Health Promotion and Maintenance

The 34-week-gestation neonate is born weighing 1.7 kg to a mother who is hepatitis B surface antigen (HBsAg) positive; all other infectious disease serologies are negative. Which orders are appropriate for this patient? Select all that apply.

The 1.9 kg neonate is born precipitously via vaginal delivery to a 32-year-old mother who received no prenatal care or infectious disease serology testing before delivery. The mother has a history of intravenous drug use. Which intervention does the nurse perform first?

The patient whose mother chose not to vaccinate him presents to the clinic the day after his 18th birthday to receive all eligible vaccinations. The nurse uses which statement to counsel the patient about the hepatitis B vaccine series?

The 19-year-old patient tells the nurse, “I was reviewing my vaccination records for school and noted I never received the varicella vaccination.” Which response by the nurse is most appropriate?

The 10-year-old female patient’s mother brings her to the clinic for a check-up and immunizations and requests that she receives the human papillomavirus (HPV) vaccination. Which question does the nurse ask first?

The 18-year-old patient calls the clinic two weeks after receiving the 2nd vaccination in the three-dose series for human papillomavirus (HPV). She states, “I didn’t realize it when I got the vaccine, but I was 6 weeks pregnant. Will my baby be okay?” Which response by the nurse is most appropriate?

The nurse is providing discharge education to the patient regarding immunizations following a hematopoietic stem cell transplant. When does the nurse instruct the patient to visit the clinic for the Haemophilus influenzae type b (Hib) vaccine?

The public health nurse encourages which individuals to receive the hepatitis A vaccine? Select all that apply.

The 18-year-old healthy female presents to the clinic requesting to receive the vaccinations her mother refused for her when she was a child. Reviewing the chart, the nurse notes the patient never received the measles, mumps, rubella (MMR) vaccine. Prior to administering the vaccination, which test is most important?

The nurse has provided discharge instructions to the patient with type II diabetes. How does the nurse assess the patient’s understanding of the teaching?

The nurse is providing discharge education to the 48-year-old patient with a third grade reading level about his new prescription for valsartan. Which is the best way for the nurse to assess the patient’s understanding of the teaching?

The nurse has provided teaching to the patient regarding the use of crutches after she broke her ankle. Which is the best way for the nurse to assess the patient’s understanding of the teaching?

Which child from an urban city is most at risk for sequelae associated with lead poisoning?

Which initiative is a primary strategy to prevent lead toxicity?

The nurse is caring for a 16-month-old child. The child’s father expresses concern to the nurse that his son cannot kick a soccer ball. Which response from the nurse is appropriate?

The nurse educates parents on the care of their 3-day-old infant prior to discharge from the hospital. Which instruction does the nurse include in the teaching?

Parents bring their 12-month-old baby who was born prematurely to the pediatrician for a well-baby appointment. How does the nurse judge the adequacy of the baby's weight gain?

The 40-year-old woman is pregnant for the first time. She undergoes prenatal testing and is found to have an elevated serum alpha-fetoprotein and asks the nurse to explain what this could mean for her baby. Which response by the nurse is most appropriate?

The 30-week gestation pregnant woman reports her fetus moved two times in an hour during her assessment of fetal activity. Which response by the nurse is best?

The patient who is 33 weeks pregnant reports fetal activity of 8 kicks/hour. Which action by the nurse is appropriate?

The patient who is 32 weeks pregnant presents to the obstetrician’s office with concern for decreased fetal movement. A biophysical profile (BPP) assessment is ordered to determine if the fetus is compromised and needs to be delivered. The nurse prepares the client for which tests as part of the BPP? Select all that apply.

The nurse is asked to assist in a contraction stress test for a patient who is 38-weeks’ gestation. Which strategies does the nurse use to stimulate contractions? Select all that apply.

The nurse is present at the delivery of a 34-weeks pregnant woman with absent end diastolic flow through the umbilical arteries. The nurse anticipated which appearance of the neonate?

The patient who is 27-weeks pregnant is admitted to the hospital with contractions and decreased fetal movement. A biophysical profile (BPP) is performed and determined to be 4 out of 10 and the amniotic fluid volume is decreased. Which action by the nurse is most appropriate?

The presence of which substance in amniotic fluid is most helpful indicator of fetal lung maturity?

The nurse notes a sinusoidal pattern on the fetal heart rate tracing of a patient who is 32-weeks pregnant. Which information is most important for the nurse to determine?

The nurse is creating an educational class for community members who care for an older relative in the home about brain injury in the older adult. Which factors does the nurse include to impress upon the individuals the high mortality risk associated with brain injuries in the older adult? Select all that apply.

The nurse is teaching a community health promotion class for older adults and includes a discussion on modifying which risks for hypertension?

Pregnancy is confirmed in the patient who states, “How did this happen? We were careful and wore condoms every time we had sex.” Which response by the nurse is most appropriate?

The 18-year-old female patient tells the nurse, “I would like to change my contraceptive method before I go away to college. I’m afraid I will forget to take the pill every day and I have had issues finding the right balance of hormones. Honestly, I don’t have a boyfriend and can’t see myself getting married or having kids until well after college.” The nurse reviews the chart and notes the patient’s medical history is negative for any infections or diseases. The patient’s BMI is 32 and metabolic panel is normal. Which contraceptive method does the nurse recommend to this patient?

The 22-year-old woman has selected the Depo-Provera injection as her preferred method of contraception. Which information, if present in the patient’s chart, prompts the nurse to hold the medication and alert the physician?

The patient had a contraceptive implant placed 14 months ago. The implant must be replaced in how many months? Enter your answer using a whole number.

The patient had a copper intrauterine device placed at aged 21. At what age will the patient be when it must be replaced if the patient desires to continue contraception? Enter your answer using a whole number.

The nurse is counseling the patient following the removal of a copper intrauterine device. Which statement is most important for the nurse to include in teaching?

The nurse is providing preprocedure education to the patient who will have the copper intrauterine device (IUD) removed. Which statement by the patient indicates an understanding of the teaching?

The nurse helps the patient into which position in preparation for the removal of an intrauterine device?

The first-time mom requests information from the nurse about providing foods other than breast milk to her 3-month-old child. Which response by the nurse is most appropriate?

The mother of a 1-month-old child tells the nurse, “I’m concerned because my child does not hold his head up during tummy time.” Which response by the nurse is appropriate?

The nurse is preparing for the well-baby visit for a 4-month-old baby and expects which behaviors from the patient? Select all that apply.

The nurse applies a fetal heart rate monitor to the abdomen of the 34-week-gestation patient in preterm labor. The patient asks the nurse, “This is so uncomfortable. Why do I have to wear this thing?” The nurse bases the response on which understanding of the rationale for fetal heart rate (FHR) monitoring?

During an amnioinfusion, the uterine resting tone is found to be three times as high as normal. Which action by the nurse is most appropriate?

The mother brings her 18-month-old child to the clinic with concerns for developmental delay. She states, “She says ‘Mama’ and ‘Dada’, and ten or so other words. I keep working with her but I’m concerned she is falling behind.” Which response by the nurse is most appropriate?

The female patient tells the nurse, “I think the man I had unprotected sex with last night might have herpes. I’m so afraid I’m going to get it, too.” Which response by the nurse is most appropriate?

Which mother is at highest risk for passing herpes simplex virus (HSV) to her fetus/neonate?

The full-term neonate (3.2 kg) born precipitously to a mother of unknown infectious disease status has had a positive rapid plasma reagin (RPR) test. The nurse plans care to perform which intervention first?

Viewing the patient’s chart, the nurse notes the patient has 20/100 vision. How does the nurse interpret these results?

The nurse is supervising a nursing student performing a comprehensive shift assessment on a patient hospitalized with severe abdominal pain from an unknown cause. Which action, if performed by the nursing student, prompts the nurse to intervene and provide additional teaching?

At the 2-month checkup, the baby’s mother tells the nurse that the 4.1 kg baby eats 3 ounces of expressed breast milk every 3 hours. How many kilocalories/kg/day is the baby receiving? Input your answer using a whole number.

The very low birth weight infant was born at 0.9 kg and now weighs 1.3 kg. The neonate is on full feeds receiving 24 kcal/oz formula with a daily kcal goal of 120 kcal/kg/day. The patient eats every 3 hours around the clock. How many milliliters does the nurse administer with each feeding? Enter your answer using a whole number.

The offspring of which couple is at highest risk for hemolytic anemia of the newborn?