NCLEX Practice Questions — Set 26
How to use this set
Run it as a timed block rather than dipping in and out. 100 items at roughly a minute each is close to the pace the real exam asks for, and pacing is a skill that only improves under a clock. Answer every item before you open a single rationale — checking as you go turns a test into a reading exercise and hides the questions you were unsure about.
These sets are numbered rather than sorted by subject. The questions come from a general NCLEX bank that carries no topic field, and labelling them by eye would put a share of them under the wrong heading, so they are presented as mixed sets — which is how the exam itself arrives.
The 100 questions
The nurse correctly assesses which of the following children for the onset of Duchenne’s muscular dystrophy?
Show answer and rationale
Correct answer: B. A preschool child
Duchenne’s muscular dystrophy is a group of progressive degenerative inherited diseases that cause muscle wasting. It has an onset between the ages of 3 and 6�years.
The nurse caring for a child with muscular dystrophy observes the child use the Gower maneuver while trying to
Show answer and rationale
Correct answer: B. stand.
At about 5 or 6�years of age, children with muscular dystrophy must use their hands to walk up their legs to achieve the standing position. This is called the Gower maneuver.
A nurse is teaching a class to parents of children with spinal deformities. Which of the following should the nurse include in the class?
Show answer and rationale
Correct answer: A. Spinal deformities may be painless and have a slow progression in the early stages
Spinal deformities are generally painless and have a slow progression in the early stages. Lordosis is an increased anterior curvature of the lumbar spine. The child and family should be taught that periodic evaluation (every 3 to 6�months) during rapid growth spurts is indicated. Scoliosis most often occurs during the growth spurt of adolescence.
The nurse is assessing four infants for fine and gross motor development. The nurse should report which of the following infants as having a problem with motor development?
Show answer and rationale
Correct answer: B. A 7-month-old infant who cannot sit without support
A 6-month-old infant should be able to sit without support. The tonic neck and Moro reflexes begin to disappear between 2 and 3�months. Using the whole hand to grasp an object occurs between 4 and 5�months. The pincer grasp begins to develop between 8 and 9�months.
The registered nurse is preparing the clinical assignments for a pediatric musculoskeletal unit. Which of the following nursing tasks should the nurse delegate?
Show answer and rationale
Correct answer: A. Bathe a client with a hip spica cast
Assessing, monitoring, and preparing a child for surgery are nursing tasks that require the skills of a registered nurse. A licensed practical nurse may bathe a client with a cast.
The nurse should report which of the following pediatric musculoskeletal assessment findings as abnormal?
Show answer and rationale
Correct answer: C. An increased muscle tone in a 2-year-old child
An increased muscle tone in a 2-year-old child is abnormal. It may indicate cerebral palsy. It is normal for an 18-month-old child to be bowlegged. A wide-based gait is normal in a 1-year-old toddler. Infants normally have lumbar curvatures of the spine and protuberant abdomens.
The parents of a newborn with bladder exstrophy ask the nurse why a suprapubic catheter is being inserted. Which of the following is the most appropriate response by the nurse? "Suprapubic catheterization
Show answer and rationale
Correct answer: B. is performed to aspirate urine when the newborn has not voided for more than 1 hour."
Suprapubic catheterization allows the aspiration of urine when a child cannot void because of a congenital abnormality such as bladder exstrophy. Generally, suprapubic catheterization is performed when a child hasn’t voided for more than an hour. It is a less desirable procedure than bladder catheterization because it is painful and the child must be restrained. It is performed less frequently now than in the past because small catheters are now available for bladder catheterization.
Which of the following should the nurse include in the postoperative management of a child who had surgery for vesicoureteral reflux?
Show answer and rationale
Correct answer: A. Inform the parents that a renal ultrasound should be done at 6�months and again at 1�year
Postoperative care of a child who has had surgery for a vesicoureteral reflux should include a renal ultrasound at 6�months and again at 1�year to evaluate renal growth. Covering the bladder with a thin, nonadhesive dressing is an appropriate intervention before surgery for a bladder exstrophy. Encouraging the parents to have the child wear loose clothing is an appropriate intervention for cryptorchidism. Oxybutynin chloride (Ditropan) is an anticholinergic used in the treatment of enuresis. Desmopressin acetate (DDAVP), a synthetic analog of vasopressin that acts by increasing water retention and urine concentration, is also used for enuresis.
When working with a child with postinfectious glomerulonephritis, which of the following is most appropriate to consider when planning the goals of care?
Show answer and rationale
Correct answer: C. Most children fully recover from this illness
Glomerulonephritis is a primary disorder or a manifestation of a systemic disorder that may range from mild to severe. The most common form is a postinfectious inflammation of the glomeruli caused by a streptococcal, pneumococcal, or viral infection. A full recovery generally occurs. Although hypertension and hematuria are clinical manifestations, they generally resolve with recovery. Recurrent urinary infections do not occur in glomerulonephritis but in vesicoureteral reflux.
The post-op care for a child who has had surgery for cryptorchidism, the nurse should perform which of the following priority nursing interventions?
Show answer and rationale
Correct answer: C. Change the diapers frequently
Cryptorchidism is failure of one or both testes to descend normally into the scrotum. Surgery is necessary to avoid exposure of the undescended testis to the body temperature, increased incidence of infertility, tumors, and physical or psychological trauma as a result of an empty scrotum. The priority nursing intervention is frequent diaper changes to prevent infection. There are no dietary restrictions, although protein will promote wound healing. Assessing the cremasteric reflex is the application of firm pressure on the external ring before palpating the abdomen or genitalia. The reflex is active in an infant and child up to 5�years of age and may result in withdrawal of the testes above the scrotum. Activity is not encouraged, and engaging in strenuous activity and playing on riding toys are to be avoided.
A mother of a 4-year-old child asks the nurse whether control of urine or stool comes first. Which of the following responses is appropriate?
Show answer and rationale
Correct answer: A. "Control of stool at night occurs first."
Control of the bowel occurs first at night followed by control of the bowel during the day. Subsequently, urine is controlled during the day; control of urine at night occurs last.
Which of the following nursing interventions is a priority for the nurse to implement in the plan of care for a child with hemolytic uremic syndrome?
Show answer and rationale
Correct answer: A. Administer prescribed sodium polystyrene sulfonate (Kayexalate) rectally
A priority nursing intervention for hemolytic uremic syndrome is the administration of rectal sodium polystyrene sulfonate (Kayexalate) to bind potassium in the body and remove it through the rectum. Glucose may be administered if hypoglycemia is present. Trimethoprim-sulfamethoxazole (Bactrim) is a sulfonamide that is nephrotoxic. Aluminum hydroxide gel may be given to bind with phosphorus.
The nurse evaluates which of the following children with end-stage renal failure to be the most appropriate candidate for a renal transplant?
Show answer and rationale
Correct answer: B. A 3-year-old child with hemolytic uremic syndrome
Renal transplantation for children with endstage renal disease is the only treatment that offers these children a chance at a normal life. The child must be free of cancer for a period of no less than 2�years and have no indications of an infection.
Which of the following is the priority for the nurse to monitor in a child who has had hypospadias surgery?
Show answer and rationale
Correct answer: C. Urethral fistula
Hypospadias is a congenital defect in which the urethral meatus appears on the ventral surface of the penis. A urethral fistula results in urine leaking from the urethra and may necessitate surgery if it does not spontaneously resolve. Although dysuria, bladder spasms, and urinary tract infections may occur following urinary surgery, the priority is the leakage of urine that may occur from the urethra with a urethral fistula.
Which of the following changes in a child’s assessment should the nurse report as a critical indication of a toxic reaction to oxybutynin chloride (Ditropan)?
Show answer and rationale
Correct answer: A. Tachycardia and hypertension
Oxybutynin chloride (Ditropan) is an anticholinergic used in the treatment of enuresis. Common adverse reactions include constipation, urinary retention, dry mouth, blurred vision, heat intolerance, and insomnia. Tachycardia and hypertension are serious adverse reactions that are indications of toxicity.
In planning the post-op care for a child following reimplantation of the ureters, the nurse should include which of the following inthe plan of care to prevent urinary tract infections?
Show answer and rationale
Correct answer: C. Assess the tubing and ureteral stents for breaks in their integrity
Assessing the ureteral stents and tubing for breaks in their integrity is a priority nursing intervention to prevent urinary tract infections following implantation of the ureters.
The registered nurse in charge of a busy genitourinary unit should most appropriately delegate which of the following nursing tasks to the appropriate unit personnel considering budget, time, and qualifications of the employee?
Show answer and rationale
Correct answer: C. Assign a registered nurse (RN) to assess an infant with hemolytic syndrome for signs of intracranial pressure
Only a registered nurse can perform assessments. Also, a child suspected of having signs of intracranial pressure may not be stable. It is not appropriate to delegate to unlicensed assistive personnel the task of taking the vital signs of a child suspected of being hypertensive and in renal failure. Taking the vital signs of this client would be an assessment and evaluation of the client’s status, which can only be performed by a registered nurse. A licensed practical nurse cannot provide education orevaluate; such tasks must be performed by the registered nurse.
The nurse should assist a 4-year-old child experiencing primary enuresis to make which of the following menu selections?
Show answer and rationale
Correct answer: D. Fried chicken and mashed potatoes
Foods such as dairy products, citrus fruits, heavily sugared foods, and beverages with artificial coloring, carbonation, and caffeine can be irritants to the bladder and increase the child’s enuresis.
The nurse is assessing the following four children for the risk of developing an inguinal hernia. The nurse should recognize that which of the following children has the highest risk of developing this condition?
Show answer and rationale
Correct answer: B. A 3-week-old male who was premature and has a low birth weight
Infantile inguinal hernias are more common within the first month of life in males. The incidence is greatly increased in males born prematurely and with a low birth weight. A 7-year-old male exposed to an infectious agent may have acute glomerulonephritis. A 2-year-old female with a history of urinary tract infections may have vesicoureteral reflux. A 2-year-old female living in an undeveloped country who ate E. coli-contaminated beef may have hemolytic uremic anemia, a disorder that is distributed equally between the sexes.
The nurse should include which of the following statements when providing education to the parents of a child who has had a bone marrow aspirate procedure?
Show answer and rationale
Correct answer: B. "You should not give your child a tub bath for 24 hours."
Tub bathing and showering will compromise the integrity of the pressure dressing applied to the bone marrow aspirate site; the dressing needs to be in place for 24 hours postprocedure. Sitting for prolonged periods of time has no ill effect on the site of injury or the iliac crest. Activity restriction is regulated by the child’s comfort level, as there are no activity restrictions associated with a bone marrow aspiration procedure.
The nurse is caring for a child who is experiencing severe mucositis. Which of the following measures would be essential to include in the child’s plan of care?
Show answer and rationale
Correct answer: D. Provide total parenteral nutrition (TPN)
The most appropriate intervention for a child with mucositis is to provide total parenteral nutrition. Because mucositis severely alters oral cavity mucosa, oral feeding would be painful. Nasogastric feedings would not be an option, because intubation could potentially cause mechanical damage to the already injured oral and esophageal mucosa. Maintaining hydration does not allow for nutrition needs, only fluid needs.
The father of a child newly diagnosed with acute lymphocytic leukemia (ALL) asks the nurse why trimethoprim-sulfamethoxazole (Bactrim) has been prescribed. The nurse would best describe the purpose of trimethoprimsulfamethoxazole (Bactrim) therapy as a means to prevent which of the following?
Show answer and rationale
Correct answer: A. A certain type of pneumonia
Leukemia is a malignant disease in which normal marrow cells are replaced by abnormal, immature lymphocytes known as blast cells. It is the most common form of childhood leukemia. Trimethoprim and sulfamethoxazole (Bactrim) is prophylactic treatment for pneumonia caused byPneumocystis carinii. Bactrim is ineffective against fungal and viral agents as well as ineffective in treating diarrhea.
An adolescent with newly diagnosed osteosarcoma of the femur asks the nurse why a computerized tomography (CT) scan of the chest was ordered. The nurse should give this client which explanation of what the CT scan will show?
Show answer and rationale
Correct answer: A. "The CT scan will reveal any metastatic lesions, if present."
Osteosarcoma is a bone tumor that usually occurs in the growth metaphysis or the long ends of the bone. It is usually not diagnosed until there is a trauma to the bone. A chest computerized tomography (CT) scan is performed during the metastatic search. A test to determine how well the lungs are functioning would be a pulmonary function test. A test determining oxygenation would be arterial blood gas (ABG), or oxygen-saturation monitoring. A test to determine how well the heart is pumping would be an echocardiogram.
Before setting out for an appointment at the hematology/oncology clinic, an adolescent begins experiencing anticipatory nausea and vomiting. When informed of this situation, the nurse should instruct the adolescent to follow which of the following medication regimens?
Show answer and rationale
Correct answer: D. Oral lorazepam (Ativan), 1 hour before arriving at the clinic
Lorazepam (Ativan) is an antianxiety medication that is effective against anticipatory nausea and vomiting. Administration of IV lorazepam (Ativan) is the incorrect route. Oral dexamethasone (Decadron) is not an antianxiety medication. Dexamethasone (Decadron) with ondansetron (Zofran) upon arrival to the clinic is not effective against anticipatory nausea and vomiting.
Which of the following assessments should the nurse perform on a child with newly diagnosed Wilms’ tumor?
Show answer and rationale
Correct answer: C. Urine dipstick for microscopic hematuria
Wilms’ tumor, or nephroblastoma, is the most common tumor of the kidney in children. Microscopic hematuria is often seen in clients diagnosed with Wilms’ tumor. Deep palpation is avoided in order to keep the malignancy encapsulated. Cranial nerve testing is assessed in suspected central nervous system tumors. Urine electrolyte analysis is performed when syndrome of inappropriate antidiuretic hormone or diabetes insipidus is suspected.
The nurse is caring for a child diagnosed with stage IV neuroblastoma. The nurse recognizes that the child may require which of the following?
Show answer and rationale
Correct answer: C. Total parenteral nutrition (TPN) to maintain nutritional requirements
Neuroblastoma is a tumor that originates from cells that are precursors of the adrenal medulla and sympathetic nervous system. With stage IV neuroblastoma, the tumor has spread to the liver, skin, or bone marrow. Nutritional support is needed when a child is not capable of maintaining requirements. Rehabilitation services after tumor resection is needed for children undergoing limb salvage procedures. Placement of a VP shunt is needed for children experiencing hydrocephalus from a brain tumor. Thyroid replacement therapy after completion of chemotherapy is needed if the thyroid was in the radiation field and can no longer function adequately.
The nurse is providing postoperative care for an adolescent immediately following a limb salvage procedure of the left femur. Which of the following assessments should the nurse perform during the immediate postoperative period?
Show answer and rationale
Correct answer: D. Circulation, movement, sensation (CMS) checks distal to operative site
Circulation, movement, and sensation (CMS) checks distal to the operative site are imperative perfusion assessments following a limb salvage of the left femur. Abduction and adduction of the left lower extremity would not be assessed immediately after surgery, due to tissue trauma and the potential for tissue injury. Assessment of the weight-bearing capacity of the operative leg would occur only after 24 to 48 hours of strict bed rest.
The nurse is caring for a child receiving radiation therapy to the scapula as part of the treatment for Ewing’s sarcoma. Which of the following interventions should the nurse include when performing skin care?
Show answer and rationale
Correct answer: C. Apply prescribed lotion to reddened skin daily after radiation treatment
Ewing’s sarcoma is a highly malignant bone tumor usually present in the pelvis, tibia, fibula, and femur. It would be appropriate to apply prescribed lotion to reddened skin after radiation treatment. Massage would increase pain and mechanical cellular damage to already irritated skin. Baby oil prior to therapy would affect the efficacy of the radiation beam during therapy. Ice application would decrease circulation to the site, which needs an adequate blood supply for tissue healing.
The nurse is caring for a child with neutropenia secondary to chemotherapy. Which of the following measures would be essential to include in the child’s discharge instructions?
Show answer and rationale
Correct answer: A. Call the doctor if the child has a fever greater than or equal to 38.3�C, or 101�F
Fever is often the first sign of infection in a child with neutropenia. Not sending the child to school does not prevent infection caused by intrinsic organisms. Neupogen should be discontinued only after the neutrophil count has recovered. Administering acetaminophen (Tylenol) can mask a fever.
The nurse is collecting a nursing history from a child with a pathological fracture of the right tibia. Which of the following questions should the nurse ask first to elicit the most accurate assessment?
Show answer and rationale
Correct answer: C. "Did you experience any trauma to your right leg?"
Bone tumors alter the integrity of the bone, which often leads to pathological fractures. A fracture can be correlated with the onset of clinical manifestations, an important component in obtaining a health history. Recent fevers do not always give the nurse information about onset of manifestations. Family history and pains in other areas do not give the nurse information about the timing of onset of clinical manifestations.
The child newly diagnosed with acute lymphocytic leukemia is scheduled to have a lumbar puncture. With which of the following statements can the nurse best describe the purpose of the lumbar puncture?
Show answer and rationale
Correct answer: A. "It will allow for collection of fluid to examine for metastasis."
The purpose of a lumbar puncture is to obtain cerebral spinal fluid to be examined for leukemic cells. Telling the client that it will relieve headaches is not appropriate, because there is a high incidence of headaches after a lumbar puncture. Examination of collected fluid for meningitis is not part of a new diagnosis evaluation of acute lymphocytic leukemia. Relieving bone pain is not correlated with accessing the intrathecal space.
Which of the following does the nurse assess as a major presenting clinical manifestation in the child with a retinoblastoma?
Show answer and rationale
Correct answer: C. Cat’s eye reflex
Retinoblastoma tumors are tumors of the eye that create a cat’s eye reflex when the light hits the eye at the right angle; the reflex is also identifiable in photographs. An icteric sclera would be associated with hepatic dysfunction. Chronic conjunctivitis is not identified as a precursor or a clinical manifestation of retinoblastoma. Aniridia is associated with Wilms’ tumor.
The nurse is caring for a child with left-sided hemiparesis after a brain tumor resection. Which of the following nursing interventions is appropriate?
Show answer and rationale
Correct answer: B. Secure a peripheral intravenous catheter in the child’s left hand
A peripheral intravenous catheter should be inserted in the child’s left hand. The child’s right hand should not be used because it would further limit the function of a compromised right side. Securing the call light near the child’s left hand would not allow the child to independently call for the nurse. Supporting the child’s right side does not consider safety during transfer. Instilling natural tears in both eyes four times a day suggests a bilateral intervention for a unilateral functional disability to keep the cornea protected.
In preparing a child for a magnetic resonance image (MRI) with sedation, the nurse should include which of the following preprocedure instructions?
Show answer and rationale
Correct answer: B. Nothing by mouth 6 hours prior to exam
Children receiving sedation for a magnetic resonance image (MRI) need to be NPO in order to prevent aspiration. Clear liquids would not be permitted. Hospital admission is not required. Postsedation monitoring is all that is required until the child is awake and alert. Immediate discharge is not allowed because the child needs to recover from sedation.
The nurse is discharging a child with Wilms’ tumor after a resection. Which of the followingmeasures would be a priority to include in the client’s discharge instructions?
Show answer and rationale
Correct answer: B. Avoid contact sports
Wilms’ tumor is the most common childhood tumor of the kidney. Avoiding contact sports is a priority to protect the remaining kidney. A lowsodium diet is part of hypertension management. Fluid restriction and limiting protein intake are part of renal failure management.
The nurse should monitor a child with a brain stem glioma receiving vincristine sulfate (Oncovin) for which of the following adverse reactions?
Show answer and rationale
Correct answer: B. Constipation
Vincristine sulfate (Oncovin) is an antineoplastic drug that inhibits mitosis at metaphase. It can cause neuropathy, including the gut, leading to constipation. Appendicitis and typhlitis are infectious processes that may arise during neutropenic episodes.
The parents of a child with acute lymphocytic leukemia, positive for Philadelphia chromosome, ask the nurse to describe the treatment plan. The priority response by the nurse is "Chemotherapy
Show answer and rationale
Correct answer: B. until the child achieves remission, then stem cell transplantation."
Acute lymphocytic leukemia accounts for 80% of childhood leukemias. Children positive for Philadelphia chromosome require related or unrelated stem cell transplantation in order to eradicate the chromosomal defect. Biologic modifiers and radiation therapy will not eradicate the chromosomal defect.
The nurse caring for a child with neuroblastoma includes which of the following assessments as a measure of tumor responsiveness?
Show answer and rationale
Correct answer: D. Urine catecholamines
Neuroblastoma is a tumor that originates from the adrenal medulla and sympathetic nervous system. Clients with neuroblastoma produce excessive amounts of urine catecholamine metabolites (VMA, HVA, dopamine). Serum copper levels and erythrocyte sedimentation rates are tumor markers for Hodgkin’s disease. Urinalysis with culture and sensitivity is an assessment conducted when urinary tract infection is suspected.
When planning the discharge of a child newly diagnosed with a malignancy, which of the following instructions should be included regarding infection prevention?
Show answer and rationale
Correct answer: B. Hand washing is the most effective method of infection prevention
Hand washing has been identified as the most effective method for preventing infection. Isolation, restricting the intake of fresh fruits and vegetables, and removing the carpet from the child’s bedroom are measures instituted when a child is discharged to home after a stem cell transplant.
When caring for a child who has a ventriculoperitoneal (VP) shunt secondary to hydrocephalus from medulloblastoma, the nurse should include which of the following interventions?
Show answer and rationale
Correct answer: B. Administer platelets when the platelet count drops below 50,000/mm3
Platelets should be administered when the platelet count drops below 50,000/mm3 in children with brain tumors to decrease the incidence of intracranial hemorrhage. Darkening the room to decreasephotosensitivity is an intervention for migraine headaches or dilated eyes. A ventriculoperitoneal (VP) shunt has no impact on the type of head covering a child can wear. Restricting dietary sodium intake is an intervention for a child experiencing hypernatremia.
An adolescent with Ewing’s sarcoma asks why radiation therapy will be needed because the entire tumor was surgically removed. In describing the purpose of multimodal therapy, the nurse should give this client which explanation of why radiation is needed?
Show answer and rationale
Correct answer: C. "It destroys remaining microscopic tumor cells."
Radiation therapy is often used with radiosensitive tumors to eradicate microscopic disease in the tumor beds if surgical margins are close in cancers such as Ewing’s sarcoma, a highly malignant bone tumor.
The registered nurse is delegating the clinical assignments for a pediatric oncology unit. Which of the following clinical assignments is most appropriate for the nurse to delegate to unlicensed assistive personnel?
Show answer and rationale
Correct answer: C. Bathe a child with acute lymphocytic leukemia
Great care is to be used in the bathing and handling of a child with a Wilms’ tumor. It is essential to limit manipulation of the abdomen to prevent spread of the malignancy should the encapsulated mass rupture. It would not be appropriate to delegate bathing this child to unlicensed assistive personnel. A child who is neutropenic and has a fever of 39�C, or 102.2�F, would most appropriately be cared for by a nurse because of the risk of infection. Because precautions should be taken when handling the bodily fluids of a client receiving radioactive fluids, this would not be the most appropriate clinical assignment for unlicensed assistive personnel. It would be appropriate to permit unlicensed assistive personnel to bathe a child with acute lymphocytic leukemia.
In examining a child with suspected anemia, the nurse would recognize which of the following as a significant objective finding?
Show answer and rationale
Correct answer: A. Cheilosis and glossitis
Cheilosis (fissures in the angles of the lips) and glossitis (inflammation of the tongue) are observable physical abnormalities that tend to occur in clients experiencing significant anemia. A history of pica, daily aspirin therapy, and tonsillectomy 3 days ago are all examples of subjective findings that may be associated with anemia.
A child is being admitted to the hematology unit of the hospital with physician orders to obtain a complete blood count (CBC). The parent inquires about the purpose of this test. The nurse’s best response would be which of the following?
Show answer and rationale
Correct answer: C. "It provides a basic description of the types of cells present and measures the quantity of all the cells in the blood."
The CBC (complete blood count) is a basic diagnostic exam that measures the number, quality, variety, concentrations, and percentages of the blood cells. A peripheral smear allows the clinician to view blood cells under a microscope. Serum iron and T(total iron-binding capacity) measure iron stores and the capacity of the body to bind with iron and form hemoglobin. Hemoglobin electrophoresis measures both normal and abnormal hemoglobins and is the diagnostic test required to identify hemoglobinopathies.
In preparing the client and family for bone marrow aspiration, the nurse should explain the procedure thoroughly. Which of the following statements represents appropriate family preparation?
Show answer and rationale
Correct answer: A. "The physician will use sterile technique while obtaining a small sample of bone marrow through a needle inserted into the child’s hip bone."
Children will be positioned on the abdomen for the procedure because the posterior iliac crest is the preferred site for bone marrow aspiration in children. Sterile technique is used during the procedure to minimize the risk for infection. The sternum is an acceptable site for bone marrow aspirationin adults, but not in children. Bone marrow aspiration is associated with discomfort during needle insertion and specimen aspiration. The length of time it takes a client to form a clot is a measure of bleeding time.
Which of the following should be included in the discharge instructions for a child with iron deficiency anemia?
Show answer and rationale
Correct answer: C. Iron supplements should be taken between meals with orange juice and monitor for black, tarry stools
Iron supplements should be given on an empty stomach with a source of vitamin C to increase absorption and may be given between meals to decrease stomach upset. Black, tarry stool is a common side effect of iron therapy. Making up for missed doses of iron supplements is never recommended. Whole milk consumption by young infants is responsible for a large number of cases of iron deficiency anemia. The immature gastrointestinal (GI) tract in infants cannot process whole milk, and this can lead to GI bleeding, blood loss, and anemia. Vitamin C increases the absorption of iron from the GI tract.
After assessing four clients with sickle cell anemia, which of the following clients is the priority for the nurse to administer care to first?
Show answer and rationale
Correct answer: C. A client whose speech is slurred and has hemiparesis
Hemiparesis and slurred speech may be indicative of stroke. Stroke requires immediate admission to the hospital for an exchange transfusion to prevent permanent motor damage. Painful swelling of the hands or feet is�called dactylitis and can be managed at home with fluids and analgesics, unless fever is present. Pallor, icteric sclera, and fatigue are continuously present in a large number of clients with sickle cell disease due to underlying anemia. Abdominal pain that occurs after eating greasy foods is associated with gallstones and is not a medical emergency.
A nurse is caring for a child with sickle cell anemia. Which of the following measures would be a priority to include in the plan of care to prevent infection?
Show answer and rationale
Correct answer: C. Administer penicillin twice daily and immunize with Pneumovax
All children with sickle cell anemia who are less than 6�years of age should be on penicillin twice daily to prevent pneumococcal sepsis. In�addition to regular immunizations, these children should receive Pneumovax, to further protect them from infection. Increasing fluids and administering analgesics are measures aimed at treating painful episodes. Monthly blood transfusions increase a client’s hematocrit and decrease the risk for stroke, but�do not prevent infection in sickle cell clients. Antipyretics are not effective in preventing infection.
In caring for a child with aplastic anemia, the nurse should immediately report which of the following assessment findings?
Show answer and rationale
Correct answer: D. Fever of 39�C, or 102�F
Children with aplastic anemia are at increased risk for overwhelming sepsis due to neutropenia. Any fever greater than 38.3�C, or 101�F, is considered a medical emergency and requires immediate treatment. Splenomegaly is not commonly associated with aplastic anemia. Pallor and fatigue are common in clients with aplastic anemia, but do not usually require immediate evaluation. Amenorrhea is actually induced in many clients with aplastic anemia to prevent further blood loss and increasing anemia.
The nurse should include which of the following instructions for the parents of a child with hemophilia A (factor XIII deficiency)?
Show answer and rationale
Correct answer: D. Encourage age-appropriate immunizations
Immunizations should be administered in children with hemophilia, but should be given s.q. In addition, pressure should be applied to the site of injection for 15�minutes. Children with hemophilia are allowed participation in noncontact sports only. Exercise is important for children with hemophilia to build flexibility, strength, and cardiovascular endurance. Ice should be applied to areas of bleeding to constrict blood vessels and decrease bleeding.
The nurse is caring for a child suspected to have ideopathic thrombocytopenic purpura (ITP). Which of the following questions would be most important to ask while obtaining the history?
Show answer and rationale
Correct answer: C. "What medications have you given your child?"
Drugs such as aspirin products and nonsteroidal anti-inflammatory drugs (NSAIDs) can adversely affect children and cause bleeding. This needs to be ruled out before making a diagnosis of ideopathic thrombocytopenic purpura (ITP). Many children with ITP have a history of preceding viral illness, although it is not a definitive indication that the child will develop ITP. The child’s blood type does not play a role in the diagnosis of ITP, although it might be necessary to know this if initial treatment options are unsuccessful. Pets in the home are insignificant for ITP.
Which of the following drugs should the nurse administer to a child with sickle cell anemia to decrease painful episodes and prevent hospitalizations?
Show answer and rationale
Correct answer: A. Hydroxyurea (Hydrea)
Hydroxyurea (Hydrea) is a daily drug prescribed to decrease painful crises and prevent hospitalization of a child with sickle cell anemia. Morphine sulfate, meperidine (Demerol), and acetaminophen with codeine are all drugs utilized during acute pain episodes.
The parent of a child with a hematological disorder inquires about the purpose of the red blood cells in the body. The nurse should respond, "Red blood cells
Show answer and rationale
Correct answer: A. carry oxygen to the tissues."
Red blood cells are responsible for carrying oxygen to the tissues and removing carbon dioxide from them. White blood cells are the body’s primary defense against infection. Platelets are the cellular components of blood that assist in the formation of blood clots. Phagocytosis is the process of removing debris from the bloodstream and is carried out by white blood cells.
The nurse is caring for a child with anemia. Which of the following would indicate to the nurse that the client’s condition is deteriorating?
Show answer and rationale
Correct answer: D. Cardiac murmur
Cardiac murmurs are only present in children with significant anemia and indicate their condition is deteriorating. Pallor, fatigue with exertion, and irritability are findings that may be present with all levels of anemia.
The nurse is caring for a child with sickle cell disease who is experiencing hematuria. Which of the following actions is an appropriate intervention?
Show answer and rationale
Correct answer: D. Push fluids
Increasing fluid intake will dilute the urine and reduce further kidney damage and may possibly correct the hematuria. Restricting activity is not specific to hematuria. Ibuprofen has no indication in the treatment of hematuria. Evaluation of temperature is not indicated in the treatment of sickle cell anemia and hematuria.
The nurse is discharging an infant who was recently diagnosed with sickle cell anemia, or hemoglobin SS disease. It is a priority to provide the infant’s parents with information on which of the following complications?
Show answer and rationale
Correct answer: A. Dactylitis
Dactylitis is the first painful episode a sickle cell client may experience and usually occurs between 6�months and 3�years of age. This information would be most relevant for the parents of an infant who was just diagnosed. A vascular necrosis and retinopathy tend to be complications experienced in adolescence and adulthood. Gallstones are not common in infancy.
Which of the following drugs should the nurse administer to a child with beta thalassemia major who has been on chronic transfusion therapy for several years?
Show answer and rationale
Correct answer: C. Deferoxamine (Desferal)
Children who are receiving chronic transfusion therapy are at risk for iron overload and subsequent organ damage. Deferoxamine (Desferal) is a chelation agent that binds with iron and helps the body remove the excess. Tylenol with codeine and hydroxyurea (Hydrea) are drugs used in the treatment and prevention of sickle cell pain. Cyclosporine (Sandimmune, Neoral) is an immunosuppressive agent used in the treatment of aplastic anemia.
The nurse is caring for a child with aplastic anemia. Which of the following measures should be included in the child’s plan of care?
Show answer and rationale
Correct answer: C. Administration of antithymocyte globulin (ATG)
Antithymocyte globulin (ATG) is routinely used to treat clients with aplastic anemia. Genetic counseling is not indicated for families experiencing aplastic anemia, as it is not a hereditary condition. Iron supplementation is not usually indicated for clients with aplastic anemia. Because children with this disease should avoid exposure to sources of infection, they should not be encouraged to interact in day care. Day care centers and schools are common sources of infection.
The nurse is caring for a child with severe hemophilia A (factor XIII deficiency). Which of the following measures is most appropriate for the nurse to implement in this child’s plan of care?
Show answer and rationale
Correct answer: B. Pad the bed rails
Padding the bed rails may help to decrease the chances of injury in a child with hemophilia. Forcing fluids is not part of routine care for hemophilia clients. Intravenous immune globulin (IVIG) is utilized in clients with ideopathic thrombocytopenic purpura (ITP). Monitoring temperatures is necessary in all clients, but is not the most appropriate intervention for this child.
After a health interview with an adolescent child, which of the following findings should the nurse report as significant?
Show answer and rationale
Correct answer: C. Delayed puberty
Delayed puberty is common in adolescents with sickle cell disease. Heavy menstrual flow is more commonly associated with bleeding disorders, such as von Willebrand’s disease. Children with sickle cell anemia have a strong tendency to be smaller and weigh less than their peers and often donot follow a normal growth curve. Spinal curvature is not associated with having sickle cell disease.
Parents who are both carriers of the beta thalassemia gene have one child with the disease and want to have another child. They ask the nurse what the chances are of having another child with this disorder. The appropriate response by the nurse is which of the following?
Show answer and rationale
Correct answer: B. "There is a 25% chance."
If both parents are carriers of the disease gene of beta thalassemia major, there will be a 25% chance of having a child with the condition with each pregnancy. The parents are both carriers of a recessive gene that has a 25% chance of being expressed with each pregnancy.
The registered nurse is delegating the nursing tasks for a pediatric hematology unit. Which of the following tasks should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: A. Administer desmopressin (DDAVP) intranasally to a child with mild hemophilia A
Administering a drug IV, monitoring a platelet count, and assessing a child for indications of bleeding are all tasks that require the skills of a registered nurse. A licensed practical nurse may administer a drug intranasally.
The nurse instructs a group of nurses about the impact of infectious diseases in the childhood population of the world. The nurse should include which of the following statements in the discussion?
Show answer and rationale
Correct answer: A. Despite improved methods of treatment, infectious diseases continue to be a health concern
Infectious diseases continue to account for many serious illnesses, and prevention of infection is a major goal of the World Health Organization.
The nurse is educating a group of health care providers on the great strides toward eradicating infectious diseases in the world that were made during the twentieth century. Which of the following events should the nurse include as having played a major role?
Show answer and rationale
Correct answer: D. Modern sanitation
Modern sanitation and our ability to sanitize surfaces and instruments used in daily activities have had a huge impact on reducing the spread of infectious diseases. Infections such as sexually transmitted diseases have played a part in reducing fertility and birth rates. Steroid-enhanced protein sources have no direct role in the spread of infectious or communicable diseases. The Immunization Act of 1986 is a legal act of Congress protecting individuals harmed by vaccines.
When instructing a client, which of the following statements should the nurse include in explaining communicable diseases?
Show answer and rationale
Correct answer: B. They are transmitted by direct or indirect contact.
Infectious or communicable diseases occur in humans of all ages. Certain infectious illnesses occur in specific age or developmental groups. Most infectious diseases are transmitted by direct or indirect contact, and isolation categories are assigned accordingly. Many infectious diseases have total systemic involvement or sequelae. Many infectious diseases develop slowly after a prolonged incubation period.
The parent of a child asks the nurse what the term "local infection" means. The nurse’s appropriate response is, "A local infection
Show answer and rationale
Correct answer: B. is limited to one area of the body."
A local infection is limited to one locality of�the body but may have some systemic repercussions, such as fever and malaise. An infection occurring in a geographic area is an endemic outbreak. Local infections are not always treated easily; treatment is dependent on the causative agent. Local infections can become severe. Local infections are not usually contagious.
A child is hospitalized with an infection that develops rapidly and resolves in a short period of time. The nurse informs the parents that the diagnosis is which of the following?
Show answer and rationale
Correct answer: B. An acute infection
An acute infection develops rapidly and resolves in a short period of time, but if not treated completely or with the appropriate pharmaceuticals, an acute infection could become chronic.
The nurse instructs the parents of a child that the greatest weapon and priority available to reduce the spread of disease is which of the following?
Show answer and rationale
Correct answer: A. Hand washing
Antibiotics, isolation, and ethyl alcohol have roles in preventing the spread of disease, but the simplest and most effective weapon against the spread of disease is hand washing.
The nurse instructs student nurses that the Centers for Disease Control (CDC) recommends that isolation be based on which of the following?
Show answer and rationale
Correct answer: B. Method of disease transmission
In 2002, the CDC guidelines for isolation of clients with infectious or communicable diseases were revised to align according to methods of transmission. The extent of illness is not a useful indication of communicability. Many infectious diseases are spread because the infected individual feels well enough to be out and about. Appropriate personal protective equipment should be readily available to all health care workers in America, so lack of such equipment is not a justifiable reason to employ isolation. A client’s ability to pay should never define the appropriate treatment course.
The mother of a child whose chickenpox rash first appeared 8 days ago asks the nurse when her child may return to school without being contagious. Which of the following is the nurse’s most appropriate response?
Show answer and rationale
Correct answer: B. "Your child is not contagious and may return to school now."
The chickenpox infection begins 1 to 2 days before the eruption of the rash and the contagious state ends 6 days after the onset of�the lesions, when crusts have formed.
When planning the care of a client diagnosed with asymptomatic herpes simplex virus type 2 (HSV-2), which of the following should the nurse consider?
Show answer and rationale
Correct answer: D. The client is a carrier, and still able to transmit the disease
The herpes simplex virus type 2 (HSV-2) is characterized by periods of latency between outbreaks and recurrence. The virus can be shed, and is contagious when the client is asymptomatic. There are effective treatments available, but no known cure, for HSV-2. Antibiotics are not effective against viruses.
A mother asks the nurse how her child became infected with rotavirus. The most appropriate response by the nurse is, "Rotavirus is primarily spread by
Show answer and rationale
Correct answer: D. the fecal-oral route."
Rotavirus is the most common cause of severe diarrhea in children. It is primarily spread by the fecal-oral route.
The nurse should consider which of the following when planning the care of a child infected with hepatitis B?
Show answer and rationale
Correct answer: B. Treatment is aimed at symptom management
There is no specific treatment for hepatitis B. Treatment focuses on symptom management. Oral acyclovir (Zovirax) is an antiviral used in the treatment of herpes genitalis (HSV-2). Doxycycline (Vibramycin) and azithromycin (Zithromax) are antibiotics used in the treatment of chlamydia. Monitoring the white blood cell is important in the treatment of infectious mononucleosis.
The nurse is caring for a child with varicella (chickenpox). Which of the following assessments are priorities to report and indicate a secondary infection requiring prompt medical attention?
Show answer and rationale
Correct answer: B. Skin pain and purulent discharge
Varicella (chickenpox) is a varicella zoster virus that is highly contagious through direct contact or may be airborne-spread from respiratory secretions. Severe skin pain, burning, or purulent discharge may indicate a secondary infection, and prompt medical attention is required. Clinical manifestations that are anticipated in chickenpox include a generalized pruritic rash and mild fever. A body rash that begins on the upper body and head and progresses to the lower body and Koplik’s spots are clinical manifestations of rubeola (measles). A red facial (slapped cheek) rash and circumoral pallor are characteristically found in erythema infectiosum (Fifth’s disease).
A mother of a child diagnosed with erythema infectiosum (Fifth’s disease) asks the nurse when the child may return to school without being contagious. The nurse should tell the mother that her child may return to school after
Show answer and rationale
Correct answer: B. the appearance of the rash.
Erythema infectiosum (Fifth’s disease) is an infectious disorder spread through contact with respiratory secretions. The child is highly contagious before the onset of the illness. Children may return to school after the appearance of the rash because they are no longer contagious. There is no immunization for Fifth’s disease. A generalized pruritic rash is characteristic of chickenpox; a child with such a rash is highly contagious. Diarrhea is not a clinical manifestation of Fifth’s disease.
The nurse is instructing the adolescent client about birth control and sexually transmitted diseases. Which of the following methods of birth control should the nurse include that is 100% effective in protecting against sexually transmitted disease?
Show answer and rationale
Correct answer: D. Abstinence from sexual behavior
Birth control pills, withdrawal method, and latex condoms and spermicidal foam are not 100% effective in preventing the spread of sexually transmitted diseases. Each method contains some risk of infection. Birth control pills simply protect individuals from pregnancy. The withdrawal method is ineffective in every way. Latex condoms and spermicidal foam are ineffective barriers in the event of tears or breakage of the device or incorrect application. Only abstinence from sexual behavior is 100% effective in protecting against sexually transmitted disease.
Which of the following is a priority nursing intervention when caring for an adolescent client to lessen the client’s risk of infection?
Show answer and rationale
Correct answer: D. Assess for high-risk behaviors, such as unprotected sex, drug use, and gang relationships
Adolescents frequently participate in behaviors that put them at risk for infection, and they falsely believe themselves not to be at risk. Unprotected sex, drug use, and gang relationships are behaviors that put them at risk for infection. Continuity of health care is important with all clients and not just adolescents. All clients require personal privacy, and, although embarrassing, they are encouraged to discuss personal physical concerns. Making the parents a part of a discussion of personal issues with an adolescent will actually make the adolescent uncomfortable and reluctant to discuss pertinent issues.
The nurse is working with a group of parents getting ready to send their children to day care for the first time. The nurse should instruct the parents that immunizations are
Show answer and rationale
Correct answer: D. an improved part of health promotion.
Immunizations are an important part of health promotion and disease prevention. Improvements have been made, but booster shots are still required. Although a small percentage of the population, some clients have adverse reaction to immunizations. Some immunizations are available in oral forms, but not every required immunization can be taken orally.
A child is receiving an immunization before starting preschool. Which of the following assessments is a priority for the nurse to make at this time?
Show answer and rationale
Correct answer: A. The child’s immunization history
The child’s general state of health, preexisting diseases, and any recent exposure to infectious diseases are important considerations in the general assessment of any child. The failure to collect this information may cause a delay in administration of the vaccine. It is a priority to obtain the child’s immunization history. This is most important in deciding which vaccines are required and determining the appropriate schedule for immunization.
Which of the following drugs should the nurse use in the treatment of a child with Giardia?
Show answer and rationale
Correct answer: C. Furazolidone (Furoxone)
Penicillin G is used in the treatment of tetanus. Giardia is a protozoan disorder transmitted by hand-to-mouth transfer of cysts from feces of an infected individual. Furazolidone (Furoxone) is the drug of choice in treatment. Mebendazole (Vermox) is used in the treatment of Enterobius (pinworm). Ceftriaxone (Rocephin) is used in the treatment of gonorrhea.
The nurse assesses which of the following to be a clinical manifestation of human papillomavirus (HPV)?
Show answer and rationale
Correct answer: D. Soft papules in the anogenital area
Soft, fleshy single or multiple papules occur in the anogenital area (genital warts) in human papillomavirus (HPV). Nocturnal anal itching is a manifestation in Enterobius (pinworm). Erythematous and macular rash on the ankles and wrists is found in Rickettsia rickettsii (Rocky Mountain spotted fever). Painful raised vesicles are the initial lesions in herpes genitalis (HSV-2).
Which of the following drugs should the nurse administer to a child with tetanus who is experiencing muscle spasms and seizures?
Show answer and rationale
Correct answer: D. Diazepam (Valium)
Although methocarbamol (Robaxin), cyclobenzaprine (Flexeril), tizanidine (Zanaflex), and diazepam (Valium) are all skeletal muscle relaxants, Valium is the drug of choice in the treatment of tetanus to control muscle spasms and seizures.
The registered nurse is preparing the clinical assignments for an infectious and communicable disease unit. Which of the following assignments should the nurse delegate to a licensed practical nurse?
Show answer and rationale
Correct answer: C. Provide comfort measures for a child with mumps
A licensed practical nurse may provide comfort measures to a child with mumps. Teaching, counseling, and monitoring are all nursing assignments that require the skills of a registered nurse.
Which of the following is the appropriate nursing intervention when a child develops a reactive purified protein derivative (PPD)?
Show answer and rationale
Correct answer: D. Obtain a full health and immunization history
The nurse should investigate whether the child has had contact with an individual who has tuberculosis (TB). The nurse also should assess whether the child has received any treatment for TB, what clinical manifestations the child has, and whether the child received the immunization BCG, which creates a positive skin test response to the PPD injection. A positive reaction to the skin test does not indicate a need for immediate treatment. Retesting the PPD skin test is most reactive within 72 hours, and the response will begin to subside after that. A positive reaction to PPD is not a positive indication that the client is infectious.
During a prenatal visit, the nurse evaluates the fundal height of the uterus to be at the umbilicus. The nurse should estimate the gestation at
Show answer and rationale
Correct answer: D. 20�weeks.
The fundal height rises 1�cm/week until the 36th week of gestation and is at the umbilicus (20�cm) at 20�weeks of gestation.
A client is receiving education about preterm labor during a prenatal visit. Which of the following is a priority for the nurse to instruct the client to report?
Show answer and rationale
Correct answer: B. Feeling that the baby is balling up and relaxing
A feeling that the baby is balling up and relaxing is a classic clinical manifestation of preterm labor. Nausea, vomiting, and back pain that radiates down the buttocks and legs should be reported if they continue, but are not indications of preterm labor. Vaginal spotting after a vaginal exam is a normal finding.
A pregnant client is admitted to the hospital for preterm labor. The nurse’s first intervention is to
Show answer and rationale
Correct answer: C. monitor for contractions and fetal well-being.
The first information the nurse should assess in a case of suspected preterm labor is to determine the labor pattern and if the fetus is evidencing any distress. This information will drive the rest of the plan of care.
After a routine screening ultrasound, a pregnant client in her third trimester asks the nurse to explain where all the fluid comes from that surrounds her baby. The nurse’s response should be based on the understanding that the amniotic fluid is
Show answer and rationale
Correct answer: D. primarily fetal urine maintained by a balance of production and reabsorption.
After the first trimester, the amniotic fluid is almost entirely fetal urine and is continually recycled via fetal swallowing and urinating.
A pregnant client who is 28�weeks pregnant and is taking an exercise class calls the prenatal clinic to ask if there are any maneuvers that should be avoided. Which of the following should the nurse instruct the client to avoid?
Show answer and rationale
Correct answer: C. Lying supine
Lifting the arms over the head, pelvic rocking, and sitting with the knees tucked up against the chest do not need to be avoided because of pregnancy. Lying supine should be avoided because it will cause compression of the vena cava by the gravid uterus and result in supine hypotension, which will impair uterine blood flow and possibly cause the pregnant woman to faint.
Admitting a pregnant client to the hospital from the prenatal clinic for preterm premature rupture of membranes, the nurse includes in the client teaching which of the following treatment expectations?
Show answer and rationale
Correct answer: B. Drugs will include antibiotic coverage
The client is at risk for an intrauterine infection and infection of the membranes called chorioamnionitis once there has been a rupture of membranes. Antibiotic coverage is the standard of care. Ambulation is restricted to prevent further loss of fluid. Blood pressure is not affected by loss of amniotic fluid. Amniotic fluid will need to be regularly monitored, but not continuously.
The nurse working in a triage clinic should return which one of the following clients’ telephone messages first? A woman who is at
Show answer and rationale
Correct answer: A. 37�weeks of gestation with shortness of breath.
Darkening blotches of skin over the cheekbone describes chloasma and is a normal finding called the mask of pregnancy. Breast tenderness from early pregnancy and hormonal changes are common. The swelling of feet at the end of the day is benign, as long as the swelling is resolved by morning. This can also indicate pre-eclampsia, a concern that should be investigated further. However, the first call should be made to the woman who is complaining of dyspnea. A woman who is in her 37th week can have dyspnea from the term gravid uterus pushing up on her diaphragm, but she may also be experiencing a respiratory emergency such as pulmonary embolus.
A pregnant client asks the nurse about gestational diabetes mellitus. The nurse responds based on the understanding that gestational diabetes in pregnancy is
Show answer and rationale
Correct answer: C. an impaired glucose tolerance.
Impaired glucose tolerance in pregnancy is the definition of gestational diabetes mellitus. Beta cell failure is the hallmark of type 1 diabetes mellitus.
A client of Mediterranean descent tells the nurse that her mother told her she was at greater risk for which of the following blood disorders?
Show answer and rationale
Correct answer: A. Thalassemia
Thalassemia is an autosomal recessive genetic condition that causes an inadequate production of normal hemoglobin. It occurs in clients of Mediterranean descent. Sickle-cell disease is genetically linked to clients of African descent. Tay-Sachs disease is linked to Ashkenazi Jews. Phenylketonuria is an inborn error of metabolism.
Which of the following is the appropriate pregnancy classification for a client pregnant for the third time, whose first pregnancy ended in a miscarriage at 9�weeks and second pregnancy was a vaginal delivery at 39�weeks of gestation and the child is 3�years old now?
Show answer and rationale
Correct answer: C. Gravida 3 para 1-0-1-1
This client has conceived three times and has delivered a term infant and has one living child. A 9-week miscarriage is a spontaneous abortion.
The nurse has implemented education about HIV in pregnancy. Which statement illustrates that the pregnant HIV-positive client understood the nurse’s teaching about HIV and pregnancy?
Show answer and rationale
Correct answer: C. "I will need to take a drug throughout my pregnancy."
Drugs (antiretrovirals) should be taken throughout pregnancy and not started at the onset of labor. The newborn will be considered infected with maternal antibodies and will be medicated until 18 months of age, when the infant can seroconvert to negative status. It is unknown if the infant will develop AIDS. Breastfeeding is prohibited to lower the risk of transmission to the newborn.
A pregnant client is African American and had a baby with a birth weight of 10 lb 2 oz with her last pregnancy. Based on this information, the nurse expects that the oral glucose tolerance test should be done
Show answer and rationale
Correct answer: B. at the first prenatal appointment.
A history of macrosomia is a positive finding in the client’s medical history indicating early screening for gestational diabetes mellitus with this pregnancy. Macrosomia is a cause of cephalopelvic disproportion.
During a prenatal visit, a client approaching term asks many questions about labor and delivery. The nurse’s response should be based on the understanding of normal adaptation to pregnancy because
Show answer and rationale
Correct answer: D. a client has fears for safe laboring and delivery as the end of pregnancy approaches.
Expressing fears of a safe delivery for the infant and self is a normal part of adaptation to pregnancy.
After delivering a newborn infant, a client asks about the appearance of the umbilical cord. Based on an understanding of anatomy and physiology, which of the following responses by the nurse would be appropriate?
Show answer and rationale
Correct answer: C. "The vessels in the cord are surrounded by a connective tissue called Wharton’s jelly."
The umbilical cord is usually straight and the vessels are surrounded by a protective connective tissue called Wharton’s jelly.
Based on the understanding of the physiologic adaptations of pregnancy, the nurse understands the client may have complications because of which of the following?
Show answer and rationale
Correct answer: C. Blood volume increases 30-50% during pregnancy
Blood volume increases to perfuse the placenta and can cause complications for clients with cardiac disease or hypertension. Thyroid function increases to meet the demands of pregnancy. Other compensatory mechanisms in the respiratory system negate the need for tachypnea during pregnancy. Production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) is suppressed once their role in fertilization is completed.
A pregnant client is hospitalized for vaginal bleeding from suspected abruptio placentae. The nurse bases the appropriate interventions on which understanding of the pathology?
Show answer and rationale
Correct answer: A. Placental abruption is premature separation of the normally implanted placenta from the uterine wall
Abruptio placentae is a premature separation of the normally implanted placenta from the uterine wall.
What to do with your score
Score the set, then spend longer on the review than you did on the questions. For every item you missed, decide which of three things went wrong: you did not know the fact, you misread what the item was asking, or you knew the fact and still chose second-best. Those need three different fixes — content review, slower reading, and priority-framework practice — and lumping them together is why question banks stop working for people.
Read the rationale on the items you got right as well. Arriving at the correct option for the wrong reason is common, and it does not survive a harder version of the same question.
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