal defect (VSD). The nurse ’ s best response is: *

“Your baby ’ s defect is small and will likely close on its own by 1 year of age.”

An adolescent who is receiving chemotherapy for the treatment of bone cancer

has stomatitis as a result of chemotherapy. What should the nurse include when
teaching the child about self-care? *

Clean the teeth with a swab.

A client is scheduled for a sonogram at 36 weeks’ gestation. Shortly before the
test she tells the nurse that she has severe abdominal pain. Assessment reveals
heavy vaginal bleeding, a drop in blood pressure, and an increased pulse rate.
What complication does the nurse suspect? *

Complete abruptio placenta

What is the initial responsibility of a nurse when teaching the pregnant

adolescent? *

Encouraging her to continue regularly scheduled prenatal care

A nurse is monitoring a client with severe preeclampsia who is receiving an

infusion of magnesium sulfate. Assessment reveals a pulse rate of 55/minute,
respirations of 12/minute, and a flushed face. What is the next nursing action? *

Stop the infusion and start an infusion of dextrose and water.

An expectant couple asks the nurse about the cause of low back pain in labor. The
nurse replies that this pain occurs most often when the position of the fetus is: *

occiput posterior.

A nurse is assessing a client with a tentative diagnosis of hydatidiform mole.

Which clinical finding should the nurse anticipate? *

Unusual uterine enlargement

What position should a nurse teach a client to avoid when the client is
experiencing back pain during labor? *

Supine

An infant is scheduled for a hypospadias and chordee repair. The parent asks the
nurse, “I understand why the hypospadias repair is necessary, but do they have to
fix the chordee as well?” Which is the nurse’s best response? *

“The repair is done to optimize sexual functioning when he is older.”

The parents of an infant who has had a surgical repair of a myelomeningocele

express concern about skin care and ask what they can do to avoid problems. The
nurse should teach the parents that their infant: *

will require long-term multidisciplinary follow-up are.

A 13-year-old adolescent is diagnosed as having idiopathic scoliosis. Because

exercise and avoidance of fatigue are essential components of care, which sport
should the nurse suggest will be most therapeutic for this preadolescent? *

Swimming

A few hours after being admitted to the hospital with a diagnosis of inevitable
abortion, a client, at 16 weeks’ gestation, begins to experience bearing-down
sensations and suddenly expels the products of conception in bed. What should
the nurse do first? *

Check the client’s fundus for firmness.

A nurse is caring for a client who had a spontaneous abortion. For what
complication should the nurse assess this client? *

Hemorrhage

A child has been seen by the school nurse for dizziness since the start of the
school term. It happens when standing in line for recess and homeroom. The child
now reports that she would rather sit and watch her friends play hopscotch
because she cannot count out loud and jump at the same time. When the nurse
asks her if her chest ever hurts, she says yes. Based on this history, the nurse
suspects that she has: *

Aortic stenosis (AS).

A nurse is reviewing the obstetric history of a client who had an abruptio
placentae. What prenatal condition does the nurse expect the client to have had?
*

Gestational hypertension

A client who is at 26 weeks’ gestation tells a nurse at the prenatal clinic that she
has pain when urinating, back tenderness, and pink-tinged urine. A diagnosis of
pyelonephritis is made. What is the most important nursing intervention at this
time? *

Observing for signs of preterm labor

A client who had a postpartum hemorrhage is to receive 1 unit of packed red

blood cells (RBCs). The nurse manager observes a staff nurse administering the
packed RBCs without wearing gloves. What does the nurse manager conclude? *

Nurse should have worn gloves for self-protection.

For what most common characteristic of autism should a nurse assess a child
suspected of having this disorder? *

Seems unresponsive to the environment.

After an 8 hour, uneventful labor, a client gives birth. After an airway is ensured
and the neonate is dried and wrapped in a blanket, the nurse places the newborn
in the mother’s arms. The mother asks, “Is my baby normal?” What is the nurse’s
best response? *

“We will unwrap your baby; now you can see for yourself.”

What is the first action a nurse should take before administering a tube feeding to
an infant? *

Offer a pacifier to the infant.

A child’s parent asks the nurse what treatment the child will need for the
diagnosis of strep throat. Which is the nurse’s best response? *

“Your child will need oral penicillin for 10 days and should feel better in a few
days.”

A client at 39 weeks’ gestation is admitted for induction of labor. Knowing that

several medications are used to induce labor, a nurse identifies those that may be
prescribed. *

Oxytocin (Pitocin)
The nurse is to receive a 4-year-old from the recovery room after an
appendectomy. The parents have not seen the child since surgery and ask what to
expect. Which is the nurse’s best response? *

“Your child will be very sleepy and have an intravenous line in the hand. If your
child needs pain medication, we will give it intravenously.”

A client at 9 weeks’ gestation asks the nurse in the prenatal clinic if she can have
her chorionic villi sampling (CVS) done at this visit. At what week gestation should
the nurse respond is the best time for this test? *

10 weeks and less than 12 weeks

A school-age child has been diagnosed with nasopharyngitis. The parent is

concerned because the child has had little or no appetite for the last 24 hours.
Which is the nurse’ s best response?

“Be sure your child is taking an adequate amount of fluids. The appetite should
return soon.”

A nurse in the pediatric clinic is assessing an infant who had a revision of a

ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial
pressure has increased? *

Tension of the anterior fontanel

A teenager at 32 weeks’ gestation is hospitalized with pre-eclampsia. She is
anorexic and appears depressed. Which comment indicates to the nurse that
further exploration of the client’s emotional status is indicated? *

“I was really happy before I got pregnant.”

A 2-year-old is brought to the emergency department for fever and ear pain. The
parent reports the child has had many ear infections and that polyethylene tubes
have been recommended, but the parent cannot afford surgery. The child is
diagnosed with bilateral otitis media. The toddler is carrying a baby bottle full of
juice, and the parent is carrying a pack of cigarettes. Which of the following
preventive measures could be taught to the parent to decrease the incidence of
ear infections? EXCEPT *

Encourage the parent to smoke outside the house.

A pregnant client with severe abdominal pain and heavy bleeding is prepared for a
cesarean birth. What is the priority nursing intervention? *

Obtaining an informed consent and assessing for drug allergies

A child with a seizure disorder has been having episodes during which she drops
her pencil and simply appears to be daydreaming. This is most likely a/an: *

Absence seizure.
A nurse is caring for a 15-year-old who has just been diagnosed with non-Hodgkin
lymphoma. Which of the following should the nurse include in teaching the
parent’s about this lymphoma? EXCEPT *

The presence of Reed-Sternberg cells in the biopsy is considered diagnostic

A client with depression is to receive fluoxetine (Prozac). What precaution should

the nurse consider when initiating treatment with this drug? *

Blood levels may not be sufficient to cause noticeable improvement for 2 to 4

weeks.

An infant is not sleeping well, is crying frequently, has yellow drainage from the
ear, and is diagnosed with an ear infection. Which nursing objective is the priority
for the family? *

Providing pain relief for the child.

The parent of a child with a tentative diagnosis of attention deficit hyperactivity

disorder (ADHD) arrives at the pediatric clinic insisting on receiving a prescription
for medication that will control the child’s behavior. What is the nurse’s best
response? *

“It must be frustrating to deal with your child’s behavior.”

A client at 38 weeks’ gestation is admitted for induction of labor. Her membranes
ruptured 12 hours ago. There are no other signs of labor. Which medication does
the nurse anticipate will be prescribed? *

Oxytocin (Pitocin)

The nurse is caring for a child with a diagnosis of Acute Lymphocytic Leukemia
(ALL) who is receiving chemotherapy. The nurse notes that the child’s platelet
count is 20,000/mm 3 . Based on this laboratory finding, what information should
the nurse provide to the child and parents? *

A soft toothbrush should be used for mouth care.

A nurse is caring for a client who had a spontaneous abortion. The client asks why
spontaneous abortions occur. The nurse responds that they are most commonly
caused by: *

embryonic defects.

A primigravida is concerned about the health of her baby and asks the nurse,
“What is the most common cause of death of babies?” The nurse explains that the
cause of more than half of the neonatal deaths in the Philippines is due to: *

preterm births.
A client arrives at the hospital in the second stage of labor. The head of the fetus is
crowning, the client is bearing down, and birth appears imminent. What should
the nurse tell the client to do? *

Pant while resisting the urge to bear down.

A pregnant woman who is in the third trimester arrives in the emergency

department with vaginal bleeding. She states that she snorted cocaine
approximately 2 hours ago. Which complication does the nurse suspect is the
cause of the bleeding? *

Abruptio placentae

After orthopedic surgery, a 15-year-old adolescent reports a pain rating of 5 on a

scale of 0 to 10. A nurse administers the prescribed 5 mg of morphine every 3
hours prn. Two hours after having been given this medication, the adolescent
reports a pain rating of 10 out of 10. What action should the nurse take? *

Request that the health care provider evaluate the need for additional
medication.

When preparing a child with asthma for discharge, what must the nurse
emphasize to the family? *
Eliminate allergens in the home.

When planning discharge teaching for the parents of a child with asthma, what
information should the nurse include? *

Minimize exertion and exposure to cold.

An adolescent with the diagnosis of conduct disorder since the age of 9 is placed
in a residential facility. The adolescent has a history of fighting, stealing,
vandalizing property, and running away from home. The adolescent is aggressive,
has no friends, and has been suspended from school repeatedly. What is the
nurse’s priority when developing a plan of care? *

Preventing violence

What safety precautions should a nurse teach a child with diminished sensation in
the legs because of cerebral palsy? *

Test the temperature of the water before a bath.

The nurse is caring for a 4-month-old with gastroesophageal reflux (GER). The
infant is due to receive ranitidine (Zantac). Based on the medication’s mechanism
of action, when should this medication be administered? *

30 minutes before the feeding.

What should supportive nursing care in the beginning mother-infant relationship

include? *

Encouraging the mother to assist with simple aspects of her newborn’s care

After an incomplete abortion, a client tells a nurse that although her health care
provider explained what an incomplete abortion was, she did not understand.
What is the nurse’s best response? *

“This is when the fetus is expelled but other parts of the pregnancy remain in
the uterus.”

An adolescent is admitted to the psychiatric service in stable physical condition

with the diagnosis of anorexia nervosa. The adolescent has lost 20 pounds in 6
weeks and is very thin but is excessively concerned about being overweight. *

Attempt to establish a trusting relationship with the adolescent.

A client asks the nurse at the prenatal clinic whether she can continue to have
sexual relations while pregnant. What is an indication that the client should
refrain from intercourse during pregnancy? *
Premature rupture of membranes

A nurse is planning a teaching program for a child who has recently been
diagnosed with type 1 diabetes. What is the nurse’s first concern relating to the
child and parents? *

Exploring their feelings about diabetes

A health care provider orders a contraction stress test (CST) for a client whose
nonstress test (NST) was nonreactive. Which maternal complications should alert
the nurse to question the order? EXCEPT *

Preterm labor

Pre-eclampsia

Incompetent cervix

Premature rupture of membrane

An 8-year-old child with cerebral palsy is admitted to the hospital for a tendon-
lengthening procedure. After the surgery, the parents ask a nurse why their child
must wear braces and shoes for at least 12 hours a day even while in bed. How
should the nurse respond? *

“They maintain body alignment and help prevent footdrop.”

The school nurse has been following a child who comes to the office frequently for
vague complaints of dizziness and headache. Today, she is brought in after fainting
in the cafeteria following a nosebleed. Her BP is 122/85, and her radial pulses are
bounding. The nurse suspects she has: *

Coarctation of the aorta (COA).

Which behavior indicates to a nurse that a new mother is in the taking-hold

phase? *

Calling the baby by name

An infant is born with a bilateral cleft palate. Plans are made to begin
reconstruction immediately. What nursing intervention should be included to
promote parent-infant attachment? *

Demonstrating a positive acceptance of the infant

An infant is born precipitously in the emergency department. What should the

nurse do first? *

Establish an airway for the newborn.

When caring for a woman who had a positive contraction stress test (CST), what
complication does the nurse suspect? *

Uteroplacental insufficiency

What assessment finding of a pregnant client should alert the nurse to notify the
health care provider? *

Fundal height at the umbilicus at 16 weeks’ gestation

Why does a nurse encourage continued health care supervision for a pregnant
woman with pyelonephritis? *

Antibiotic therapy should be administered until the urine is sterile.

An 11-year-old child with juvenile idiopathic arthritis (JIA) will be receiving

continued nonsteroidal anti-inflammatory drug (NSAID) therapy at home. Which
important toxic effect of NSAIDs must be included in the nurse’s discharge
instructions to the child and family? *

Blood in the urine

A laboring client reports low back pain. What should a nurse recommend to the
client’s coach that will promote comfort? *
Apply pressure to her back during contractions.

Which is the nurse’s best response to the parent of an infant diagnosed with the
first otitis media who wonders about long-term effects? *

“The child could suffer recurrent ear infections.”

A client tells a nurse that she does not want an episiotomy and would rather tear
naturally. What information should be offered regarding each birthing method? *

Lacerations are easier to repair than an episiotomy.

A school nurse is teaching a group of teachers’ aides about the cause of lead
poisoning in children. What is important to consider in terms of prevention? *

Environmental factors are involved because lead is available for ingestion and
inhalation.

What is the most important factor for a nurse to consider when selecting nursing
measures to help parent-child relationships during the immediate postpartum
period? *
Physical status of the infant

Which nursing intervention provides the most support to the parents of an infant
with an obvious physical anomaly? *

Encourage them to express their concerns.

A nurse is counseling a woman who was just diagnosed with a multiple gestation.
Why does the nurse consider this pregnancy as high risk? *

Perinatal mortality is 2 to 3 times greater in multiple than in single births.

A client visiting the prenatal clinic for the first time asks a nurse about the
probability of having twins because her husband is one of a pair of fraternal twins.
What is the appropriate response by the nurse? *

“There is no greater probability of having twins than in the general population.”

Despite medication, a client’s preterm labor continues, her cervix dilates, and
birth appears to be inevitable. Which medication does the nurse anticipate will be
prescribed to increase the chance of the newborn’s survival? *

Betamethasone (Celestone)
Sitz baths are ordered for a client with an episiotomy during the postpartum
period. A nurse encourages her to take the sitz baths because they aid the healing
process by: *

promoting vasodilation.

A client at 28 weeks’ gestation has a sonogram. The results reveal a small for
gestational age (SGA) fetus and a low-lying placenta. For what complication should
the nurse assess this client during the last trimester of pregnancy? *

Placenta previa

The nurse is caring for a 10-year-old with leukemia who is receiving

chemotherapy. The child is on neutropenic precautions. Friends of the child come
to the desk and ask for a vase for the flowers they have brought with them. Which
of the following is the best response? *

“The flowers from your garden are beautiful but should not be placed in the
room at this time.”

A client admitted with preeclampsia is receiving magnesium sulfate. Which

assessment indicates that a therapeutic level of the medication has been
reached? *

Deep tendon reflexes of +2

Which sign or symptom leads a nurse to suspect that a client has a tubal
pregnancy? *

A sharp lower right or left abdominal pain radiating to the shoulder

A 5-year-old child is admitted to the pediatric intensive care unit with a diagnosis
of acute asthma. A blood sample is obtained to measure the child’s arterial blood
gases. What finding does the nurse expect? *

Increased carbon dioxide level

A client is admitted to the birthing unit in active labor. Cervical dilation has
progressed from 2 to 3 cm during an 8-hour period. The health care provider
determines that she has hypotonic dystocia, and an infusion of oxytocin (Pitocin)
is prescribed to augment her contractions. What is the most important nursing
action at this time? *

Monitoring the duration and intensity of the contractions

Checking the perineum for bulging

A 7-year-old child has recently been diagnosed with juvenile idiopathic arthritis
(JIA). The parents are concerned about the lifelong effects of the disorder and are
investigating other therapies to use with the medications. What referral should
the nurse recommends? *

Physical therapy

A client arrives at the clinic in preterm labor and terbutaline (Brethine) is

prescribed. For what therapeutic effect should the nurse monitor the client? *

Decreased frequency and duration of contractions

A client at 26 weeks’ gestation is admitted to the high-risk unit with an influenza

infection. She is in labor. Which of these instructions should a nurse question? *

I&O and IV Ringer lactate 500 mL/24 hours

Women who become pregnant for the first time at a later reproductive age (35
years of age or older) are at risk for what complications? EXCEPT. *

Development of seizures

When picked up by a parent or the nurse, an 8-month-old infant screams and

seems to be in pain. After observing this behavior, what should the nurse discuss
with the parent? *

Any other behaviors that the parent may have noticed

A client tells a nurse in the prenatal clinic that she has vaginal staining but no pain.
Her history reveals amenorrhea for the last 2 months and pregnancy confirmation
after her first missed period. She is admitted to the high-risk unit because she may
be having a spontaneous abortion. What type of abortion is suspected? *

Threatened

A client who had a severe abruptio placentae asks the nurse why there was so
much bleeding. What should the nurse consider is the cause of the heavy bleeding
before responding in language the client will understand? *

Hypofibrinogenemia

A child is complaining of throat pain. Which statement by the mother indicates

that she needs more education regarding the care and treatment of her child’s
pharyngitis? *

“I will ask the nurse practitioner for some amoxicillin.”

The nurse is caring for an infant diagnosed with Hirschsprung disease. The mother
states she is pregnant with a boy and wants to know if her new baby will likely
have the disorder. Which is the nurse’s best response? *

“Genetics play a small role in Hirschsprung disease, so there is a chance the baby
will develop it as well.”