(Test Bank) The Nclex-Rn & Nclex-Pn Test Bank, Answered With Lengthy Rationales 2022.

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NCSBN TEST BANK – for the NCLE X-RN & NCLEX -PN TEST BANK, ANSWERED With Lengthy Rationales 2022. (NCSBN – NCLEX ) Assistive devices are used when a caregiver is required to lift more than 35 lbs/15.9 kg true or false True During any patient transferring task, if any caregiver is required to lift a patient who weighs more than 35 lbs/15.9 kg, then the patient should be considered fully dependent, and assistive devices should be used for transfer If a draining wound test positive for MRSA, the patient is placed on contact precautions True or False True Patients with abscess or draining wounds who tests positive for MRSA are placed on contact precautions Hands can be cleaned with alcohol -based hand rub after caring for a patient with C. diff True or False False Alcohol does not kill C diff spores and soap and water should be used for hand hygiene as recommended by CDC Disaster triage differs from route emergency department triage True or False True Disaster triage categories range from most urgent (first priority), urgent, nonurgent (the walking wounded), and dead/catastrophic/coma. Newborns are fitted with tamperproof security sensors during their stay at the hospital True or False True Wearing a tamper proof safe ty device reduces the risk of abduction. The sensor shows the location of the infant and the security system can activate other devices (such as cameras, door locks, public address systems, sirens, and other alarms) in the event of an attempted abduction Restraints can be ordered prn by health care providers True or False False HCP are required to specify duration and circumstances for which restraints are required and for how they should be used. Nurses and HCPs must frequently monitor patients to reassess for the continued need for restraints. Sensor pads may be used on beds of individuals who are a fall risk True or False True Bed alarms and sensor pads can be used to alert caregivers when a patient is attempting to get up from a bed or chair, especially for a patient that is at risk for a fall. This is an effective alternative to the use of restraintts The 3 elements of radiation protection are time, duration, and shielding True or False True The farther away people are from a radiation source, the less their exposure; as a rule, if you double the distance, you reduce the exposure by a factor of four. The amount of radiation exposure typically increases with the time people spend near the sourc e of radiation You should quickly remove contaminated clothing by pulling it over your head True or False False Contaminated clothing should never be removed quickly, but it should be cut off instead of pulled over your head. place contaminate d clothing inside a plastic bag, seal the bag, and then place inside another plastic bag Standard precautions also include respiratory/cough etiquette True or False True Standard precautions are used to reduce the risk of transmission of bloodborne and other pathogens from both recognized and unrecognized sources. Respiratory hygiene/cough etiquette is now considered part of standard precautions The nurse is making patient room assignments. In order to minimize the risk of a hospital acquired infection, which of these children would be the most appropriate roommate for a 3 - year-old child diagnosed with minimal change disease a. 3 year old with fracture, with a sibling that has Fifth disease b. 2 year old diagnosed with respiratory infection c. 6 year old with sickle cell disease experiencing vaso-occlusive crisis d. 4 year old with bilateral inguinal hernia repair d. 4 year old with bilateral inguinal hernia repair Minimal change disease is a kidney disorder that can lead to nephrotic syndrome. Corticosteroids can cure the disease in most children, but cytotoxic therapy and other drugs may be needed, but this treat ment can reduce the child's ability to fight infection. The charge nurse must select a roommate who does not have an infection, which is the child child who had surgery. The sickle cell crisis may have triggered an infection. The child's sibling who has a viral disease has the potential to develop an infection. The nurse is setting up a patient's dinner tray. When the nurse turns her back to the patient, the patient grabs the nurse's buttocks and states that he is hungry for much more than dinner. Which of the following response by the nurse is indicated? a. ignore the behavior b. call the HCP c. quickly leave the room and ask UAP to assist the patient d. complete an incident reportd. complete an incident report To keep the therapeutic relationship intact, a nurse needs to set limits on appropriate behavior and not ignore bad behavior. Sexual harassment is a form of violence and is never part of the job. The nurse should report the incident to her supervisor and complete an incident report. The nurse has the right to ask not to be assigned to this patient . The paramedics are transporting a poisoning victim to the local hospital. In which of these cases does the nurse anticipate that hyperbaric O2 therapy will be used? a. 6yo found sitting on bathroom floor beside an empty bottle of diazepam b. 21 yo with suspected ethanol intoxication c. 35 yo found unconscious with suspected CO poisoning 2 yo who ate an undetermined amount of crystal drain cleaner c. 35 yo found unconscious with suspected CO poisoning CO poisoning is the leading cause of poisoning in the US. It causes severe hypoxia which is why treatment includes high-dose oxygen. In severe poisoning, hyperbaric O2 therapy may be used. Treatment for: -crystal drain cleaner and diazepam may include gastric lavage and/or activated charcoal -alcohol intoxication may include gastric lavage, IV fluids, and supportive care A neonate is having difficulty maintaining a temperature above 98F and is placed in an infant warming system. Which of the following actions will ensure the safety of the neonate? a. monitor temperature continuously b. avoid touching neonate with cold hands c. warm all medications and liquids before administration d. wrap the neonate snugly in a cotton blanket a. monitor temperature continuously When using the warming device, the neonate's temperature should be continuously monitored using a probe that securely attached to the skin. Monitoring the neonate's temperature is the priority safety concern because the skin burns, permanent brain damage o r even death can result due to improper use or monitoring of equipment. No clothing or swaddling is needed in the IWS; usually babies are dressed only in a diaper (although bubble wrap blankets or plastic wrap blankets can be used to minimize heat loss in high risk newborns). For healthy term newborns, nurses should warm their hands and stethoscopes prior to contact with the baby . A nurse is conducting a community -wide seminar on childhood safety issues. Which of these children is at the highest risk for po isoning a. 20 month old who has just learned to climb the stairs b. 10 yo who occassionally stays at home unattended c. 15 yo who likes to repair bicycles d. 9 month old who stays with a sitter 5 days a weeka. 20 month old who has just learned to climb the stairs Toddlers, aged 1-3 years, are at highest risk for poisoning because they are increasingly mobile, need to explore and engage in autonomous behavior A nurse is performing well -child assessments at a day care center when a staff member interrupts the exam for assistance with another child. The nurse finds a 3 yo child on the floor with bleeding gums and 2 unlabeled open bottles nearby. What should the nurses first action be? a. call poison control and then 911 b. administer syrup of Ipecac to induce vomiting c. ask the staff member about the contents of the bottles d. give the child milk to coat the stomach c. ask the staff member about the contents of the bottles The nurse needs to asses the situation and determine what the child ingested. Once the substance is identified, the poison control center and the emergency medical services should be called. The nurse administer a new medication to the patient. Which of the following actions best demonstrates an awareness of safe and proficient nursing practice? a. verify order prior to administration. ask for patient name b. verify patient's allergies on chart and name on door, ask date of birth c. ask name and allergies, then check wristband and allergy band d. ask name then check wristband c. ask name and allergies, then check wristband and allergy band A dual check is always done for the patient's name. This would involve verbal and visual checks. Because this is a new medication an allergy check is appropriate. The other option have parts that might be correct actions. However, to be the correct answer all the parts of an option need to be correct. The nurse is caring for a patient who is not oriented to time, place, or person and has repeatedly attempted to pull out IV line and a feeding tube. The nurse receives an order from HCP to apply a vest and soft wrist restraints. Which of the following actions by nurse are appropriate? Select all that apply a. release the restraints and provide care Q4 b. call HCP for new order Q48 c. document which alternative interventions were used or attempted d. tie restraints using quick release knots e. explain the rationale for restraints to patient f. conduct a thorough assessment of the patient c. document which alternative interventions were used or a ttempted d. tie restraints using quick release knots e. explain the rationale for restraints to patient f. conduct a thorough assessment of the patient Prior to applying restraints, the nurse must first conduct a thorough assessment of the patient and document the behavior and/or events leading up to the use of the restraints. The nurse should also document which alternatives to restraints were tried and the patient's response to those measures. Even though the patient is confused, nurse must still explain the reason for applying the restraints. A physician's order is renewed daily. Many policies state that the patient in restraints must be assessed hourly , care is given and documented at least every 2 hours. A patient diagnosed with gastroenteritis, caused by a salmonella infection. Which of these actions is the primary nursing intervention designed to limit the transmission of salmonella? a. hand hygiene before and after patient contact b. decontaminate with alcohol -based skin disinfectant c. wear 2 pairs of gloves when changing contaminated linens d. isolate the patient in a single room without a roommate a. hand hygiene before and after patient contact Salmonella is a bacteria and of the causes for gastroenteritis. Gastroenteritis is characterized by acute onset of nausea, vomiting, abdominal cramps, and/or diarrhea. The CDC recommends using standard precautions for this illness, which is the why the primary nursing intervention is thorough handwashing before and after contact with patient using soap a nd water. Skin disinfectants can reduce the number of bacteria on the hands but cannot replace the importance of washing with soap and water. Contact isolation is not needed. Symptomatic patients can be cohorted. Double -gloving can be effective in surgery, but it is probably not needed when changing contaminated linens. The medication benztropine mesylate is ordered, but the nurse incorrectly administers carvedilol. What are the most important actions the nurse should take after making this medication error? Select all that apply a. document administration of carvedilol b. monitor and document the patient's BP c. notify HCP d. notify patient e. notify nurse manager a. document administration of carvedilol b. monitor and document the patient's BP c. notify HCP e. notify nurse manager When the nurse makes a medication error, the patient's safety and well-being are the top priority. The nurse will document giving the beta blocker carvedilol and as well as any effects the medication has on the patient. The HCP must be notified; the nurse will document that the provider was called and that orders were implemented. The nurse manager must be notified. Once the patient is stable, the nurse will complete an incident/variance/quality assurance report within 24 hours of the incident. The initial disclosure of the medication error with the patient should occur as soon as reasonably possible after the event, usually 1-2 days after the event . After an explosion at a factory, one of the employees approaches the nurse and says, "I am a CNA at the local hospital." Which of these tasks would be appropriate for nurse to assign to this worker who is assisting in the care of the injured. a. take temp b. palpitate pulses c. measure BP d. check alertness b. palpitate pulses The heart rate and regularity would indicate if the patient is in shock or has the potential for shock. If pulses cannot be easily palpitated or are irregular, those patients would be seen first and further assessment by the nurse could be done (including measuring BP). Taking the temperature is not a priority at this time Which situation requires hand washing? Select all that apply a. after cleaning a wound b. after contact with inanimate objects in the immediate vicinity of a patient c. prior to eating d. before having direct contact with a patient e. after making a chart entry a. after cleaning a wound b. after contact with inanimate objects in the immediate vicinity of a patient c. prior to eating d. before having direct contact with a patient Handwashing is still the simplest and most effective strategy to prevent the spread of infection. It is necessary to wash one's hands to p rotect oneself prior to eating, after removing gloves following any patient procedure, and even after having contact with intact ski or objects in the patient's room. However, it is not necessary to wash hands after handling every chart (although using an alcohol -based hand rub would be advisable). The nurse is offering safety instructions to a parent with a 4 -month old infant and a 4 yo child. Which statement by the parent indicates a correct understanding of the appropriate precautions to take with the children. a. "I have the 4 yo hold and help feed the 4 month old a bottle with me." b. "I place my infant in the middle of the living room floor on a blanket to play with my 4yo while I make supper in the kitchen." c. My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the 4 yo naps on the sofa." d. "I strap the infant car seat on the front seat to face backwards." a. "I have the 4 yo hold and help feed the 4 month old a bottle with me." The infant seat should be placed on the rear seat. Small children and infants should not be left unsupervised. Infants are to be placed on their backs when they are sleeping or lying in a crib. A 4 yo could assist with the care of an infant, such as feeding with proper direct supervision . A patient is admitted to an impatient crisis unit with the diagnosis of acute mania and has been placed in seclusion. The nurse is assigned to observe the patient at all times. It is now time for the patient's dinner. What action should the nurse take next? a. Serve dinner in the seclusion room maintaining close observation. b. Obtain a contract for safe behavior before accompanying the patient to the dining room c. Accompany the patient to the dining room and maintain observation d. Hold the meal until after the seclusion order is discontinued. a. Serve dinner in the seclusion room maintaining close observation. Seclusion is ordered by the physician and requires continuous observation, unless the order is discontinued or amended. It is incorrect to amend the seclusion or mealtime. Meals can be eaten in the seclusion room with the nurse continuing 1:1 observation. Meals should be offered on time and should not be withheld. Contracts for safe behavior are meaningless in the presence of psychotic behavior - mania The hospital sounded the call for disaster drill on the evening shift. Which of these patients would the nurse put first on the list for discharge in order to make room for new admissions? a. A middle -aged patient with 7 -year history of being ventil ator dependent and who was admitted with bacterial pneumonia 5 days ago. b. An older adult with a history of hypertension, hypercholesterolemia, and lupus, and who was admitted with Steven Johnson syndrome that morning c. A young adult with DM2 for more than 10 years and was admitted with antibiotic induced diarrhea d. An adolescent with a positive HIV test and was admitted with cellulitis of the lower leg 48 hours ago. a. A middle -aged patient with 7-year history of being ven tilator dependent and who was admitted with bacterial pneumonia 5 days ago. The best candidate for discharge is one who has a chronic condition and has an established plan of care. The patient who has been on a ventilator for years is most likely stable and could continue medication therapy at home. The other patients have a risk for instability or are unstable. The school nurse is providing information for teachers at a sch ool where 10 yo child with epilepsy attends. What is the most important action a teacher can take when the child experiences a tonic -clonic seizure in the classroom. a. Clear the immediate are of anything that could harm the child b. provide privacy and reassure the other children c. note the sequence of movements with the time lapse of the event d. Place something soft and flat under the child's head d. Place something soft and flat under the child's head During seizure activity, the priority would be to protect the child from physical injury. The teacher could place something soft and flat, like folded jacket under the child's head to help prevent head trauma. After protecting the head, the prioritized seq uence would be to move furniture away from the child, note movements and time, and then provide privacy, if possible, while reassuring the other students. The charge nurse on the evening shift is asked to determine which patient is a candidate for discharge following an internal disaster in the hospital at 2100. which of these patients would the nurse select as a potential candidate for discharge? a. An older adult female who is actively dying and has a DNR b. A middle -aged adult with a history of DM1 and 1 day post DKA c. A young adult admitted at the beginning of the shift, with an asthma exacerbation d. An adolescent admitted on the day shift to rule out acute pancreatitis, who reports a history of alcohol abuse b. A middle -aged adult with a history of DM1 and 1 day post DKA The patient selected to be discharged should be one whose condition is more stable than the others and where there is less of a risk for complications or instability after discharge. Although the patient with asthma has a chronic condition, she was just admitted and is experiencing acute exacerbation of the condition. The adolescent is experiencing an acute condition, probably brought on by alcohol abuse. Neither of these patients are stable enough for discharge. It is a humane choice to allow the patient who is in the process of dying to stay in the hospital. The patient is admitted to same day surgery for carpal tunnel release of the left wrist. Before the anesthetic is administered, what measures are used to prevent surgical errors? Select all that apply a. The pre-op nurse reviews all relevant documents b. The anesthesiologists asks if anyone has any concerns c. Surgical site is marked by surgeon d. The patient is asked to confirm correct surgical site e. The patient is asked to state name and DOB c. Surgical site is marked by surgeon d. The patient is asked to confirm correct surgical site e. The patient is asked to state name and DOB Marking the correct site helps prevent wrong site operations. The patient must also verbally state name and DOB (and any other identifiers required by facility). Pre -op verification of all required document is done independently by at least 2 providers. Wh en the patient is in the OR suite, a time out is called. This is the final safety check between the surgical, nursing, and anesthesia care teams immediately before the procedure. It is not enough for one person to ask if there are any other questions or co ncerns. The parent of a toddler ask the nurse how long their child will have to sit in a car seat while in an automobile. What is the nurse's best response to the parents? a. "The child can use a regular seat belt when can sit still." b. "Your child must reach a height of 50 inches to sit in a seat belt." c. "The child must be 5 yo to use a regular seat belt." d. "Your child must use a car seat until he weighs at least 40 lbs." d. "Your child must use a car seat until he weighs at least 40 lbs." The guidelines for car seats depend on the child's weight, height, age, and car type. Children should use car seats until they weight 40 lbs according tho the US National Highway Traffic Safety Administration. The nurse observes a nursing assistant using aseptic hand rub and rubbing hands vigorously after leaving the room of a patient with C diff. Which action is most appropriate by the nurse? a. Ensure that visitors wash hands thoroughly before and after visiting. b. Require that the nursing assistant wash hands again using soap and water. c. Tell the patient to ask caregivers if they have all washed their hands d. Praise the nursing assistant for proper use of antiseptic hand rub b. Require that the nursing assistant wash hands again using soap and water. Anyone who is hospitalized should be encouraged to ask caregivers if they washed their hands and to remind visitors to wash their hands. However, it is the nurse's responsibility to supervise the nursing assistant and to correct practice errors as needed. C diff is one of the few pathogens that require soap and water for cleansing the hands. Since antiseptic hand rub is ineffective against the hardy spores produced by the bacterium, the nurse should require the nursing assistant to wash his or her hands with soap and water, especially after providing care to this patient. An 80 yo patient has taken a benzodiazepine for insomnia for many years. The patient now reports experiencing anxiety and some confusion. What is most likely the reason for this? a. Decrease GI motility b. Poor rate of elimination by the kidneys c. Decreased liver function d. Decrease in lean body mass and increase in body fat d. Decrease in lean body mass and increase in body fat Absorption, distribution and elimination of medications are al affected by age -related changes. Since drug distribution is most affected by the change in the body fat and lean body mass, this can lead to increased elimination half -life and prolonged effect of lipid soluble drugs such as benzodiazepines. Dosages that may have a therapeutic effect of a 65yo can produce significant side effects for older patients. An adolescent patient arrives at a clinic three weeks after the birth of her first baby. She tells the nurse she is very worried about not returning to her pre-pregnancy weight. What approach should the nurse take first? a. Review the patient's pattern of weight gain over the past year b. Give her several pamphlets on postpartum nutrition c. Ask the mother to record her diet for the next few weeks d. Encourage her to talk about her self-image d. Encourage her to talk about her self - image Body image is very important to an adolescent. The nurse must acknowledge this and collect more information about the client's self-image before discussing nutritional needs, diet and/or exercise. Adolescents often need more support and information about what to expect after the birth of a child, especially since the postpartum period can be overwhelming for them. Nonjudgmental and developmentally appropriate interactions are needed to car e for the physical and emotional needs of adolescents. The partner of a patient with Alzheimer's disease expresses concern about the burden of caregiving. Which of these actions by the nurse should be a priority? a. Link the caregiver with a support group b. Ask the friends to visit regularly c. Schedule a home visit each week d. Request anti-anxiety prescription a. Link the caregiver with a support group Assisting caregivers to locate and join support groups will be most helpful and effective. Families share feelings and learn about services such as respite care. Health education is also available through local and national Alzheimer's Association chapters. The school nurse is checking students for pediculosis capitis. Which manifestation observed by the nurse confirms the presence of pediculosis capitis? a. Scratching the head more than usual b. Whitish oval specks sticking to the hair shaft c. White flakes on the student's shoulders d. Oval patterns of occipital hair loss b. Whitish oval specks sticking to the hair shaft Diagnosis of pediculosis capitis, or head lice, is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children o ver 2 years -old and meticulous combing with a special comb for the removal of all nits. The nurse is explaining an illness to a 10yo child. What should the nurse keep in mind about the cognitive development of children at this age? a. Children of this age are able to make simple association of ideas b. They are able to think logically in the organization of facts c. Interpretation of events originate from their own perspective d. Conclusions are based on previous experiences b. They are able to think logically in the organization of facts Children in concrete operations stage, according to Piaget, are capable of mature thought when they are allowed to mentally or physically manipulate and organize objects. The RN is making a presentation about Lyme di sease to a group of volunteers who host hiking tours through grassy areas. Which statement made by one of the volunteers indicates that more teaching is needed? a. Lyme disease can spread to my brain if I don't seek treatment b. Lyme disease is caused by a virus because the symptoms are similar to the flu c. I should wear light-colored clothing and long pants when hiking d. I will call the doctor if I see a rash that looks like a bull's eye b. Lyme disease is caused by a virus because the symptoms are similar to the flu Lyme disease is caused by bacteria called Borrelia burgdeorferi. It is transmitted by ticks that are passed it on from infected mice or deer. Because the ticks are so small, it is easier to see them on light-colored clothing; long pants and long -sleeved shirts help protect hikers. Symptoms of lyme disease are similar to influence and there may be a bull's eye rash at the site of the tick bite. Without antibiotics , the disease can spread to the brain, heart, and joints of the body. The nurse is assessing the mental status of a patient admitted with possible dementia. Which of these options would best assess the functioning of the patient's short -term memory? a. Ask the patient to recall 3 words the nurse had previously asked the patient to remember b. Ask the patient to copy an image of 2 simple, intersecting geometric shapes c. Ask the patient to calculate simple arithmetic operations d. Ask the patient to name the last four presidents a. Ask the patient to recall 3 words the nurse had pr eviously asked the patient to remember Short -term memory refers to the temporary storage of information in memory and the management of the information so that it can be used for more complex cognitive tasks, such as learning and reasoning. Tests of cognitive function are used to evaluate cognitive impairment. The Mini -Mental Status Exam, for example, measures orientation to time and place, calculation, language, short -term verbal memory, and immediate recall. To help determine short -term memory functioning, the health care practitioner would ask the client to recall three words that the client had previously been asked to remember. A nurse is providing foot care instructions to a patient with arterial insufficiency. The nurse would identify the need for additional teaching if the patient makes which statement? a. I will trim corns and calluses regularly b. I cannot go barefoot around my house c. I can only wear cotton socks d. I should ask a family member to inspect my fee daily a. I will trim corns and calluses regularly Older adults should not cut their nails, corns, and calluses. They should have them trimmed by their HCP , nurses, or another provider who specializes in foot care. Older adult patients who have diagnosis of diabetes or vascular disease often have decreased circulation and sensation in one or both feet. Their vision may also be impaired. Therefore, they need to be taught to examine their feet daily or have someone else do so. They should wear cotton socks that have not been mended, and they should always wear shoes when out of bed. The nurse is performing the following actions immediately following a delivery of a health, normal newborn. Indicate the correct sequence of actions by dragging and dropping the options below into the correct order. a. Administer Vitamin K b. Assess the infant's airway and breathing c. Perform bulb suctioning if excessive mucus is present d. Assess the infant's heart rate e. Place ID bands on infant and mother b. Assess the infant's airway and breathing c. Perform bulb suctioning if excessive mucus is present d. Assess the infant's heart rate e. Place ID bands on infant and mother a. Administer Vitamin K Assessing the airway and respirations is the first action. Next if indicated, the baby should be suctioned. Then the heart rate is assessed. After these initial assessments, the identification bands are placed on both mother and baby. IM administration of vitamin K is recommended for the newborn but this can be done after the initial assessments and proper identification. Using a vibrating fork, the nurse will perform the Rinne test to assess the patient's hearing. Where will the nurse place the tuning fork to assess for bone conduction of sound? The Rinne test helps distinguish between conductive and sensorineural hearing loss. To assess for bone conduction of sound, the nurse holds the tip of a vibrating tuning fork against the mastoid bone. Normally, air conduction is audible longer than bone conduction, but the reverse is true for someone with conductive hearing loss. The nurse is assessing the heart sounds of a patient admitted to the telemetry unit with a diagnosis of mitral stenosis. Indi cate where the nurse should place the stethoscope to best assess the mitral valve. Auscultation of heart sounds is a key component of the physical assessment. It is important that the nurse is able to identify the area on the chest that corresponds to each of the four valves. The mitral area or apex of the heart is located at the fifth intercostal space, left midclavicular space. A parent asks the nurse about a Guthrie Bacterial Inhibition test that was ordered for her newborn. Which of the following points should the nurse discuss with the patient prior to this test? a. Routine screening of newborn infants is not mandatory in the US b. This test identifies an inherited disease c. This test will be delayed if the baby's weight is less than 5 pounds d. The urine test can be done after 6 weeks of age e. Positive tests require dietary control for prevention of brain damage f. Best results occur after the baby has been breast -feeding or drinking formula for 2 full days b. This test identifies an inherited disease c. This test will be delayed if the baby's weight is less than 5 pounds d. The urine test can be done after 6 weeks of age e. Positive tests require dietary control for prevention of brain damage f. Best results occur after the baby has been breast -feeding or drinking formula for 2 full days Screening for PKU is mandated in all 50 states., though methods of screening vary. The Guthrie Bacterial Inhibition Assay (BIA) is one test used to diagnose phenylketonuria (PKU), a disease characterized by an enzyme deficiency. A blood sample is taken from the baby's heel shortly after birth, with a follow -up test 7 to 10 days later. Test results are more accurate if the baby weighs more than 5 pound and has been regularly drinking milk for more than 24 hours. A urine test is normally done after 6 weeks of age if a baby did not have the blood test. A patient is in the 3rd month of her first pregnancy. During the interview, she tells a nurse that she has several sex partners and is unsure of the identity of her baby's father. Which of these nursing intervent ions is best at this time? a. Refer the patient to family planning clinic b. Discuss the risk for cervical cancer c. Counsel the woman to consent to HIV screening d. Perform tests for STDs c. Counsel the woman to consent to HIV screening The patient's behavior places her at high risk for HIV. While it would be a good idea to draw blood to test for STDs, this can't be one without informed consent of the patient. Since the woman is already at a clinic seeking health care, it would be best to provide information (and possibly begin treatment) now, instead of simply referring her to another health care facility. The best response is for the nurse to provide information and counsel the woman to consent to HIV screening. The nurse is assessing a patient in her 3rd trimester. The patient is informed that the ultrasound suggests the baby is small for gestational age. An earlier ultrasound indicated normal birth. The nurse understands that this change is most likely due to what factor? a. Exposure to teratogens b. STIs c. Maternal hypertension d. Chromosomal abnormalities c. Maternal hypertension Pregnancy -induced hypertension is a common cause of late pregnancy fetal growth restriction. Vasoconstriction reduces placental exchange of oxygen and nutrients. The other 3 conditions are associated with the first trimester time period. The nurse performs a heel stick for a blood glucose check on a 1 hour old, full -term newborn who weighed 9 lbs at birth. The serum glucose reading is 45 mg/dL. What action is needed by the nurse? a. Repeat the test in 2 hours b. Give oral glucose water c. Notify the pediatrician d. Check the pulse oximetry reading a. Repeat the test in 2 hours A serum glucose of 45 mg/dL is considered normal (normal range for the neonate is about 40 - 90). Neonatal hypoglycemia is defined as a blood glucose level of less than 30 in the f irst 24 hours of life and less than 45 in thereafter. Risk for hypoglycemia includes newborns who weigh more than 4 kg or less than 2 kg at birth, are large for gestational age; also gestational age less than 37 weeks and newborns suspected of hypoglycemia in the first hour of life. Due to the weight of the newborn, repeat blood glucose testing is indicated. A patient referred for mammography questions the nurse about the cancer risks from radiation exposure. What is the appropriate response by the nurse? a. You have nothing to worry about, it is less than tanning in the nude b. A chest x-ray gives you more radiation exposure c. The radiation from a mammography is equivalent to one hour of sun exposure d. Exposure to mammography every 2 years is not dangerous c. The radiation from a mammography is equivalent to one hour of sun exposure A patient would have to have several mammograms in a year's time to be at a risk for cancer. The radiation exposure from one mammogram session is thought to be equivalent to being out in natural sunlight for one hour. This answer is concise and gives the patient a point of reference. To say not to worry is judgmental and non therapeutic. In the other 2 options one is not accurate and can cause further concern about radiation exposure and one does not clearly address the patient's question. The nurse is caring for a neonate i mmediately following a vaginal delivery. Which of the following interventions will promote temperature regulation in the neonate? Select all that apply. a. Place the neonate under a radiant warmer b. Bathe the neonate to remove contaminants after delivery c. Wrap the neonate in blankets d. Dry the neonate in warm towels e. Encourage skin to skin contact with the mother a. Place the neonate under a radiant warmer c. Wrap the neonate in blankets d. Dry the neonate in warm towels e. Encourage skin to skin contact with the mother After drying off the wet amniotic fluid, placing the neonate under the radiant warmer or placing the neonate skin to skin against the mother will provide a source of heat for the neonate. Wrapping the neonate in blankets will help to reduce heat loss. The neonate should not be bathed until the temperature is stabilized. While giving care to a 2 yo patient, the nurse should remember that the toddler's tendency to say "no" to almost everything is an indication of what psychosocial skill? a. Frustration with adults b. Rejection of parents c. Assertion of control d. Stubborn behavior c. Assertion of control Negativity is a normal behavior in toddlers. The nurse must be aware that this behavior is an important sign of the child's progress from dependency to autonomy and independence. Nurse is doing preconception counseling with a woman who is planning a pregnancy. Which statement suggests that the patient understands the connection between alcohol consumption and fetal alcohol syndrome? a. Beer is not really hard alcohol, so I guess I can drink some b. I understand that a glass of wine with dinner is healthy c. If I drink, my baby may be harmed before I know I am pregnant d. Drinking with meals reduces the effects of alcohol c. If I drink, my baby may be harmed before I know I am pregnant Alcohol has the greatest teratogenic effect during organogenesis in the first weeks of pregnancy. Therefore, women considering a pregnancy should not drink any alcoholic beverages. A nurse prepares for Denver Screening II of a 3yo child in the clinic when the mother asks the nurse to explain the purpose of the test. What is the nurse's best response about the purpose of the Denver Screening II? a. It measures a child's intelligence b. It helps to determine problems c. It assesses a child's development d. It evaluates psychological responses c. It assesses a child's development The Denver Development Test II is a screening test to assess children from birth through 6 years of age in the personal/social, fine motor adaptive, language and gross motor development. During this test a child experiences the fun of play. This screening test determines the highest level of functioning in these areas at the time of the examination. Fetal movem ent count during the third trimester should be at least 5 movements per day. True or false False In the third trimester, an awake healthy fetus should move at least 3 times per hour. If the baby does not move, the mother should drink a glass of juice and then start a new count. The fourth stage of labor is placental separation and expulsion. True or false False The third stage of labor is placental separation and expulsion and lasts about 5 to 30 minutes. The fourth stage of labor is maternal adaptation, occurring 1 to 2 hours after birth. When the fetus is active, its heart rate should increase by about 15 beats per minute. True or false True When the fetus is active, its heart rate will accelerate by about 15 beats per minute abov e the baseline. Average fetal heart rate is about 130 ppm when near term. Most pregnancy tests measure the level of estrogen in the woman's blood. True or false False Pregnancy tests measure the hormone human chorionic gonadotropin (hcG) in the urine or in the blood. Levels can be first detected about 12 to 14 days after conception and peak in the first 8 to 11 weeks of pregnancy. One if the first signs of pregnancy is Chadwick's sign, which is the softening of the cervix. True or false False There are several findings of pregnancy during the first trimester, increased vascularity in the vagina is called the Chadwick's sign; the increased vascularization and softness of the uterine isthmus is Hegar's sign; and the softening of the cervix is Goodall's sign. The nurse will give Rh immune globulin (RhoGAM) to a Rh negative women after a misca rriage (spontaneous abortion). True or false True RhoGam is administered to Rh negative women after any possible exposure to fetal blood such as after each ectopic pregnancy, miscarriage, abortion or amniocentesis, RhoGAM will be given to help prevent problems associated with incompatible blood types in future pregnancies. Chloasma is the first milk the new mother produces. True or false False Chloasma is a skin discoloration of pregnancy. The first breast milk is called colostrum. Colostrum is low in fat, high in carbohydrates, protein and antibodies and is easy for the newborn to digest. The fetus receives more oxygenated blood when the laboring mother lies on her side. True or false True