Health Promotion and Maintenance

The full-term neonate is born via normal spontaneous vaginal delivery (NSVD). The neonate cries at the perineum and maintained flexion against gravity but is noted to be bluish gray. Which intervention is appropriate?

The neonate of 36 weeks estimated gestational age is born via emergency cesarean section, appears limp, blue, and apneic, and is brought to the warming table. He is warmed, dried, and stimulated, and a pulse oximeter is placed on his right wrist. At 30 seconds of life, his heart rate is 66 bpm and his oxygen saturation is 54%. Positive pressure ventilation is initiated via CPAP bag and mask. At one minute of life, the heart rate is 118 bpm, the extremities are still blue but the trunk is pink, and he begins to move and cry with stimulation. The nurse documents which number for the Apgar score? Enter your answer using a whole number.

Which patient is at the highest risk for ovarian cancer?

A newborn was delivered one minute ago. He is not breathing, has a heart rate of 128 bpm, has a moderate amount of lanugo, has some muscle tone without active movement, does not grimace with stimuli, and has a pink body with blue extremities. Which APGAR score is correct?

A cesarean section is the only safe method of delivery for the fetus when the pregnant woman has which condition? 

A patient presents to the ER after having impaled his hand with a nail from a pneumatic nail gun at work. His friend removed the nail at the scene. Which statement indicates the patient understands the teaching provided by the nurse?

The nurse is counseling the parents of a 7-year-old child who are concerned because of a strong family history of type 2 diabetes mellitus. The nurse instructs the parents that the initial screening for type 2 diabetes mellitus will occur at which time? 

The nurse instructs parents on which type of diet to decrease the risk for lead poisoning in their children? 

The patient who will be travelling out of the country soon is concerned about traveler's diarrhea. How does the nurse counsel the patient? 

The nurse uses which technique to counsel a patient with chronic obstructive pulmonary disorder (COPD) about quitting smoking? 

The nurse is caring for a 71-year-old who was recently diagnosed with age-related macular degeneration (AMD) in the left eye. The nurse encourages the patient to increase dietary intake of which substances? 

The 9-year-old patient presents to the clinic for a routine well-child visit. Which health screening does the nurse perform?

The nurse is evaluating a 9-month-old male infant who presents for a routine checkup. In obtaining the patient’s history from his mother, the nurse discovers they live in a home built in 1975. The nurse instructs the mother on which health screening schedule?

The 17-year-old pregnant female patient presents for her first prenatal visit. The nurse plans care based on which understanding of recommended screening?

The 28-year-old female patient presents to the clinic after missing her usual monthly menstrual cycle. A urine hCG level confirms that she is pregnant; further questioning estimates a gestational age of 11 weeks. The patient asks about the possibility of getting an abortion in the next few weeks. Which response by the nurse is appropriate? 

The 29-year-old female patient who presents at six weeks postpartum for a routine checkup requests to start taking oral contraceptives again. The patient reports successful breastfeeding and a desire to continue for the next year. Which oral contraceptive is recommended for this patient?

The nurse is providing disease management education to the parents of a 10-year-old patient newly diagnosed with type 1 diabetes mellitus. Which instruction is appropriate to give the family? 

Which developmental milestone is expected of the six-month-old infant who presents for a routine check-up?

At a routine check-up, the nurse expects the healthy 4-month-old to have met which milestone?

At a well-child visit, the mother of a 2-year-old child states, "My child is not keeping up with the other kids." Further evaluation reveals the patient can stack 6 cubes, walk backwards, and copy a line. The child exhibits separation anxiety and has a vocabulary of 10 words but cannot use symbols or use pronouns. Which assessment does the nurse make about the child's development?

The nurse instructs the mother at her child's 9-month well-child visit that patient will be screened for developmental delays and disabilities at which visits?

The nurse informs the parent of an 18-month-old patient at the well-child visit that screening for an autism spectrum disorder at which time(s)?

The nurse is assigned to a 32-year-old G1P0 female at 30 weeks estimated gestational age who presents with pre-eclampsia. On physical assessment, the patient’s blood pressure is 180/125 mm Hg. The patient is prescribed magnesium sulfate by the provider. Which of the following is the most indicative that magnesium sulfate has been effective?

The nurse receives report on a 24-year-old G1P0 female at 32 weeks estimated gestational age who presents with pre-eclampsia with severe features. The nurse expects the patient to exhibit which symptom? 

The 23-year-old G1P0 patient who is 14 weeks pregnant presents to the emergency department with weakness and lethargy due to intractable nausea and vomiting. The patient has lost approximately 7% of pre-pregnancy weight. The nurse is aware the patient's symptoms are due to excess production of which hormone(s)? Select all that apply.

Which statement by the patient with type 2 diabetes mellitus who has received education about foot care indicates a need for further teaching?

The nurse knows which immunoglobulins are passed to the neonate through breastfeeding? Select all that apply.

A 23-year-old pregnant woman presents to the clinic stating, “I am a teacher and have heard there is a measles outbreak in my community. I want to get the measles vaccine to protect my baby and myself. Which response by the nurse is most appropriate?

Which neonate must be most closely monitored for signs of Hirschsprung disease?

The nurse is creating a tool to automatically screen for patients who are at an increased risk for aspiration pneumonia. Which patient conditions or medical histories does the nurse include in the screening tool? Select all that apply.

The nurse is teaching the nursing student the care of a patient with a tracheostomy. Which action by the nursing student when preparing to change the tracheostomy tube would prompt the nurse to intervene immediately?

The nurse is creating a tool to screen patients for depression and includes questions about which symptoms in the tool? Select all that apply.

Which information does the nurse provide to the woman who is 8 weeks pregnant about a transvaginal ultrasound?

The 58-year-old patient asks the nurse if he is at risk of heart disease. Which response by the nurse is appropriate?

A missed menstrual period is which type of sign of pregnancy?

The nurse is performing an initial assessment on a 26-year-old patient. The nurse auscultates a high-pitched sound late in systole, like a click. This sound most likely indicates which condition?

The child is brought to the clinic by the parent who reports the child has a lazy eye. The nurse assesses the patient for which condition?

Which statement describes the role of luteinizing hormone in the female body?

The nurse is in the delivery room of a full-term neonate who requires additional stimulation to begin spontaneous respirations. The nurse removes wet blankets from below the baby to decrease cold stress due to which form(s) of heat loss? Select all that apply. 

The nurse is preparing for the delivery of a 35-week gestation neonate being born via cesarean section for maternal preeclampsia with severe features. The nurse sets the fraction of inspired oxygen (FiO2) for the flow-inflating bag to which percentage?

Which normal characteristic of the preterm infant places them at a higher risk for evaporative heat loss via the respiratory tract?

The 7-day-old neonate born at 32-weeks’ gestation has an axillary temperature of 38.9°C. The nurse notes the infant is lethargic, with pale extremities and flash central capillary refill. Which nursing action is appropriate?

The 23-week gestation neonate is being cared for in a double-walled, heated isolette with ambient humidity set to 85%. The patient is at risk for sepsis due to which organism related to the care environment?

The nurse is preparing for an infant’s two-month well-baby check-up. Which immunizations does the nurse prepare? Select all that apply.

The nurse prepares a diphtheria, tetanus, and pertussis (DTaP) vaccination for a 6-year-old patient. The patient’s mother states, “Wait! He’s already gotten that vaccine, several times when he was younger. I have it written down in his records.” Which response by the nurse is appropriate?

The nurse is preparing a Haemophilus influenzae type b (Hib) immunization for the 2-month-old patient. The baby’s mother states, “I recently read the influenza vaccine isn’t given until at least a year. Are you sure he should be getting this now?” Which response by the nurse is most appropriate?

The nurse reviewing the vaccination record of a 12-month-old infant expects the infant to have completed which vaccine series?

The nurse is preparing for the well-baby visit of the 6-month-old who is up-to-date on vaccines. Which vaccinations does the nurse prepare for the visit? Select all that apply.

The 13-year-old female patient presents to the clinic in January to begin the vaccine series for human papillomavirus. The nurse instructs the patient’s mother to schedule an appointment for the next vaccine in the series during which month at the earliest?

The baby born at 32 weeks’ gestation to a mother who is hepatitis B surface antigen negative (HBsAg-negative) is taken to the Neonatal Intensive Care Unit (NICU) for care. The neonate, who weighs 1.8 kg, requires continuous positive airway pressure of 7 cm H20, intravenous fluids containing dextrose, and intravenous caffeine. After getting consent from the mother, when is the most appropriate time to administer the hepatitis B vaccine to the baby?