Health Promotion and Maintenance

1. Health Promotion and Maintenance Maternity; Newborn; Growth and Development; Elderly Pediatrics

2. Use Nagele’s rule to estimate the EDC for a patient whose LMP began on October 1. 2007. • October 11, 2008 • August 1, 2008 • July 1, 2008 • July 8, 2008

3. Use Nagele’s rule to estimate the EDC for a patient whose LMP began on October 1. 2007 • October 11, 2008 • August 1, 2008 • July 1, 2008 • July 8, 2008 • Add 7 days to the first day of LMP • Subtract 3 months • Add One year

4. The client has been pregnant 4 times. Her first died in utero at 16 weeks gestation. She delivered one infant at 24 weeks. Twins were born at 36 weeks gestation. The youngest delivered at 41 weeks. This client’s GTPAL would be _____. (G)4,(T)1,(P)3,(A)1,(L)4 Gravidity = # pregnancies Term = # term births Preterm Births = occurring before 40 weeks Abortions/Miscarriages . Living = # live births

5. The pregnant client’s hemoglobin and hematocrit levels are 11g/dL and 30g/dL. What is the most appropriate intervention for this client? • Administration of 1 unit of packed cells • Administration of 1000ml of D5NS with 40 KCL • Administration of Epoetin sq QD. • No intervention is indicated.

6. The pregnant client’s hemoglobin and hematocrit levels are 11g/dL and 30g/dL. What is the most appropriate intervention for this client? • Administration of 1 unit of packed cells • Administration of 1000ml of D5NS with 40 KCL • Administration of Epoetin sq QD. Stimulates RBC production. • No intervention is indicated. If drops below Hgb 10 g/dl and/or Hct 30% indicates anemia and need for intervention.

7. Which of the following clients requires further teaching regarding nutrition during pregnancy/lactation? • Client #1 is at the beginning of her third trimester. She has gained 40 lbs at this point of her pregnancy. • Client #2 is at the beginning of the 2nd trimester. She has increased calories by adding additional servings of fruits and vegetables. • Client #3 is in the middle of her 3rd trimester. She has been feeling “bloated” and “full” over the past few days. She has decided to limit her fluid intake to 8 glasses of water per day to correct this problem. • Client #4 has eliminated all foods with folic acid from her diet. She has read that folic acid might cause cancer in laboratory rats.

8. Which of the following clients requires further teaching regarding nutrition during pregnancy/lactation? • Client #1 is at the beginning of her third trimester. She has gained 30 lbs at this point of her pregnancy. 25-35 lb OK • Client #2 is at the beginning of the 2nd trimester. She has increased calories by adding additional servings of fruits and vegetables. Increase by 300 cal. / day • Client #3 is in the middle of her 3rd trimester. She has been feeling “bloated” and “full” over the past few days. She has decided to limit her fluid intake to 8 glasses of water per day to correct this problem. 8 glasses minimal OK • Client #4 has eliminated all foods with folic acid from her diet. She has read that folic acid might cause cancer in laboratory rats.Should consume a diet rich in folic acid.

9. The nurse is caring for a client in labor. The FHR has averaged around 150 beats/minute for the past hour. The nurse notices now that as the client’s contraction begins, the FHR begins to decline. The decline returns to the 150 baseline by the end of each contraction. Which nursing intervention is indicated for this deceleration pattern? • Continue to monitor the client. • Turn the client on her left side. • Place the client in the Lithotomy position. • Decrease the rate of the Pitocin drip, notify the MD.

10. The nurse is caring for a client in labor. The FHR has averaged around 150 beats/minute for the past hour. The nurse notices now that as the client’s contraction begins, the FHR begins to decline. The decline returns to the 150 baseline by the end of each contraction. Which nursing intervention is indicated for this deceleration pattern? • Continue to monitor the client. • Turn the client on her left side. • Place the client in the Lithotomy position. • Decrease the rate of the Pitocin drip, notify the MD. Early decelerations

11. Early decelerations: • decr in FHR below baseline • Occur during contractions as fetal head in pressed against the woman's pelvis or soft tissues • Return to baseline by the end of the contraction • Tracing shows uniform shape and mirror image of uterine contractions • Not asso with fetal compromise and require no intervention

13. Late decelerations: • Nonreassureing patterns • Reflect impaired placental exchange or uteroplacental insufficiency • look similar to early decelerations • Begin well after the contraction begins and return to baseline after the contraction ends • Tx: improve placental bld flow and fetal oxygenation

14. Variable decelerations: • Caused by conditions that restrict Bld flow through the umbilical cord • Do not have uniform appearance • Shape, duration, degree of fall below baseline HR are variable • Fall and rise abruptly with the onset and relief of cord compression • Can appear to be unrelated to contractions • Significant when FHR repeatedly decr to less than 70 and persists at that level for at least 60 seconds.

16. Dystocia Difficult, prolonged labor Excessive abdominal pain, abnormal contraction pattern, fetal distress, lack of progress in labor Assessment: FHR, uterine contractions, maternal temp and HR adm prophylactic antibiotics as prescribed, IVF as prescribed monitor I&O Monitor color of amniotic fluid Problems with L&D

17. Problems with L&D • Prolapsed cord • Compromises fetal circulation • Assessment: mother feeling that something is coming through vagina, visible/palpable umbilical cord • FHR irregular and slow • Fetal monitor shows variable decelerations or bradycardia after rupture of membrane • Fetal hypoxia: violent fetal activity then no/minimal movement • TX: • Relieve cord pressure: extreme Trendelenburg or modified Sims’s, knee-chest • Elevate fetal presenting part (sterile gloved hand apply finger pressure • Monitor FHR • Oxygen to mother • Prepare for emergency C section

18. Precipitous L&D Labor lasting less than 3 hrs Delivery tray available Stay with mother Do not try to keep fetus from being delivered Asst with delivery if MD unavailable Preterm Labor Occurs after 20th wk but before the 37th wk of gestation Contractions occur more frequ than q10 min and last 30 seconds or longer, persist May be assoc with infection (UTI) Problems with L&D

19. Premature Rupture of Membranes Spontaneous rupture of the amniotic membrane before the onset of labor Gestational age determines the plan Risk of infection TX: tests to assess gestational age, monitor maternal and fetus status, adm antibiotics as prescribed Problems with L&D

20. Problems with L&D • Rupture of uterus • Complete or incomplete separation of the uterus as a result of tear in the wall of the uterus from the stress of labor • Complete: direct communication betw uterine and peritoneal cavities • Incomplete: rupture into the peritoneum covering the uterus but not the peritoneal cavity • Assessment: abd pain, chest pain, contractions may stop or fail to progress, rigid abdomen, absent FHR, maternal shock, fetus palpated outside uterus • TX: monitor and TX s/s shock (Oxygen, IVF, Bld products) • Prepare for c-section • Emotional support

21. Placenta Previa Improperly implanted placenta in the lower uterine segment Assessment: Sudden onset of painless, bright reg vatinal bleedings in the last half of pregnancy Uterus soft, relaxed, nontender, Fundal height amy be more than epected for gestational age Tx: Monitor maternal v/s, FHR, fetal activity Ultrasound to confirm dx No vaginal exam Bedrest in a side-lying postion Montor bleeding, tx s/s shock Adm IVF, bld products, tocolytic medicaitons Perhaps c section Problems with L&D

22. Abruptio Placentae • Premature separation of the placenta from the uterine wall after the 20th wk of gestation and before the fetus is delivered • Assessment: • Dark red vaginal bleeding…or absence of Bld if bleed is higher in the uterus • Uterine pain/tenderness • Uterine rigidity • Severe abd pain • Signs of fetal distress • s/s maternal shock (excessive bleeding) • Tx: • Monitor maternal v/s and FHR • Assess vaginal Bld, abd pain, incr in fundal ht • Bedrest, oxygen, IVF, blood products • Trendelenburg’s position if indicated to decr pressure of fetus on placenta or lateral position with HOB flat if shock occurs • Monitor for s/s of disseminated intravascular coagulation

23. Amniotic Fluid Embolism Escape of amniotic fluid into the maternal circulation Debris-containing amniotic fluid deposits in the pulmonary arterioles and is usu fatal to mother Assessment: abrupt onset of resp distress and chest pain Cyanosis, seizures, heart failure, PE TX Emergency measures to maintain life Oxygen Prepare for intubation and mechanical ventilation Position mother lateral IVF, Bld products, medications to correct coagulation failure Monitor fetal status Prepare for emergency delivery once the woman is stable

24. Problems with L&D Supine hypotensive syndrome • Venous return to the heart impaired by the wt of the fetus • Assessment: • faintness, light-headedness, dizziness • Hypotension • fetal distress • TX: • Left lateral recumbent • Monitor v/s and FHR

25. Problems with L&D • Fetal Distress • Assessment: • FHR less than 120 or greater than 160 • Meconium-stained amniotic fluid • Fetal hyperactivity • Progressive decr in baseline variability • Severe variable decelerations • Late decelerations • TX: • Position mother lateral position • Oxygen (8-10 L via face mask) • d/c oxytocin • Monitor…

26. The FHR has been 105 for 15 minutes. Select the appropriate actions for the nurse: • Increase the rate of the Pitocin drip. • Turn the client to her side. • Notify the MD. • Administer facemask oxygen at 8 L/minute. • Elevate the foot of the bed.

27. The FHR has been 105 for 15 minutes. Select the appropriate actions for the nurse: • Increase the rate of the Pitocin drip. • Turn the client to her side. • Notify the MD. • Administer facemask oxygen at 8 L/minute. • Elevate the foot of the bed.

28. Which change in the FHR described below would necessitate a nursing intervention? • The FHR goes from 145 to 155 when a vaginal exam is performed on the mother. • The FHR goes from 145 to 143 as the mother’s contraction begins. • The FHR goes from 145 to 142 after the mother’s contraction begins. • The FHR goes from 145 to 160 as the fetus moves about in the uterus.

29. Which change in the FHR described below would necessitate a nursing intervention? • The FHR goes from 145 to 155 when a vaginal exam is performed on the mother. Normal acceleration • The FHR goes from 145 to 143 as the mother’s contraction begins. Early deceleration • The FHR goes from 145 to 142 after the mother’s contraction begins.Late deceleration • The FHR goes from 145 to 160 as the fetus moves about in the uterus. Normal acceleration

30. The nurse is caring for a client in labor. Her BP is 70/52. What nursing action is indicated first? • Turn her on her left side. • Administer facemask oxygen. • Notify MD. • Monitor FHR.

31. The nurse is caring for a client in labor. Her BP is 70/52. What nursing action is indicated first? • Turn her on her left side. • Administer facemask oxygen. • Notify MD. • Monitor FHR.

32. The nurse has just received report from the night shift. Which of the following postpartum clients should the nurse see first? • The client in room #1 who is complaining of pain secondary to breast engorgement. • The client in room #2 who is 24 hours post caesarian section and needs assistance to ambulate. • The client in room #3 who has not voided since delivery at 2 AM. • The client in room #4 who delivered 24 hours ago and continues to have rubra described as bright red.

33. The nurse has just received report from the night shift. Which of the following postpartum clients should the nurse see first? • The client in room #1 who is complaining of pain secondary to breast engorgement. psychosocial • The client in room #2 who is 24 hours post caesarian section and needs assistance to ambulate. Not an acute need • The client in room #3 who has not voided since delivery at 2 AM. • The client in room #4 who delivered 24 hours ago and continues to have rubra described as bright red. See 2nd – no info to indicate acute need.

34. Newborn, Concepts r/t G&D

35. All of the following interventions are indicated during the initial care of a newborn. Sequence the interventions as appropriate immediately following the birth: • Position newborn on his side. • Dry newborn and stimulate crying by rubbing. • Wrap newborn in warm blankets. • Suction mouth and nares with bulb syringe.

36. All of the following interventions are indicated during the initial care of a newborn. Sequence the interventions as appropriate immediately following the birth: • Position newborn on his side…4 • Dry newborn and stimulate crying by rubbing….2 • Wrap newborn in warm blankets….3 • Suction mouth and nares with bulb syringe…1

37. The newborn’s initial Apgar score is 8. What nursing interventions are indicated? • Rub the infant’s back. • Tickle the infant’ s feet. • Administer nasal cannula oxygen at 2L/min. • Place the infant on his side.

38. The newborn’s initial Apgar score is 8. What nursing interventions are indicated? • Rub the infant’s back. • Tickle the infant’ s feet. • Administer nasal cannula oxygen at 2L/min. • Place the infant on his side. Apgar of 8-10 OK and no intervention is indicated.

39. Which of the following sets of vital signs would be considered to be within normal limits for a newborn? • HR90, R32, Axillary Temp. 99 degrees F. • HR 110, R45, Axillary Temp. 99 degrees F. • HR152, R20, Axillary Temp. 98.6 degrees F. • HR98, R16, Axillary Temp. 100 degrees F.

40. Which of the following sets of vital signs would be considered to be within normal limits for a newborn? • HR90, R32, Axillary Temp. 99 degrees F. • HR 110, R45, Axillary Temp. 99 degrees F. • HR152, R20, Axillary Temp. 98.6 degrees F. • HR98, R16, Axillary Temp. 100 degrees F.

41. Normal newborn vital signs • HR100-170, • Resp. 30-80, • Axillary temp 96.8-99 degrees F • BP 73/55.

42. Vitamin K is prescribed for a neonate. The nurse prepares the medication and selects which muscle site to administer the medication? • Deltoid • Triceps • Vastus lateralis • Biceps

43. Vitamin K is prescribed for a neonate. The nurse prepares the medication and selects which muscle site to administer the medication? • Deltoid • Triceps • Vastus lateralis • Biceps

44. Magnesium sulfate is being used in a client diagnosed with preeclampsia. Assessment of the client reveals respirations of 8, sluggish reflexes, and a HR of 42. Which intervention described below would be appropriate? • Increase the dosage of Magnesium sulfate. • Administer calcium gluconate. • Turn the client on her right side. • Elevate the foot of the bed.

45. Magnesium sulfate is being used in a client diagnosed with preeclampsia. Assessment of the client reveals respirations of 8, sluggish reflexes, and a HR of 42. Which intervention described below would be appropriate? • Increase the dosage of Magnesium sulfate. • Administer calcium gluconate. s/s of magnesium toxicity…Ca gluconate raises Ca levels and therefore decr Magnesium level • Turn the client on her right side. • Elevate the foot of the bed.

46. Which of the following represents a developmental task of a 13 year old girl? • Jane reminisces about the major events of her life. • Mary is looking for some one to share her life with. • Jennifer enjoys working on service projects with the other members of her girl scout troop. • Lilly is trying hard to improve her grades in Math.

47. Which of the following represents a developmental task of a 13 year old girl? • Jane reminisces about the major events of her life. ..Later (65 yrs +) • Mary is looking for some one to share her life with …Early adulthood(20-35yrs) • Jennifer enjoys working on service projects with the other members of her girl scout troop...Adolescence (12-20yrs) • Lilly is trying hard to improve her grades in Math. ..School Age (6-12yrs)

48. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. The most appropriate nursing response would be which of the following? • “You need to be concerned.” • “You need to monitor the child’s behavior closely.” • “At this age the child is developing his own personality.” • “You need to provide more praise to the child to stop this behavior.”

49. The mother of an 8-year-old child tells the clinic nurse that she is concerned about the child because the child seems to be more attentive to friends than anything else. The most appropriate nursing response would be which of the following? • “You need to be concerned.” • “You need to monitor the child’s behavior closely.” • “At this age the child is developing his own personality.” • “You need to provide more praise to the child to stop this behavior.”

50. Which patient described below would experience the greatest distress when separated from his parent(s)? • Joshua who is 18 months old and the youngest of three children. • Jonathon who is 4 years old and is the oldest of 2 children. • Michael who is 10 years old and is the second of three children in his family. • Michael who is 13 years old and is an only child.