Pediatric Nursing Concerns for Hospitalized Children

10/6/21, 4:35 PM bstrandable NCLEX OB/Peds 3 of 3 Flashcards | Quizlet
Science / Medicine / Pediatrics
bstrandable NCLEX OB/Peds 3 of 3

Terms in this set (761)
the infant fears _____ most when separation from loved object
hospitalized
the toddler fears _________ most when separation from family

hospitalized
the preschooler fears separation as mutilation- remember preschoolers have vivid imaginations...
well as ________ when hospitalized fantasy
the toddler and preschooler will think something they did wrong
that illness is caused by ______________
the school aged hospitalized child is age group

afraid of separation from ______
the school aged child perceives the external- she knows that illness is not a result of bad behavior
cause of illness to be external or
internal?
the adolescent who is hospitalized peers, loss of independence

fears separation from ___ and loss of
_______
preschoolers may require physical true

restraint during painful procedures
(t/f)
which age group engages in stalling school-aged

tactics before painful procedures
most?
https://quizlet.com/31253355/bstrandable-nclex-obpeds-3-of-3-flash-cards/ 1/124
which age groups are most likely to school aged, adolescents

physically resist the nurse during
procedures?
toddlers may require physical restraint true

for painful procedures (t/f)
"The mother of a child diagnosed with "Correct Answer: A
a potentially life-threatening form of Parents of children diagnosed with cancer require major
cancer says to the nurse, ""I don't emotional support, and should be allowed to express their
understand how this could happen to feelings. Prevention and blaming oneself is not supportive, nor
us. We have been so careful to make is telling the parents that there are many other children with
sure our child is healthy."" Which cancer."
response by the nurse is most
appropriate?
"A. ""This must be a difficult time for

you and your family. Would you like to
talk about how you are feeling?""
B. ""Why do you say that? Do you think

that you could have prevented this?""
C. ""You shouldn't feel that you could

have prevented the cancer. It is not
your fault.""
D. ""Many children are diagnosed with

cancer. It is not always life-
threatening."""
"A preschool-age child undergoing "Correct answer: D
chemotherapy experiences nausea While all options can be done to encourage nutrition, allowing
and vomiting. Which of the following the preschooler choices meets two issues: nutrition and
would be the best intervention to developmental tasks."
include in the child's plan of care?
"a. Administer tube feedings.
b. Offer small, frequent meals.
c. Offer fluids only between meals.
d. Allow the child to choose what to

eat for meals."
A 12 year old boy seen in the clinic, Correct Answer 4 . Hodgkin's disease is a neoplasm of
and a diagnosis of Hodgkin's disease lymphatic tissue. The presence of gaint multinucleated cells (
is suspected . Which diagnostic test Reed- Sternbergs cells) is the hallmark of this disease. The
results confirm the diagnosis of presence of blast cells in the bone marrow indicates leukemia.
Hodgkin's disease? The Epstein-Barr virus is associated with infectious
1 . Elevated vanillylmandelic acid mononucleosis . Elevated levels of vanillylmandelic acid in the
urinary level.
urine may be found in children with neroblastoma.
2. The presence of blast cells in the
bone marrow
3. The presence of Epsetin-Barr virus

in the blood.
4. The presence of Reed-Sternberg

cells in the lymph nodes
"Which nursing diagnosis is highest- "Correct Answer: A
priority for a child undergoing While all of the nursing diagnoses listed here are important,
chemotherapy and experiencing dehydration and fluid and electrolyte loss secondary to
nausea and vomiting?
vomiting is the priority for this client."
"A. Fluid and Electrolyte Imbalance
B. Alterations in Nutrition
C. Alterations in Skin Integrity
D. Body Image Disturbances"
"A child with cancer has the following "Correct answer: A Hemorrhage
lab result: WBC 10,000, RBC 5, and plts The lab values presented all are normal except for the platelet
of 20,000. When planning this child's count. Decreases in platelet counts place the child at greatest
care, which risk should the nurse risk for hemorrhage."
consider most significant?
"A. Hemorrage
B. Anemia
C. Infection
D. Pain"
"Chemotherapy dosage is frequently "Answer: 4 To ensure that the client receives optimal doses of
based on total body surFace area chemotherapy, dosing is usually based on the total Body
(BSA), so it is important for the nurse surface area(BSA) which requires accurate height and weight
to do which of the following before before each med administration.
administering chemotherapy?
Simply asking the client about height/weight may lead to
"1. Measure abdominal girth
inaccuracies in determining BSA. Calculating BMI and
2. Claculate BMI
measuring abdominal girth does not provide the data needed."
3. Ask the client about his/her height
and weight
4. Weigh and measure the client on

the day of medication administration"
"Which diagnostic test should be Answer d: Surface blood vessels of polyps and cancers are
performed annually after age 50 to fragile and often bleed with the passage of stools, so a fecal
screen for colon cancer?
occult blood test and CT scan can help establish tumor size
"a. Abdominal computed tomography and metastasis. A colonoscopy can help to locate a tumor as
(CT)
well as polyps, but is only recommended every 10 years.
b. Abdominal X-ray
c. Colonoscopy
d. Fecal occult blood test"
"David, age 15 months, is recovering "Correct: D
from surgery to remove Wilms' tumor. Answer D. One of the most valuable clues to pain is a behavior
Which findings best indicates that the change: A child who's pain-free likes to play. A child in pain is
child is free from pain?
less likely to consume food or fluids. An increased heart rate
"a. Decreased appetite
may indicate increased pain; decreased urine output may
b. Increased heart rate
signify dehydration."
c. Decreased urine output
d. Increased interest in play"
A nurse analyzes the lab values of a 4. **Correct... Rationale: Leukemia is a malignant increase in the
child with leukemia who is receiving number of leukocytes, usually at an immature stage, in the
chemotherapy. The nurse notices that bone marrow. It affects the bone marrow, causing from
the platelet count is 19,500 cell/mm3. decreased erythrocytes, infection from neutropenia, and
Based on this lab value which bleeding from decreased platelet production. If the platelet
intervention would the nurse count is les than 20,000 than bleeding precautions need to be
document in her plan of care. "
taken.
"1. Monitor closely for signs of
infection.
2. Temp every four hours.
3. Isolation precautions
4. Use a small toothbrush for mouth

care"
"The parent of a child undergoing "Correct: B
chemotherapy asks
Chemotherapeutic agents decrease the immunity of
the nurse why the child must wear a the child. Proper use of the mask will decrease the chance of
mask in public places. Which of the
acquiring
following responses by the nurse an infection. Cancer is not spread; a mask cannot contain
would be most appropriate?
moisture; and
"A) ""Chemotherapy causes dry mouth, unsightly mouth sores are not a medical reason to wear a
and the mask will help contain mask."
moisture.""
B) ""Chemotherapy decreases immune

system function, increasing the risk of
acquiring an infection.""
C) ""Chemotherapy makes the oral

mucous membranes deteriorate and
makes them susceptible to infection.""
D) ""Chemotherapy kills cancer cells,

and your child might spread those
cells to others."""
A child is diagnosed with Wilms' tumor. Correct answer: 1. Do not put pressure on the abdomen.
In planning teaching interventions, Palpation of Wilms' tumor can cause rupture and spread of
what key point should the nurse cancerous cells. Frequent visitation might allow the child to be
emphasize to the parents?
exposed to more infections, and activity and sports are
"1. Do not put pressure on the discouraged because of the risk of rupture of the
abdomen.
encapsulated tumor.
2. Frequent visits from friends and
family will improve morale.
3. Appropriate protective equipment

should be worn for contact sports.
4. Encourage the child to remain

active."
"A child is diagnosed with Wilms' "CORRECT: D
tumor. During assessment, the nurse in The most common sign of Wilms' tumor is a painless, palpable
charge expects to detect:
abdominal mass, sometimes accompanied by an increase in
"a. Gross hematuria
abdominal girth. Gross hematuria is uncommon, although
b. Dysuria
microscopic hematuria may be present. Dysuria is not
c. Nausea and vomiting
associated with Wilms' tumor. Nausea and vomiting are rare in
d. An abdominal mass" children with Wilms' tumor."
The mother of a 5-year-old child asks "Correct: A.
the nurse questions regarding the While all of the answer choices are correct, recommending the
importance of vigilant use of use of sunscreen to decrease the incidence of skin cancer (a)
sunscreen. Which information is most is the best response."
important for the nurse to convey to
the mother?
"a.) Appropriate use of sunscreen

decreases the risk of skin cancer.
b.) Repeated exposure to the sun

causes premature aging of the skin.
c.) A child's skin is delicate, and burns

easily.
d.) In addition to causing skin cancer,

repeated sun exposure predisposes
the child to other forms of cancer."
Correct: 2. Fever and petechiae associated with acute

lymphocytic leukemia indicate a suppression of normal white
blood cells and thrombocytes by the bone marrow and put
"A 15-year-old has been admitted to the client at risk for other infections and bleeding. The nurse
the hospital with the diagnosis of should initiate infection control and safety precautions to
acute lymphocytic leukemia. Which of reduce these risks. Fatigue is a common symptom of leukemia
the following signs and symptoms due to red blood cell suppression. Although the client should
require the most immediate nursing be told about the need for rest and meal planning, such
intervention?
teaching is not the priority intervention. Swollen glands and
(Choices were deleted) lethargy may be uncomfortable but they do not require
immediate intervention. An enlarged liver and spleen do
require safety precautions that prevent injury to the abdomen;
however, these precautions are not the priority.
A child with leukemia is being Answer B - fresh vegetables harbor microorganisms, which can
discharged after beginning cause infections in immune-compromised children, fruit or
chemotherapy. Which of the following vegetables should be either peeled or cooked. The physician
instructions will the nurse include should be notified of a temp above 100 degrees F. A diet low in
when teaching the parents of this protein is not indicated. Humidifiers harbor fungi in the water
child?
containers.
"A. provide a diet low in protein and
high in carboydrates
B. avoid fresh vegetables that are not

cooked or peeled
C. notify the doctor if the child's temp

exceeds 101 degrees F
D. increase the use of humidifiers

throughout the house"
"The pediatric nurse understands that "Correct: 2.
the most common cancer found in 1. No - this is not a common cancer in children
children is:
2. YES! this is the most common form of cancer found in
"1. Non-hodgkin's lymphoma
children is acute lymphocytic leukemia.
2. Acute lymphocytic leukemia

3. No - this is not a common cancer in children
3. Chronic lymphocytic leukemia

4. No - this is not a common cancer in children"
4. Ewing's sarcoma"
"When assessing a child with Wilm's "Answer: B. The abdomen of the child with Wilm's tumor should
tumor, the nurse should keep in mind not be palpated because of the danger of disseminating tumor
that it is most important to avoid which cells. Children with Wilm's tumor should always be handled
of the following?
gently and carefully.
"A. Measuring the child's chest
circumference
Other answers. The child's head and chest measuring will not
B. Palpating the child's abdomen
affect Wilm's tumor. Repositioning a child in the upright
C. Placing the child in an upright position may cause more pain to the child, but priority this is
position
not worse than disseminating tumor cells."
D. Measuring the child's
occipitofrontal circumference"
A nurse is teaching a client about the "Correct: 1.
risk factors associated with colorectal Colorectal cancer risk factors include age older than 50 years,
cancer. The nurse determines that a family history of the disease, colorectal polyps, and chronic
further teaching related to the colo- inflammatory bowel disease."
rectal cancer is necessary if the client
identifies which of the following as an
associated risk factor?
"1. Age younger than 50 years
2. History of coloractal polyps
3. Family history of colorectal cancer
4. Chronic inflammatory bowel

disease"
What are the needs of the patient with "Correct: B.
acute lymphocytic leukemia and a-— poses little or no threat
thrombocytopenia?
B(CORRECT:)- protects patient from exogenous bacteria,
"(A) to a private room so she will not risk for developing infection from others due to depressed
infect other patients and health care WBC count,
workers
alters ability to fight infection
(B) to a private room so she will not c-— should be placed in a room alone
be infected by other patients and

d-ensure that patient is provided with
health care workers

opportunities to express feelings about illness"
(C) to a semiprivate room so she will
have stimulation during her
hospitalization
(D to a semiprivate room so she will

have the opportunity to express her
feelings about her illness
"
"The postoperative care of a "D CORRECT: Because of cerebral edema and the danger of
preschool child who has had a brain increased intracranial pressure postoperatively, fluids are
tumor removed should include which carefully monitored.
of the following?
A. Colorless drainage may be leakage of cerebrospinal fluid
"a. colorless drainage is to be from the incision site. This needs to be reported as soon as
expected
possible.
b. analgesics are contraindicated B. Analgesics can be used for postoperative pain.
because of altered consciousness

C. Child should not be positioned in Trendelenburg position
c. positioning is on the operative side postoperatively."
in the Trendelenberg position
d. carefully monitor fluids due to

cerebral edema"
A child with lymphoma is receiving "Answer A is Correct
extensive radiotherapy. Which of the Malaise is the most common side effect of radiotherapy. For
following is the most common side children, the fatigue may be especially distressing because it
effect of this treatment?
means they cannot keep up with their peers."
"A. Malaise
B. Seizures
C. Neuropathy
D. Lymphadenopathy"
A school-age child is being seen in "Answers: b and d (complaints of night sweats, painless cervical
the oncology clinic for possible nodes.)
Hodgkin's disease. During the course Painless cervical nodes are a hallmark sign of HD. In addition
of the nursing assessment, which to this, night sweats also are characteristic. Fever, poor
findings would be expected? Select appetite, and painful cervical nodes are more characteristic of
all that apply.
infection."
"a) fever.
b) painless cervical nodes.
c) painful cervical nodes.
d) poor appetite.
e) complaints of night sweats"
"A nurse is performing an assessment "D. painless, firm, and movable adenopathy in the cervical area
on a 10-year old child suspected - Clinical manifestations specifically associated with Hodgkin's
having Hodgkin's disease. The nurse disease include painless, firm, and movable adenopathy in the
understands that which of the cervical and supraclavicular areas. Hepatosplenomegaly also
following assessment findings is is noted. Although fever, malaise, anorexia, and weight loss are
characteristic of this disease?
associated with Hodgkin's disease, these manifestations are
"a) fever and malaise
seen in many disorders."
b) anorexia and weight loss
c) painful, enlarged inguinal lymph

nodes
d) painless, firm, and movable

adenopathy in the cervical area"
"The nurse is admitting a patient who "Correct: 1.
is jaundiced due to pancreatic cancer. 1. profound weight loss and anorexia occur with pancreatic
The nurse should give the highest cancer. Correct.
priority to which of the following 2. jaundiced patients are concerned about how they look, but
needs?
physiological needs take priority
"1. Nutrition
3. jaundice causes dry skin and pruritis, scratching can lead to
2. Self-image
skin breakdown
3. Skin integrity
4. urine is dark due to obstructive process, kidney function is
4. Urinary elimination" not affected"
"The mother of a 4 year old child "Answer: 1
brings the child to the clinic and tells Rationale: Wilm's tumor is the most common intra-abdominal
the pediatric nurse specialist that the and kidney tumor of childhood. If Wilm's tumor is suspected,
child's abdomen seems to be swollen. the tumor mass should not be palpated by the nurse.
During further assessment of the Excessive manipulation can cause the seeding of the tumor
subjective data, the mother tells the and spread of cancerous cells. Fever, hematuria, and
nurse that the child has been eating hypertension are all clinical manifestations of Wilm's tumor."
well and that the activity level of the
child is unchanged. The nurse,
suspecting the possibility of a Wilm's
tumor, would avoid which of the
following during the physical
assessment?
"1. Palpating the abdomen for a mass.

2. Assessing the urine for hematuria
3. Monitoring the temperature for

presence of fever
4. Monitoring the blood pressure for

presence of hypertension"
"A 9-year old child with leukemia is in "Correct anwser: 2.
remission and has returned to school. Rationale: immunocompromised children are unable to fight
The school nurse calls the mother of varicella adequately. Chickenpox can be deadly to the them. If
the child and tells the mother that a the child who has not had chickenpox is exposed to someone
classmate has just been diagnosed with varicella, the child should receive varicella zoster immune
with chickenpox. The mother globulin within 96hrs of exposure. Options 1,3,4, are incorrect
immediately calls the clinic nurse because they do nothing to minimize the chances of
because the leukemic child has never developing the disease."
had chickenpox. The appropriate
response by the clinic nurse to the
mother is:
"1. There is no need to be concerned.
2. Bring the child into the clinic for a

vaccine.
3. Keep the child out of school for 2

week period.
4. Monitor the child for an elevated

temperature, and call the clinic if this
happens."
The nurse is completing a care plan "Correct: 4.
for a client diagnosed with leukemia. Grieving is an independent problem, and the nurse can assess
Which independent problem should and treat this problem with or without collaboration."
be addressed?
"1.Infection.
2.Anemia.
3.Nutrition.
4.Grieving."
A client is admitted to the hospital for "ANSWER:C
a colon resection and in preparation Because neomycin is limited absorption form the GI tract, it
for surgery the physician orders exerts it antibiotic effect on the intestinal mucosa. In
neomycin. The nurse understands the preparation of GI surgery, the level of microbial organisms will
main reason why this antibiotic is be reduced."
especially useful before colon surgery
is because it:
"A. Will not affect the kidneys
B. Acts systemically without delay
C.Has limited absorption from the GI

tract.
D.Is effective against many different

organisms "
"A child is undergoing remission "CORRECT: Answer A. The massive cell destruction resulting
induction therapy to treat leukemia. from chemotherapy
Allopurinol is included in the regimen. may place the client at risk for developing renal calculi; adding
The main reason for administering allopurinol decreases this risk by preventing the breakdown of
allopurinol as part of the client's xanthine
chemotherapy regimen is to:

to uric acid. Allopurinol doesn't act in the manner described in
"a. Prevent metabolic breakdown of the
xanthine to uric acid

other options."
b. Prevent uric acid from precipitating
in the ureters
c. Enhance the production of uric acid

to ensure adequate excretion of urine
d. Ensure that the chemotherapy

doesn't adversely affect the bone
marrow"
"After teaching the parents of a child "CORRECT: B. Leukemia is a neoplastic, or cancerous, disorder
newly diagnosed with leukemia
of blood-forming
about the disease, which of the tissues that is characterized by a proliferation of immature
following descriptions given by the
white blood
mother best indicates that she cells."

understands the nature of leukemia?"
"A) ""The disease is an infection

resulting in increased white blood cell
production.""
B) ""The disease is a type of cancer

characterized by an increase in
immature white blood cells.""
C) ""The disease is an inflammation

associated with enlargement of the
lymph nodes.""
D) ""The disease is an allergic disorder

involving increased circulating
antibodies in the blood."""
"A 10 year old child with hemophilia A "CORRECT: C

has slipped on the ice and bumped his Hemophila refers to a group of bleeding disorders resulting
knee. The nurse should prepare to from a deficiency of specific coagulation proteins. the primary
administer an:
meds used are to replace missing clotting factor. Factor VIII
"A. injection of factor X
will be prescribed intravenously to replace the missing clotting
B. intravenous infusion of iron
factor and minimize the bleeding,"
C. intravenous infusion of factor VIII
D. intramuscular injection of iron using

the Z track method"
When caring for an 11-month-old Answer D. The body compensates for metabolic acidosis via
infant with dehydration and metabolic the respiratory system, which tries to eliminate the buffered
acidosis, the nurse expects to see acids by increasing alveolar ventilation through deep, rapid
which of the following?
respirations, altered white blood cell or platelet counts are not
"a. A reduced white blood cell count
specific signs of metabolic imbalance.
b. A decreased platelet count
c. Shallow respirations
d. Tachypnea"
The nurse understands a primary step "ANSWER: B
toward achievement of a long range The client must be ready to accept changes in body image
goal associated with the rehabilitation and function; this acceptance will facilitate mastery of the
of a client with a new colostomy is:
techniques of colosotomy care and optimal use of community
"A. Mastery of techniques of resources."
colostomy care
B. Readiness to accept an altered

body function
C. Awareness of available community

resources
D.Knowledge of the neccessary

dietary modifications.
"Nursing considerations related to the "CORRECT c. Chemotherapeutic agents can be extremely

administration of chemotherapeutic damaging to cells. Nurses experienced with the administration
drugs include which of the following?
of vesicant drugs should be responsible for giving these drugs
"a) Anaphylaxis cannot occur, since and be prepared to treat extravasations if necessary.
the drugs are considered toxic to a. Anaphylaxis is a possibility with some chemotherapeutic and
normal cells.
immunologic agents.
b) Infiltration will not occur unless b. Infiltration and extravasations are always a risk, especially
superficial veins are used for the with peripheral veins.
intravenous infusion.
d. Gloves are worn to protect the nurse when handling the
c) Many chemotherapeutic agents are drugs, and the hands should be thoroughly washed afterward."
vesicants that can cause severe
cellular damage if drug infiltrates.
d) Good hand washing is essential

when handling chemotherapeutic
drugs, but gloves are not necessary."
A nurse is discussing childhood cancer "Correct: A.
with the parents of a child in an Childhood cancers occur most commonly in rapidly growing
oncology unit. Which statement by the tissue, especially in the bone marrow. Mortality depends on
nurse would be the most accurate?
the time of diagnosis, the type of cancer, and the age at which
"A. ""The most common site for the child was diagnosed. Children who are diagnosed
children's cancer is the bone marrow.""
between the ages of 2 and 9 consistently demonstrate a better
B. ""All childhood cancers have a high prognosis. Treatment strategies are tailored to produce the
mortality rate.""
most favarable prognosis. (NCLEX-RN Questions & Answers,
C. ""Children with leukemia have a made Incredibly Easy)"
higher survival rate if they are older
than 11 when diagnosed.""
D. ""The prognosis for children with

cancer isn't affected by treatment
strategies."""
What assessment finding would the Correct: 4. Enlarged lymph nodes with progression to
nurse expect to find specifically for a extralymphatic sites. This is a characteristic specifically to
client admitted with Hodgkin's lymphoma, where as fatigue and weakness can occur with
disease?
other diseases. Weight loss is more likely than weight gain.
"1. Fatigue
2. weakness.
3. Weight gain
4. Enlarged lymph nodes."
"What is a characteristic manifestation Correct: #3 "Knowledge of the usual pattern of spread of this
of Hodgkin's Disease?
lymphoma, with its orderly progression through lymph node
"1.) petechiae
groups and its typical forms of extranodal involvement,
2.) erythematous rash
facilitates timely diagnosis, staging, and treatment planning".
3.) enlarged lymph nodes
4.) pallor"
"A 4-year-old has a right nephrectomy Answer D is correct. Because the child has only one remaining
to remove a Wilms tumor. The nurse kidney, it is important to prevent urinary tract infections.
knows that it is essential to:
Answers A, B, and C are not necessary, so they are incorrect.
"A. Request a low-salt diet
B. Restrict fluids
C. Educate the family regarding renal

transplants
D. Prevent urinary tract infections"
"The goals of cancer treatment are "Correct answer: C
based on the principle that

Rationale: The goals of cancer treatment are cure, control, and
"a. surgery is the single most effective palliation. When cure is the goal, treatment is offered that is
treatment for cancer.
expected to have the greatest chance of disease eradication.
b. initial treatment is always directed Curative cancer therapy depends on the particular cancer
toward cure of the cancer.
being treated and may involve local therapies (i.e., surgery or
c. a combination of treatment irradiation) alone or in combination, with or without periods of
modalities is effective for controlling adjunctive systemic therapy (i.e., chemotherapy)."
many cancers.
d. although cancer cure is rare, quality

of life can be increased with treatment
modalities. "
"After a client is admitted to the "Correct Answer: B. Prevent client exposure to infections
pediatric unit with a diagnosis of acute Rationale: Neutropenia is a decreased number of neutrophil
lymphocytic leukemia, the laboratory cells in the blood which are responsible for the body's defense
test indicates that the client is against infection. Rest and avoid exertion would be related to
neutropenic. The nurse should erythrocytes and oxygen carrying properties. Monitoring the
perform which of the following?
blood pressure, and observing for bruising would be related
"a. Advise the client to rest and avoid to platelets and sign and symptoms of bleeding."
exertion
b. Prevent client exposure to

infections
c. Monitor the blood pressure

frequently
d. Observe for increased bruising"
A preschool-aged child is to undergo "Answer: B
several painful procedures. Which of Preschoolers have the cognitive ability to understand simple
the following techniques is most- terms.
appropriate for the nurse to use in Use of a favorite doll is contraindicated because it is ""part"" of
preparing the child?
that child and he/she might perceive the doll is experiencing
"A. Allow the child to practice pain."
injections on a favorite doll.
B. Explain the procedure in simple

terms.
C. Allow a family member to explain

the procedure to the child.
D. Allow the child to watch an

educational video."
Which condition assessed by the "Correct: 4.
nurse would be an early warning sign Swelling or lumps or masses anywhere on the body are early
of childhood cancer?
warning signs whereas difficulty swallowing or cough or
1. difficulty swallowing \
hoarseness are signs of cancer in adults. there may be a
2. nagging cough or hoarseness
marked sign in changes to bowel or bladder function, not a
3. slight changes in bowel and slight change"
bladder function
4. swelling, lumps, masses on body
A patient who has been told by the "Correct Answer: C
health care provider that the cells in a Rationale: An undifferentiated cell has an appearance more
bowel tumor are poorly differentiated like a stem cell or fetal cell and less like the normal cells of the
asks the nurse what is meant by organ or tissue. The DNA in cancer cells is always different
"poorly differentiated." Which from normal cells, whether the cancer cells are well
response should the nurse make? "a. differentiated or not. All tumor cells are mutations form the
""The cells in your tumor do not look normal cells of the tissue."
very different from normal bowel
cells.""
b. ""The tumor cells have DNA that is

different from your normal bowel
cells.""
c. ""Your tumor cells look more like

immature fetal cells than normal
bowel cells.""
d. ""The cells in your tumor have

mutated from the normal bowel
cells."""
A child being treated for Acute CORRECT is #3 - RATIONALE: in leukemia, the WBCs that are
Lymphocytic Leukemia (ALL) has a present are immature and incapable of fighting infection.
white blood cell (WBC) count of increases or decreases in the number of WBCs can be related
7,000/mm3. the nursing care plan lists to the disease process and treatment, and not related to
risk for infection as a priority nursing infection. the only value that indicates the child is infection-
diagnosis, and measures are being free is the temperature. the use of proper handwashing
taken to reduce the child's exposure technique is a measure or intervention used to meet a goal.
to infection. the nurse determines that but is not a goal itself. STRATEGY: the core issue of the
the plan has been successful when question is knowledge of an indicator of infection in a client
which outcome has been met?
who is immunosuppressed from leukemia. recall that
"1. child's WBC count goes up.
temperature and WBC counts are frequently used as indicators
2. child's WBC count goes down.
of infection. recall that in leukemia the WBCs are abnormal so
3. child's temperature remains within choose the option related to temperature.
normal range.
4. parents demonstrate good hand

washing technique."
A pediatric nurse specialist provides a "2.) ""The child does not experience pain at the primary tumor
teaching session to the nursing staff site."" (CORRECT ANSWER--Need for further clarification).
regarding osteogenic sarcoma. Which Osteogenic sarcoma is the most common bone cancer in
statement by a member of the nursing children. Cancer usually is found in the metaphysis of long
staff indicates a need for clarification bones, especially in the lower extremities, with most tumors
of the information presented?
occurring in the femur (omit #1). Osteogenic sarcoma is
"1.) ""The femur is the most common manifested clinically by progressive, insidious, and intermittent
site of this sarcoma.""
pain at the tumor site (correct answer: #2). By the time these
2.) ""The child does not experience children receive medical attention, they may be in
pain at the primary tumor site.""
considerable pain from the tumor. All options: 1, 3, 4 are
3.) ""Limping, if a weight-bearing limb accurate regarding osteogenic sarcoma.
is affected, is a clinical manifestation.""

"
4.) ""The symptoms of the disease in
the early stage are almost always
attributed to normal growing pains."""
"A child is admitted to the hospital with "1. Answer: C
a diagnosis of Wilm's tumor, Stage II.
Which of the following statements The staging of Wilm's tumor is confirmed at surgery as follows:
most accurately describes this stage?
Stage I, the tumor is limited to the kidney and completely
"A) The tumor is less than 3 cm. in size resected; stage II, the tumor extends beyond the kidney but is
and requires no chemotherapy.
completely resected; stage III, residual nonhematogenous
B) The tumor did not extend beyond tumor is confined to the abdomen; stage IV, hematogenous
the kidney and was completely metastasis has occurred with spread beyond the abdomen;
resected.
and stage V, bilateral renal involvement is present at
C) The tumor extended beyond the diagnosis."
kidney but was completely resected.
D) The tumor has spread into the

abdominal cavity and cannot be
resected."
"The most common signs and "Correct answer: A
symptoms of leukemia related to bone Signs of infiltration of the bone marrow are petechiae from
marrow involvement are which of the lowered platelet count, fever related to infection from the
following?
depressed number of effective leukocytes, and fatigue from
"a. Petechiae, fever, fatigue
the anemia.
b. Headache, papilledema, irritability

The other options are not signs of bone marrow involvement."
c. Muscle wasting, weight loss, fatigue
d. Decreased intracranial pressure,

psychosis, confusion"
A diagnostic workup is being ANSWER: 1 Rationale: Neuroblastoma is a solid tumor found

performed on a 1-year-old child with only in children. It arises from neural crest cells that develop
suspected neuroblastoma. The nurse into the sympathetic nervous system and the adrenal medulla.
reviews the results of the diagnostic Typically, the tumor compresses adjacent normal tissue and
tests and understands that which of organs. Neuroblastoma cells may excrete catecholamines and
the following findings is most their metabolites. Urine samples will indicate elevated VMA
specifically related to this type of levels. The presence of blast cells in the bone marrow occurs
tumor?
in leukemia. Projectile vomiting occurring most often in the
"1. Elevated vanillylmandelic acid morning and a positive Babinski's sign are clinical
(VMA) urinary levels
manifestations of a brain tumor.
2. Presence of blast cells in the bone
marrow
3. Projectile vomiting, usually in the

morning
4. Postive Babinski's sign"
"1. Up to 90% of clients respond well to
"The female client recently diagnosed standard treatment with chemotherapy
with Hodgkin's lymphoma asks the and radiation therapy, and those who
nurse about
relapse usually respond to a change of
her prognosis. Which is the nurse's chemotherapy medications. Survival
best response?
depends on the individual client and
"1. Survival for Hodgkin's disease is the stage of disease at diagnosis (correct).
relatively good with standard therapy.

2. Investigational therapy regimens would
2. Survival depends on becoming not be recommended for clients initially
involved in an investigational therapy diagnosed with Hodgkin's disease because
program.
of the expected prognosis with standard
3. Survival is poor, with more than 50% therapy
of clients dying within six (6) months.

3. Clients usually achieve a signiﬁcantlylonger survival rate than
4. Survival is ﬁne for primary six (6) months.Many clients survive to develop long-
Hodgkin's, but secondary cancers termsecondary complications.
occur within a year." 4. Secondary cancers can occur as long as 20 years after a
remission of the Hodgkin'sdisease has occurred."
An adolescent with a history of "Answer C Because the incidence of testicular cancer is

surgical repair for undescended testes increased in adulthood among children who have
comes to the clinic for a sport undescended testes. It is extremely important to teach the
physical. Anticipatory guidance for the adolescent how to perform the testicular self-examination
parents and adolescent would focus monthly."

on which of the following as most
important?
"a) the adolescent sterility
b) the adolescent future plans
c) technique for monthly testicular

self-examinations
d) need for a lot of psychosocial

support"
The doctor suspects that the client has Answer D is correct. The signs of an ectopic pregnancy are
an ectopic pregnancy. Which vague until the fallopian tube ruptures. The client will complain
symptom is consistent with a diagnosis of sudden, stabbing pain in the lower quadrant that radiates
of ectopic pregnancy?
down the leg or up into the chest. Painless vaginal bleeding is
a sign of placenta previa, abdominal cramping is a sign of
a. Painless vaginal bleeding
labor, and throbbing pain in the upper quadrant is not a sign of
b. Abdominal cramping
an ectopic pregnancy, making answers A, B, and C incorrect.
c. Throbbing pain in the upper
quadrant
d. Sudden, stabbing pain in the lower

quadrant
A client telephones the emergency Answer D is correct.
room stating that she thinks that she is
in labor. The nurse should tell the The client should be advised to come to the labor and delivery
client that labor has probably begun unit when the contractions are every 5 minutes and consistent.
when:
She should also be told to report to the hospital if she
experiences rupture of membranes or extreme bleeding. She
a. Her contractions are 2 minutes should not wait until the contractions are every 2 minutes or
apart.
until she has bloody discharge, so answers A and B are
b. She has back pain and a bloody incorrect. Answer C is a vague answer and can be related to a
discharge.
urinary tract infection
c. She experiences abdominal pain
and frequent urination.
d. Her contractions are 5 minutes

apart.
Which of the following instructions Answer B is correct.
should be included in the nurse's
teaching regarding oral When the client is taking oral contraceptives and begins
contraceptives?
antibiotics, another method of birth control should be used.
Antibiotics decrease the effectiveness of oral contraceptives.
a. Weight gain should be reported to Approximately 5-10 pounds of weight gain is not unusual, so
the physician.
answer A is incorrect. If the client misses a birth control pill,
b. An alternate method of birth she should be instructed to take the pill as soon as she
control is needed when taking remembers the pill. Answer C is incorrect. If she misses two,
antibiotics.
she should take two; if she misses more than two, she should
c. If the client misses one or more take the missed pills but use another method of birth control
pills, two pills should be taken per day for the remainder of the cycle. Answer D is incorrect because
for 1 week.
changes in menstrual flow are expected in clients using oral
d. Changes in the menstrual flow contraceptives. Often these clients have lighter menses.
should be reported to the physician.
A nursing instructor is conducting a. FSH and LH are released from the anterior pituitary gland.
lecture and is reviewing the functions
of the female reproductive system. FSH and LH, when stimulated by gonadotropin-releasing
She asks Mark to describe the follicle- hormone from the hypothalamus, are released from the
stimulating hormone (FSH) and the anterior pituitary gland to stimulate follicular growth and
luteinizing hormone (LH). Mark development, growth of the graafian follicle, and production
accurately responds by stating that:
of progesterone.
a. FSH and LH are released from the

anterior pituitary gland.
b. FSH and LH are secreted by the

corpus luteum of the ovary
c. FSH and LH are secreted by the

adrenal glands
d. FSH and LH stimulate the formation

of milk during pregnancy.
A woman who's 36 weeks pregnant b. vaginal bleeding
comes into the labor & delivery unit
with mild contracts. Which of the contractions may disrupt the microvascular network in the
following complications should the placenta of a client with placenta prevue and result in
nurse watch out for when the client bleeding. If the separation of the placenta occurs at the
informs her that she has placenta margin of the placenta, the blood will escape vaginally.
prevue?

Sudden rupture of the membranes isn't related to placenta

a. sudden rupture of membranes
prevue. Fever would indicate an infectious process, and emesis
b. vaginal bleeding
isn't related to placenta previa
c. emesis
d. fever
A 21y.o. client has been diagnosed 4.
with hydatidiform mole. Which of the
following factors is considered a risk previous molar gestation increases risk for developing
factor for developing hydatidiform subsequent molar gestation by 4-5 times. Adolescents and
mole?
women ages 40+ are at increased risk for molar pregs.
MULTIGRAVIDAS, esp women with prior preg loss, and women
1. age in 20s or 30s
with LOWER SES are at increased risk for this problem.
2. high in SES
3. Primigravida
4. prior molar gestation
A 21 y.o. has arrives to the ER with c/o 2. Ecoptic pregnancy
cramping abdominal pain and mild
vaginal bleeding. Pelvic exam shows a most ecoptic pregnancies dont appear as obvious life
left adnexal mass that's tender when threatening med emergencies. THey must be considered in
palpated. Culdocentesis shows blood any sexually active woman of childbearing age who c/o
in the culdesac. This client probably menstrual irregularity, cramping abdominal pain, and mild
has which of the following conditions?
vaginal bleeding.
1. Abruptio placentae
PID, abruptio placentae and hydatidiform moles wont show
2. Ecoptic pregnancy
blood in the cul de sac
3. Hydatidiform mole
4. Pelvic Inflammatory Disease
1. Abruptio placentae
a client w/ severe abruptio placentae will often have SEVERE

abdominal pain. The uterus will have increased tone w/ little to
no return to resting tone btw/ contractions.
A client, 34 weeks pregnant, arrives at
the ER with SEVERE abdominal pain, The fetus will start to show signs of distress, with decels in the
uterine tenderness and an increased HR or even fetal death w/ large placental separation.
uterine tone. The client denies vaginal
bleeding. The external fetal monitor Placenta previa usually involves PAINLESS vaginal bleeding
shows fetal distress with severe, w/out UCs.
variable decels. The client most likely
has which of the following? A molar preg. generally would be detected before 34 weeks
gestation.
An ecoptic preg. which usually occurs in the FALLOPIAN

TUBES, would rupture well before 34 weeks gestation
Before the placenta functions, the 2. estrogen and progesterone
corpus luteum is the primary source
for synthesis of which of the following The CL produces progesterone and estrogen for the 1st 8-10
hormones?
weeks of pregnancy until the placenta takes over this function.
1. cortisol and thyroxine

The high levels of estrogen and progesterone cause
2. estrogen and progesterone
suppression of LH and FSH.
3. LH and FSH

4. T4 and T3 T4 and T3 are produced in the adrenal gland
1. increased tidal volume
Which of the following changes in a pregnant client breathes deeper, which increases the tidal
resp functioning during pregnancy is volume of gas moved in and out of the respiratory tract w/
considered normal?
each breath.
1. increased tidal volume

The expiratory volume and residual volume DECREASE as the
2. increases expiratory volume
preg. progresses.
3. decreased inspiratory capacity

4. decreased oxygen consumption. The inspiratory capacity INCREASES during preg.
The increases oxygen consumption in the preg client is 15-20%

greater than in the nonpreg state
3. physiologic anemia
Which of the following conditions is Hgb and Hct values DECREASE during preg as the INCREASE
common in pregnant clients in the 2nd in plasma volume exceeds the increase in RBC production.
trimester of preg?

Alterations in acid-base balance during pregnancy result in a

1. mastitis
state of resp. alkalosis, compensated by mild metabolic
2. metabolic alkalosis
acidosis.
3. physiologic anemia

4. respiratory acidosis Mastitis is an infection in the breast characterized by a swollen

tender breast and flu like Sx. this condition is most freq. seen in
breast feeding clients.
2. ELECTROLYTE IMBALANCE
a 21 y.o. client, 6 weeks pregnant, is
diagnosed with hyperemesis Excessive vomiting in clients with hyperemesis grav often
gravidum. This excessive vomiting causes weight loss / fluid and electrolyte, acid base imbalance.
during pregnancy will often result in
which of the following?

PIH and bowel perforation arent r/t hyper grav
1. bowel perforation
the effects of hyper grav on the fetus depend on the severity
2. electrolyte imbalance
of the disorder.
3. miscarriage

4. PIH clients w/ severe hyper grav may have low birth weight infant,
but the disorder isnt life threatening to the fetus.
a client is being admitted to the 1. Trophoblastic disease
antepartum unit for hypovolemia
secondary to hyperemesis is associated w/ hyperemesis grav
gravidarum. WHich of the following obesity and maternal age younger than 20 y.o. are risk factors
factors predisposes a client to the too.
development of this?

High levels of estrogen HCG have also been associated with

1. trophoblastic disease
the development.
2. maternal age > 35 y.o.
3. malnourished or underweight
clients
4. low levels of HCG
Clients with gestational diabetes are 1. diet
usually managed by which of the
following therapies?
oral hypoglycemics are contraindicated in preg.
long acting insulin usually inst needed for blood glucose

1. diet
control in the client with GDM
2. long acting insulin
3. oral hypoglycemic drugs
4. oral hypoglycemic drugs/insulin
Rh isoimmunization in a pregnant 2. Rh positive fetal blood crosses into maternal blood,

client develops during which stimulating maternal antibodies.
conditions?

Rh isoimmunization occurs when Rh positive fetal blood cells

1. Rh positive maternal blood crosses cross into the maternal circulation and stimulate maternal
into fetal blood, stimulating fetal antibody production.
antibodies.

2. Rh positive fetal blood crosses into In subsequent pregnancies w/ Rh positive fetuses, maternal
maternal blood, stimulating maternal antibodies may cross back into the fetal circulation and
antibodies.
destroy fetal blood cells.
3. Rh Negative fetal blood crosses
into maternal blood, stimulating
maternal antibodies.
4. Rh negative maternal blood crosses

into fetal blood, stimulating fetal
antibodies.
Which of the following doses of Rh 4. 300 mcg in a unsensitized client
immune globulin RhoGAM is
appropriate for a pregnant client at 28 An Rh negative unsensitized woman should be given 300 mcg
weeks gestation?
of RhoGAM at 28 weeks after an indirect Coombs test is done
to verify that sensitization hasn't occurred.
1. 50 mcg in a sensitized client

2. 50 mcg in an unsensitized client

For a 1st trimester abortion or ectopic pregnancy, 50 mcg of
3. 300 mcg in a sensitized client
RhoGAM is given.
4. 300 mcg in a unsensitized client
A client hospitalized for premature 3. Encourage her to empty her bladder and drink plenty of
labor tells the nurse she's having fluids, IV fluids
occasional contractions. Which of the
following nursing interventions would An empty bladder and adequate hydration may help decrease
be the most appropriate?
or stop labor contractions.

1. Teach the client the possible Walking may encourage contractions to become stronger.
complications of premature birth.

2. Tell the clients to walk to see if she Teaching the potential complications is likely to increase the
can get rid of the contractions.
clients anxiety rather than relax her
3. Encourage her to empty her
bladder and drink plenty of fluids, IV It would be inappropriate to call anesthesia

fluids
4. Notify anesthesia for immediate

epidural placement to relieve the pain
associated with contractions.
The phrase gravida 4, para 2 indicated 2. a client has been pregnant 4 times and had 2 live born
which of the following prenatal children
histories?

Gravida refers to the number of times a client has been

1. a client has been pregnant 4 times pregnant.
and had 2 miscarriages.

2. a client has been pregnant 4 times Para refers to the # of viable children born.
and had 2 live born children

3. a client has been pregnant 4 times Therefore, the client who's gravida 4, para2 has been pregnant
and had 2 c-sections
4x and had 2 live born children.
4. a client has been pregnant 4 times
and 2 spontaneous abortions.
Which of the following factors would 4. a woman w/ a hx of diabetes has an increased risk for
contribute to a high risk pregnancy?
perinatal complications, including HTN, preeclampsia, and
neonatal hypoglycemia.
1. Blood type O positive

2. first pregnancy at age 33y.o.

The age of 33 years w/out other risk factors doesn't increase
3. Hx of allergy to honey bee pollen
risk, nor does type O positive blood or environmental
4. Hx of insulin dependent DM allergens.
3. pulmonary edema
Tocolytics are used to stop labor contractions.
Which of the following complications
can be potentially life threatening and The most common adverse effect associated with the use of
can occur in a client receiving a these drugs is pulmonary edema.
tocolytic agent?

Clients who dont have diabetes dont need to be observed for

1. diabetic ketoacidosis
diabetic ketoacidosis.
2. hyperemesis gravidarum

3. pulmonary edema
Hyperemesis gravidium doesnt result from tocolytic use.
4. sickle cell anemia
Sickle cell anemia is an inherited genetic condition and doesnt

develop spontaneously
Oxytocin is the hormone responsible for stimulating UCs.
Which of the following hormones Pitocin, the synthetic form, may be given to clients who are
would be administered for the past their due date.
stimulation of uterine contractions?

Progesterone has a relaxation effect on the uterus
1. Estrogen

2. Fetal cortisol
Fetal cortisol is believed to slow the production of
3. Oxytocin
progesterone by the placenta
4. Progesterone
although estrogen has a role in UC, it isnt given in a synthetic

form to help UC
Which of the following answers best 4. maternal and fetal blood are never exchanged
describes the stage of pregnancy in
which maternal and fetal blood are only nutrients and waste products are transferred across the
exchanged?
placenta.
1. conception
blood exchange never occurs
2. 9 weeks gestation when the fetal
heart is well developed

complications and some medical procedures can cause an
3. 32-34 weeks gestation 3rd exchange to occur accidentally
Trimester
4. maternal and fetal blood are never

exchanged
Which of the following rationales best 3. to prevent compression of vena cava
explains why a pregnant client should
lie on her left side when resting or the weight of the preg uterus is sufficiently heavy to compress
sleeping in the later stages of the vena cava, which could impair blood flow to the uterus,
pregnancy?
possibily decreasing oxygen to the fetus. The side lying
position hasnt been shown to prevent fetal anolmaies nor
1. to facilitate digestion
bladder emptying and or digestion
2. to facilitate bladder emptying
3. to prevent compression of vena

cava
4. to avoid fetal anomalies
An NST is based on the theory that a healthy fetus will have

Because uteroplacental circulation is
transient fetal heart rate accelerations with fetal movement.
compromised in clients with

preeclampsia, a NST is performed to

A fetus with compromised uteroplacental circulation usually
detect which conditions?
wont have these accelerations, which indicate a nonreactive

NST.
1. Anemia
2. Fetal well being
Serial US wil detect IUGR and oligohydramnios in a fetus.
3. IUGR
4. oligohydarminos
An NST cant detect anemia in a fetus
2. 85 mg/dl
A client is 33 weeks pregnant and has

recommended fasting blood sugar levels in pregnant clients
had diabetes since she was 21. When
w/ dm are 60-90 mg/dl
checking her fasting blood sugar

level, which values indicate the clients

a fasting blood sugar level of 45mg/dl is low and may result in
disease was controlled.
hypoglyecemia
1. 45 mg/dl
a bs level below 120mg/dl is recommeded for 1hour

2. 85 mg/dl
postprandial values
3. 120 mg/dl
4. 136 mg/dl
a bs level above 136 mg/dl in a pregnant client indicates
hyperglycemia
2. NST 2X/week
Which of the following is best to NST is the preferred antepartum HR screening test for
monitor a fetus of a client with pregnant clients with diabetes.
diabetes in her 3rd trimester

NSTs should be done at least 2x per week staring at 32 weeks
1. US exam weekly
gestation, as fetal deaths in clients w/ diabetes have been
2. NST 2x/week
noted within 1 week of a reactive NST.
3. Daily contraction stress test at 32
weeks
US should be done ever 4-6 weeks to monitor fetal growth.
4. monitoring fetal activity by client
weekly CST wouldnt be initiated at 32 weeks

Maternal fetal activity monitoring should be done daily
A client diagnosed with preterm labor 2. regular uterine contractions (every 10 min or more) along
at 28 weeks gestation. Later, she with cervical dilation change before 36 weeks = PTL
comes to the emergency dept saying
"I think im in labor" The nurse would no cervical change with UC isnt' PTL
expect her physical exam to show
which condition?
1. painful contractions with no cervical

dilation
2. regular uterine contractions with

cervical dilation
3. irregular uterine contractions with

no cervical dilation
4. irregular uterine contractions with

cervical effacement
3.
Calcium gluconate should be kept at the bedside while a client

Which drug would the nurse choose is recieivng mag sulfate infusion. If magnesium toxicity occurs,
to utilize as an antagonist for calcium gluconate is admined as an antidote
magnesium sulfate?

oxytocin is the synthetic form of the naturally occurring

1. Oxytocin
pituitary hormone used to initiate or augment UCs
2. Terbutaline

Terbutaline is a beta2 adrenergic agonist that may be used to

relax smooth muscle of the uterus, esp for PTL and uterine
3. Calcium gluconate
hyperstimulation
4. Narcan

Naloxone is an opiate antagonist admin to reverse resp

distress
3. Y tubing, normal saline, 18G cath
The nurse receives an order to start an

infusion for a client whos

blood transfusions require
hemorrhaging due to a placenta

Y tubing
previa. What supplies will be needed?
Normal Saline solution
to mix with the blood product and an 18G cath to avoid lysing
1. Y tubing, normal saline solution, and
breaking the RBCs.
20G cathether
2. Ytubing, lactated Ringers solution

A 20G cath lumen isnt large enough for a blood transfusion.
and 18G cath
3. Y tubing, normal saline, 18G cath
Lactated RIngers solutions isnt the IV solution of choice for

4. Y tubing, lactated RIngers, 20G cath
blood transfusions
3. Maternal Blood count
- evaluates maternal, not fetal well being
BPP
During the last 6 weeks of gestation, - uses US to eval fetal body movements, breathing movements,
which of the following tests isnt used muscle tone, reactive fetal cardiac rate,
to determine FWB?
amniotic fluid volume
1. BPP NST
2. NST
- evals the FHR for accels during FM
3. Maternal blood count

4. FM count FM
- counts are used during the last trimester to obtain a rough

index of fetal health
- the number of FM are counted at diff times throughout the

day and then charted to detect any change in overall activity
over a number of days
Which of the following conditions isnt 3. maternal diabetes
dx by abdominal US during the
prenatal period?
abdominal US evals fetal presentation, fetal heart activity,
amniotic fluid volume
1. fetal presentation

2. fetal heart activity

although it may show increased amnitoic flud, thus helping to
3. maternal diabetes
diagnose maternal diabetes, it isnt used for that purpose.
4. amniotic fluid volume
When teaching an antepartal client 1. Descent
about the passage of the fetus 2. Flexion
through the birth canal during labor, 3. Internal rotation
the nurse describes the cardinal 4. Extension
mechanisms of labor. Place these 5. External rotation
events in the proper sequence in 6. Expulsion
which they occur:

DFI EEE
1. Flexion
2. External rotation
3. Descent
4. Expulsion
5. Internal Rotation
6. Extension
A client who is 32 weeks pregnant is 1. Evaluate VS
being monitored in the antepartum 4. Evaluate FHT
unit for PIH. She suddenly complains 5. Monitor amt of vaginal bleed
of continuous abdominal pain and 6. Monitor I&O
vaginal bleeding. Which of the
following nursing internventions The clients Sx indicate that she's experiencing abruptio
should be included in the care of this placenta.
client? Check all that apply

The nurse must immed eval the moms well being by eval VS,
1. Evaluate VS
FWB, by auscultation of heart tones, monitoring amt of blood
2. Prepare for vaginal delivery
loss and eval the vol status by measuring I&O.
3. Reassure client that she'll be able to
continue pregnancy
After the severity of the abruption has been determined and
4. Evaluate FHT
blood and fluid have been replaced, prompt C-SECTION
5. Monitor amt of vaginal bleed
delivery of the fetus (not vaginal) is indicated if the fetus is in
6. Monitor I&O distress
A woman with a term, uncomplicated 2. Noting color, amount and odor of the fluid as well as the
pregnancy comes into L&D in early time of the rupture, will help guide the nurse in her next action.
labor saying that she thinks her water
broke. Which action should the nurse There's no need to call the doctor immed or prep the client for
take?
delivery if the fluid is clear and delivery isnt imminent.
1. prep the woman for delivery

ROM isnt unusual in early stages of labor.
2. note color, amt and odor of fluid

Fluid collection for microbe analysis isnt routine and theres no
3. immed contact doctor
concern for infection/maternal fever.
4. collect sample of fluid for microbial
analysis
2. Vaginal bleeding
A woman who's 36 week preg comes
into L&D with mild contractions. Which contractions may disrupt the microvascular network in the
of the following complications should placenta of the client with placenta previa and result in
the nurse watch for when the client bleeding.
informs her that she has placenta
previa?
if the separation of the placenta occurs at the margin of the
placenta, the blood will escape vaginally.
1. sudden ROM

2. Vaginal bleeding
sudden ROM isnt r/t placenta previa
3. emesis

4. fever fever would indicate an infections process, and emesis isnt r/t
placenta previa
A clients labor doesnt progress. After 3 = 0.2
ruling out CPD, the doctor orders IV
admin of 1,000 ml normal saline w/ each unit of oxytocin contains 1,000 miliunits. Therefore, 1,000
Pitocin 10 units to run at 2 miliunits / ml of IV fluid contains 10,000 miliunits (10 units) of Pitocin
min. 2 miliunits/min is equivalent to
how many ml/unit
1. 0.002
2. 0.02
3. 0.2
4. 2.0
A client at 42 weeks gest is 3cm 4. Excessive fetal activity and fetal tachycardia
dilated, 30% effaced, with membranes
intact and the fetus at +2 station. FHR Fetal tachycardia and excessive fetal activity are the FIRST
is at 140-150 bpm. After 2 hours, the SIGNS OF FETAL HYPOXIA
nurse notes on the EFM that, for the
past 10 min, the FHR ranged from 160- The duration of UCs is w/in normal limits.
190bpm. The client states that her
baby has been extremely active. UCs Uterine intensity can be mild-strong and still be w/in normal
are strong, occurring every 3-4 min. limit.
and lasting 40-60 sec. Which of the
following findings would indicate fetal The frequency of contractions is w/in normal limits for the
hypoxia?
active phase of labor.
1. Abnormally long UCs
2. Abnormally strong uterine intensity

3. Excessively frequent contractions
with rapid fetal movement
4. Excessive fetal activity and fetal

tachycardia
A client at 33 weeks gestation and 2. You may feel fluttering or tight sensation in your chest
leaking amniotic fluid is place on an
EFM. The monitor indicates uterine A fluttering or tight sensation in the chest is a common adverse
irritability and contractions occuring reaction to terbutaline
every 4-6 min. The doctor orders
terbutaline. Which of the following It relives bronchospasm but the client is getting it to reduce
teaching statements is approp for this uterine motility.
client?

Mouth dryness and thirst occur w/ the inhaled form but are
1. This medicine will make you breathe unlikely with subcut form
better

2. You may feel fluttering or tight Hypokalemia is a potential adverse reaction following large
sensation in your chest
doses of terbutaline but not at doses of 0.25 mg
3. This will dry your moth and make
you thirsty
4. You'll need to replace potassium

lost by this drug
2. Stop the mag sulfate infusion
A 17 y.o. primpigravida with severe PIH

has been receiving mag sulfate IV for

Mag sulfate should be withheld if the clients resp rate or urine
3 hours. The latest assessment reveals
output falls or if reflexes are diminished / absent.
DTR of +1, BP 150/100 mmgHg, pulse

92 bpm, respiratory rate 10bpm and

The client also shows other signs of impending toxicity such as
urine output 20ml/hr. Which of the
flushing / feeling warm.
following actions would be most

approp?
Inaction wont resolve the clients suppressed DTRs and low RR

/ urine output.
1. Continue monitoring per standards

The client is already showing CNS depression bc of excessive
of care
magsulfte so increasing the infusion is wrong.
2. Stop the mag sulfate infusion
3. Increase infusion by 5gtt/min
Impending toxicity indicates that the infusion should be

4. Decrease infusion by 5gtt/min
stopped rather than just slowed down.
During a vaginal exam of a client in 3. The client may need interventions to ease back pain and
labor, the nurse palpates the fetus' change fetal position
larger, diamond shaped fontanelle
toward the anterior portion of the The fetal position is occiput posterior, a position that
clients pelvis. Which of the following commonly produces intense back pain during labor.
statements best describes this
situation?
Most of the time, the fetus rotates during labor to occiput
anterior position.
1. The client can expect a brief and
intense labor, which potential for Positioning the client on her side can facilitate this rotation.
lacerations.

2. The client is at risk for uterine An occiput posterior position would most likely result in
rupture and needs constant prolonged labor
monitoring
POSTERIOR - PROLONGED.
3. The client may need interventions to
ease back pain and change fetal occiput posterior alone doesnt create a risk of uterine rupture.
position

4. The fetus will be delivered using The fetus wont be delivered with forceps / vacuum only if its
forceps or vacuum extractor presenting part DOESNT rotate and descend spontaneously
The cervix of a 26 year old THe client should be placed on her left side or sitting up right,
primigravida in labor is 5cm dilated with her shoulders parallel and legs slightly flexed.
and 75% effaced, and the fetus is at 0
station. The doctor prescribes an Her back shouldnt be flexed bc this position increases
epidural regional block. Into which of increases the possibility that the dura may be punctured and
the following positions should the the anesthetic will accidentally be given as spinal, not
nurse place the client when the epidural, anesthesia.
epidural is admin?
1. Lithotomy
2. Supine
3. Prone
4. Lateral
3. Effacement
effacement is cervical shortening and thinning
Which of the following terms is used

while dilation is widening of the cervix
to describe the thinning and

shortening of the cervix that occurs

both facilitate opening the cervix in prep for delivery.
just before and during labor?
Ballottement is the ability of another individual to move the

1. Ballottement
fetus by externally manipulating the maternal abdomen.
2. Dilation
3. Effacement
A ballotable fetus hasn't yet engaged in the maternal pelvis.
4. Muliparous

Multiparous refers to a woman who has had previous live

births.
1. Vertex presentation
flexion of the fetal head is the optimal presentation for

Which of the following fetal positions passage thru the birth canal.
is most favorable for birth?

Transverse lie is an unacceptable fetal position for vaginal birth

1. Vertex
and requires c-section
2. Transverse lie

3. Frank breech presentation

frank breech presentation, in which the buttocks presents first,
4. Posterior position of the head can be difficult vaginal delivery.
posterior positioning of the fetal head can make it difficult for

the fetal head to pass under the maternal symphysis pubis.
1. Give a fluid bolus of 500 ml
Which of the following nursing actions

one of the major adverse effects of epidural admin is
is required before a client in labor
hypotension
receives an epidural?
therefore, a 500ml fluid bolus is usually admin to help prevent

1. Give a fluid bolus of 500 ml
hypotension in the client who wishes to receive an epidural for

2. check for maternal pupil dilation
pain relief.
3. assess maternal reflexes
4. assess maternal gait

assessments of meternal reflexes, pupil response and gait
arent necessary
3. prolonged dyspareunia - painful intercourse
Which of the following complications may result when complications such as infection interefere with
is possible with an episiotomy?
wound healing.
1. blood loss
minimal blood loss occurs when an episitomy is done
2. uterine disfigurement
the uterus isnt affected bc its the perineum that's cut to
3. prolonged dyspareunia
accomodate the fetus
4. hormonal flucuation postpartum
hormonal fluctuations that occur during the postpartum

period arent the result of an episiotomy
A client in early labor states that she 4. after the 4th month, colostrum may be expressed.
has a thick yellow discharge from both
of her breasts. Which of the following the breasts normally produce colostrum for the first few days
actions by the nurse would be after delivery.
correct?

milk production begins 1-3 days PP
1. tell her that her milk is starting to
come in bc she's in labor

A clinical breast exam isnt indicated in intrapartum
2. complete a thorough breast exam although a culture may be indicated, it requires advanced
and document the results in the chart.
assessment as well as a medical order
3. perform a culture on the discharge
and inform the client that she might
have mastitis
4. inform the client that the discharge

is colostrum, normally present after
the 4th month of preg.
Which statement best describes lochia 1. lochia rubra contains a mixture of
rubra?
mucus
tissue debris
1. it contains a mixture of mucus, tissue blood
debris and blood

2. it contains placental fragments, and normal lochia rubra contains NO PLACENTAL FRAGMENTS
blood
3. it contains mucus, placental

fragments and blood.
4. it contains tissue debris and blood
occurs as the body starts to reduce the extracellular fluid

volume that increased during preg
On the 2nd PP day, a client complains
that shes urinating more than when renal plasma flow and GFR also increase slightly until approx 1
she was pregnant. Which is the week PP
primary cause of increased urinary
output post delivery?

Renal malfunctioning is more likely to decrease urinary output,
not increase it
1. postpartum diuresis
increase PP fluid intake and breast feeding arent major causes

of PP diuresis
Lochia alba follows lochia serosa and 2. creamy white to brown, contains decidual cells, may have
usually lasts from the 1st to 3rd week stale odor
PP. Which of the following statements
best describes lochia alba?

also contais leukocytes but it shouldnt contain tissue
fragments or have a foul odor
1. creamy white-brown, stale odor
2. creamy white to brown, contains

decidual cells, may have stale odor
3. brown to red, tissue fragments,

odor
4. brown to red contains decidual

cells and leukocytes
sudden dyspnea
diaphoresis
confusion
tachycardia
Pulmonary embolus signs
stationary blood clot from a varicose vein becomes an

embolus (moving clot) that lodges in the pulmonary circulation
chills and fever = infection
studies have proven that breast milk provides preterm

neonates w/ better protection from infection such as NEC bc
of the antibodies contained in breast milk
Commercial formula doesn't provide any better nutrition than

Breastfeeding preterm neonates
breast milk
breast milk feedings can be started as soon as the neonate is

stable and the neonate is more likely to develop infections
when fed formula rather than breast milk
helps the lungs remain expanded after the initiation of

breathing
Main role of surfactant in the neonate

works by reducing surface tension in the lung
allows the lung to remain slightly expanded
decreases amount of work required for inspiration
how long should normal acrocyanosis max 24 hours post birth

last max.
1 year of age
A positive Babinski's signs is present in

infants until approx. what age?

this is normal in neonates but abnormal in adults
At what gestational age is a conceptus 3. 23 / 24 weeks
considered viable (able to live outside
the womb)?
the lungs are developed enough to sometimes maintain
extrauterine life. the lungs are the most immature system
1. 9 weeks
during the gestational period.
2. 14 weeks

3. 24 weeks
medical care for premature labor begins much earlier
4. 30 weeks (aggressively at 21 weeks0
vitamin K, deficient in the neonate, is needed to activate

clotting factors II,IV,IX and X
In the event of trauma, the neonate would be at risk for

Role of vitamin k in a neonate
EXCESSIVE BLEEDING
vitamin k doesnt assist the gut to mature but the gut

PRODUCES vitamin K once maturity is achieved
Neonates born to women infected 4. Hep B immune globulin within 12 hours of birth and Hep B
with hepatitis B should undergo which vaccine at birth, 1 month, 6 months
Tx regimen

Hep B immune globulin should be given as soon as possible

1. Hep B vaccine at birth and 1 month
after birth but within 12 hours
2. Hep B immune globulin at birth, no
hepatitis B vaccine
neonates should also receive hep B vaccine at regularly
3. Hepatits B immune globulin within scheduled intervals
48 hours of birth and Hep B vaccine at
1 month
this sequence of care has been determined as superior to the
4. Hep B immune globulin within 12 others
hours of birth and Hep B vaccine at
birth, 1 month, 6 months
Two days after circumcision, the nurse 1. the yellow white exudate is part of the granulation process
notes a yellow - white exudate around and a normal finding for a healing penis after circumcision
the head of the neonates penis. What
would be the most appropriate therefore, notifying the doctor isnt necessary
nursing intervention?

theres no indication of an infection that would necessitate

1. Leave the area alone as this is a taking the neonates temp
normal finding

2. report findings to physician and the exudate shouldnt be removed

document it
3. Take the neonate's temperature bc

an infection is suspected
4. Try to remove the exudate with a

warm washcloth
A client has just given birth at 42 3. desquamation of the epidermis
weeks gestation. When assessing the
neontate, which phsycial finding is postdate fetuses lose the vernix caseosa and the epidermis
expected?
may become desquamated
1. a sleepy, lethargic baby

these neonates are usually VERY alert
2. lanugo covering body

3. desquamation of the epidermis

lanugo is missing in the postdate neonate
4. vernix caseosa covering the body
The SGA neonate is at increased risk 4. polycythemia probably due to chronic fetal hypoxia
during the transitional period for
which complication?
the SGA baby is at risk for developing polycythemia during the
transitional period in an attempt to decrease hypoxia
1. anemia probably due to chronic
fetal hypoxia
the neonates are also at increased risk for developing
2. hyperthermia due to decreased hypoglycemia due to decreased glycogen stores
glycogen stores
3. hyperglycemia due to decreased

glycogen stores
4. polycythemia probably due to

chronic fetal hypoxia
3. decreased temp
WHich finding might be seem in a

temp instability esp when it resutls in low temp in the neonate,
neonate suspected of having an
may be a sign of infection.
infection?
the neonate's color often changes with an infection process

1. flushed cheeks
but generally becomes ashen or mottled
2. increased temp
3. decreased temp
the neonate w/ an infection will usually show a decrease in

4. increased activity level
activity level or lethargy
Which Sx would indicate the neonate 4. resp rate of 40-60 breaths/min is normal for a neonate
was adapting approp to extrauterine during the transitional period
life w/out difficulty?

nasal flaring, resp rate > 60 and audible grunting = SIGNS OF

1. nasal flare
RESP DISTRESS!
2. light audible grunting
3. resp rate 40-60 breaths/min
4. resp rate 60-80 breaths/min
3. resp depression
After reviewing the client's maternal

history of magnesium sulfate during

mag sulfate crosses the placenta and adverse neonatal effects
labor, which condition would the
are:
nurse anticipate as a potential

problem in the neonate?
resp depression
hypotonia
1. hypoglycemia
bradycardia
2. jitteriness
3. resp depression
the serum blood sugar isnt affected by mag sulfate
4. tachycardia
the neonate wold be floppy, not jittery
Convection heat loss the flow of heat from the body surface to COOLER AIR
the loss of heat that occurs when a liquid is converted to a

Evaporation Heat Loss
vapor
is the loss of heat from the BODY SURFACE to COOLER

Conduction heat loss
SURFACES in direct contact
is the loss of heat from the body surface to COOLER SOLID

RADIATION HEAT LOSS SURFACES NOT in direct contact but in relative proximity
4. it involves swelling of the tissue over the presenting part of

A neonate has been diagnosed with the head due to sustained pressure
caput succedaneum. which statement
is true?
this boggy edematous swelling is present at birth,
CROSSES the suture line
1. usually resolves in 3-6 weeks

occurs in occipital area
2. collection of blood btw/ skill and
periosteum
a cephalohematoma is a collection of blood btw/ the skill and
3. doesnt cross the cranial suture line
periosteum that DOESNT cross the suture lines and resolves in
4. it involves swelling of the tissue 3-6 weeks
over the presenting part of the head
caput seccedaneum resolves within 3-4 DAYS
collects in the GI tract during gestation and is initially STERILE
greenish black bc of occult blood and is viscous
stools of breast fed neonates
MENCONIUM
- are loose golden yellow after the transition to extrauterine
life
stools of formula fed babies are
- typically soft and pale yellow after feeding's well established
3 day old neonate needs 3. mask
phototherapy for hyperbilirubinemia.
nursery care of a neonate getting the neonate's eyes must be covered with eye patches to
phototherapy would include which prevent damage
nursing intervention?

the mouth of the neonate doesnt need to be covered
1. tube feedings

2. feeding the neonate under the neonate can be removed from the lights and held for
phototheraphy lights
feeding
3. mask over the eyes to prevent
retinal damage
the neonates temp should be monitored at least every 2-4
4. temp monitored every 6 hours hours due to risk of hyperthermia w/ phototherpahy
during phototherapy
4. CHRONIC MATERNAL HTN
Which assessment finding would be unlikely factor bc chronic fetal stress tends to INCREASE
LUNG MATURITY
the most unlikely risk factor for RDS
premature neonates < 35 weeks are associated with RDS
1. second born of twins
2. neonate born at 34 weeks
Even with a mature lecithin to sphingomyelin ration, neonates

3. neonate of diabetic mom
of moms with diabetes still develop RDS
4. chronic maternal HTN

2nd born of twins may be prone to greater risk of asphyxia
A male neonate has just been 4.
circumcised. Which nursing
intervention is part of the initial care of Petroleum gauze is applied to the site for the 1st 24 hours to
a circumcised neonate?
prevent the skin edges from sticking to the diaper
1. apply alcohol to the site

neonates are initially kept in the prone position
2. Change the diaper as needed

3. keep the neonate in supine position

diapers are changed more freq to insepct the site
4. apply petroleum gauze to the site
for 24 hours alcohola is CONTRAINDICATED
1. bradycardia
When performing an assessment on a
neonate, which assessment finding is hypothermic neonates become bradycardic proportional to

MOST SUGGESTIVE of hypothermia?
the degree of core temp
1. bradycardia
HYPOGLYCEMIA is seen in HYPOTHERMIC NEONATES
2. hyperglycemia

3. metabolic alkalosis
Shivering is rarely observed in neonates
4. shivering
metabolic ACIDOSIS, not alkalosis is seen due to slowed resp
Which nursing ntervention helps 3. immed drying the neonate
prevent evaporative heat loss in the
neonate immed after birth?

decreases evaoporative heat loss from moist body from birth

1. admin warm oxygen

placing the neonate on a warm, dry towel decreases
2. controlling drafts in the room
CONDUCTIVE losses.
3. immed drying the neonate

4. placing neonate on a warm, dry controlling draft in the room and admin warm oxygen helps
towel reduce CONVECTIVE LOSS
Infant (Birth-12 months) stage Trust v. Mistrust
learn to trust the environment and caregivers depending on

Infant (Birth-12 months) major task
the response to crying, nurturing, feeding
Toddler (1-3 years) stage Autonomy v. Shame and Doubt
reassurance and self-respect are obtained through learning,

Toddler (1-3 years) major task
exploring, and independence
Preschool (3-6 years) stage Initiative v. Guilt
Preschool (3-6 years) major task performance of activities to gain approval
School-Age (6-12 years) stage Industry v. Inferiority
working through competition to completion and tangible

School-Age (6-12 years) major task
results
Adolescent (12-18 years) stage Identity v. Role Confusion
establish independence with ideals and goals, understand and

Adolescent (12-18 years) major task
enact adulthood
Young Adult (18-35 years) stage Intimacy v. Isolation
seek close, personal relationships to develop productivity and

Young Adult (18-35 years) major task
bstrandable NCLEX OB/Peds 3 of 3 contentment
Middle Adult (36-65 years) stage Generativity v. Stagnation
Middle Adult (36-65 years) major task pursues self-fulfillment for sense of accomplishment
Older Adult (>65 years) stage Ego Integrity v. Despair
Older Adult (>65 years) major task adjust to aging with self-worth; reflect on life with satisfaction
Infant age range 0-12 months
Toddler age range 1 year - 3 years
Preschool age range 3 years - 6 years
School-Age age range 6 years - 12 years
Preadolescent age range 10 - 12 years
Adolescent age range 12 years - 18 years
Young Adult age range 18 years - 35 years
Middle Adult age range 36 years - 65 years
Older Adult age range greater than 65 years
1. posterior fontanelle closes
0-3 months 2. makes noise when spoken to
3. holds head up when prone
1. birth weight doubles, teeth emerge
3-6 months 2. sits up, rolls over, makes sounds
3. puts objects in mouth
1. fears separation from mother
6-9 months 2. combines syllables
3. transfers objects, crawls
1. birth weight triples; anterior fontanelle closes by 18 mo.
2. words emerge
9-12 months
3. stands alone; begins to walk
1. importance of rituals, training, and instruction
1-3 years 2. temper tantrums, parallel play
3. partial to total toilet training
1. conscience develops; learns the rules

2. transitions from fantasy to reality; has feelings; fears
3-6 years
intrusions into body 3. teeth completely emerge; leg and foot
growth rapid; tie shoes at 6 years
1. begin to discard parental standards; competence and

6-12 years perseverance; able to classify; seek sense of accomplishment
2. lose baby teeth; develop speed and strength
1. variability in growth and maturation
10-12 years
2. strong desire to conform
1. rational sense of self; actualizes abilities; moral judgment 2.

12-18 years confused; indecisive; antisocial 3. rapid growth; bone growth
completed; secondary sexual features develop
1. leave home; commit to personal relationships and career 2.

18-35 years develop a lifestyle; increase responsibility 3. physical growth
complete; chronic disease is uncommon
1. desire to accomplish unfulfilled goals 2. examine the past;

36-65 years assess current life; plan for future, and realize mortality 3.
chronic disease emerges; life subtly changes
1. desire to find satisfaction with life
65+ years 2. assure housing and relationships
3. adjust to losses; manage illness; prepare for death
Passenger, Passageway, Powers, Position of laboring woman,

Five P's
Pyschological response
Relationship of maternal spine and fetal spine (transverse

makes a cross and will not accomodate vaginal birth, Parallel is
Lie
linear, but vaginal birth depends on presentation)
Relationship of body parts to one another. Fetal flexion-chin

Attitude flexed to chest, extremities into torso
Fetal extension- chin extended, extremities extended
Part of fetus entering pelvic inlet first. Head (occiput) Chin

Presentation
(mentum), shoulder (scapula), breech (sacrum)
Relationship between presenting part and direction relating to

maternal quadrants. 1st: R or L maternal pelvis 2nd: presenting
Fetopelic position
part of fetus (O,S,M, Sc) 3rd: References anterior (A), posterior
(P), Transverse (T) of maternal pelvis
Station measurement of fetal descent
Passageway Birth canal
External Electronic Monitoring Toco, on maternal stomach

(tocotransducer)
Intrauterine Pressure catheter IUPC, Measures pressure
Lightening (fetal head drops into pelvis), backache,

Signs preceding labor Contractions, Bloody show (cervical mucus plug discharged),
wt loss, energy, rupture of membranes.
pale to straw yellow, no odor, watery and clear, between 500-

Amniotic fluid assessment
1,200ml, Nitrazine paper will turn BLUE!
Engagement, Descent (fetal head drops through pelvis),

Flexion (head flexes toward chin), Internal rotation (fetal head
Mechanism of labor rotates to lateral anterior position CORKSCREW), Extension
(passes through symphysis pubis and head deflects anteriorly
chin extends away), External rotation, Expulsion.
First stage (latent, active, transition), Second stage, Third stage,

States of labor
fourth
Latent- Cervix 0-3 some dilation and effacement
Active- Cervix 4-7 strong contractions rapid dilation and

First stage
effacement
Transition 8-complete dilation of cervix, feeling to push
Second stage full dilation of cervix to birth, maternal pushing
Third stage Birth to delivery of placenta
Fourth stage Delivery of placenta to maternal stabilization
1. Respirations
2. heart rate (apical)
Order of attaining vital signs

3. Blood pressure
4. temp
Who should not be getting a rectal children over 3 months

temp?
When to start oral temp? age 5-6
What happens to the growth rate decreases

between 6-12 years of age?
How much earlier to girls experience 1-2 years

the onset of adolescence?
h/h
Lab values that are important in albumin
determining nutritional status creatinine
nitrogen
C=crying (0-2)
R=Requires increased oxygen (0-2)
I=increased vital signs (0-2)
Pain assessment CRIES scale E=Expressions (0-2)
S=sleepless (0-2)
Face, Legs, Activity, Crying, Consolability
Pain assessment: FLACC

0-10 scale, each worth 2 points
Wong-Baker rating scale AKA faces
any age, but usually 3 and older
Make sure the child has cognitive development and is not

How old for Wong-Baker scale?
delayed.
Scale is 0-5
When is the numerical pain scale used age 5 and older

in children?
-Most common type of croup experienced by children

Laryngotrachiobronchitis
admitted to the hospital and primarily affects children under 5
Virus
Causes of Laryngotrachiobronchitis -Parainfluenza
(Croup) adenovirus
RSV
slight to severe diarrhea
S/S of Laryngotrachiobronchitis barking or brassy cough
increased temp
Epiglottitis Serious obstructive disease caused by H. ifluenza
absence of cough
drooling
S/S of Epiglottitis agitation with rapid progression to severe resp. distress
*Children with epiglottitis usually look worse than they
bstrandable NCLEX OB/Peds 3 of 3 sound, and the id with LTB sounds worse then they look**
This is an emergency
Treatment for epiglottitis -may require intubation or a trach
-IV antibiotics and corticosteroids
Difficulty swallowing and breathing so child is a mouth

breather and they have bad breath
impaired taste and smell, voice has a nasal.muffled quality
Tonsilitis S/S
persistent cough
swollen tonsils can block drainage of the ear canal and cause
otitis media
Treatment for tonsilitis tonsilectomy
What would indicate that hemorrhage frequent swallowing

is occuring post tonsilectomy?
How many post op days is the child at up to 10 days

risk for hemorrhage after a
tonsilectomy?
sore throat and slight ear pain
Complaints/normal occurrences after

low grade temp
tonsilectomy
bad breath
what does tympanic membrane look bulging and bright red

like with otitis?
-heating pads help (alternate with ice)
-avoid chewing (soft foods)
-lie on the affected side
-may not hear you
Treatment of otitis media

-avoid smoke
-May require PE (pressure equalizing) tubes to keep the

middle ear drained. The ear tube (grommet) stays in about 6
months and then falls out
An acute viral infection that affects the bronchioles and

includes RSV bronchiolitis or RSV pna
RSV Respiratory Syncytial Virus

Leading cause of lower resp tract illness in children less than 2
years
prematurity
congenital disorders
Risk factors for RSV

smoke
focus is on prevention (high risk will get RSV vaccine)
URI
nasal discharge
mild fever
dyspnea
S/S of RSV
nonproductive cough
tachypnea with flaring nares
retraction and wheezing
disease becomes worse on days 2-3
Contact precautions
What is the transmission of RSV?

teach good handwashing techniques
mild: treat symptoms
Treatment for mild vs. severe RSV

severe: hospitalization, may use antivirals like Ribavirin
1. Viral (RSV, adenovirus or parainfluenza)
2. Bacterial (culprit is strep pneumonia) children <4 years
Causes of pna 3. Mycotic (walking pna) primarily in adolescents Mycoplasma

pna
4. Aspiration pna (something other than air gets into the lungs)
fine crackles or rhonchi with a cough that is productive or

nonproductive
abdominal distention
S/S of pna
back pain
fever that is usually high
chest pain from coughing
oxygen
fluids
antibiotics
Treatment for pna

antipyretics
nebulizer
cough suppressant
What type of infections are Down Respiratory because they have a poor immune system
Syndrome children prone to
developing?
The most common type of defect heart defects

associated with Down's is
Causes of cystic fibrosis inherited trait, and must get from both parents
**thick, sticky secretions everywhere (resp and GI)
-characterized by exocrine gland dysfunction. These secrete

S/S of cystic fibrosis
mucus
-Thick, sticky secretions found in the resp and GI tracts
-positive sweat chloride test
-At risk for hyponatremia because they are losing sodium

through the skin
Dx of Cystic Fibrosis
-The earliest sign in the newborn is the meconium ileus (does
not pass meconium)
-They will have steatorrhea stools (fatty and frothy)
-Enzymes that help improve digestion are the pancreatic

enzymes
-Take 30 minutes prior to eating, do not crush or chew
-Need a well balanced, low fat, high calorie, high protein diet
Treatment for cystic fibrosis

-Require 150% of the recommended daily allowance
-They need to take water soluable forms of vitamin A, D, E, and

K because they are not able to have the fat soluable regular
forms
What is the hallmark sign of heart lips turn blue when feeding
failure in babies?
-rarely get more than 1 cc
-give 1 hour before and 2 hours after eating
Digoxin for infants -do NOT mix with medicine, food, or fluid
-Always check the dose with another nurse
-check the apical pulse for 60 seconds
-decrease blood pressure
Ace Inhibitors for infants (prils, -can cause kidney problems
Vasotec, Capoten) -dry cough
What other drug might be given to lasix

pediatric patient with HF?
Nutrition for infants with HF (when to small frequent feedings every 3 hours, no longer than 30
give meals?) minutes
inflammatory disease that occurs after an infection with group

Rheumatic Fever
A beta hemolytic strep
What is the major cardiac clinical carditis

manifestation of Rheumatic Fever?
What is the medication to treat penicillin G (or erythromycin if they are allergic)
Rheumatic Fever?
characterized by wide-spread inflammation of the small and

Kawasaki Disease medium sized blood vessels. Coronary arteries are most
susceptible.
-High dose of IV immune-globulin
Treatment of Kawasaki Disease -aspirin therapy
-quiet environment
How should you feed an infant with a -elongated nipple on the side of the mouth
cleft lip/palate?
After cleft repair surgery, how should Cleft lip repair: back or side lying to protect the suture
the nurse position the client? Cleft Palate: prone to promote drainage
small, frequent feedings with thickened formula
Feedings for patients with GER/GERD Breast feeding continues with more frequent feeding or
expressing the milk for thickening with rice cereal
Medications for GERD H2 blockers, proton pump inhibitors

The saliva can't make it to the stomach because the esophagus

Esophageal Atresia/T-E fistula ends in a blind pouch (closed off at the bottom, not
connected to the stomach)
Why do babies with esophageal They never swallowed amniotic fluid

atresia not have meconium?
Coughing
What are symptoms of T-E fistula? Cyanotic
Choking (esp while drinking)
What should the first feeding be sterile and observed

because of T-E fistula?
projectile vomiting
very hungry
S/S of pyloric stenosis

olive shaped mass in epigastric region
peristalsis is obvioius
when a piece of bowel goes backwards inside itself forming an

Intussusception
obstruction
sudden onset
cramping and abdominal pain
What are S/S of intussusception? inconsolability
drawing up knees
CURRANT JELLY stools
Definitive Dx is through barium enema and that can sometimes

Dx/Tx of intussuscpetion fix the problem
Teach what to watch for with reoccurence
A congenital anomaly also known as aganglionic megacolon

Hirschsprung's Disease that results in a mechanical obstruction along the bowel (esp.
sigmoid)
-presenting symptom is constipation
S/S of Hirschsprung's Disease -abdominal distention
-ribbon-like stools that have a very foul odor

There is no rectal opening, therefore, the baby will not pass

Imperforate Anus
meconium...have to do surgery
Think Sam
Celiac Disease -a genetic malabsorption disorder where there is a permanent

intestinal intolerance to gluten
Barley
Rye
Celiac's can't have BROW

Oats
Wheat
Rice
Celiac's can have RCS Corn
Soy
-newborns and children under 2: the s/s may be non-specific,

Symptoms of UTIs vary with young
might even seem to be a GI problem
children vs. babies

-Classic symptoms in children >2 (same as adults)
Surgical emergency
-Painful condition caused by the sudden twisting of the

spermatic cord which results in the loss of blood flow to the
testicle. Occurs in 1/40,000 males with a peak onset of 13 years
Testicular torsion
-Most common cause of testicular loss in adolescent males
-If not diagnosed in a timely manner, they can lose the

affected testicle
-Unilateral pain to the affected testicle
This is a hereditary disorder in which the hemoglobin is partly

Sickel Cell Disease
or completely replaced with sickle-shaped hemoglobin
bed rest, hydration, analgesics, antibiotics, blood transfusions,

Treatment for Sickle Cell disease
and oxygen
Cancer of the blood forming tissue and proliferation of

immature white cells
Leukemia -Always remember immunosuppresion, thrombocytopenia,

and anemia
bstrandable NCLEX OB/Peds 3 of 3 -ALL and AML
-fever
-pallor
-anorexia
S/S of Leukemia
-petechiae
-vague abdominal discomfort
-easily acquired infections
kidney
Cancer: Wilm's tumor or

-Swelling or non-tender mass on the side of the abdomen
nephroblastoma are found?

-DONT PALPATE
A disturbance of the ventricular circulation of the cerebral

spinal fluid in the brain
-bulging in the anterior fontanel
-dillated scalp veins
Hydrocephalus
-depressed eyes
-irritability and changes in LOC
-high-pitched cry
-Tx is insertion of VP shunt
Parial Seizure limited to a particular location of the brain
without the loss of consciousness with various sensations:

Simple Partial seizure
numbness, tingling, prickling, pain
impaired consciousness and may be confused or unable to

Complex Partial:
respond
LOC
Tonic-Clonic (grand mal)
Generalized seizure Myoclonic (sudden, brief contractions of a muscle or group of

muscles; may look like a startle reflex)
Absence (petit mal, brief loss of consciousness)
Observation
3 O's treatment for scoliosis Orthosis (supports and braces)
Operation (usually spinal fusion with rod)
How are pin worms diagnosed? tape test in the morning before defacation
Medication treatment for pinworms Mebendazole (Vermox)
Home remedies that alleviate itching oatmeal baths
from chicken pox baking soda paste
Is acyclovir ever prescribed for if they have an increased risk for severe varicella
chicken pox?
What is the virus that causes infectious epstein barr

mononucleosis?
Why should Mono patients be enlarged spleen

involved in contact sports
First trimester reasons for bleeding Spontaneous abortion, ectopic pregnancy
vaginal bleeding, cramping, expulsion of products. Types

Spontaneous abortion
include: threatened, inevitable, incomplete, complete, missed.
Abnormal implantation of ovum outisde of uterus. S/S: US with

Ectopic Pregnancy empty uterus, WBC 15,000, unilateral stabbing pain, REFERRED
RIGHT SHOULDER PAIN.
May have cramps, spotting to moderate bleeding, no tissue

Threatened abortion
passed, cervix closed.
Moderate cramping, mild to severe bleeding, no tissue passed,

Inevitable abortion
dilated cervix with membranes or tissue bulging,
Severe cramps, continuous bleeding, partial tissue passed,

Incomplete abortion
dilated cervix.
No cramps, minimal bleeding, complete expulsion, closed

Complete abortion
cervix.
Missed abortion No cramps, brown discharge, No tissue passed, Closed cervix
bstrandable NCLEX
Septic OB/Peds 3 of 3
Abortion Malodorous discharge usually with cervix dilated.
Second trimester bleeding Gestational trophoblastic disease,incompetent cervix
Uterine size increases abnormally fast, abnormally high levels

Gestational Trophoblastic disease of hCG, N/V hyperemesis, no fetus present, dark brown or red
vaginal bleeding
a condition in which the cervix dilates silently during the

second trimester; without intervention, the membranes bulge
Incompetent cervix
through the cervix and rupture, and the fetus drops out,
resulting in a premature preterm delivery or abortion.
Third trimester bleeding Placenta Previa, abruptio placenta, preterm labor
placenta abnormally implants in lower segment of utuerus

over the cervix. Results in bleeding in third trimester at cervix
begins to dilate and efface. Complete (entire cervical os
covered) vs Incomplete (partially covered) Marginal (does not
Placenta Previa touch os, but is close) S/S: BRIGHT red blood as cervix dilates,
relaxed uterus with normal tone, palpable placenta, fundal
height great than gestational age norm. Assess: bleeding with
counting pads, NOTHING inserted vaginally (NO CHECKS),
corticosteriods to mature fetal lungs for C-section.
Premature separation of placenta (partial or complete

detachment) Leading cause of maternal death. DIC is
associated with abruption. Ultrasound for placental and fetal
well-being, hgb/hct, BPP. S/S: sudden onset of intense uterine
pain, vaginal bleeding that is bright red or dark, BOARD LIKE
Abruptio Placenta
ABDOMEN (blood pooling) that is tender, uterine
hypertonicity, hypovolemic shock. Assess: uterus, bleeding,
FHR, VS, RR, cardiac sounds, LOC, cap refill, U/O.
Interventions: bedrise, no vaginal exams, admin blood
products, corticosteriods, delivery.
Excessive N/V (high hCG levels). Causes dehydration, wt loss,

electrolyte imbalance, ketosis and acetonuria. Risk for IUGR for
Hyperemesis Gravidarum fetus. Assess for ketones (muscle breakdown for nutrients).
Interventions: NPO, IV LR, vitamins as tolerated, Promethazine,
metoclopramide. May need TPN if severe.
Gestational Hypertension, Mild preeclampsia, severe

HTN in pregnancy preeclampsia, eclampsia, HELLP
HTN that begins after 20 week with a BP of 140/90 mm Hg or

Gestational Hypertension
greater, but without edema or proteinurea.
characterized by hypertension of >140/90 after 20wks

Mild Preeclampsia
gestation and protienuria of 1-2+(by dipstick)
BP >160/110, proteinuria >2g in 24h urine, oliguria, ALOC, HA,

blurry vision, epigastric pain, ^ LFT's, thrombocytopenia, fetal
growth restrictions. Mngmnt: ^ prot, decrease Na, adequate
Severe Preeclampsia
fluids, BR, antiHTN (Hydralizine or labetalol target
diastolic=95-100) Risk: new partner, young 1st pregnancy,
delivery is the cure.
Eclampsia is severe preeclampsia with seizure or coma.
This stands for H = Hemolysis, EL = Elevated Liver Enzymes, LP

HELLP = Low platelets (<100,000) PREECLAMPSIA WITH LIVER
DAMAGE!
D&C Dilation and curettage- dilate cervix and scrape uterine walls
D&E Dilation and evacuation after 16 weeks gestation
Anticonvulsant, lowers BP and depresses CNS. Signs of

toxicity: absense of patellar DTRs, <30ml urine, RR <12, <LOC.
Magnesium Sulfate
Calcium gluconate is antidote. Client will feel flushed, hot,
sedated with magnesium sulfate.
Tests: 1 hour glucose screen, 50g sugar load then 1 hour test
(24-28 weeks) 3 hour glucose test, overnight fast, fasting
Gestational Diabetes
glucose obtained, 100g load is given and levels are
determined at 1,2,3 hours.
Comes from eating raw meat or cleaning cat litter. Affects

pregnant women and immunosuppressed patients. S/S:
Cervical lymphadenopathy, HA, fever, malaise, sore throat, can
Toxoplasmosis
cause still birth or severe congenital anomalies in fetus of
pregnant women. Tx: Spiramycine, sulfadine, pyramethamine
(potentially harmful but must kill parasite)
Contact with children with rashes or other mothers who had

rubella during pregnancy. S/S: rash, aches, joint pain,
Rubella
miscarriage, congenital anomalies, death. Tx: Immunize before
pregnancy, avoid crowds. Vaccination not an option.
Transmission by droplet. semen, vaginal secretions, breask

Cytomegalovirus milk, placenta, milk, urine, feces, blood. S/S: asymptomatic or
mononeucleosis-like. Tx: No treatment
Direct contact with oral or genital lesion. S/S: lesions. Tx: C-

Herpes Simplex Virus
section delivery recommended for mothers with active lesions.
Fear of surgery for toddler separation
Fear of surgery for preschooler mutilation
Fear of surgery for school-ager loss of control
loss of independence, being different from peers, alterations in

Fear of surgery for adolescent
body image
teach parents to expect regression in toddler

toilet training & difficult separations
allow child to play with models of preschooler

equipment; encourage expression of
feelings
explain procedures in simple terms; school-ager

allow choices when possible
involve them in procedures & adolescent

therapies; expect resistance; express
understanding of concerns; point out
strengths
teaching for toddler simple directions
teaching for preschool & school aged allow to play with equipment
expect resistance with this age group adolescent
typical fears for newborn loud noises; sudden movements
typical fears for 6-12 months strangers; heights
typical fears for 3-5 years separation from parents; ghosts; scary people
separation from parents; animals;strangers; change in

typical fears for 12-36 months
environments
typical fears for 5+ years dark;injury;being alone;death
typical fears for adolescent social incompetence;war; accidents;death
age appropriate preparation for include parents; mummy restraint

health care procedures for newborn
age appropriate preparation for model desired behavior

health care procedures for 6-12
months
age appropriate preparation for simple explanations; use distractions; allow choices
health care procedures for toddler
age appropriate preparation for encourage understanding by playing with puppets or dolls,
health care procedures for demonstrate equipment; talk at child's eye level
preschooler
age appropriate preparation for allow questions; explain why; allow to handle equipment
health care procedures for school age
child
age appropriate preparation for explain long term benefit; accept regression; provide privacy
health care procedures for adolescent
Eliminate all dietary supplements at 2 to 3

least ___ to ____ weeks before surgery.
respiratory depression; circulatory depression; delirium during

side effects of general anesthesia via
induction & recovery; nausea & vomiting; aspiration during
inhalation (halothane)
induction; myocardial depression; hepatic toxicity
side effects of nitrous oxide hypotension; postop nausea; vomiting
side effects of IV thiopental sodium respiratory depression; low BP; laryngospasm; poor muscle
(pentothal) relaxation; hypotension; irritating to skin & subcutaneous tissue
side effects of spinal anesthesia hypotension; headache
side effects of conduction blocks hypotension; respiratory depression
side effects of local anesthesia excitability; toxic reactions such as respiratory difficulties;
(xylocaine) vasoconstriction if substance contains epinephrine
side effects of moderate (conscious) respiratory depression; apnea; hypotension; bradycardia

sedation (Versed, Valium)
situations where pt turns & deep ICP; intrabdominal pressure; eye surgeries; brain surgeries
breathe but does not cough vigorusly
hemorrhage; shock; atelectasis; pneumonia; embolism; deep

vein thrombosis; paralytic ileus; infection of wound;
13 potential complications of surgery
dehiscence; evisceration; urinary retention; urinary infection;
psychosis
nursing considerations for replace blood volume; monitor vital signs

bstrandable
hemorrhage NCLEX OB/Peds 3 of 3
nursing considerations for shock treat cause; oxygen; IV fluids
nursing considerations for atelectasis experienced second day postop; suctioning; postural
& pneumonia drainage; antibiotics; cough & turn
experienced second day post op; oxygen; anticoagulants; IV

nursing considerations for embolism
fluids
nursing considerations for deep vein experienced 6-14 days up to 1 year later; anticoagulant therapy
thrombosis
nursing considerations for paralytic nasogastric suction; IV fluids; decompression tubes

ileus
nursing considerations for infection of experienced 3-5 days post op; antibiotics; aseptic technique;
wound good nutrition
experienced 5-6 days postop; low fowlers position; no

nursing considerations for dehiscence
coughing; NPO; notify MD
experienced 5-6 days postop; low fowlers position; no

nursing considerations for evisceration
coughing; NPO; cover viscera with sterile saline; notify MD
nursing considerations for urinary experienced 8-12 hours postop; catheterize as needed
retention
nursing considerations for urinary experienced 5-8 days postop; antibiotics; force fluids
infection
nursing considerations for psychosis therapeutic communication; medications
assessment for hemorrhage decreased BP; increased pulse; cold & clammy skin
assessment for shock decreased BP; increased pulse; cold & clammy skin
assessment for atelectasis & dyspnea; cyanosis; cough; tachycardia; elevated temperature;
pneumonia pain on affected side
dyspnea; pain; hemoptysis; restlessness; ABG- low oxygen &

assessment for embolism
high carbon dioxide
assessment for DVT positive homan's sign
assessment for paralytic ileus absent bowel sounds; no flatus or stool
assessment for infection of wound elevated WBC & temperature; positive cultures
assessment for dehiscence disruption of surgical incision or wound
assessment for evisceration protrusion of wound contents
assessment for urinary retention unable to void after surgery; bladder distention
assessment for urinary infection foul smelling urine; elevated WBC
assessment for psychosis inappropriate affect
A mother expresses fear about Place petroleum ointment around the glans with each diaper
changing the infant's diaper after change and cleansing.
circumcision. Which information
should the nurse include in the
teaching plan?
The nurse is counseling a client who January 29 to 30

wants to become pregnant. She tells
the nurse that she has a 36-day
menstrual cycle and the first day of
her last menstrual period was January
8. When will the client's next fertile
period occur?
This client can expect her next period 36

to begin ------- days from the first day
of her last menstrual period
Six hours after an oxytocin induction Place the client in a slight Trendelenburg position
was begun and 2 hours after
spontaneous rupture of the
membranes, the nurse notes several
sudden decreases in the fetal heart
rate with quick return to baseline, with
and without contractions. Based on
this fetal heart rate pattern, which
intervention is best for the nurse to
implement?
A mother who is breastfeeding her Ensure that the baby is positioned correctly for latch-on.
baby receives instructions from the
nurse. Which instruction is most
effective in preventing nipple
soreness?
The most common cause of nipple incorrect positioning

soreness is ___________.
The nurse observes an antepartum Notify the healthcare provider

client, on bedrest for preterm labor, * The healthcare provider should be notified when a client
eating ice rather than the food on her practices pica (craving for and consumption of nonfood
breakfast tray. The client states that substances)
she has been craving ice and then
feels too full to eat anything else.
What is the best response by the
nurse?
A client at 32 weeks of gestation is Respiratory rate decreases from 24 to 16
hospitalized with severe pregnancy- *Magnesium sulfate, a CNS depressant, helps prevent seizures.
induced hypertension (PIH), and A decreased respiratory rate indicates that the drug is
magnesium sulfate is prescribed to effective. However, a respiratory rate below 12 indicates toxic
control the symptoms. Which effects.
assessment finding indicates that
therapeutic drug levels have been
achieved?
Place the client in a lateral position
Twenty minutes after a continuous * The nurse should immediately turn the client to a lateral
epidural anesthetic is administered, a position or place a pillow or wedge under one hip to deflect
laboring client's blood pressure drops the uterus. Other immediate interventions include increasing
from 120/80 to 90/60. What action the rate of the main line IV infusion and administering oxygen
should the nurse take immediately? by face mask at 10 to 12 L/min.
A client at 28 weeks of gestation calls "Come to the clinic today for an ultrasound."
the antepartal clinic and states that * Third trimester painless bleeding is characteristic of a
she just experienced a small amount placenta previa. Bright red bleeding may be intermittent,
of vaginal bleeding, which she occur in gushes, or be continuous. Rarely is the first incidence
describes as bright red. The bleeding life threatening, nor cause for hypovolemic shock. Diagnosis is
has subsided. She further states that confirmed by transabdominal ultrasound (A). Bleeding that has
she is not experiencing any uterine a sudden onset and is accompanied by intense uterine pain
contractions or abdominal pain. What indicates abruptio placenta, which is life threatening to the
instruction should the nurse provide? mother and fetus.
An off-duty nurse finds a woman in a Put the newborn to breast
supermarket parking lot delivering an * Putting the newborn to breast will help contract the uterus
infant while her husband is screaming and prevent a postpartum hemorrhage
for someone to help his wife. Which
intervention has the highest priority?
The client's investment in what is being taught
* When teaching any client, readiness to learn is related to how

Client teaching is an important part of
much the client has invested in what is being taught, or how
the perinatal nurse's role. Which factor
important the material is to their particular life. For example,
has the greatest influence on
the client with severe morning sickness in the first trimester
successful teaching of the pregnant
may not be "ready to learn" about labor and delivery, but is
client?
probably very "ready to learn" about ways to relieve morning
sickness
The nurse is counseling a couple who Two weeks before menstruation
has sought information about * Ovulation occurs 14 days before the first day of the menstrual
conceiving. The couple asks the nurse period
to explain when ovulation usually
occurs. Which statement by the nurse
is correct?
Ovulation occurs _____ days before the 14

first day of the menstrual period.
Place petroleum ointment around the glans with each diaper

change and cleansing.
A mother expresses fear about * With each diaper change, the glans penis should be washed
changing the infant's diaper after with warm water to remove any urine or feces and petroleum
circumcision. Which information ointment should be applied to prevent the diaper from sticking
should the nurse include in the to the healing surface. Prepackaged wipes often contain other
teaching plan? products that may irritate the site. The yellow exudate, which
covers the glans penis as the area heals and epithelializes, is
not an infective process and should not be removed
On admission to the prenatal clinic, a 22-Nov
client tells the nurse that her last * (A) correctly applies Nägele's rule for estimating the due
menstrual period began on February date by counting back 3 months from the first day of the last
15 and that previously her periods menstrual period (January, December, November) and adding
were regular (28-day cycle). Her 7 days (15 + 7 = 22).
pregnancy test is positive. What is this
client's expected date of birth (EDB)?
A 25-year-old client has a positive Gravida 2, para 0
pregnancy test. One year ago she had *

a spontaneous abortion at 3 months
of gestation. What is the correct
description of this client that should
be documented in the medical
record?
A client who is 3 days postpartum and Breastfeed the infant every 2 hours
breastfeeding asks the nurse how to * The mother should be instructed to attempt feeding her
reduce breast engorgement. Which infant every 2 hours while massaging the breasts as the infant is
instruction should the nurse provide? feeding
One hour following a normal vaginal Obtain a serum glucose level
delivery, a newborn infant boy's * This infant is demonstrating signs of hypoglycemia, possibly
axillary temperature is 96° F, his lower secondary to a low body temperature
lip is shaking, and when the nurse
assesses for a Moro reflex, his hands
shake. What intervention should the
nurse implement first ?
A client at 30 weeks of gestation is on "Take your blood pressure now, and if it is seriously elevated,
bedrest at home because of increased go to the hospital."
blood pressure. The home health * Checking the blood pressure for an elevation is the best
nurse has taught her how to take her instruction to give at this time. A blood pressure exceeding
own blood pressure and given her 140/90 or increased by 15 mm Hg diastolic and/or 30 mm Hg
parameters to judge a significant systolic is indicative of preeclampsia. Epigastric pain can be a
increase in blood pressure. When the sign of an impending seizure (eclampsia), a life-threatening
client calls the clinic complaining of complication of PIH.
indigestion, which instruction should
the nurse provide?
A blood pressure exceeding _____ or 140/90
increased by 15 mm Hg diastolic 30
and/or ___ mm Hg systolic is indicative
of preeclampsia.
An expectant father tells the nurse he Reassure him that normal maternal/fetal bonding is occurring
fears that his wife "is losing her mind." *

He states she is constantly rubbing
her abdomen and talking to the baby,
and that she actually reprimands the
baby when it moves too much. What
recommendation should the nurse
make to this expectant father?
between Birth to 2 Months Hep B #1
between 1-4 Months Hep b #2
exactly at 2 Months Dtap 1, Hib 1, IPV 1, PCV1
exactly 4 months Dtap 2, Hib 2, IPV 2, CV2
exactly 6 months Dtap 3, Hib3, PCV 3
between 6-18 Months (6 months- 1.5 Hep B 3, IPV 3

year)
between 12-15 Months (1 year- 1y 3 Hib 4, MMR 1, PCV 4

bstrandable
Months) NCLEX OB/Peds 3 of 3
12-18 Month (1 yr-1.5) Varicella (Chicken pox)
15-18 months (1y 3m- 1.5 y) Dtap 4
4-6 year Dtap 5, IPV 4, MMR 2
6-12yr
Task= Industry vs. Inferiority
Positive- sense of confidence
Negative-self-doubt, inadequate
School Aged Erickson Stage Acheivement and acomplishment are very important as they
take on tasks and carry them through, they become parts of
teams and groups and it is important for them to be
encouraged during these endevors. If they can not accomplish
this, they have feelings of inadequacy or infferiority
12-20yr
Task= Identity vs. role confusion
Positive- coherent sense of self; plans for education/work

future
Negative-lack of personal or vocational identity
Adolescence Erickson Stage

Very emotional and physical time...fitting in is very important,
roles are changing and they want to fit in with their peers..what
their peers think becomes much more important than what
parents think and by the end they should be thinking about
their careers and what they are going to do...very braud stage
20-45yr
Task=Generativity vs Stagnation
Positive- Creative and productive
Negative- Self Centered
Young Adulthood Erikson Stage They now have personal attatchments with a job, career, and
family...Now start to think about what they can leave the
generations behind them and have interest in what they can
give back to the community...Those that do not reach this may
be self centered and almost adolescent
65+
Task= Integrity vs. despair
Positive-sees life as meaningful
Negative-Fear of death; life lacks meaning
Late Adulthood Erikson Stage Individuals are progressing towards the end of life....if they
have a positive outcome...they will feel they have made a
contribution to life and if negative, they may become distainful
or bitter
-Self centered, show off, rude
School Age Growth and -Sensitive to criticism (might cheat on things and dont like to
Development: 6 years lose)
-Begins loosing temparary teeth
-Team games/sports
School Age Growth and
-Developes concept of time
Development: 7 years
-Prefers playing with same sex child
School Age Growth and -Seeks out friends (much more social)
Development: 8 years -Writing replaces printing
School Age Growth and -Conflicts between adult authority and peer group
Development: 9 years -Conflicts between independence and dependence
-Remainder of teeth (except Wisdom) erupt
-Uses telephone; loves conversation
-Increasingly responsible/social
School Age Growth and

-More selective when choosing friends
Development: 10 years
-Begins to develop interest in the opposite sex
-Might be able to left alone for a little while at this age
-Might Enjoy reading now more than before
-Construction Toys
-Tools, household and sewing tools
-Table games, sports
Toys & Activities for School Age

-Bicycle with helmet (be sure to stress helmet to parents)
-May be getting into hobbies
-They like to have a goal and meet it (industry vs. inferiority)
-Enuresis- Bed Wetting (beyond the age of voluntary bladder

control)
(child is easily embarrassed, they dont like to be critcized so

they may be mortified about bed wetting)
Potential Problems for School Age -Encopresis- Incontinent of stool
-Safety: Injuries & Head lice (lice normally at school when kids
are in close proximities with others)
-Need to be taught to wear seat belts to avoid injuries
-void at bed time
-may need to be wakened to void if they are a heavy sleeper
-some medications to help a child stay dry through the night

are available
Interventions for Enuresis

-need to explore if this is a new thing :if they were once able to
stay dry and now a routine physical exam may be needed to
role out other potential problems like UTI, Neuro deficits, and
Diabetes
Physical Development: Puberty (physical growth and sexual

maturation; can begin as early as 8 in girls)
-Girls develop more rapidly than boys
Adolescent Growth and Development -Rapid alterations in height and weight: May cause easy fatigue
-Development of secondary sexual characteristics
-Preoccupation with physical appearance (body image is

everything for this child)
-By the End of this stage: They should have
Accomplishments by the End of

-Complete development of secondary sexual characteristics
Adolescent Growth and Development

-Improved motor coordination and wisdom teeth appear
-Increase in genital size
-Pubic, facial, axillary, and chest hair
-Deepening voice
-Producation of fuctional sperm
-Nocturnal emissions "Wet Dreams" (important for them to

understand that this is normal)
Adolescent Growth and Development: -They can also develop gynecomastia and even some milk
Male Changes leaking from the breasts due to hormonal flucuations and can
become HIGHLY destressed by this (make sure that they
understand that this may happen and should subside as they
continue to grow
(It is considered pubertal delay if boys have had not testes

enlargment by age 13 or 14)
-Breast Development
-Axillary and pubic hair
-Menarche (1st menstral period) Can occur between age 9-13
-Puberty for girls usually starts with breast buds, followed by

Adolescent Growth and Development:
pubic hair, then menstral period (average age for menarch is
Female Changes
12.8years...as young as 10 1/2 and as old as 15
-Pubertal delay is considered if breasts have not formed by

age 13 or if menarch has not occured within 4 years of breast
development
-Masturbation
Adolescent Psychosexual
-Sexual Fantasies
Development
-Experimental sexual intercourse
-Conforms to peer pressure (want to be liked and do what

peers are doing
-Moody (this is the age of raging hormones)
Adolescent Psychosocial
-Increased independence
Development
-It is important that we teach...what they are feeling is normal
and safety tip for sexual intercourse (regarding unplanned
pregnancies and STD's
-Adolesent pregnancy
-Poort self-image
-Safety (automobile accidents, diving accidents)
-Drug and alcohol abuse
-AIDS
-High school dropout
-Violence
Potential Problems for Adolescence

(need teaching regarding preventing pregancy whats a myth
and whats a fact...need teaching for sexual protection..need
counselling to delay any impulsive action that could have long
term consequences...need help identifying coping
mechanisms...help identify who their friends are and who their
peer support group is
-Increased reality
-Independence from parents
-Marriage, partnership
-Peak Intelligence, memory
Adult Growth and Development: 20- -Maximum problem solving
33yr (having a family, and balancing a career, and their health...SO

Health Promotion is a huge part of this age group...Smoking,
Smoking cessation, maintaing weight at an optimal level,
proticipating in regular exercise, and being aware of ETOH and
drug abuse) How are they dealing with stress??
-Increased sense of urgency
-Life more serious
-Major goals to accomplish
Adult Growth and Development: 33- -Plateaus at work and marriage
40yr -Sense of satisfaction
(Very important to acheive balance..of work, family and taking

care of self, bodies are also changing and they may need to
understand what normal changes are)
-Self questioning (am I doing what I should be?)
-Fear of middle age and aging (more worried about wrinkles)
-Potential changes of work, marriage
Adult Growth and Development: 35-

-Dicards unrealistic goals
45yr
-"Sandwhich" generation (between young adulthood, going
into middle adult hood)
bstrandable NCLEX OB/Peds 3 of 3 -Increased awarness of mortality
-Difficulty with relationships
Potential Problems with Adulthood -Stress (normally about balance of life as a whole and are how
they are taking care of their physical bodies)
-Physical decline
Older Adult Growth and -Loss of significant others
Development: 65-80yr & 80+ -Appearance of chronic diseases
-Change in social roles
-Self care deficit (are they still able to care for themselves)
-Isolation (they may have lost a spouse, children, or friends)
-Altered relationships
Problems of Older Adult -Decreased independence

(Consider that children in middle adulthood may be the
caregivers now, so care giver strain, elder abuse, and
increased falls and injuries)
Based on IQ
Mild: IQ 55-70
Moderate: IQ 40-55
Severe: IQ 25-40
Mental Retardation Profound: IQ <25
Level of Retardation Affects
-Preschool Growth and Development
-School training and education
-Adult social and vocational level
-Hereditary
-Infection
-Fetal anoxia
-Cranial or chromosomal abnormalites
Mental Retardaiton Causes

-Things that occured at birth
-Things that noone had any control over
(be sure to evaluate family adjustment and explore resources

for the individual to help them perform at their optimal level)
Assessment:
-Mental deficiencies, motor deficiencies
-Physical: thin upper lip/ epicanthal folds, maxillary hypoplasia
Implementation:
Fetal Alcohol Syndrome

-Prevention: Avoid ETOH 3 months before conception
(remember there is not a safe level of ETOH consumption
during pregnancy)
-Monitor weight gain, promote nutrition
Assessment:
-Mental deficiencies: IQ 20-70
-Hypotonia
-Altered physical development (epicanthal folds, low set ears,

protruding tounge, low nasal bridge)
Implementation:
Downs Syndrome -Provide stimulation: OT/PT/Special Ed
-Assess for physical problems (often have other problems like

heart defects, respiratory infections...be sure to monitor and
screen for these)
-Parental education
-Be sure to provide resources to allow child to reach optimal

function
ADD (decreased attention span) /ADHD

(hyperkinesis)/Dyslexia (Perceptual deficits)
-main thing to know is that these children normally have a high

IQ so detection of these things and diagnosis can be difficult
so be sure that resources for parents are available
-Commorbidities such as depression are not uncommon

becuase child may feel inferior or that they are constanly in
Learning Disabilities
trouble and not doing things right so it it important to figure
out what is going on with resources for child and parent
Implementation:
-Special education interventions
-Medications
-Support groups
A bottle-fed infant, age 3 months, is "I'm giving my baby iron-fortified formula and a flouride
brought to the ped. office for well supplement because our water isn't flouridated."
child visit. At previous visit, nurse
taught mom about nutritional needs.
Which statement by the mother during
the current visit indicates effective
teaching?
A nurse is teaching new parents about 5 months

normal development. Voluntary grasp
is usually present at what age?
A parent whose family drinks low-fat 2 years

milk asks if her child can begin to drink
low fat milk. The AAP recommends
that children can begin to drink low fat
milk at what age?
A nurse is doing discharge teaching. 12-18 months

She explains that the anterior fontanel
normally closes between ages:
Toddlers are at high risk for injuries sports injury- a toddler clearly would not be involved in team
because of their increasing curiosity, sports. :)
advancement in cognition, and
improved motor skills. All these
hazards are a concern for this age-
group except:
1. burns
2. poisoning
3. sports injury
4. falls
In a clinic, the mother of an 8-month formula

old asks the nurse what to feed her
infant because she wants to stop
breast feeding. The nurse
recommends :
Directional trends in growth and Cephalocaudal trend

development are easily seen in the
neonate. Which term describes
development in the head-to-tail
direction?
3yo is hospitalized for femur fracture. Allow the child to administer her own Keflex (cehphalexin) via
As her nurse, what nursing action oral syringe.
would help foster the child's sense of
autonomy?
A 16yo male is hospitalized for cystic Encourage the teen's friends to visit him in the hospital.
fibrosis. He will be an inpatient for 2
weeks while he receives IV antibiotics.
As the nurse caring for this pt. what
action can you take that will most
enhance his psychosocial
development?
A 6-month old male is at his well-child "At 6 months his weight should be approximately twice his birth
visit. The nurse weighs him, and his weight."
mom ask if his weight is normal for his
age. The nurse's best response is?
The nurse caring for a 4yo female in Show the child the IV placement equipment, and demonstrate
the ER is about to start an IV. The the procedure on the doll.
nurse's best method for explaining the
procedure to the child is to:
A 17yo male is being seen in the ER. In Gather info. during a casual conversation
order to obtain the adolescent's
health information, his nurse should:
How can the nurse best facilitate the The nurse should encourage the parents to hold their child as
trust relationship between infant and much as possible.
parent while the infant is hospitalized?
A 3yo female is hospitalized for an "Your mommy and daddy will be back after your nap."
ASD repair. Her parents have decided
to go home for a few hours to spend
time with her siblings. The child asks
when her mommy and daddy will be
back. The nurse's best response is:
An ER nurse is assessing a 12-month The nurse should assess the child while she is in her mother's
old female. Which statement lap.
accurately describes the best method
for assessing this child?
An 11yo male is being evaluated in the The nurse should explain to the child what the nurse will be
ER for an inguinal hernia. Which doing in basic understandable terms.
statement accurately describes how
the nurse should approach him for his
physical assessment?
amenorrhea, nausea & vomiting, tired, urinary frequency,

Presumptive signs of Pregnancy
breast tenderness, quickening, constipation
(examiners objective findings) Positive pregnancy test, enlarge

Probable signs of pregnancy abdomen uterus, Gooddells signs, chadwick, hegars signs,
ballottement, braxtons hicks contractions
A softening of the lower uterine segment found upon

Hegar's Sign
palpation in the second or third month of pregnancy.
A purplish-blue color of the cervix and vagina caused by the

Chadwick's Sign
increased vascularity are both noted at about 8 wks.
Goodell's Sign softening of the cervix
the rebounding of the fetus against the examiner's finger on

palpation. when the cervix is tapped, the fetus floats upward in
Ballottement
the amniotic fluid. a rebound is felt by the examiner when the
fetus falls back
A method of determining the estimated date of birth (EDB):
Nagele's Rule after obtaining the first day of the last menstrual period,
subtract 3 months and add 7 days.
Gravidity Number of pregnancies
Number of pregnancies which fetus(es) reach viability (20-24

Parity
weeks) regardless of if fetus is born live or not.
# pregnancys, term preg, preterm pregnancy,

GTPAL
abortions/miscarriages, living children
Reproductive- uterus increases in size/shape and position.
Cardiovascular- C/O and blood volume increase. HR increases

Respiratory-Oxygen needs increase
M/S-weight increase, pelvic joints relax
Physiological Changes in Pregnancy GI- N/V r.t hormone, organs displaced due to uterine
enlargement
Renal-Filtration rate increases (urinary frequency)
Endocrine- HCG, Progesterone, estrogen, lactogen and

prostaglandins increase.
Measure HCG levels (26 days after conception in urine, 6-11

Home Pregnancy Tests days in serum) Urine samples should be first void morning
specimens
mask of pregnancy; pigmentation disorder that occurs during

Chloasma
pregnancy characterized by brown spots on the face
a dark line appearing on the abdomen and extending from the

Linea Nigra
pubis toward the umbilicus
Striae gravidarum Stretch marks
• Telescoping of one portion of the bowel into another portion.

This condition results in obstruction to the passage of intestinal
Intussusception Definition
contents. Causes edema, vascular compromise, then partial or
total bowel obstruction.
-Sudden onset of severe, intermittent abdominal pain
-screaming and drawing up legs with periods of calm in

between episodes
Intussusception S/S
-pain relieved once abdomen relaxes
-currant jelly stools (blood and mucus)
-sausage shaped mass in RUQ
Barium enema for reduction
surgical reduction if BE not effective
Intussusception Tx & Dx Bowel resection if all fails
DX also based on findings during physical exam (distended

abdomen, sausage mass, BS)
-If tx is managed thru reduction, nurse observes for passage of

stool and barium-->must monitor and record # stool
Intussception Nursing care -if tx is sx, chld is NPO, NG inserted and IV fluids given
-monitor for perforation (acute pain, rigid abdomen, tachy,

fever chills), peritonitis, increased pain
Hypertrophy of pyloric sphincter (between stomach and

Pyloric Stenosis Definition intestine) causing obstruction Can run in families, more
common in males. Develps in first few weeks of life
-olive size mass in RUQ (moveable/firm)
-peristaltic waves during and after feedings
Pyloric Stenosis S/S -projectile vomiting!**
-hungry and irritable after vomiting
-dehydration & metabolic acidosis
laprascopic pyloromyotomy-->incision and suture of pyloric

Pyloric Stenosis Tx
sphincter
If dehydration present (depressed fontanel, skin turgor, low

UO), surgery is done after correction with fluids/electrolytes
Pyloric stenosis Nursing Pre op -NPO
-IV Fluids
-NG tube
-Maintain fluid balance
-vomiting for 24-36 hrs after sx is NORMAL
Pyloric Stenosis Nursing Post op -small clear liquid feedings @ 4-6 hrs post op
-breastfeeding in 24 hrs if clear liquid diet is tolerated
-weigh wet diapers to measure ouput
save and weight wet diapers
breastfeeding in 24 hrs if clear diet is tolerated
Pyloric stenosis teaching watch infants response to feeding bc vomiting can still occur
**if vomiting after 48 hrs--call Dr!
monitor for infection
-Prevent infection!**
-keep area as clean as possible bc urine on skin will cause

irritation and ulceration
Exstrophy of bladder Care

-change diaper frequently, keep it loose fitting
-wash with mild soap and water
-cover exposed bladder with vaseline gauze
proteinuria
hypoproteinemia
hyperlipidemia
pallor, lethar
hepatomegaly
Nephrotic syndrome assessment

weight gain
HTN
preorbital facial edema in moring
asicite
scrotal/ankle edema
-Bed rest. quiet games, things that conserve energy
-long term use of corticosteroids ( impaired wound healing,

hyperglycema, osteoporosis, moon facies)
-prevent infection-->keep kids away from sick kids
Nephrotic syndrome teaching

-urine testing (in the morning)
-need for long term follow up
-high protein and low sodium diet during edema phase
-antbiotics for bacterial infections & diuretics
urine backflows from bladder to ureters and back to kidney,

occuring at vesicoureteral junction (normally creates a one-
way valve from urine to enter the bladder without reflux back
Vesicoureteral Reflux definition
into urterers). Primary is d/t congenital defect, secondary d/t
obstruction
- UTI from urine stasis
Vesicoureteral reflux predisposis child

-pyelonehprosis from chronic UTI
to:
-hydronephrosis from increased pressure on renal pelvis
-Recurring UTI most common
-flank pain
Vesicourereteral reflux S/S

-abdominal pain
-enuresis
-Grades 1 & 2 may resolve on its own, more severe may need
surgery
Vesicour reflux Tx -management is preventing and treating UTI.
-pts will take long term prophylatic antibiotics and ditropan to

relieve bladder pressure
* monitor I & O and pain control*
-monitor drains- check output from drains Q 1 hr
-ureters should be draining the most
Vesicour reflux nursing -if anything stops draining, call HCP
-look at color and make sure there are no breaks that could
cause infection
-observe drainage from abdominal dressing
-nurse must observe for urinary discomfort during:
-voiding or straining to void
-dribbling of urine
Vesicour reflux nursing infants (book)

-starting and stopping of stream
-monitor for fever and irritability as a sign of uti-->obtain clean

catch
-3 C's: couching and choking with feedings & intermittent

cyanosis
TEF S/S
-distended abdomen from inhaled are
-aspiration pneunomnia from reflux into trachea

Priority: maintain patent airway/prevent aspiration
-NPO
-IV fluids
TEF nursing Pre OP -position semi-fowlers to protect trachea from secretions
-turn head to side to prevent aspiration
-regular suctioning
-antibiotics started bc aspiration pneumonia is inevitable!
-baby will return with chest tube and still intubated (will go
home with this)
TEF nursing Post OP -minimal suctioning to avoid disruption of surgical repair
-TPN initially followed by oral feedigs
-infant will lead normal life after sx
-position on BACK or SIDE opposite of repair
-avoid strain on suture
cleft lip post op -use elbow restraints
-keep suture line clean
-maintain patent airway!
-position PRONE or side
-emergency suction at bedside
-prevent injury to suture line
Cleft palate post op -give water after feeding to clean suture line
-no brushing teeth, hard foods, or putting things in mouth,

sucking
-hold and cuddle!
-feed in upright position to decrease aspiration and swalloing

of air
-burp frequently
-tube feedings as neccesary
Cleft lip/palate feeding

-can still breastfeed until sx
-bottle feed with special nipple that is longer to help prevent

aspiration
-haberman nipple
nuchal rigidity
bulging fontanel
fever/chills/headache
poor feeding or anorexia
seizures
Meningitis S/S
photophobia
petechial/purpura rash
positive kernig sign (pain behind knee during leg extension)
positive brudzinski (flexion of hip and knee with passive flexion

of nexk)
-Respiratory ISOLATION for 24 hrs after antibiotics
-monitor I7O- decreased UO may be a sign of SIADH (also

fluid retention, cerebral edema, dilutional hyponatremia)
-steroids to reduce cerbral edema and prevent hearing loss,

hydrocephalus, learning disorders
Meningitis care
-monitor for increased ICP- high BP, low pulse, high pitched
cry, irritably, bulging fontanel
-keep room quiet, dim
-seizure precaution
-NPO until N/V subsides
when does the anterior fontanel 18 to 24 months

close?
infant's birth weight should ___ in six double

months
infant's birth weight should ____in a triple

year
infant's respiratory rate is ____ to _____ 30-60

breaths per min
infant's heart rate is _____ to _______ per 110-160

minute
which are the first teeth to erupt lower central incisors
when does infant's teeth first erupt 4-6 months

what age can infant follow an object 2 months

with its head?
what age are children first afraid of 6-7 months

strangers
when does an infant walk alone? 14-15 months
what age does an infant have a pincer 12-13 months

grasp
when can an infant roll over 4-5 months
when can an infant sit up unassisted? 6-8 months
what age does an infant stand alone? 12-13 months
what age does an infant crawl? 8-9 months
what age does an infant walk holding 10-11 months

onto furniture?
Birth - 1 year = infancy stage trust vs. mistrust
What is a positive outcome for trust self and others (need to meet infants basic needs)
infancy?
What is a negative outcome for an inability to trust; withdrawal, isolation

infancy?
1 yr -3 yr = Toddler stage autonomy vs. shame and doubt (if no contact)
What is a positive outcome for a exercises self-control and directly influences the environment,
toddler? they want to do things themselves
What is a negative outcome for a demonstrates defiance and negativism

toddler?
3-6 = preschool stage initiative vs. guilt
What is a positive outcome for a begins to evaluate own behavior; learns limits on influence in
preschooler? the environment
What is a negative outcome for a Demonstrates fearful pessimistic behaviors; lacks self
preschooler? confidence
6-12 = school age stage industry vs. inferiority
develops a sense of confidence thro achievement &

What is a positive outcome for a
accomplishments; uses creative energies to influence the
school age child?
environment
What is a negative outcome for a demonstrates feelings of inadequacy, mediocrity, and self-
school age child? doubt
identity vs. role diffusion aka prob if a kid is DM w/diet

12-20 yr = adolescent stage
compliance b/c want to do what peers are doing
What is a positive outcome for develops a coherent sense of self; plans for a future of
adolescence? work/education
What is a negative outcome for demonstrates inability to develop personal and vocational
adolescence? identity
20-35 = young adulthood stage intimacy vs. isolation
What is a positive outcome for young develops connections to work and intimate relationships
adulthood?
What is a negative outcome for young demonstrates an avoidance of intimacy and vocational career
adulthood? commitments
35-64 = middle adulthood stage generativity vs stagnation (want to leave a legacy)
What is a positive outcome for middle involved w/est family; expands personal creativity and
adulthood? productivity
What is a negative outcome for demonstrates lack of interests, commitments; preoccupation

middle adulthood? w/self-centered concerns
> 65 = late adulthood stage integrity vs. despair
What is a positive outcome for late identification of life as meaningful

adulthood?
What is a negative outcome for late demonstrates fear of death' life lacks meaning
adulthood?
height increases by 3/4 inch per infant

month
weight is doubled at 5-6 months & infant

tripled at 12 months
at birth, head circumference is _____cm 33-35 cm; 13.2-14 inches; 2-3 cm

or _____inches, approximatley____cm
more than chest circumference
by 2-3 years of age, head equal

circumference are?
anterior fontanelle in a normal infant soft and flat
anterior fontanelle closes ? by 12-18 months
posterior fontanelle closes? by end of second month
posterior fontanelle in normal infant? soft and flat
infant has 10 upper and 10 lower 2.5 years

decidous teeth by what age?
Lower central incisors are present? by 6-8 months
by what age do most infants develop 3-4 months

a nocturnal pattern of sleep that lasts
9-11 hours.
between ages 1 and 2 years the head 1 inch

circumference increases by?
after 2 years until 5 years, the head 1/2 inch

circumference increases by
anterior fontanelle closes by? 12-18 months (1-1.5 year)
average weight at age 2 years? 22-27 pounds
average toddler height at 2 years? 34 inches
lordosis is noted in what age? toddler
When should a toddler see a dentist? soon after the first teeth erupt
why should a toddler never fall to dental caries

sleep with a bottle of milk, juice, soda,
or sweetened water ?
when is a daytime nap discontinued in 3 years

a toddler?
What can help the toddler prepare for having a ritual

sleep?
average height of preschooler at 3? 37 inches
average height of preschooler at 4? 40.5 inches
average height of preschooler at 5? 43 inches
average weight at age 5? 35-40 pounds
how many hours of sleep does a 12 hours

preschooler require?
When is the eruption of the primary at the beginning of the preschool periord
teeth complete?
girls grow faster than boys in what school age

period?
sleep requirements for school age? 10-12 hours
PKU
Hypothyroidism
Health Screening for Newborn Galactosemia
Sickle-Cell disease
HIV
Galactosemia error of carbohydrate metabolism
developmental screening(DENVER II)
Cystic fibrosis screening
Cholesterol screening for children with family history of

Health Screening for Infant/Child
sudden death, MI
Lead poisoning
Neuroblasta
children 6-72 months at highest risk
live in deteriorated housing
Lead Poisoning Risk Factors sibling or close peer with lead poisoning
household member with hobbies( stained glass) or lead

related occupations
hearing/vision test at 4 yr and yearly
School-Age Screening dental exams
medical assessments
When should Pelvic Exam start? annually after sexual active or after 18years of age
18-20
When to begin breast self exam?

monthly
35-39 once as baseline
Mammogram should start when?

40 year old + annually
18-20
Testicular self-exam
monthly
cuff is too short or too narrow or the brachial artery is below

Inaccurately high BP?
the heart
High diastolic BP? auscultatory gap
cuff is too long or wide
Inaccurately low BP?

brachial artery is above the heart
low systolic BP unrecognized auscultatory gap
active is permament and in active immunity, the individual

What is the difference between active already has their own antiobody for the antigens
immunity and passive immunity? passive antibodies are formed from being introduced from
other sources ie breastfeeding
severe febrile illness
live viruses should not be given to anyone with an altered

immune system ie going through chemo or
Contradictions for Immunization
imunocompromised
previous allergic response to a vaccine
blood transfusion
not necessary to repeat immunization when the schedule is

interrupted just continue from where left off
if no record of immunization and the child is younger than 7

Interrupted schedule or uncertain give DTAP,IPV, and 4-6 weeks later give MMR
immunity status 1 month later give DTAP and IPV
this is repeated in another month and then again in 10-16

months
two doses 4-8 weeks apart
DTAP Immunization schedule third dose 6-12 months
booster 10 years intervals for life
ages 19-49 years for persons each fall
Influenza indications?
dont give if allergic to eggs
adults born after 1957 without proof on or after first birthday
HIV patients without severe immunosuppression
Measles and Mumps indications

travelers to foreign countries
persons entering college
one dose
two doese if in college, in health care profession, or traveling

Measles and Mumps Schedule
to foreign countries with second dose more than a month after
the first
Measles and Mumps Vaccine avoid immunization 30 days after shot

Contraindications
first responders
Small Pox Vaccination Indications

one dose needed
history of eczema or orther skin condition, pregnancy, or

Contraindications of Small Pox
breast feeding or women who want to concieve in the next
Vaccination
month
disease can be passed from unhealed vaccination site to other

people with close contact
wash hands with soapy watery immediately after changing

Small Pox Vaccination Care
bandage and seal in plastic bag

wear long sleeve clothing
can be given to 4-6 year olds and 11-16 years if in high

prevalence areas
TB Test

elevated 48-72 hours
IPV in the US no longer recommended
persons especially women without proof of vacacine on or

after first birthday
Rubella Indications?
health care personnel at risk of exposure to rubella and who

have contact with pregnancy client
Rubella Schedule one dose
allergy to neomycin
Rubella Contraidications pregnancy-avoid pregnancy 3 months after vaccination
receipt of blood transfusion
household contacts of ppl with HBV
at risk to exposure of bloody products
Gay men
Hepatitis B Vaccine Indications

heterosexual with multiple sex partners
Inmates of long term correctional facilities
unvaccinated adolescents
three doses
HBV Vaccine Schedule second dose 1-2 months after 1st
third dose 4-6 months after 1st
Varicella Immunization person who didnt have disease or havent had a vaccination
Varicella immunization two doses 4-8 wks apart
Contraindications of varicella immunosuppresive therapy or HIV
immunization pregnancy- avoid pregnancy for 1 month
travelers to countries with high incidence
gay men
Hepatitis A Vaccine Indications drug addicts
clotting factor disorders
food handlers
Hep A Vaccine Schedule two doses 6-12 months apart
HEP A Vaccine considerations welling and redness at injection site is normal
HPV Vaccine Indications all females 11/12 to 25
three doses
HPV Vaccine Schedule second dose 2 months after first
third dose 6 months after 2nd
c/o weakness, apprehension, impending frrom dry/scratchy

Allergic Prodromal Assessment
throat, N/V
generalized intense pruritis and uritcaria(hives)

Allergic Cutaneous Assessment
angioedema(swelling) of lips and eyelips
increasing resp distress with audible wheezing, rales,

Allergic Bronchial Assessment
diminished breath sounds and heard on auscultation
diminished breath sounds and heard hypotension and a rapid, weak, irregular pulse, dysrhythmias,
on auscultation Circulatory shock, cardiac arrest can occur within minutes
Assessment
Histamine evidence of allergic response
establish ABC
Plan for Allergic Reaction adminsiter epi in arm opposite to side of injection and can be
bstrandable NCLEX OB/Peds 3 of 3 repeated in 15-20 minutes PRN (3 times with children)
allergies to bananas, avocado, chestnut, papaya, peaches
health care workers,hairdressers,cleaning staff
H/O of multiple surgeries
Latex Allergy Risk Factors

clients with spinal cord injuries
clients with urgogenital abnormalities
children with neural tube defects
gloves
catheters and syringes
brown ace bandages
band-aid dressing
Avoid Latex products

elastic pressure stocking
balloons
condoms
feminine hygiene pad
Physical Assessment: Tips empty bladder beforehand
moderate to loud, low-pitched clear(clear,hollow) sound of

Resonance
moderate duration; found with air-filled tissue(normal lung)
loud, booming, low-pitched sound of longer duration found

Hyperresonance with overinflated air-filled tissue (pulmonary emphysema)
normal in child due to thin chest wall
loud, drumlike high pitched or musical sound of moderately

Tympany
long duration found with enclosed, air-filled structures(bowel)
dull-soft, muffled, moderate to high pitched sound of short

Liver sounds
duration, found with dense, fluid-filled tissue
flat-very soft; high pitched sound of short durationl found with

Sounds over bone
very dense tissue
Normal Resp Rate for new born 30-60 min
Normal Resp Rate 1-4 years 20-40 min
Normal Resp Rate 5-12 years 15-25

Normal Resp Rate adult 12-20 min
Normal Pulse Rate new born 120-160, or 180 bpm when crying
Normal Pulse Rate 1-4 years 80-140 bpm
Normal Pulse Rate 5-12 years 70-115 bpm
Normal Pulse Rate adult 60-100 bpm
Normal Blood Pressure newborn 65/41
Normal Blood Pressure 1-4 years 90-99/60-65
Normal Blood Pressure 5-12 years 100-110/56-60
Normal Blood Pressure adult <120/80
Rectal: 99.6
Normal Temp Oral: 98.6
Axillary: 97.6
PERRLA size, shape, equality, reactivity to light and accommodation
Cranial Nerve I olfactory-smell
Cranial Nerve II optic-sense of vision
Oculomotor-pupil contriction raising eyelids
Cranial Nerve III to assess have patient look up & down, inaward and observe
for symmetry
Cranial Nerve IV trochlear- downward and inward movement of eyes
trigeminal-motor jaw movement
Cranial Nerve V
sensory-senation on the face and neck
abducens
Cranial Nerve VI lateral movement of the eyes
facial muscle movement
Cranial Nerve VII

sensory taste of sweet and salt
Cranial Nerve VIII acoustic-sense of hearing and balance
Glossopharyngeal-
Cranial Nerve IX ability to swallow
taste of sour and bitter
Cranial Nerve X vagus swallowing and speaking(smooth)
spinal accessory
Cranial Nerve XI flexion/rotation of head
shrugging/shoulders
Cranial Nerve XII motor tongue movements
S1lubb closure of tricuspid and mitral valves
S2 dubb closure of aortic and pulmonic valves
Apical Pulse left at 5th intercostal space at midclavicular line
incubation of chicken pox (varicella) 13- 17 days
incubation of diphtheria 2-5 days
incubation of pertussis (whooping 5-21 days

cough)
incubation of rubella (german 14-21 days

measles)
incubation of rubeola 10-20 days

incubation of scarlet fever 2-4 days
incubation of mononucleosis 4-6 weeks
incubation of mumps 14-21 days
prodromal definition early symptom indicating onset of an attack
prodromal: slight fever, malaise, chicken pox (Varicella)

anorexia
rash is pruritic, begins as a macule, chicken pox (varicella)

then papule, & then vesicle with
successive crops of all three stages
present at any one time;
lymphadenopathy; elevated
temperature
transmission of chicken pox (varicella) spread by direct contact, airborne, contaminated object
prodromal: resembles common cold diphtheria
low grade fever, hoarseness, malaise, diphtheria

pharyngeal, lymphadenitis, white/gray
pharyngeal membrane
direct contact with a carrier, infected client contaminated

transmission of diptheria
articles
prodromal: upper respiratory infection pertussis

for 1-2 weeks
severe cough with high pitched pertussis

whooping sound, especially at night,
lasts 4-6 weeks, vomiting
transmission of pertussis direct contact, droplet, contaminated articles
prodromal: none in children, low fever, rubella (german measles)

& sore throat in adolescent
maculopapular rash appears first on rubella (german measles)

face &then on rest of the body,
symptoms subside first day after rash
transmission of rubella droplet spread & contaminated articles
prodromal: fever & malaise followed rubeloa

by cough & Koplk's spots on buccal
mucosa
erythematous maculopapular rash rubeloa

with face first affected; turns brown
after 3 days when symptoms subside
transmission of rubeloa direct contact with droplets
prodromal: high fever with vomiting, scarlet fever

chills, malaise, followed by enlarged
tonsils covered with exudate,
strawberry tongue
rash: red tiny lesions that become scarlet fever

generalized & then desquamate; rash
appears within 24 hours
transmission of scarlet fever droplet spread or contaminated articles
malaise, fever, enlarged lymph nodes, mononucleosis

sore throat, flulike aches, low grade
temperature
transmission of mononucleosis direct contact with oral secretions
fever, white exudate on tonsils, tonsillitis

positive group A strep
malaise, headache, fever, parotid mumps

gland swelling
transmission of mumps direct contact with saliva, droplet
Chicken pox: Avoid use of _____ due to aspirin

association with Reye's syndrome.
precaution for chicken pox airborne & contact precautions
diptheria: contact & droplet negative nose & throat cultures

precautions until two successive ______&
____ are obtained.
pneumonia, weight loss, dehydration, hemorrhage, hernia,

complications for pertussis
airway obstruction
rare complications of rubella (german arthritis & encephalitis

measles)
rubeola: isolate until ___; maintain 5th day; 3 to 4 days

bedrest durng first _____days.
mono: advise family members to avoid 3 months.

contact with saliva for about ____
complications of mono encephalitis & spleen rupture
serious complications of tonsillitis rheumatic fever & glomerulonephritis
complications of mumps deafness, meningitis, encephalitis, sterility
A nurse is caring for a client in labor. 4. The second stage of labor begins when the cervix is dilated
The nurse determines that the client is completely and ends with the birth of the neonate.
beginning in the 2nd stage of labor
when which of the following
assessments is noted?
1.The client begins to expel clear
vaginal fluid
2.The contractions are regular
3.The membranes have ruptured
4.The cervix is dilated completely
A nurse in the labor room is caring for 3. Late decelerations are due to uteroplacental insufficiency as
a client in the active phases of labor. the result of decreased blood flow and oxygen to the fetus
The nurse is assessing the fetal during the uterine contractions. This causes hypoxemia;
patterns and notes a late deceleration therefore oxygen is necessary. The supine position is avoided
on the monitor strip. The most because it decreases uterine blood flow to the fetus. The client
appropriate nursing action is to:
should be turned to her side to displace pressure of the gravid
1.Place the mother in the supine uterus on the inferior vena cava. An intravenous
position
2.Document the findings and continue

to monitor the fetal patterns
3.Administer oxygen via face mask
4.Increase the rate of pitocin IV

infusion
A nurse is performing an assessment 1. A normal fetal heart rate is 120-160 beats per minute. A count
of a client who is scheduled for a of 180 beats per minute could indicate fetal distress and would
cesarean delivery. Which assessment warrant physician notification. By full term, a normal maternal
finding would indicate a need to hemoglobin range is 11-13 g/dL as a result of the hemodilution
contact the physician?
caused by an increase in plasma volume during pregnancy.
1.Fetal heart rate of 180 beats per
minute
2.White blood cell count of 12,000
3.Maternal pulse rate of 85 beats per

minute
4.Hemoglobin of 11.0 g/dL
A client in labor is transported to the 4. Vena cava and descending aorta compression by the
delivery room and is prepared for a pregnant uterus impedes blood return from the lower trunk
cesarean delivery. The client is and extremities. This leads to decreasing cardiac return,
transferred to the delivery room table, cardiac output, and blood flow to the uterus and the fetus. The
and the nurse places the client in the:
best position to prevent this would be side-lying with the
1.Trendelenburg's position with the uterus displaced off of abdominal vessels. Positioning for
legs in stirrups
abdominal surgery necessitates a supine position; however, a
2.Semi-Fowler position with a pillow wedge placed under the right hip provides displacement of
under the knees
the uterus.
3.Prone position with the legs
separated and elevated
4.Supine position with a wedge under

the right hip
A nurse is caring for a client in labor 4. The nurse simultaneously should palpate the maternal radial
and prepares to auscultate the fetal or carotid pulse and auscultate the fetal heart rate to
heart rate by using a Doppler differentiate the two. If the fetal and maternal heart rates are
ultrasound device. The nurse most similar, the nurse may mistake the maternal heart rate for the
accurately determines that the fetal fetal heart rate. Leopold's maneuvers may help the examiner
heart sounds are heard by:
locate the position of the fetus but will not ensure a distinction
1.Noting if the heart rate is greater between the two rates.
than 140 BPM
2.Placing the diaphragm of the

Doppler on the mother abdomen
3.Performing Leopold's maneuvers
first to determine the location of the
fetal heart
4.Palpating the maternal radial pulse

while listening to the fetal heart rate
A nurse is caring for a client in labor 2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late
who is receiving Pitocin by IV infusion or variable decelerations indicate fetal distress and the need
to stimulate uterine contractions. to discontinue to pitocin. The goal of labor augmentation is to
Which assessment finding would achieve three good-quality contractions in a 10-minute period.
indicate to the nurse that the infusion
needs to be discontinued?
1.Three contractions occurring within a
10-minute period
2.A fetal heart rate of 90 beats per

minute
3.Adequate resting tone of the uterus

palpated between contractions
4.Increased urinary output
A nurse is beginning to care for a 2. Continuous electronic fetal monitoring should be

client in labor. The physician has implemented during an IV infusion of Pitocin.
prescribed an IV infusion of Pitocin.
The nurse ensures that which of the
following is implemented before
initiating the infusion?
1.Placing the client on complete bed

rest
2.Continuous electronic fetal

monitoring
3.An IV infusion of antibiotics
4.Placing a code cart at the client's

bedside
A nurse is monitoring a client in active 4. A normal fetal heart rate is 120-160 beats per minute. Fetal
labor and notes that the client is bradycardia between contractions may indicate the need for
having contractions every 3 minutes immediate medical management, and the physician or nurse
that last 45 seconds. The nurse notes mid-wife needs to be notified.
that the fetal heart rate between
contractions is 100 BPM. Which of the
following nursing actions is most
appropriate?
1.Encourage the client's coach to

continue to encourage breathing
exercises
2.Encourage the client to continue

pushing with each contraction
3.Continue monitoring the fetal heart
rate
4.Notify the physician or nurse mid-

wife
A nurse is caring for a client in labor 1. Accelerations are transient increases in the fetal heart rate
and is monitoring the fetal heart rate that often accompany contractions or are caused by fetal
patterns. The nurse notes the movement. Episodic accelerations are thought to be a sign of
presence of episodic accelerations on fetal-well being and adequate oxygen reserve.
the electronic fetal monitor tracing.
Which of the following actions is most
appropriate?
1.Document the findings and tell the

mother that the monitor indicates fetal
well-being
2.Take the mothers vital signs and tell

the mother that bed rest is required to
conserve oxygen.
3.Notify the physician or nurse mid-

wife of the findings.
4.Reposition the mother and check

the monitor for changes in the fetal
tracing
A nurse is admitting a pregnant client 2. Assessing the baseline fetal heart rate is important so that
to the labor room and attaches an abnormal variations of the baseline rate will be identified if
external electronic fetal monitor to the they occur. Options 1 and 3 are important to assess, but not as
client's abdomen. After attachment of the first priority.
the monitor, the initial nursing
assessment is which of the following?
1.Identifying the types of accelerations
2.Assessing the baseline fetal heart

rate
3.Determining the frequency of the

contractions
4.Determining the intensity of the

contractions
A nurse is reviewing the record of a 1. Station is the relationship of the presenting part to an
client in the labor room and notes that imaginary line drawn between the ischial spines, is measured in
the nurse midwife has documented centimeters, and is noted as a negative number above the line
that the fetus is at -1 station. The nurse and a positive number below the line. At -1 station, the fetal
determines that the fetal presenting presenting part is 1 cm above the ischial spines.
part is:
1.1 cm above the ischial spine
2.1 fingerbreadth below the symphysis

pubis
3.1 inch below the coccyx
4.1 inch below the iliac crest
A pregnant client is admitted to the 4. Anemic women have a greater likelihood of cardiac
labor room. An assessment is decompensation during labor, postpartum infection, and poor
performed, and the nurse notes that wound healing. Anemia does not specifically present a risk for
the client's hemoglobin and hemorrhage. Having a loud mouth is only related to the
hematocrit levels are low, indicating person typing up this test.
anemia. The nurse determines that the
client is at risk for which of the
following?
1.A loud mouth
2.Low self-esteem
3.Hemorrhage
4.Postpartum infections
A nurse assists in the vaginal delivery 4. As the placenta separates, it settles downward into the
of a newborn infant. After the delivery, lower uterine segment. The umbilical cord lengthens, and a
the nurse observes the umbilical cord sudden trickle or spurt of blood appears.
lengthen and a spurt of blood from
the vagina. The nurse documents
these observations as signs of:
1.Hematoma
2.Placenta previa
3.Uterine atony
4.Placental separation
A client arrives at a birthing center in 2. Amniotomy can be used to induce labor when the condition
active labor. Her membranes are still of the cervix is favorable (ripe) or to augment labor if the
intact, and the nurse-midwife prepares process begins to slow. Rupturing of membranes allows the
to perform an amniotomy. A nurse fetal head to contact the cervix more directly and may
who is assisting the nurse-midwife increase the efficiency of contractions.
explains to the client that after this
procedure, she will most likely have:
1.Less pressure on her cervix
2.Increased efficiency of contractions
3.Decreased number of contractions
4.The need for increased maternal

blood pressure monitoring
A nurse is monitoring a client in labor. 2. Variable decelerations occur if the umbilical cord becomes
The nurse suspects umbilical cord compressed, thus reducing blood flow between the placenta
compression if which of the following and the fetus. Early decelerations result from pressure on the
is noted on the external monitor fetal head during a contraction. Late decelerations are an
tracing during a contraction?
ominous pattern in labor because it suggests uteroplacental
1.Early decelerations
insufficiency during a contraction. Short-term variability refers
2.Variable decelerations
to the beat-to-beat range in the fetal heart rate.
3.Late decelerations
4.Short-term variability
A nurse explains the purpose of 2. Effleurage is a specific type of cutaneous stimulation

effleurage to a client in early labor. involving light stroking of the abdomen and is used before
The nurse tells the client that transition to promote relaxation and relieve mild to moderate
effleurage is:
pain. Effleurage provides tactile stimulation to the fetus.
1.A form of biofeedback to enhance
bearing down efforts during delivery
2.Light stroking of the abdomen to

facilitate relaxation during labor and
provide tactile stimulation to the fetus
3.The application of pressure to the

sacrum to relieve a backache
4.Performed to stimulate uterine

activity by contracting a specific
muscle group while other parts of the
body rest
A nurse is caring for a client in the 2. Pains, helplessness, panicking, and fear of losing control are
second stage of labor. The client is possible behaviors in the 2nd stage of labor.
experiencing uterine contractions
every 2 minutes and cries out in pain
with each contraction. The nurse
recognizes this behavior as:
1.Exhaustion
2.Fear of losing control
3.Involuntary grunting
4.Valsalva's maneuver
A nurse is monitoring a client in labor 1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse

who is receiving Pitocin and notes that immediately would intervene to reduce uterine activity and
the client is experiencing hypertonic increase fetal oxygenation. The nurse would stop the Pitocin
uterine contractions. List in order of infusion and increase the rate of the nonadditive solution,
priority the actions that the nurse check maternal BP for hyper or hypotension, position the
takes.
woman in a side-lying position, and administer oxygen by snug
1.Stop of Pitocin infusion
face mask at 8-10 L/min. The nurse then would attempt to
2.Perform a vaginal examination
determine the cause of the uterine hypertonicity and perform
3.Reposition the client
a vaginal exam to check for prolapsed cord.
4.Check the client's blood pressure
and heart rate
5.Administer oxygen by face mask at 8

to 10 L/min
A nurse is assigned to care for a client 3. Therapeutic management for hypotonic uterine dysfunction
with hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a
and signs of a slowing labor. The nurse labor that slows.
is reviewing the physician's orders and
would expect to note which of the
following prescribed treatments for
this condition?
1.Medication that will provide sedation
2.Increased hydration
3.Oxytocin (Pitocin) infusion
4.Administration of a tocolytic
medication
A nurse in the labor room is preparing 2. Management of hypertonic labor depends on the cause.
to care for a client with hypertonic Relief of pain is the primary intervention to promote a normal
uterine dysfunction. The nurse is told labor pattern.
that the client is experiencing
uncoordinated contractions that are
erratic in their frequency, duration, and
intensity. The priority nursing
intervention would be to:
1.Monitor the Pitocin infusion closely
2.Provide pain relief measures
3.Prepare the client for an amniotomy
4.Promote ambulation every 30

minutes
A nurse is developing a plan of care 3. The priority is to monitor the fetal heart rate.
for a client experiencing dystocia and
includes several nursing interventions
in the plan of care. The nurse
prioritizes the plan of care and selects
which of the following nursing
interventions as the highest priority?
1.Keeping the significant other

informed of the progress of the labor
2.Providing comfort measures
3.Monitoring fetal heart rate
4.Changing the client's position

frequently
A maternity nurse is preparing to care 3. In a client with a multi-fetal pregnancy, each fetal heart rate
for a pregnant client in labor who will is monitored separately.
be delivering twins. The nurse
monitors the fetal heart rates by
placing the external fetal monitor:
1.Over the fetus that is most anterior to

the mothers abdomen
2.Over the fetus that is most posterior

to the mothers abdomen
3.So that each fetal heart rate is

monitored separately
4.So that one fetus is monitored for a

15-minute period followed by a 15
minute fetal monitoring period for the
second fetus
A nurse in the postpartum unit is 4. Because the placenta is implanted in the lower uterine
caring for a client who has just segment, which does not contain the same intertwining
delivered a newborn infant following a musculature as the fundus of the uterus, this site is more prone
pregnancy with placenta previa. The to bleeding.
nurse reviews the plan of care and
prepares to monitor the client for
which of the following risks associated
with placenta previa?
1.Disseminated intravascular
coagulation
2.Chronic hypertension
3.Infection
4.Hemorrhage
A nurse in the delivery room is 4. Signs of placental separation include lengthening of the
assisting with the delivery of a umbilical cord, a sudden gush of dark blood from the introitus
newborn infant. After the delivery of (vagina), a firmly contracted uterus, and the uterus changing
the newborn, the nurse assists in from a discoid (like a disk) to a globular (like a globe) shape.
delivering the placenta. Which The client may experience vaginal fullness, but not severe
observation would indicate that the uterine cramping.
placenta has separated from the
uterine wall and is ready for delivery?
1.The umbilical cord shortens in length

and changes in color
2.A soft and boggy uterus
3.Maternal complaints of severe

uterine cramping
4.Changes in the shape of the uterus
A nurse in the labor room is 1. When cord prolapse occurs, prompt actions are taken to
performing a vaginal assessment on a relieve cord compression and increase fetal oxygenation. The
pregnant client in labor. The nurse mother should be positioned with the hips higher than the
notes the presence of the umbilical head to shift the fetal presenting part toward the diaphragm.
cord protruding from the vagina. The nurse should push the call light to summon help, and other
Which of the following would be the staff members should call the physician and notify the delivery
initial nursing action?
room. No attempt should be made to replace the cord. The
1.Place the client in Trendelenburg's examiner, however, may place a gloved hand into the vagina
position
and hold the presenting part off of the umbilical cord. Oxygen
2.Call the delivery room to notify the at 8 to 10 L/min by face mask is delivered to the mother to
staff that the client will be transported increase fetal oxygenation.
immediately
3.Gently push the cord into the vagina
4.Find the closest telephone and stat

page the physician
A maternity nurse is caring for a client 1. DIC is a state of diffuse clotting in which clotting factors are
with abruptio placenta and is consumed, leading to widespread bleeding. Platelets are
monitoring the client for disseminated decreased because they are consumed by the process;
intravascular coagulopathy. Which coagulation studies show no clot formation (and are thus
assessment finding is least likely to be normal to prolonged); and fibrin plugs may clog the
associated with disseminated microvasculature diffusely, rather than in an isolated area. The
intravascular coagulation?
presence of petechiae, oozing from injection sites, and
1.Swelling of the calf in one leg
hematuria are signs associated with DIC. Swelling and pain in
2.Prolonged clotting times
the calf of one leg are more likely to be associated with
3.Decreased platelet count
thrombophebitis.
4.Petechiae, oozing from injection
sites, and hematuria
A nurse is assessing a pregnant client 3. In abruptio placentae, acute abdominal pain is present.
in the 2nd trimester of pregnancy who Uterine tenderness and pain accompanies placental abruption,
was admitted to the maternity unit especially with a central abruption and trapped blood behind
with a suspected diagnosis of abruptio the placenta. The abdomen will feel hard and boardlike on
placentae. Which of the following palpation as the blood penetrates the myometrium and causes
assessment findings would the nurse uterine irritability. Observation of the fetal monitoring often
expect to note if this condition is reveals increased uterine resting tone, caused by failure of the
present?
uterus to relax in attempt to constrict blood vessels and
1.Absence of abdominal pain
control bleeding.
2.A soft abdomen
3.Uterine tenderness/pain
4.Painless, bright red vaginal bleeding
A maternity nurse is preparing for the 3. Manual pelvic examinations are contraindicated when
admission of a client in the 3rd vaginal bleeding is apparent in the 3rd trimester until a
trimester of pregnancy that is diagnosis is made and placental previa is ruled out. Digital
experiencing vaginal bleeding and has examination of the cervix can lead to maternal and fetal
a suspected diagnosis of placenta hemorrhage. A diagnosis of placenta previa is made by
previa. The nurse reviews the ultrasound. The H/H levels are monitored, and external
physician's orders and would question electronic fetal heart rate monitoring is initiated. External fetal
which order?
monitoring is crucial in evaluating the fetus that is at risk for
1.Prepare the client for an ultrasound
severe hypoxia.
2.Obtain equipment for external
electronic fetal heart monitoring
3.Obtain equipment for a manual

pelvic examination
4.Prepare to draw a Hgb and Hct

blood sample
An ultrasound is performed on a client 2. The goal of management in abruptio placentae is to control

at term gestation that is experiencing the hemorrhage and deliver the fetus as soon as possible.
moderate vaginal bleeding. The results Delivery is the treatment of choice if the fetus is at term
of the ultrasound indicate that an gestation or if the bleeding is moderate to severe and the
abruptio placenta is present. Based on mother or fetus is in jeopardy.
these findings, the nurse would
prepare the client for:
1.Complete bed rest for the remainder

of the pregnancy
2.Delivery of the fetus
3.Strict monitoring of intake and

output
4.The need for weekly monitoring of

coagulation studies until the time of
delivery
A nurse in a labor room is assisting 2. Excessive fundal pressure, forceps delivery, violent bearing
with the vaginal delivery of a newborn down efforts, tumultuous labor, and shoulder dystocia can
infant. The nurse would monitor the place a woman at risk for traumatic uterine rupture. Hypotonic
client closely for the risk of uterine contractions and weak bearing down efforts do not alone add
rupture if which of the following to the risk of rupture because they do not add to the stress on
occurred?
the uterine wall.
1.Hypotonic contractions
2.Forceps delivery
3.Schultz delivery
4.Weak bearing down

bstrandable NCLEXefforts
OB/Peds 3 of 3
A client is admitted to the birthing 1. Determining the fetal well-being supersedes all other
suite in early active labor. The priority measures. If the FHR is absent or persistently decelerating,
nursing intervention on admission of immediate intervention is required.
this client would be:
1.Auscultating the fetal heart
2.Taking an obstetric history
3.Asking the client when she last ate
4.Ascertaining whether the

membranes were ruptured
A client who is gravida 1, para 0 is 3. A station of +1 indicates that the fetal head is 1 cm below the
admitted in labor. Her cervix is 100% ischial spines.
effaced, and she is dilated to 3 cm.
Her fetus is at +1 station. The nurse is
aware that the fetus' head is:
1.Not yet engaged
2.Entering the pelvic inlet
3.Below the ischial spines
4.Visible at the vaginal opening
After doing Leopold's maneuvers, the 3. Fetal heart tones are best auscultated through the fetal
nurse determines that the fetus is in back; because the position is ROP (right occiput presenting),
the ROP position. To best auscultate the back would be below the umbilicus and on the right side.
the fetal heart tones, the Doppler is
placed:
1.Above the umbilicus at the midline
2.Above the umbilicus on the left side
3.Below the umbilicus on the right side
4.Below the umbilicus near the left

groin
The physician asks the nurse the 3. This is the way to determine the frequency of the
frequency of a laboring client's contractions
contractions. The nurse assesses the
client's contractions by timing from the
beginning of one contraction:
1.Until the time it is completely over
2.To the end of a second contraction
3.To the beginning of the next

contraction
4.Until the time that the uterus

becomes very firm
The nurse observes the client's 3. by 36 weeks' gestation, normal amniotic fluid is colorless
amniotic fluid and decides that it with small particles of vernix caseosa present.
appears normal, because it is:
1.Clear and dark amber in color
2.Milky, greenish yellow, containing

shreds of mucus
3.Clear, almost colorless, and

containing little white specks
4.Cloudy, greenish-yellow, and

containing little white specks
At 38 weeks' gestation, a client is 4. Adjusting the catheter would be indicated. Normal fetal
having late decelerations. The fetal pulse oximetry should be between 30% and 70%. 75% to 85%
pulse oximeter shows 75% to 85%. The would indicate maternal readings.
nurse should:
1.Discontinue the catheter, if the

reading is not above 80%
2.Discontinue the catheter, if the

reading does not go below 30%
3.Advance the catheter until the

reading is above 90% and continue
monitoring
4.Reposition the catheter, recheck the

reading, and if it is 55%, keep
monitoring
When examining the fetal monitor 2. Variable decelerations usually are seen as a result of cord
strip after rupture of the membranes compression; a change of position will relieve pressure on the
in a laboring client, the nurse notes cord.
variable decelerations in the fetal
heart rate. The nurse should:
1.Stop the oxytocin infusion
2.Change the client's position
3.Prepare for immediate delivery
4.Take the client's blood pressure
When monitoring the fetal heart rate 1. An acceleration is an abrupt elevation above the baseline of
of a client in labor, the nurse identifies 15 beats per minute for 15 seconds; if the acceleration persists
an elevation of 15 beats above the for more than 10 minutes it is considered a change in baseline
baseline rate of 135 beats per minute rate. A tachycardic FHR is above 160 beats per minute.
lasting for 15 seconds. This should be
documented as:
1.An acceleration
2.An early elevation
3.A sonographic motion
4.A tachycardic heart rate
A laboring client complains of low 4. A persistent occiput-posterior position causes intense back
back pain. The nurse replies that this pain because of fetal compression of the sacral nerves.
pain occurs most when the position of Occiput anterior is the most common fetal position and does
the fetus is:
not cause back pain.
1.Breech
2.Transverse
3.Occiput anterior
4.Occiput posterior
The breathing technique that the 1. Blowing forcefully through the mouth controls the strong
mother should be instructed to use as urge to push and allows for a more controlled birth of the
the fetus' head is crowning is:
head.
1.Blowing
2.Slow chest
3.Shallow
4.Accelerated-decelerated
During the period of induction of 2. Uterine tetany could result from the use of oxytocin to
labor, a client should be observed induce labor. Because oxytocin promotes powerful uterine
carefully for signs of:
contractions, uterine tetany may occur. The oxytocin infusion
1.Severe pain
must be stopped to prevent uterine rupture and fetal
2.Uterine tetany
compromise.
3.Hypoglycemia
4.Umbilical cord prolapse
A client arrives at the hospital in the 4. Gentle pressure is applied to the baby's head as it emerges
second stage of labor. The fetus' head so it is not born too rapidly. The head is never held back, and it
is crowning, the client is bearing should be supported as it emerges so there will be no vaginal
down, and the birth appears imminent. lacerations. It is impossible to push and pant at the same time.
The nurse should:
1.Transfer her immediately by stretcher

to the birthing unit
2.Tell her to breathe through her

mouth and not to bear down
3.Instruct the client to pant during

contractions and to breathe through
her mouth
4.Support the perineum with the hand

to prevent tearing and tell the client to
pant
A laboring client is to have a pudendal 1. A pudendal block provides anesthesia to the perineum.
block. The nurse plans to tell the client
that once the block is working she:
1.Will not feel the episiotomy
2.May lose bladder sensation
3.May lose the ability to push
4.Will no longer feel contractions
Which of the following observations 1. A fetal scalp pH below 7.25 indicates acidosis and fetal
indicates fetal distress?
hypoxia.
1.Fetal scalp pH of 7.14
2.Fetal heart rate of 144 beats/minute
3.Acceleration of fetal heart rate with

contractions
4.Presence of long term variability
1. Vertex presentation (flexion of the fetal head) is the optimal

Which of the following fetal positions
presentation for passage through the birth canal. Transverse lie
is most favorable for birth?
is an unacceptable fetal position for vaginal birth and requires

1.Vertex presentation
a C-section. Frank breech presentation, in which the buttocks

2.Transverse lie
present first, can be a difficult vaginal delivery. Posterior

3.Frank breech presentation
positioning of the fetal head can make it difficult for the fetal
4.Posterior position of the fetal head
head to pass under the maternal symphysis pubis.
A laboring client has external 4. Oxygenation of the fetus may be indirectly assessed through
electronic fetal monitoring in place. fetal monitoring by closely examining the fetal heart rate strip.
Which of the following assessment Accelerations in the fetal heart rate strip indicate good
data can be determined by examining oxygenation, while decelerations in the fetal heart rate
the fetal heart rate strip produced by sometimes indicate poor fetal oxygenation.
the external electronic fetal monitor?
1.Gender of the fetus
2.Fetal position
3.Labor progress
4.Oxygenation
A laboring client is in the first stage of 3. Cervical dilation occurs more rapidly during the active
labor and has progressed from 4 to 7 phase than any of the previous phases. The active phase is
cm in cervical dilation. In which of the characterized by cervical dilation that progresses from 4 to 7
following phases of the first stage cm. The preparatory, or latent, phase begins with the onset of
does cervical dilation occur most regular uterine contractions and ends when rapid cervical
rapidly?
dilation begins. Transition is defined as cervical dilation
1.Preparatory phase
beginning at 8 cm and lasting until 10 cm or complete dilation.
2.Latent phase
3.Active phase
4.Transition phase
A multiparous client who has been in 3. A complaint of rectal pressure usually indicates a low
labor for 2 hours states that she feels presenting fetal part, signaling imminent delivery. The nurse
the urge to move her bowels. How should perform a pelvic examination to assess the dilation of
should the nurse respond?
the cervix and station of the presenting fetal part. Don't let the
1.Let the client get up to use the potty
client use the potty or bedpan before she is examined
2.Allow the client to use a bedpan
because she could birth that there baby right there in that darn
3.Perform a pelvic examination
potty.
4.Check the fetal heart rate
Labor is a series of events affected by 3. The five essential factors (5 P's) are passenger (fetus),
the coordination of the five essential passageway (pelvis), powers (contractions), placental position
factors. One of these is the passenger and function, and psyche (psychological response of the
(fetus). Which are the other four mother).
factors?
1.Contractions, passageway, placental

position and function, pattern of care
2.Contractions, maternal response,

placental position, psychological
response
3.Passageway, contractions, placental

position and function, psychological
response
4.Passageway, placental position and

function, paternal response,
psychological response
Fetal presentation refers to which of 1. Presentation is the fetal body part that enters the pelvis first;
the following descriptions?
it's classified by the presenting part; the three main
1.Fetal body part that enters the presentations are cephalic/occipital, breech, and shoulder. The
maternal pelvis first
relationship of the presenting fetal part to the maternal pelvis
2.Relationship of the presenting part refers to fetal position. The relationship of the long axis to the
to the maternal pelvis
fetus to the long axis of the mother refers to fetal lie; the three
3.Relationship of the long axis of the possible lies are longitudinal, transverse, and oblique.
fetus to the long axis of the mother
4.A classification according to the

fetal part
A client is admitted to the L & D suite 3. Uterine rupture is a medical emergency that may occur
at 36 weeks' gestation. She has a before or during labor. Signs and symptoms typically include
history of C-section and complains of abdominal pain that may ease after uterine rupture, vomiting,
severe abdominal pain that started vaginal bleeding, hypovolemic shock, and fetal distress. With
less than 1 hour earlier. When the placental abruption, the client typically complains of vaginal
nurse palpates titanic contractions, the bleeding and constant abdominal pain.
client again complains of severe pain.
After the client vomits, she states that
the pain is better and then passes out.
Which is the probable cause of her
signs and symptoms?
1.Hysteria compounded by the flu
2.Placental abruption
3.Uterine rupture
4.Dysfunctional labor
Upon completion of a vaginal 1. Station of - 1 indicates that the fetal presenting part is above
examination on a laboring woman, the the ischial spines and has not yet passed through the pelvic
nurse records: 50%, 6 cm, -1. Which of inlet. A station of zero would indicate that the presenting part
the following is a correct has passed through the inlet and is at the level of the ischial
interpretation of the data?
spines or is engaged. Passage through the ischial spines with
1.Fetal presenting part is 1 cm above internal rotation would be indicated by a plus station, such as +
the ischial spines
1. Progress of effacement is referred to by percentages with
2.Effacement is 4 cm from completion
100% indicating full effacement and dilation by centimeters
3.Dilation is 50% completed
(cm) with 10 cm indicating full dilation.
4.Fetus has achieved passage through
the ischial spines
Which of the following findings meets 4. Variability indicates a well oxygenated fetus with a
the criteria of a reassuring FHR functioning autonomic nervous system. FHR should accelerate
pattern?
with fetal movement. Baseline range for the FHR is 120 to 160
1.FHR does not change as a result of beats per minute. Late deceleration patterns are never
fetal activity
reassuring, though early and mild variable decelerations are
2.Average baseline rate ranges expected, reassuring findings.
between 100 - 140 BPM
3.Mild late deceleration patterns

occur with some contractions
4.Variability averages between 6 - 10

BPM
Late deceleration patterns are noted 2. Late deceleration patterns noted are most likely related to
when assessing the monitor tracing of alteration in uteroplacental perfusion associated with the
a woman whose labor is being strong contractions described. The immediate action would be
induced with an infusion of Pitocin. to stop the Pitocin infusion since Pitocin is an oxytocic which
The woman is in a side-lying position, stimulates the uterus to contract. The woman is already in an
and her vital signs are stable and fall appropriate position for uteroplacental perfusion. Elevation of
within a normal range. Contractions her legs would be appropriate if hypotension were present.
are intense, last 90 seconds, and Oxygen is appropriate but not the immediate action.
occur every 1 1/2 to 2 minutes. The
nurse's immediate action would be to:
1.Change the woman's position
2.Stop the Pitocin
3.Elevate the woman's legs
4.Administer oxygen via a tight mask

at 8 to 10 liters/minute
The nurse should realize that the most 4. Epidural anesthesia can lead to vasodilation and a drop in
common and potentially harmful blood pressure that could interfere with adequate placental
maternal complication of epidural perfusion. The woman must be well hydrated before and
anesthesia would be:
during epidural anesthesia to prevent this problem and
1.Severe postpartum headache
maintain an adequate blood pressure. Headache is not a side
2.Limited perception of bladder effect since the spinal fluid is not disturbed by this anesthetic
fullness
as it would be with a low spinal (saddle block) anesthetic; 2 is
3.Increase in respiratory rate
an effect of epidural anesthesia but is not the most harmful.
4.Hypotension Respiratory depression is a potentially serious complication.
Abnormal transmission of which Dopamine

neurotransmitter is throught to play a
part in tic disorders
persistant failure to speak in social situations where speaking is

What is selective mutism
expected
Waving, rocking, twirling objects, biting fingernails, handing

Sterotypic movement disorders
the head, biting or hitting ones self, picking at the skin or body
include
orfices
Echolia Repeating the last heard sound, word, or phrase
in which grade are reading and First Grade

written expression disorders usually
identified?
Most appropriate intervention for an adolescent who is

Limit setting
manipulative and exhibiting agressve behaviors
Infroming the client of the rule or limit
What are the three steps of limit

Explaining the consequences if the client exceeds the limit
setting
Stating the expected behavior
What perentage range of children 30-50 %

with conduct disorder fo on to be
diagnosed with antisocial personality
as adults?
What is the most effective drug for Ritalin

ADHD
What must a child diagnosed with He or she must accept responsibitlity for his or her own actions
conduct disorder do?
Profound Retadation -- less than 20
What are the IQ levels of the vairous Severe retardation -- between 20 and 35
levels of Retardation Moderate retardation -- between 35 and 50
Mild Retardation -- betwween 50 and 70
Which of the following is a drug Haloperidol (Haldol)

choice for Tourett's disorder?
Which medication has been found to (Haloperidol (Haldol)

be effective as treatment for autism?
The use of socially unacceptable words, which are frequently

What is Coprolalia
obscene
What is palilia Repeating of ones own words or sounds
What percentage of children with aproximately 75%

pervasive developmental disorders
have mental retardation?
Which side effects should be Monitor appetite supression
monitored with a child taking *** Growth delays

Methylphenidate (ritalin) for treatment
of ADHD
Which of the following is an Atomextine (Strattera)

antidepressant used to treat ADHD?
Missing details
What are some inattentive behavior Avoiding tasks that require mental effort
seen in ADHD? Making careless mistakes
Being forgetful in daily activities
fidgiting,
What are some hyperactive/impulsive interrupting,
behaviors seen in ADHD? talking excessively
Inability to play quietly
Loss of motor skill and begin showing stereotyed movements

What is Rett's disorder
instead
a disturbance of te normal fluency and time patterning of

What is stuttering
speech
What is phonlogic disorder Involves problems with articulation
includes problems of expressive language disorder aling with

What is Mixed receptive-expressive
difficulty understanding and determining the meaning of
language disorder
words and sentences
involves an impaired abilit to communicate through verbal and

Expressive language disorder
sign language
persistant antisocial behavior in choldren and adolecants that

Conduct disorder significantly imairs their ability to function in social, academic,
or occupational areas.
Rumination disorder the repeated regurgitation and rechewing of food
ADHD Inattentiveness, overactivity, and impulsiveness
Which of the following cerebral lobes FRONTAL - responsible for attention, impulse control,
has decreased metabolism in brain organization, sustained goal-directed activity
images of people with ADHD
What is the most common disorder of ADHD

childhood
Which of the following meds is used in Tic disorders are usually treated with ANTIPSYCHOTICS, like
the treatment of tic disorders? risperidone (Risperdal) or olanzapine (Zyprexa)
The nurse should advise the clinet Early in the afternoon to prevent the insomnia effect of
diagnosed with ADHD who is taking stimulants
dextroamphetamine to take his or her
last dose at what time?

Pediatric Nursing Concerns for Hospitalized Children

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Pediatric Nursing Concerns for Hospitalized Children

Uploaded by

Copyright:

Available Formats

10/6/21, 4:35 PM bstrandable NCLEX OB/Peds 3 of 3 Flashcards | Quizlet

Science / Medicine / Pediatrics

bstrandable NCLEX OB/Peds 3 of 3

the toddler fears _________ most when separation from family

the school aged hospitalized child is age group

the adolescent who is hospitalized peers, loss of independence

preschoolers may require physical true

which age group engages in stalling school-aged

bstrandable NCLEX OB/Peds 3 of 3

which age groups are most likely to school aged, adolescents

toddlers may require physical restraint true

"The mother of a child diagnosed with "Correct Answer: A

"A. ""This must be a difficult time for

B. ""Why do you say that? Do you think

C. ""You shouldn't feel that you could

D. ""Many children are diagnosed with

"A preschool-age child undergoing "Correct answer: D

"a. Administer tube feedings.

b. Offer small, frequent meals.

c. Offer fluids only between meals.

d. Allow the child to choose what to

bstrandable NCLEX OB/Peds 3 of 3

3. The presence of Epsetin-Barr virus

4. The presence of Reed-Sternberg

"Which nursing diagnosis is highest- "Correct Answer: A

C. Alterations in Skin Integrity

D. Body Image Disturbances"

bstrandable NCLEX OB/Peds 3 of 3

4. Weigh and measure the client on

d. Fecal occult blood test"

"David, age 15 months, is recovering "Correct: D

d. Increased interest in play"

bstrandable NCLEX OB/Peds 3 of 3

2. Temp every four hours.

4. Use a small toothbrush for mouth

"The parent of a child undergoing "Correct: B

B) ""Chemotherapy decreases immune

C) ""Chemotherapy makes the oral

D) ""Chemotherapy kills cancer cells,

bstrandable NCLEX OB/Peds 3 of 3

3. Appropriate protective equipment

4. Encourage the child to remain

"A child is diagnosed with Wilms' "CORRECT: D

The mother of a 5-year-old child asks "Correct: A.

"a.) Appropriate use of sunscreen

b.) Repeated exposure to the sun

c.) A child's skin is delicate, and burns

d.) In addition to causing skin cancer,

bstrandable NCLEX OB/Peds 3 of 3

Correct: 2. Fever and petechiae associated with acute

B. avoid fresh vegetables that are not

C. notify the doctor if the child's temp

D. increase the use of humidifiers

"The pediatric nurse understands that "Correct: 2.

2. Acute lymphocytic leukemia

3. Chronic lymphocytic leukemia

bstrandable NCLEX OB/Peds 3 of 3

"A. Measuring the child's chest

A nurse is teaching a client about the "Correct: 1.

"1. Age younger than 50 years

2. History of coloractal polyps

3. Family history of colorectal cancer