Maternal & Newborn Health Pharmacology

Question 1

Your client is receiving a nonsteroidal anti-inflammatory medication (NSAID) in addition to a narcotic analgesic. The client asks why they aregiving an NSAID because the narcotic analgesic is much better than the NSAID. How would you respond to this client’s question?

A. I don’t know why I suggest that you ask your doctor this question when you see her the next time.

B. You are getting the NSAID because we are trying to wean you off the narcotic analgesic for moderate to severe pain.

C. You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective.

D. You are getting the NSAID because this NSAID is a placebo, and it is proven to be effective for severe pain.

Answer 1

Correct Answer is C.When your client asks you why they are receiving a nonsteroidal anti-inflammatory medication (NSAID) in addition to a narcotic analgesic because the narcotic analgesic is much better than the NSAID, you would respond by saying, “.You are getting the NSAID, so the effects of the narcotic analgesic to combat your pain are more effective”. An NSAID is an adjuvant medication used in combination with narcotic analgesics to treat moderate to severe pain.

Choice A is incorrect. This response is not appropriate because the nurse should know or be able to look up why the NSAID is being given, and they should be able to address this client’s question without referring the client to their doctor. The NSAID is being provided for another reason.

Choice B and D are incorrect. Narcotic analgesic with or without an NSAID is an appropriate intervention for moderate to severe pain. NSAID is added to combat pain more effectively. It is not a placebo.

Question 2

You are evaluating a Nursing Care Plan for a 6-month-old infant with severe postoperative pain. Which of the following is the best-expected client outcome when the client’s pain is managed effectively?

A. The nurse will assess pre and post analgesic client responses.

B. The infant will not demonstrate any behavioral indications of pain.

C. The nurse will evaluate pre and post analgesic client responses.

D. The infant will not demonstrate any physiological indications of pain.

Answer 2

Explanation

Correct Answer is B. Of all the choices in the question above, the best-expected client outcome when the client’s pain is managed effectively is that “The infant will not demonstrate any behavioral indications of pain.” This expected outcome is client-oriented, specific, and measurable.

Because behavioral indicators of pain are more accurate and reliable than physiological indicators of pain, “The infant will not demonstrate any physiological indications of pain” (Choice D) is not the best client outcome to be listed in the care plan.

Firstly, it is important to understand a Nursing Care Plan and its components to answer this question appropriately. A Nursing Care plan provides direction on the type of nursing care the client may need. Six components of a Student Nursing care plan include Assessment, Diagnosis, Outcomes/Planning, Interventions, Rationale, and Evaluation.

Assessment includes both subjective and objective assessment of the client. Diagnostic component of care plan determines the most likely reason for the client’s problems based on the history, assessment, and lab tests.

Outcomes/Planning column of the care plan is client-oriented – a list of measurable goals for the client is set for example, managing pain with enough medication.

Interventions refer to a set of actions that a nurse can undertake to achieve the outcomes.Interventions are nurse-oriented and are aimed at addressing the diagnoses to achieve the desired outcomes. While addressing the diagnoses and planning a specific intervention, prioritizing is crucial. Life-threatening problems should be given high priority and diagnoses are grouped as having a high, medium, or low priority. Maslow’s hierarchy of needs is often used when setting priorities.

The rationalecolumn is to provide scientific explanation to support the reasons why certain nursing interventions were chosen in the care plan.

Finally, Evaluation refers to evaluating the client’s progress towards achieving the desired outcomes. If the evaluation indicates the client’s progress is not as expected, the Nursing Care plan should be adjusted or rewritten to define a better strategy to achieve desired outcomes.

In this question, the nursing care plan is focused on addressing the infant’s pain. The desired client outcome here is that the “infant will not demonstrate behavioral indicators of pain”. Nursing interventions (Choices A and D) are delivered to evaluate if such an outcome is achieved.

Several parameters can be used in clients’ pain assessment, includes behavioral indicators, physiological indicators, and self-report measures.

Physiological indicators of pain (Choice D) refer to variations in heart rate, blood pressure, oxygen saturation, and breathing patterns. Pain leads to an increase in heart rate and blood pressure, a decrease in oxygen saturation, and more rapid or shallow breathing. However, a big limitation of physiological indicators is that these variations may be due to the underlying illness itself rather than the pain. This makes them less specific for pain. Therefore, this should not be considered the best-expected client outcome to effective pain management

While Self-report measures (verbal/ non-verbal) are considered as the ‘gold standard’ in the pain measurement, these cannot be used in infants because to generate such verbal/non-verbal response, the client should have proper cognitive and language development. Therefore, behavioral measures are used as a proxy for objective pain measurement in infants. These include crying, facial expressions, and body postures, or a combination of these indicators. Facial expressions are the most used behavioral measure in children.

The Neonatal Infant Pain Scale (NIPS)shown below incorporates these behaviors to assess infant pain or distress.

Choices A and C are incorrect. “The nurse will assess pre and post analgesic client responses” (Choice A) and “The nurse will evaluate pre and post analgesic client responses” (Choice C) are appropriate nursing interventions, but they are NOT expected client outcomes. These statements are nurse oriented and not client-oriented.

Choice D is incorrect. “The infant will not demonstrate any physiological indications of pain” is not a very reliable indicationof pain outcomeso this is not thebest-expectedclient outcome when the client’s pain is managed effectively.

Question 3

Your client is experiencing severe, acute anxiety prior to a scheduled endoscopy procedure. Which of the following medications is most likely to be ordered by the physician?

A. Oxycodone

B. Midazolam

C. Clonazepam

D. Haloperidol

Answer 3

Explanation

The correct answer is B. Midazolam (Versed) is a benzodiazepine used for acute anxiety attacks. Midazolam is preferred in this setting because of “Rapid Onset” (2 to 5 minutes after IV administration) and “Short Duration” of action (3 to 8 hours). It can be administered intravenously or orally. Given these benefits, Midazolam would be the most useful for the patient experiencing an acute anxiety attack before or during endoscopic procedures, or before surgery. Additional benefits of Midazolam during procedures are sedation and amnesia. Midazolam as continuous IV infusion is also used in sedating mechanically ventilated patients in critical care settings. The nurse should keep Flumazenil as an antidote ready in case severe respiratory depression occurs with benzodiazepines.

Choice A is incorrect. Oxycodone is an opioid pain medication. This is prescribed for severe pain. It is not indicated for the patient experiencing an acute anxiety attack.

Choice C is incorrect. Clonazepam is a long-acting benzodiazepine often used in anxiety attacks after a traumatic event, panic disorders, or generalized anxiety disorder. Your client has pre-procedural anxiety and, therefore, does not need a long-acting anxiolytic. Your client needs an anxiolytic with a rapid onset of action and short duration. Midazolam fits that criteria among the above list.

Choice D is incorrect. Haloperidol is an antipsychotic and is often used in mental health settings to address acute and severe agitation/ aggression associated with psychiatric disorders (Schizophrenia, Substance intoxication). It would not be useful for a patient experiencing pre-procedural acute anxiety.

Question 4

The nurse is providing a client with discharge instructions on his newly initiated Digoxin. Which of the following statements by the client indicates he correctly understood the instructions? Select all that apply.

A. “If I note color vision changes, I will call my eye doctor right away.”

B. “I will check my pulse before each dose and if pulse less than 60 bpm, will hold Digoxin and call my doctor.”

C. “I will increase my calcium intake significantly.”

D. “I will make sure I get enough potassium in my daily diet.”

E. “The water pills that I am on may increase the risk of side effects with Digoxin.”

F. “I should avoid medications that have licorice extract.”

Answer 4

Explanation

Correct answers are B, D, E, and F.

A nurse should understand the mechanism of action of Digoxin to understand its uses, side effects, monitoring responsibilities, and patient education elements. Digoxin is a cardiac-glycoside that acts via the Sodium-Potassium pump in the myocardium. It has inotropic (influences contractility), chronotropic (influences heart rate), and dromotropic (influences conduction speed) effects.

Digoxin is a positive inotrope (increases the power of heart contraction) and a negative chronotrope (decreases heart rate by its effect on Sinus Node) and negative dromotrope (reduces the speed of conduction by acting at atrioventricular node level).

Because of these cardiac effects of Digoxin, it is often used in patients with congestive heart failure and arrhythmias like atrial fibrillation.

However, Digoxin has a narrow therapeutic index, which means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Therapeutic serum digoxin levels range from 0.5 to 2 ng/mL. A level higher than two ng/mL is considered toxic.

The nurse needs to understand Digoxin’s side effects and offer proper education to the clients. Some early side effects of Digoxin include visual aberrations (yellowish-green color changes or halos) and gastrointestinal side effects like Nausea, Vomiting, and Lack of Appetite. The first cardiac side effects include Bradycardia (reduced heart rate), but cardiac arrhythmias can follow later.

It is essential to monitor for these early side effects, so the next dose of Digoxin can be held, and the physician can be notified. For inpatients, the nurse should always check the apical heart rate for one full minute before giving Digoxin, and if the heart rate < 60 (adults), the nurse should hold the medication and notify the physician. The heart rate threshold for holding Digoxin in a child is less than 70 beats per minute, and in an infant, it is less than 90-110 beats per minute.

For patients being discharged home, education should be given to monitoring their pulse before every dose of Digoxin and if pulse < 60, to hold the medication and call their doctor (Choice B). The patient should also be educated that vision changes like yellow-green color distortions may be a sign of early toxicity, and the patient should call the prescribing physician as soon as possible so the cause can be determined. Digoxin can be held early ( Should call the prescribing physician rather than the eye doctor, Choice A reflects an incorrect statement by the patient).

Some patients are prone to digoxin toxicity more than others:

Certain electrolyte imbalances such as Hypokalemia (< 3.5 mEq/L); Hypercalcemia (>10.2 mg/mL) and Hypomagnesemia (<1.5 mg/dL) can increase the toxicity.
So, patients who are on diuretics concomitantly for heart failure are prone to more side effects because diuretics tend to cause hypokalemia(Choice E). Such patients need to be educated regarding consuming adequate potassium-rich diets(Choice D).
Any action that precipitates hypercalcemia should be avoided because high calcium increases toxicity (there is no need to increase calcium intake significantly, Choice C reflects an incorrect statement by the patient).
Elderly patients are at more risk for toxicity because they have an age-dependent decrease in liver and kidney functions. Digoxin is metabolized via liver and kidney, so lower kidney/ liver function predisposes to toxicity.
Patients taking calcium channel blockers (CCBs) are also at risk for digoxin toxicity.

The nurse should also be aware of specific over the counter medications that may precipitate digoxin toxicity and educate patients accordingly. These include a. Ephedra that increases cardiac stimulation b. Licorice extract (Choice F) acts as hormone aldosterone - causing sodium and water retention and growing potassium loss. Hypokalemia, in turn, precipitates digoxin toxicity.

This video below will provide a quick summary of all you need to know about Digoxin for NCLEX:

https://player.vimeo.com/video/409317953

Question 5

Which of the following maternal deficiencies may result in neural tube defects in a fetus?

A. Folic acid

B. Vitamin B12

C. Vitamin E

D. Iron

Answer 5

Explanation

The correct answer is A.Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the machine to close.
B, C, and D are incorrect. Neither of these answer options is associated with neural tube defects.

Neural tube defects are one of the most common congenital disabilities, occurring in approximately one in 1,000 live births in the United States. A neural tube defect is an opening in the spinal cord or brain that occurs very early in human development. The first spinal cord of the embryo begins as a flat region, which rolls into a tube (the neural tube) 28 days after the baby is conceived. When the neural tube does not close completely, a neural tube defect develops. Neural tube defects develop before most women know they are even pregnant. Neural tube defects are congenital disabilities of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly.

Neural tube defects are considered a complex disorder because they are caused by a combination of multiple genes and multiple environmental factors. Known environmental factors include folic acid, maternal insulin-dependent diabetes, and maternal use of certain anticonvulsant (antiseizure) medications. While only a few environmental factors have been characterized, many different studies provide evidence that NTDs have a genetic component in their development. Studies of twins with NTDs have shown both identical twins have NTDs more than both fraternal twins. Studies of families show that the chance of having a second family member born with an NTD after one child is born with an NTD increase. For example, the general population’s chance of having an NTD is approximately 0.1% (1 in 1000). However, once the couple has one child with an NTD, their chance of having a second child with an NTD is increased to approximately 2-5%. Further studies have shown evidence for a genetic pattern of inheritance for NTDs.

NTDs are a feature (or symptom) of known genetic syndromes, such as trisomy 13, trisomy 18, specific chromosome rearrangements, and Meckel-Gruber syndrome.

Question 6

Which of the following obstetrical procedures can be used to assist the head of the fetus during vaginal delivery? Select all that apply.

A. Amniotomy

B. Forceps assisted delivery

C. External version

D. Vacuum assisted delivery

Answer 6

Explanation

Choices B and D are correct.
Forceps are tools used to help pull on the head of the baby to assist with the delivery. Vacuum-assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. This helps to deliver the head of the infant.

Choice A is incorrect. An amniotomy is the use of a hook or finger to break the amniotic sac. This helps to induce labor but does not assist in the delivery of the head of the fetus.

Choice C is incorrect. The external version is a technique used when the baby is not in an appropriate position for vaginal delivery. The external cephalic version is used to turn a fetus from a breech position or side-lying (transverse) position into a more favorable head-down (vertex) position to help prepare the baby for a vaginal delivery. The external version is typically done before the labor begins, often around 37 weeks. Occasionally, it is done during the labor but before the membranes have ruptured. If the amniotic sac has ruptured or if there is not enough amniotic fluid around the fetus (oligohydramnios), version must not be done as it may end up injuring the fetus. Version does not directly assist in the delivery of the head of the fetus.

Question 7

Which of the following medications does the Obstetrics nurse expect to be ordered for the patient who is experiencing hypotonic labor?

A. Oxytocin

B. Fentanyl

C. Magnesium sulfate

D. Betamethasone

Answer 7

Explanation

Answer: A

A is correct. Because this patient is in hypotonic labor, meaning she is not having contractions that are strong and coordinated enough for her work to progress, she needs intervention. Oxytocin, or Pitocin, is the medication that will strengthen contractions by stimulating the muscles of the uterus. The nurse expects this medication to be ordered for her patient in hypotonic labor.

B is incorrect. Fentanyl is an opioid used for severe pain. This medication may be used in an epidural for a laboring patient, but it would not be indicated for hypotonic labor.

C is incorrect. Magnesium sulfate is a medication used in preterm labor to help stop contractions. It would be contraindicated in the patient experiencing hypotonic labor.

D is incorrect. Betamethasone is a steroid administered to mothers in preterm labor to help the development of the fetus’s lungs in anticipation of preterm delivery. It would not be indicated for hypotonic work.

Question 8

The nurse is preparing ephedrine nasal spray for a client in the medical ward. The nurse understands that ephedrine is contraindicated in which of the following patients?

A. A client with pheochromocytoma

B. A client with bronchial asthma

C. A client with allergic rhinitis

D. A client with hypotension due to sepsis

Answer 8

Explanation

Choice A is correct. A Pheochromocytoma is a small vascular tumor of the adrenal medulla, causing irregular secretion of epinephrine and norepinephrine. Clinical manifestations of pheochromocytoma include paroxysmal hypertension, episodic headache, sweating, and palpitations. Ephedrine is an adrenergic agonist and is often, used as a nasal decongestant. It is also used to prevent low blood pressure during spinal anesthesia.

In pheochromocytoma, there is a systemic overload of catecholamines. Ephedrine is contraindicated in clients with pheochromocytoma because it may lead to further exacerbation of adrenergic activity which could be fatal.

Choice B is incorrect. Ephedrine is indicated in bronchial asthma as it stimulates the dilation of the bronchial muscles by stimulating the beta receptors found in the bronchus.

Choice C is incorrect. Ephedrine is used in allergic rhinitis because it may serve as a nasal decongestant due to its vasoconstrictive effects.

Choice D is incorrect. Adrenergic agonists such as ephedrine are used in hypotension due to its sympathomimetic effects on the body leading to increased blood pressure. Ephedrine is often used to prevent low blood pressure during spinal anesthesia.

Question 9

The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply.

A. Urinary incontinence.

B. Pupil constriction.

C. Diarrhea.

D. Altered level of consciousness (LOC).

E. Constipation.

Answer 9

Correct Answers: B, D, E

Explanation

Hydromorphone is a potent opioid indicated for pain. Side effects include constipation, Altered level of consciousness, and Pupil constriction and urinary retention.

Diarrhea and urinary incontinence are not expected while a client is receiving hydromorphone.

Question 10

What behavior would the nurse expect to see in a couple that is over the age of 35 and expecting a baby?

A. Increased financial concern related to costs associated with the birth

B. Increased confidence related to previous childbirth experiences

C. Increased anxiety of physical risk related to maternal age

D. Moderate anxiety related to uncertainty about the fetal well being

Answer 10

Explanation

Advanced maternal age for childbearing has been traditionally set at 35 years old, although the average age for a first pregnancy in the United States has been increasing in recent years. Some of the reasons women delay pregnancy are that they want to be in a stable relationship, they have fertility problems, or they want to be established in their careers. An advanced maternal age for childbearing is seen by healthcare professionals to be correlated with poorer outcomes in pregnancy. This may be because of a higher incidence of chronic medical conditions among

The correct answer is D. In addition to nursing diagnoses applicable to all pregnant women, the expectant couple over the age of 35 may have additional concerns about the well-being of their baby as it relates to Down syndrome or other genetic disorders.
A is incorrect. Most couples over the age of 35 are more financially secure and have fewer concerns related to the cost of birth.
B is incorrect. Couples over the age of 35 may have experienced infertility problems, births many years before, or have had problem births.
C is incorrect. Maternal age may affect how well a woman can physically cope with pregnancy and childbirth.

Question 11

The nurse is administering eye drops to a client diagnosed with conjunctivitis. Place the following steps in the correct sequence for the nurse to perform appropriate eye drop administration:

Pull down the lower eyelid
Administer the medication in the center of the lower eyelid
Tilt the patients head back
Ask the patient to close their eyes

Answer 11

Explanation

First: tilt the client’s head back.

Second: pull down the lower eyelid, thus creating a pocket in which to administer the medication.

Third: administer the medication in the center of the lower eyelid where the pocket was created by pulling down the lower eyelid.

Fourth: ask the client to close their eyes (without squeezing) for 1-3 minutes to allow the eye drops to fully absorb.

Question 12

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective?

A. “At around the time I would normally have my period, I should abstain from intercourse.”

B. “I should no longer have sex during the last trimester of pregnancy.”

C. “My sexual desire will remain the same for the entire pregnancy.”

D. “The best time to enjoy sex is in the second trimester.”

Answer 12

Explanation

Correct Answer is D. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities.

Choices A and B are incorrect. As long as risk factors such as preterm labor or incompetent cervix are not present, intercourse should not harm the pregnancy. Sexual intercourse should not be a cause of concern even in the third trimester unless risk factors such as preterm labor or placenta previa are present.

Choice C is incorrect. Many women experience changes in sexual desire at different stages in pregnancy, depending on their general sense of well being and the presence of certain discomforts brought about by the pregnancy. It is not the same throughout pregnancy.

Question 13

The mother of a 2-month old infant tells the nurse that her mother-in-law said to her that picking her baby up immediately when she cries, “spoils her baby”. What would be the nurse’s best response?

A. “You can let your baby wait a while before picking her up.”

B. “Babies need to be cuddled and comforted; this does not spoil your child.”

C. “You need to feed her right away because crying means that they are hungry.”

D. “You can just let your baby cry; she will stop once she gets tired.”

Answer 13

Explanation

Choice B is correct. Infants need to have their security needs met by being held and cuddled.

A is incorrect. Not picking up the baby after she has cried does not meet the baby’s need for security.

C is incorrect. Infants cry for many reasons. Assuming that the child is hungry and feeding them each time they cry may cause overfeeding problems such as obesity.

D is incorrect. Letting the baby cry to sleep does not meet the baby’s security needs.

Question 14

A client diagnosed with acute gastroenteritis is prescribed 30mEq of oral potassium chloride twice daily for hypokalemia. The nurse should implement which nursing intervention in administering the medication:

A. Sprinkle contents of capsule on apple sauce to increase palatability

B. Crush the extended release tablet to improve palatability

C. Give potassium supplements separate from other medications.

D. Give potassium 2 hours before meals.

Answer 14

Explanation

Choice A is correct. Potassium supplements can have an inferior taste. To improve palatability, the nurse may sprinkle the contents of the potassium capsule on apple sauce, and the client can swallow it. The client must not chew on a capsule or tablet.

Choice B is incorrect. Breaking or crushing the potassium tablet may cause too much of the drug to be released at one time. An extended-release tablet should never be crushed.

Choice C is incorrect. Potassium can be given with other medications. It is not necessary to give potassium alone.

Choice D is incorrect. They are giving potassium two hours before meals are typically the same as providing it on an empty stomach, which predisposes the client to be esophageal and gastric irritation. Potassium is irritating to the esophagus and the stomach. Potassium should not be given on an empty stomach. It is best tolerated when given with food.

Question 15

Upon noticing fetal bradycardia, the labor and delivery room nurse performs a vaginal examination on her client in labor. She discovers a pulsatile mass. What is the initial action of the nurse?

A. Prepare for a Cesarean section.

B. Tell the client not to push when contractions arrive.

C. Escort the father out of the room.

D. Place the client in Trendelenburg position.

Answer 15

Explanation

Choice D is correct. Cord prolapse is a condition where the umbilical cord descends before or with the fetal presenting part. It should be suspected when there is a non-reassuring fetal heart rate tracing and absent membranes. A digital vaginal exam or external inspection will help the nurse confirm the suspicion of cord prolapse. The diagnosis is confirmed by palpating a pulsatile mass in the vaginal vault.

In this condition, the presenting fetal part puts pressure on the prolapsed cord, compromising the fetal blood supply. Additionally, fetal blood flow is further compromised by umbilical vasospasm that occurs due to exposure to the cold atmosphere. Compromise of fetal blood supply results in fetal hypoxia and non-reassuring fetal heart rate pattern (Fetal bradycardia or recurrent, variable decelerations). The Trendelenburg position makes use of gravity to pull the embryo back into the uterus, relieving pressure off the umbilical cord from the presenting part.

Cord prolapse is an obstetric emergency. The nurse should suspect it if fetal bradycardia or variable decelerations occur especially, immediately after the rupture of membranes. The nurse should:

Call for help
Avoid handling the cord, as it can cause further vasospasm and worsen outcomes.
Manually lift the presenting part off the cord by vaginal digital exam. Do not push the cord back.
Place the client in the left-lateral, Trendelenburg position, with head down and a pillow placed under the left hip.
Prepare for immediate delivery ( usually via. emergency Cesarean section).
If delivery is not immediately available and fetal decelerations persist, consider tocolysis ( eg: terbutaline) while awaiting the Cesarean section. Tocolytics relax the uterus, stop contractions, and therefore, relieve some pressure off the cord.

Choice A is incorrect. With the fetus in distress, the nurse should prepare for an emergency C-section; however, this is not the first action of the nurse.

Choice B is incorrect. In cord prolapse, the primary goal of the nurse is to ensure that the fetal blood supply and fetal oxygenation is restored. Telling the client not to push during contractions is an inappropriate action.

Choice C is incorrect. The nurse may ask the client’s husband to leave, especially if they are disruptive. However, this is not the primary concern at this moment.

Here is a short 2-minute video on Dos and Don’ts of umbilical cord prolapse :

https://youtu.be/iYDdB1K46wk

Question 16

While in the OBGyn clinic, your client tells you that this is her 4th pregnancy. She had an abortion of her first pregnancy at 22 weeks. Her second pregnancy was twins, born at 25 weeks, and they passed away in the NICU shortly after their delivery. Her third pregnancy was a boy born at 32 weeks, healthy. She is currently 30 weeks pregnant. Which of the following describes your patient?

A. G2T4P0A0L2

B. G4T0P3A0L1

C. G4T0P4A0L1

D. G4T0P3A1L1

Answer 16

Explanation

Choice B is correct. This describes your patient: she has been pregnant four times (G4), had 0 term births (T0), three preterm births (P3), 0 abortions (the fetus that is aborted after 20 weeks, spontaneously or electively, is counted as premature birth, and P will increase but A and L will not) and has one living child (L1). The GTPAL acronym is commonly used to describe pregnancy outcomes:-

The G stands for gravidity, the number of times that the patient has been pregnant. This includes current pregnancies, so for this question, it is 4.
The T stands for term births or the number of births occurring at 37 weeks gestation or later. In this question, the patient has had no births at term, so for T, we have a 0.
The P stands for preterm births or the number of births occurring before 37 weeks. For this question, the patient had twins at 25 weeks, so she gets P1 for twins, a baby boy at 32 weeks, and had an abortion after 20 weeks. Hence, she gets a total of 3 preterm births or 3 for “P.” Note: Multiple births (twins, triplets, and higher multiples) count as one pregnancy (gravidity – G1) and as one birth (P1 or T1 based on whether twins/triplets are pre-term or term).
The A stands for abortions or miscarriages. The "abortions" number refers to the total number of spontaneous or induced abortions and miscarriages, including ectopic pregnancies, before 20 weeks. If a fetus is aborted after 20 weeks, spontaneously or electively, it is counted as premature birth, and P will increase, but A and L will not.
If the abortion occurred before 20 weeks, count it under ‘A’ and ‘G.’ If the abortion happened after 20 weeks, count it under ‘P’ and ‘G.’ For this patient, she had one abortion. It happened after 20 weeks, so it gets counted under the G and P sections but not under “A.”
Lastly, L stands for the current number of living children. She tells us her twins passed away in the NICU, and her baby boy from her third pregnancy lives at home, so she gets a 1 for ‘L.’

Choice A is incorrect. This patient has been pregnant two times, had four term births, no preterm births, no abortions, and has two living children.

Choice C is incorrect. This patient has been pregnant four times, had 0 term births, four preterm births,0 abortions, and has one living child.

Choice D is incorrect. This patient has been pregnant four times, had no term births, three preterm births, one abortion (likely occurred before 20 weeks as it is not counted here under P), and has one living child.

Question 17

While reviewing fetal monitoring strips, the labor and delivery nurse notes that the piece is nonreassuring. What features characterize a fetal monitoring strip as nonreassuring? Select all that apply.

A. Fetal heart rate less than 110 beats/minute.

B. Increase in variability.

C. Late decelerations

D. Mild variable decelerations

Answer 17

Explanation

Answer: A and C

A is correct. A fetal heart rate less than 110 beats/minute or greater than 160 beats/minute is nonreassuring.

B is incorrect. An increase in variability is a reassuring factor. A decrease in variability would be nonreassuring.

C is correct. Late decelerations are an ominous sign, and immediate interventions should be taken to improve the fetal heart rate. They are characteristic of a nonreassuring heart rate.

D is incorrect. Mild, variable decelerations are okay, only when the variable decelerations are severe are they nonreassuring.

Question 18

The nurse is administering medications to a 5 year old client diagnosed with pneumonia. The health care provider has ordered a cough suppressant. Which medication does the nurse administer?

A. Dextromethorphan

B. Guaifenesin

C. Dexmedetomidine

D. Protonix

Answer 18

Explanation

Answer: A
A is correct. Dextromethorphan is a cough suppressant. It is the ingredient in many over the counter cough medicines such as Delsym, Robitussin, and NyQuil. Dextromethorphan works by signaling the brain to stop triggering the cough reflex.

B is incorrect. Guaifenesin is an expectorant, not a cough suppressant. Unlike a cough suppressant, Guaifenesin loosens the congestion in a client’s chest and throat making it washer for them to cough out mucus and phlegm.

C is incorrect. Dexmedetomidine is a sedative medication. It activates receptors in the brain that inhibits neuronal firing, which causes sedation. It is not a cough suppressant.

D is incorrect. Protonix is a proton pump inhibitor used to decrease the amount of acid produced by the stomach. It is not a cough suppressant.

Question 19

Place the following items in the correct sequential order from the most reliable and accurate indication of pain to the least competent, precise evidence of torture.
Physiological indicators of pain
Conditions that can lead to pain
Self-reports of pain using a pain scale
Behavioral indicators of pain

Answer 19

Explanation

The most reliable and accurate indication of pain is the client’s self-report of pain using a pain scale and with other mechanisms such as narrative accounts of torture, including sensory and emotional descriptors.

The second most pain scale reliable and accurate indication of pain is the client’s current conditions that can lead to anxiety; the third most reliable and dependable evidence of pain is the client’s behavioral indicators of illness; and, of the above choices, the client’s physiological signs of illness are the least reliable and least accurate indication of illness.

Question 20

Which of the following are invasive procedures not routinely done on all pregnant women? Select all that apply.

A. Contraction stress test

B. Amniocentesis

C. Nonstress test

D. Nitrazine test

Answer 20

Correct Answers are A and B.

A is correct. In a contraction stress test, contractions are induced with oxytocin. This is only done if a nonstress test is nonreactive, or there are other concerns.

B is correct. An amniocentesis is a sampling of amniotic fluid that is sent for genetic testing. This is only done if indicated.

C is incorrect. A nonstress test is noninvasive and done as routine antepartum testing.

D is incorrect. While an atrazine test is not routinely done on all pregnant women, it is not invasive. Please note the question is asking to name the “non-routine” and “invasive” tests. Nitrazind test refers to the testing of the pH of vaginal secretions to determine if they are amniotic fluid, and there has been a rupture of membranes.

NCSBN Client Need:
Topic: Physiological Integrity Subtopic: Physiological adaptation

Question 21

The nurse is preparing a 3-year-old child for an incision and drainage of large left leg abscess. The nurse understands which of the following types of anesthesia will be administered to the child?

A. Peripheral nerve block

B. Spinal anesthesia

C. General Anesthesia

D. Local Anesthesia

Answer 21

Explanation

Choice C is correct. A large leg abscess will need significant time for incision and drainage (I and D). Children who are not yet adolescents are not mature enough to cooperate adequately during such surgical procedures. Children undergoing most surgeries require general anesthesia because this minimizes their fears of intrusive or mutilating procedures. General anesthesia provides necessary sedation so the surgery can be safely performed.

Choice A is incorrect. A peripheral nerve block will not be able to provide adequate anesthesia to proceed with I and D procedure of a large leg abscess. For the child to cooperate with such surgery, sedation is necessary. General anesthesia provides necessary analgesia and sedation to the child.

Choice B is incorrect. Although spinal anesthesia may achieve analgesic effect, the child still may not cooperate with the surgical procedure because spinal anesthesia does not provide sedation.
Choice D is incorrect. Local anesthesia is helpful while addressing small abscesses. A large abscess requires more time and needs the child to cooperate. Children undergoing such procedures require general anesthesia to provide necessary sedation as well because this minimizes their fears of intrusive or mutilating procedures.
Reference:
Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 22

The equianalgesic chart on the wall of the medication room states that 10 mg of IV morphine is equivalent to 7.5 mg of oral hydromorphone in terms of potency. Your client has been effectively treated with 80 mg of IV morphine. Calculate and fill in the blank with the equianalgesic dose of oral hydromorphone.

______ mg of Oral Hydromorphone ( Please enter numeric only).

Answer 22

Explanation

The correct answer is 60mg of oral hydromorphone.

The calculation of the equianalgesic of oral hydromorphone, when compared to IV morphine, should be made based on known equivalent potency. The potency of 10 mg of IV morphine is equivalent to that of 7.5 mg of oral hydromorphone.

10 mg IV Morphine = 7.5 mg Oral Hydromorphone.

1 mg of IV Morphine then equals 0.75mg of Hydromorphone ( 7.5/10) so Equi-analgesic factor = 0.75.

Multiply IV morphine dose with Equi-analgesic factor to arrive at oral hydromorphone dose.

80 mg IV Morphine = 80 x 0.75mg oral Hydromorphone= 60 mg of oral hydromorphone.
NCSBN Client Need:
Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation.
Reference:
Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.

Question 23

The nurse administers bumetanide (Bumex), a loop diuretic, to a client with pulmonary edema. The nurse should watch out for which symptom that indicates a complication to the medication?

A. Distended neck veins.

B. Crackles and rhonchi.

C. Painful leg cramps.

D. Increase in urine output.

Answer 23

Explanation

Choice C is correct. Leg cramps may occur due to a low potassium level (hypokalemia), a common complication of loop diuretics.

A is incorrect. Distended neck veins may indicate fluid overload, CHF, or a Cardiac tamponade. Fluid overload and CHF may be indications for administration of the drug but is not a complication.

B is incorrect. Crackles and rhonchi are manifestations of pulmonary edema and fluid in the alveoli. Diuretics may be administered to relieve these symptoms, but these are not complications of the drug.

D is incorrect. An increase in urine output is the desired effect of the medication, not its complication.

Reference
Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier

Question 24

The nurse is observing a client who has been in labor for 16 hours. For which of the following observations, should she notify the healthcare provider? Select all that apply.

A. FHR 170-200 for 20 minutes

B. Early decelerations

C. Variable decelerations

D. Moderate variability

Answer 24

Explanation

Answer: A and C

A is correct. A Fetal Heart Rate of 170-200 for 20 minutes is fetal tachycardia and should be reported to the healthcare provider. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention.

B is incorrect. Early decelerations do not need to be reported to the healthcare provider. They occur when the fetal heart rate decreases at the same time as a contraction, and are followed by a return to baseline. They occur due to the pressure of the fetus’s head on the pelvis or soft tissue, and the nurse requires no intervention after an early deceleration.

C is correct. Variable decelerations need to be reported to the healthcare provider immediately. They are sharp, and profound drops in the fetal heart rate unrelated to the time of contractions are a non-reassuring sign on a fetal heart rate strip. Variable decelerations are caused by cord compression, such as a prolapsed cord, and are an emergency requiring quick nursing intervention.

D is incorrect. Moderate variability does not need to be reported to the healthcare provider. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from baseline. A moderate amount of variability is what is expected, and is considered a reassuring sign.

NCSBN Client Need:

Topic: Physiological Integrity

Subtopic: Reduction of Risk Potential

Subject: Maternity Nursing

Lesson: Problems with Labor and Delivery

Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.

Question 25

The nurse is administering digoxin to her 11-year-old patient with congestive heart failure. She knows to verify the pulse rate before administering the medication and holds it for a pulse less than _________.

Answer 25

Explanation Answer: 70 In children, the nurse should hold digoxin at a heart rate of less than 70. Digoxin is a cardiac glycoside that lowers the heart rate. Therefore, it should not be administered if the heart rate is already low to prevent severe bradycardia. The nurse should always check her order parameters to ensure the drug is being properly administered. Always, before giving Digoxin, the nurse should check the apical pulse for 1 complete minute. The apical pulse rate at which the nurse should hold digoxin differs based on age because the normal reference heart rate is higher in infants and children. In infants, the nurse should hold digoxin for an apical pulse <90. In older children, such as this question asked, the nurse should hold digoxin for an apical pulse < 70. In an adult, hold digoxin for an apical pulse <60. Then, the nurse should notify the physician because the physician may want to investigate if the patient is experiencing digoxin toxicity. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies

Question 26

You are caring for a pregnant woman with a baseline BMI of 22. Your education for this client is that a desirable weight gain during pregnancy with one baby for her is: A. 28 to 40 pounds B. 25 to 35 pounds C. 15 to 25 pounds D. 11 to 20 pounds

Answer 26

Explanation The Correct Answer is B (25 to 35 pounds). The amount of optimal weight gain during pregnancy is determined based on the woman’s body mass index (BMI) before pregnancy. BMI is a measure of body fat calculated from weight and height. A baseline BMI of 22 indicates that this woman’s baseline is in the healthy range (Normal BMI = 18.5 to 24.9). The recommended weight gain for this client is 25 to 35 pounds. Weight gain during pregnancy is crucial to the health and well-being of the baby and the mother. Gaining too little weight can lead to premature birth and low infant birth weight. Gaining too much weight can also result in premature birth and obesity of the child in later life. Excessive weight gain can result in strenuous labor, the increased possibility of needing a caesarian section, and increased bleeding. Choice A is incorrect. This is the recommended weight gain during singleton pregnancy for an underweight woman. Choice C is incorrect. This is the recommended weight gain during singleton pregnancy for an overweight woman. Choice D is incorrect. This is the recommended weight gain during singleton pregnancy for an obese woman. NCSBN Client Need Topic: Reduction of Risk Potential; Sub-topic: System-Specific Assessment.

Question 27

The nurse is providing discharge instructions to a client with accelerated hypertension who has been newly started on Nifedipine. His home medications include calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the need for additional teaching regarding Nifedipine? Select all that apply A. “If I get ankle swelling with this medication, furosemide will help.” B. “My gums may swell because of this medication.” C. “I will avoid getting up too quickly from sitting or lying position.” D. “I will check my pulse daily as the drug may significantly slow my heart rate.” E. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.” F. “It is highly likely that I will get constipated from this drug.” G. “My heartburn may worsen with this medication.” H. “If I get cough and tongue swelling, I will hold Nifedipine”

Answer 27

Explanation Correct answers are A, D, E, F, and H. Calcium channel blockers (CCBs) are very commonly used to treat hypertension. The nurse needs to be aware of the common side effects of calcium channel blockers and educate the clients appropriately. There are two classes of calcium channel blockers: Dihydropyridines and Non-dihydropyridines. Dihydropyridines, including nifedipine and amlodipine, are more selective to blood vessels (potent vasodilators) and have little or no effect upon cardiac contractility/ conduction. These are used to treat hypertension or chronic stable angina. Significant side effects include dose-dependent pedal edema, headache, flushing, and orthostatic hypotension. Non-dihydropyridines, including verapamil and diltiazem, are less vaso-selective (less potent vasodilators) but more cardio-selective (depress cardiac conduction and contractility). These are used to treat cardiac arrhythmias, hypertension, chronic stable angina. Significant side effects include dose-dependent constipation, bradycardia, and reduced cardiac output. Their mechanisms of action explain their different side effect profiles. Dihydropyridines like Nifedipine cause peripheral edema in 20 to 30 percent of clients. The mechanism of this edema involves the redistribution of fluid from the intravascular compartment into the interstitial compartment. Therefore, this edema is not from fluid retention or increased plasma volume. Diuretic therapy with Furosemide will not help treat this pedal edema. Therefore, Choice A does not reflect correct understanding by the client and needs additional teaching. Since this edema is dose-dependent, it is often treated by a reduction in dose of the CCB. Rather than just taking other furosemide, the client needs to contact the healthcare provider so the edema can be addressed with dose adjustment. Dihydropyridines like Nifedipine have minimal effect on cardiac contractility or conduction. They do not cause bradycardia. On the contrary, they may cause reflex tachycardia due to vasodilation. Therefore, Choice D does not reflect correct understanding by the client and needs additional teaching. Please note that because of their cardo-selectivity and suppressive effect on contractility/ conduction, Verapamil and Diltiazem cause bradycardia and decreased cardiac output (seen in 25% patients on Verapamil). While IV calcium gluconate/ calcium chloride is often used to treat toxicity from calcium channel blockers, there is no evidence to say oral calcium supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore, Choice E does not reflect correct understanding by the client and needs additional teaching. Constipation is a more common side effect with Non-Dihydropyridines like Verapamil (20% incidence). Illness is less common with Dihydropyridines. While there is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that the client is highly likely to get constipated from Nifedipine. Therefore, Choice F does not reflect correct understanding by the client and needs additional teaching. It is those Clients that are on Verapamil that need to be instructed to increase their fiber intake significantly. Constipation with Verapamil is dose-dependent. Cough and tongue swelling (Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI), which may lead to this side effect, so the nurse will need to explain this to the client. Therefore, Choice E does not reflect correct understanding by the client and needs additional teaching. Choice B is incorrect. Choice B reflects a correct understanding and does not need additional teaching. Gum/ gingival hyperplasia is familiar with extended-standing use of Nifedipine. Both Dihydropyridines and Non- Dihydropyridines may cause this. It is more common with Nifedipine than with Amlodipine. Choice C is incorrect. Because of peripheral vasodilation, Dihydropyridines like Nifedipine cause postural or orthostatic hypotension. So, the client should be aware of getting up slowly from the lying/ sitting position (Choice C), so they do not become dizzy. Choice C reflects a correct understanding and does not need additional teaching. Choice G is incorrect. All calcium channel blockers reduce the pressure in the lower esophageal sphincter exacerbating heartburn. This effect is seen more with Amlodipine/ Nifedipine. Of all the CCBs, Diltiazem is least likely to increase reflux symptoms. Therefore, it may be more appropriate to prefer diltiazem over other CCBs in patients with moderate to severe heartburn. Choice G reflects a correct understanding and does not need additional teaching. Test-taking strategy: While answering the questions that ask about “need for additional teaching regarding the medication,” always look for negative options ( the options that reflect incorrect understanding) in the list. NCSBN client need. Topic: Pharmacological and parenteral therapies; Sub-Topic: Adverse effects of medications.

Question 28

Which of the following medication classes are considered ‘quick-relief’ or ‘rescue medications’ for a child having an acute asthma attack? Select all that apply. A. Corticosteroids B. Leukotriene modifiers C. Short-acting beta 2 agonists D. Anticholinergics

Answer 28

Explanation Choices C and D are correct. C is correct. Short-acting beta-2 agonists are "rescue" medications used for bronchodilation in an acute asthma attack. Examples include albuterol and salbutamol. A "rescue" medication is the one that can provide relief even after bronchospasm is triggered. D is correct. Anticholinergics are rescue medications used for the relief of acute bronchospasm. Examples include Ipratropium and Tiotropium. A is incorrect.Corticosteroids are long term control medications used to reduce inflammation. They are not immediately useful as "rescue" medications but are useful in long term management of persistent asthma. B is incorrect.Leukotriene modifiers are long term control medications used to prevent bronchospasm and inflammatory cell infiltration. They are often used as prophylactic agents before a triggering event, for example, in exercise-induced asthma. They are not useful as a "rescue" once bronchospasm occurs. For example, Montelukast is indicated to be used " as needed" before exercising in patients who do not require daily bronchodilator. Montelukast is taken at least two hours before the initiation of exercise.

Question 29

The nurse is caring for four newborns during her shift in the unit. After performing an assessment, which newborn should the nurse give her attention to? A. A 24 hour old newborn that has not yet passed meconium. B. A 3-day old infant with mild jaundice and a bilirubin of 3 mg/dL. C. A 3 hour old infant that has just passed meconium D. A 5 day old infant with a positive Babinski reflex

Answer 29

Explanation Correct Answer is A.A newborn that has not yet passed meconium after 24 hours should be evaluated for Hirschsprung’s disease. Choice B is incorrect. An infant with slight jaundice after the first 24 to 48 hours of life should not cause concern to the nurse. The physician should be notified if the disease occurs within the early 24 hours to evaluate if the jaundice is pathological. Jaundice is considered pathologic if it presents within the first 24 hours after birth, the total serum bilirubin level rises by more than 5 mg/dL/day or absolute level at anytime higher than 17 mg/dL, or an infant has signs and symptoms suggestive of serious illness Choice C is incorrect. This is entirely normal as meconium is expected to be passed within the first 24 hours of the child’s life. Choice D is incorrect. Babinski reflex is a primitive reflex that is present in newborns. The nurse should not be concerned about this assessment finding. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003.

Question 30

SORRY MISSED TO COPY THE CORRECT QUESTION

Answer 30

SORRY MISSED TO COPY THE CORRECT QUESTION Explanation Choice C is correct. The nurse acknowledges the patient’s emotions and educates the patient regarding the situation. False reassurance is not given, and client expectations are set. The client's age and the symptoms she has been experiencing over the last few months indicate that she is likely peri-menopausal or post-menopausal. Pregnancy around such age is unusual. Some post-menopausal women have elevations in β-hCG that may cause the serum and urine pregnancy tests to be reported as positive; however, such patients are not pregnant. Since false-positive pregnancy tests can occur, an ultrasound would be helpful to confirm. Alternatively, serial serum β-hCG can be performed to see if there is an expected increasing trend with the progression of pregnancy. The absence of such a serial increase indicates a false-positive test. Choice A is incorrect. The nurse is still unsure whether the client is pregnant. Clients undergoing menopause tend to have a false-positive pregnancy test due to high levels of g. The nurse should not jump to conclusions which may give the client a false reassurance. Choice B is incorrect. The nurse’s response to the client is inappropriate. The response conveys a sense of ridicule to the patient and challenges the patient. Choice D is incorrect. A repeat urine pregnancy test is still likely to be positive. The nurse should acknowledge the client’s feelings and should tell her that a confirmatory test early in pregnancy is an ultrasound. Alternatively, serial serum β-hCG can be performed to see if there is an expected increasing trend with the progression of pregnancy. The absence of such a serial increase indicates a false-positive test.

Question 31

While reviewing medication-related hematological side effects, the nurse recognizes which of the following as the most severe form of bone marrow toxicity: A. Aplastic anemia B. Leukocytosis C. Thrombocytosis D. Granulocytosis

Answer 31

Explanation Choice A is correct. Aplastic anemia leads to pancytopenia, a severe decrease in all hematological cell types: red blood cells, white blood cells, and platelets. Aplastic anemia may be caused by primary bone marrow failure or from secondary causes such as medications. Some medications that cause aplastic anemia include chloramphenicol, phenylbutazone, sulfonamides, anticonvulsants, cimetidine, and NSAIDs. Drug-induced aplastic anemia is the result of an idiosyncratic hypersensitivity reaction and is often reversible. In such drug-related aplastic anemias, the nurse must notify the physician and withdraw the offending agent. Choice B is incorrect. Leucocytosis refers to increased white blood cells. Leucocytosis can be induced by some medications (for example, Lithium); however, it is not serious bone marrow toxicity. Instead, Leukopenia (a reduced number of white blood cells) is more serious and makes the patient susceptible to infection. Choice C is incorrect. Thrombocytosis refers to increased platelet count. It is not the most serious form of bone marrow toxicity. Severe Thrombocytopenia (a reduced number of platelets) is more serious as it causes the blood not to clot as easily and increases bleeding risk. Choice D is incorrect. A granulocyte is a type of white blood cell. White blood cells are classified into two types: granulocytes ( neutrophils, eosinophils, basophils) and agranulocytes ( monocytes, lymphocytes). Granulocytosis is an elevated granulocyte count. Granulocytosis may be seen as the body responds to an infection. However, it is not as serious as agranulocytosis. Agranulocytosis ( granulocytopenia) is a more serious disorder that causes a severe decrease in the neutrophil count and predisposes the client to severe infections. Medications that cause agranulocytosis include antithyroid medications (carbimazole and methimazole); anti-inflammatory medications (sulfasalazine, nonsteroidal anti-inflammatory drugs (NSAIDs)), and some antipsychotics (clozapine) NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological Therapies

Question 32

You are working in the intensive care nursery and are assigned to take care of an infant withdrawing from cocaine. At your first assessment, you appreciate the following: a high pitched cry, no tremors, increased muscle tone, sleeping for 3 hours in between feedings, no congestion, respiratory rate = 42. excessive sucking on the pacifier, poor nutrition, no vomiting, and no loose stools. What is the Neonatal Abstinence (NAS) score for this patient? A. 7 B. 12 C. 2 D. 8

Answer 32

Explanation Choice A is correct. Neonatal abstinence syndrome (NAS) occurs due to sudden withdrawal of the fetus due to the discontinuation of substances used/abused by the mother during pregnancy. The Finnegan scoring system is commonly used to assess the severity of NAS. The NAS score uses 21 symptoms that are most seen in opiate-exposed infants. A numerical score is assigned to each sign and its corresponding severity. The total abstinence score is determined by the sum of the numerical score attached to each sign. This scoring can help guide initiation, monitoring, and cessation of treatment in the newborn. The initial treatment of NAS includes nonpharmacological methods. If improvement not noted with nonpharmacological measures or if the infant develops severe withdrawal symptoms, pharmacological agents are used. NAS score helps in assessing the severity. The most common agent used in the treatment of NAS secondary to opioids is Morphine. The infant may breastfeed unless the mother is involved in polysubstance abuse or has HIV. The Neonatal Abstinence Score (NAS score) uses 21 symptoms that are most seen in opiate-exposed infants. A numerical score is assigned to each withdrawal symptom and its corresponding severity. The total abstinence score is determined by the sum of the numerical score attached to each sign. Each of these observations gives you a part of the NAS score for this infant: ``` High pitched cry = 2 points. No tremors = 0 points Increased muscle tone = 2 points Sleeping for 3 hours in between feedings =0 points No congestion = 0 points RR = 42 = 0 points Excessive sucking on the pacifier = 1 point Poor feeding = 2 points No vomiting = 0 points No loose stools = 0 points ``` This adds up to a total of 7 points for the NAS score for this patient. A score of 7 is in the moderate range. Less than five is mild, 5-8 is average, 8-12 is severe, and greater than 12 is very critical. For a score of 7, a breakthrough dose of morphine may not be appropriate, but the infant may not be ready to wean down on their methadone further. NCSBN Client Need: Topic: Health Promotion and Maintenance Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences

Question 33

Your client, who has chronic pancreatitis and gastroparesis, is complaining of a migraine headache. The doctor has ordered butorphanol orally as needed for pain. What would you do? A. Call the doctor and suggest transnasal butorphanol because the client has gastroparesis. B. Call the doctor and suggest rectal butorphanol because the client has pancreatitis. C. Administer the butorphanol orally as ordered. D. Administer the butorphanol transdermally for pain.

Answer 33

Explanation Choice A is correct. This is a client with chronic pancreatitis and gastroparesis and is complaining of a migraine headache.Butorphanol is available in the oral form, the transnasal form, the transdermal, and the parenteral form. You would call the doctor and suggest transnasal butorphanol because the client has gastroparesis. The doctor has ordered butorphanol orally as needed for pain. Choice B is incorrect. Butorphanol is not available for rectal administration. Butorphanol is available only in the oral form, the transnasal form, and the parenteral form. Choice C is incorrect. You would not administer the butorphanol orally for pain because this route is contraindicated among clients with gastroparesis. Choice D is incorrect. You can not administer transdermal butorphanol without a doctor's order. The doctor needs to be called to obtain such an order. Reference: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 34

The nurse is providing discharge education regarding the client's eye drop medications. Which of the following actions does the nurse instruct the client to implement to minimize the eye drops' systemic effects? A. Instill the drops before meals. B. While instilling the drops, swallow several times. C. Blink vigorously to after instilling the drops. D. Place a finger over the inner canthus for 30 – 60 seconds after instilling the drops.

Answer 34

Explanation Choice D is correct. Eye drops are often prescribed for their topical effects in relieving local eye conditions. Occasionally, side effects may occur due to systemic absorption of the active medication in the eye drop solutions. Certain precautions can help reduce systemic absorption and, thereby, minimize side effects. Mucous membranes of the eye serve as the routes of systemic absorption. Placing a finger over the inner canthus occludes the nasolacrimal duct preventing the eye drop solution from reaching the mucous membranes and being absorbed into the systemic circulation. Choices A, B, and C are incorrect. These instructions do not help minimize systemic side effects of eye drops. Unlike orally administered medications, the absorption of instilled eye drops is not affected by gastric contents (Choice A). Swallowing at the time of instillation does not affect the absorption of eye drops (Choice B). Finally, blinking vigorously forces the solution out of the eyes, decreasing its local therapeutic effect and is not recommended (Choice C). Reference Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins

Question 35

One of the most severe side effects of selective serotonin reuptake inhibitors (SSRI) is a serotonin syndrome. While educating a patient who was just initiated on an SSRI, which of the following symptoms of serotonin syndrome should the nurse emphasize to the patient? Select all that apply. A. Rapid heart beat B. Muscle twitches C. Sweating D. Diarrhea

Answer 35

Explanation Choices A and B are correct. Serotonin syndrome is a medical emergency. A persistent rapid heartbeat, muscle twitches or jerking of the muscles are typical symptoms of a serotonin syndrome. Such patients should seek medical attention immediately. Choices C and D are incorrect. Sweating and diarrhea are common side effects of SSRIs, but these by themselves do not indicate serotonin syndrome. If the patient is experiencing these symptoms along with other symptoms/ signs such as rapid heartbeat and muscle twitching, then they should seek urgent medical attention. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Pharmacological therapies Reference: Hockenberry, M., Wilson, D. & Rodgers, C. (2017). Wong’s Essentials of Pediatric Nursing (10th ed.) St. Louis, MO: Elsevier Limited.;Subject: Fundamentals;Lesson: Medication Administration

Question 36

The nurse is preparing to administer Dopamine (Intropin) to a client intravenously. All of the following are precautions are to be taken when administering the medication, except: A. Use caution in calculating and preparing doses of the drug. B. Monitor patient response slowly (blood pressure, ECG, urine output, cardiac output). C. Dilute the drug before use if it is not prediluted. D. Have Phenylephrine on standby in case extravasation occurs.

Answer 36

Explanation Choice D is correct. This is not the precaution a nurse needs to take because it represents an erroneous statement. Phentolamine should be on standby to save the vein in case of infiltration, not Phenylephrine. Phentolamine is an antidote that counteracts the effects of Dopamine, Vasopressin, Norepinephrine, and Phenylephrine by causing vasoconstriction by alpha-receptor stimulation. Dopamine-induced extravasation can cause tissue injury with blanching and hematoma. Subcutaneous injection of phentolamine has been proven to be clinically effective in preventing tissue injury in the case of Dopamine or Vasopressin extravasation. Choice A is incorrect. This is the precaution that the nurse should take. The nurse should use extreme caution when calculating and preparing doses of the drug because even small errors could have serious effects. Choice B is incorrect. This is the precaution that the nurse should take. Monitoring the patient’s response to the medication ensures that the most benefit is achieved with the least amount of toxicity to the client. Choice C is incorrect. This is the precaution that the nurse should take. Diluting the drug prevents tissue irritation on injection. Reference: Karch, A. Focus on Nursing Pharmacology, 3rd edition. Lippincott, Williams & Wilkins 2006

Question 37

The nurse is educating a patient who is taking phenytoin. To make sure phenytoin does not fail, which Over-The-Counter (OTC) medication should the nurse advise the patient not to take at the same time? A. Acetaminophen B. Ibuprofen C. Calcium Carbonate D. Ranitidine

Answer 37

Explanation Correct Answer is C. Calcium Carbonate (Tums) should not be taken at the same time as Phenytoin because taking them together can decrease the effects of phenytoin. Antacids containing calcium carbonate reduce the bioavailability of phenytoin by reducing both the rate of absorption and the amount of intake. Phenytoin is an anticonvulsant, and not getting it at therapeutic dose may result in the client having a recurrent seizure. Clients should be cautioned against concomitant use of antacids/ tums and phenytoin. If the client needs calcium carbonate, he should be instructed to separate the times of intake of calcium carbonate and phenytoin by at least two to three hours. Choice A is incorrect. Acetaminophen and Phenytoin can be taken together without any concern for therapeutic failure. Choice B is incorrect. Ibuprofen and Phenytoin can be taken together and do not cause the therapeutic failure of Phenytoin. Choice D is incorrect. Ranitidine and Phenytoin can be taken together and do not cause the therapeutic failure of Phenytoin. Ranitidine may, however, increase the effects of Phenytoin, and the patient should be monitored for any phenytoin related adverse effects. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological Therapies Reference: Core Concepts in Pharmacology (Holland/Adams)

Question 38

A 14-year-old is admitted to the medical ward for status asthmaticus. He has put on IV Theophylline. Which manifestation would the nurse consider as a side effect of the drug? A. Grand mal seizures B. Palpitations C. Sleeplessness D. Headache

Answer 38

Explanation Choice D is correct. Headache is one of the most common side effects of Theophylline. It is important to understand the difference between a side effect and drug toxicity, A side effect is something that can occur at a usual recommended dosage. On the contrary, drug toxicity ( adverse drug event) occurs when there is overdosage or significant drug accumulation in the body above the therapeutic range. A is incorrect. Seizures are a sign of toxicity of Theophylline, not just a common side effect. B is incorrect. Palpitations and arrhythmias are a sign of theophylline drug toxicity as well C is incorrect. Insomnia is not associated with theophylline. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4thEdition; Lippincott, Williams & Wilkins

Question 39

The nurse is attending a client who is 20 weeks pregnant and has completed patient education. Which of the following statements by the client indicates that she has a good understanding of her baby’s development? A. "My baby is able to breathe now." B. "My baby can open his eyes." C. "My baby is about 7 ½ inches long." D. "My baby has fully grown fingernails."

Answer 39

Explanation The correct answer is C. By 20 weeks gestation; the fetus is approximately 20cm long or 7 ½ inches. This statement reflects a proper understanding of the mother regarding fetal development and does not require further teaching. Choices A, B, and D are incorrect. There are several stages of fetal development. Pregnancy comprises first, second, and third trimesters. In the first trimester, critical events include changes to the fertilized cell and the development of major organs and structures. During the second trimester, the organs and structures continue to develop, and the woman becomes more aware of the growing fetus. During the third trimester, the fetus gains weight, matures, and prepares for life outside the uterus. Fetal lungs do not begin the movements of respiration until 24 weeks. The placenta provides oxygen to the fetus, and the developmental function of the lungs for breathing does not occur until birth. Therefore, the statement in Choice A needs further teaching. The fetus can open its eyes at 28 weeks gestation, not at 20 weeks. Therefore, the statement in Choice B needs further teaching. Fingernails begin to grow at ten weeks gestation but are not complete until 38 weeks. Therefore, the statement in Choice D needs further teaching. NCSBN Client Need Topic: Health Promotion and Maintenance. Reference: Safe Maternity and Pediatric Nursing (Linnard-Palmer/Coats); Chapter 3: Human Reproduction and Fetal Development

Question 40

The nurse is educating a pregnant client who is admitted with deep vein thrombosis in her left lower extremity. The client is at 24 weeks of gestation. The client is placed on Low Molecular Weight Heparin (LMWH). Which of the following statements by the client indicate(s) that she understands the education regarding LMWH? A. “My blood thinner will be stopped soon after delivery.” B. “Since I am on LMWH, I must have a planned cesarean section.” C. “I hate injections. I will likely switch to Warfarin after delivery.” D. “There is an increased risk of fractures with long term LMWH therapy.” E. “If I notice blisters or black-red areas at the injection site, I will hold LMWH and immediately contact the doctor.” F. “If I decide to switch to warfarin after delivery, I should not breastfeed.”

Answer 40

Explanation Choices C, D, and E are correct. LMWH is the anticoagulant of choice during pregnancy because it does not cross the placenta, but one may switch to Warfarin in the post-partum period. While Warfarin is contraindicated during active pregnancy due to its potential to cause congenital fetal disabilities, maternal/fetal bleeding, and miscarriages, it is considered safe in the post-partum period. Warfarin is also safe in lactating/ breastfeeding women. The client will need a minimum of 3 to 6 months of anticoagulation and, therefore, will be requiring anticoagulation for a few weeks even after delivery. Additionally, the risk of recurrent venous thromboses is high up to 6 weeks post-partum. Since the client does not like injections, oral anticoagulation with Warfarin is an option for her after delivery (Choice C). Long term treatment with LMWH may decrease bone mineral density (osteopenia, osteoporosis) and increases the risk of fractures (Choice D). For those with pre-existing osteoporosis and fracture risk, close monitoring is needed on long term LMWH therapy. It is common to have some bruising and swelling at the injection site. However, the presence of blisters and necrotic areas (blackish-red central portion) at the injection site may serve as a warning sign of a complication known as Heparin-Induced-Thrombocytopenia (HIT). If the patient or the nurse notes necrotic areas at the injection site, the physician must be notified immediately, and LMWH must be discontinued(Choice E). HIT is a rare but dangerous complication with unfractionated and low-molecular-weight heparins. The body forms antibodies to heparin that may cross-react with platelet antigens and cause a drop in the platelets. Despite a decline in the platelet count, HIT is associated with the formation of thromboses (deep vein thrombosis and pulmonary embolism) because HIT antibodies disrupt and activate the clotting system. If HIT is confirmed, heparin should never be re-initiated. Other anticoagulants, such as Argotraban or Fondaparinaux, are used. Choice A is incorrect. Anticoagulation will not be stopped soon after delivery. The client will need a minimum of 3 to 6 months of anticoagulation and, therefore, will be requiring anticoagulation for a few weeks even after delivery. Anticoagulation in a client with a history of venous thromboses should never be discontinued immediately after birth because there is a high risk of recurrent venous thromboses at least up to 6 weeks post-partum. Choice B is incorrect. It is not mandatory that the patient have a cesarean section. Normal vaginal delivery is still possible with adequate planning. If the patient is in labor, she should hold LMWH and notify the physician immediately. LMWH should be held at least 24 hours before the planned delivery. If the client ended up receiving LMWH within 24 hours of delivery, she should not be given epidural or spinal anesthesia. Choice B is incorrect. Warfarin is safe in lactating women as it does not pass into breast milk to any measurable level. The client should be encouraged to breastfeed. Both LMWH and Warfarin are safe to take when breastfeeding. NCSBN Client Need: Topic:Pharmacological therapies;Sub-topic:Adverse Effects/Contraindications/Side Effects/Interactions

Question 41

The nurse had just finished receiving the shift report from the night nurse. Which of the following newborns should the nurse assess first? A. A 3 hour old newborn weighing 6 pounds B. A 4 hours old newborn delivered at 42 weeks C. A 6 hour old newborn 21 inches long D. An 8 hour old newborn delivered at 40 weeks

Answer 41

Explanation Choice B is correct. Post-maturity refers to any baby born at or beyond 42 weeks gestation (42 0/7 weeks) or at or beyond 294 days from the first day of the mother's last menstrual period (LMP). Post-maturity is also referred to as prolonged pregnancy, post-term, and post-dates pregnancy. At about 40-42 weeks, placental insufficiency ensues due to the aging placenta. Therefore, the infants rely on their subcutaneous fat reserves to sustain them after 40 to 42 weeks since the aging placenta is unable to provide the necessary nutrition. Due to these depleted subcutaneous fat reserves, the post-term infant is at risk for hypoglycemia and hypothermia. In at-risk infants, the incidence of neonatal hypoglycemia is highest in the first few hours after birth. A 4-hour old infant delivered at 42 weeks is at-risk. Additionally, the risk of meconium aspiration is high in the post-term fetuses and can cause respiratory distress when the baby is born. The nurse should prioritize and assess this post-term infant first. Choice A is incorrect. According to the World Health Organization (WHO), the average birth weight for full-term babies is around 7.5 lb. However, a birth weight range between 5.5 lb. (2.5 kg) and 8.2 lb. (4.0 kg) is considered normal. Small for gestational age (SGA) is defined as a birth weight of less than 10th percentile for gestational age. Large for gestational age (LGA) refers to a birth weight equal to or more than the 90th percentile for a given gestational age. Macrosomia refers to a birth weight greater than 4000 to 4500 grams ( 4 to 4.5 kg), regardless to gestational age. The infant weighing 6 pounds ( Choice A) is within the normal weight range for a newborn; the nurse does not need to see this infant first. Choice C is incorrect. The average length of full-term babies at birth is 20 inches (50 cm). The normal range is between 18 to 22 inches. Macrosomia is defined based on the birth weight, not the birth length. Twenty-one inches is a bit longer than the average for most infants, but this is not a relevant finding that causes complications soon after birth. The nurse does not need to see the infant first. Choice D is incorrect. The risk of neonatal hypoglycemia is highest in first few hours after birth in some "at-risk" infants. These "at risk" infants include those who are post-term infants ( at or beyond 42 weeks gestation), late preterm (34-36.6 weeks gestation), term infants who are small for gestational age, infants of diabetic mothers, and large for gestational age infants. An infant born at 40 weeks ( Choice D) is referred to as a term infant, and there are no reported problems from the previous shift. No risk factors have been mentioned. The American Academy of Pediatrics (AAP) guidelines do not recommend routine screening and monitoring of blood glucose in healthy term infants after a normal pregnancy and delivery. The nurse does not need to assess this newborn first. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family; Lippincott, Williams & Wilkins

Question 42

A woman was admitted to the obstetric unit in active labor and has had a frank rupture of membranes. A fetal scalp electrode and intrauterine pressure catheter were inserted promptly. The woman had progressed to 8-cm dilation when the nurse noticed abrupt decreases in the fetal heart rate of 15-20 bpm that quickly returned to baseline. The changes in fetal heart rate occurred with and without contractions. At this point, the nurse should prepare to initiate a client teaching about the possibility of which procedure? A. High forceps delivery B. Oxytocin induction C. Amnioinfusion D. Cesarean birth

Answer 42

Explanation Correct Answer is C. The fetus is experiencing variable decelerations of heart rate in the setting of ruptured membranes. Amnioinfusion refers to the infusion of a warmed isotonic solution into the uterine cavity through the IUPC. It is mostly used as a treatment to correct fetal heart rate changes caused by umbilical cord compression, indicated by variable decelerations seen on cardiotocography. It can help cushion the cord and relieve pressure when the membranes have ruptured. Choice Ais is incorrect. A high forceps delivery is contraindicated because it is associated with fetal and maternal tissue damage. The situation does not meet the criteria to resolve to forceps deliveries. Per ACOG, appropriate forceps deliveries are indicated as in 1. Outlet forceps ( when presenting part on the perineum, the scalp visible at the vaginal opening) 2.Low Forceps ( when the leaning edge of the fetal skull is at station 3) Mid Forceps ( when the leaning side of the fetal head is between 0 and 2 stations). Choice B is incorrect. The fetal heart rate findings in this case of ruptured membranes describe variable decelerations caused by cord compression. Oxytocin infusion could increase the pressure on the umbilical cord. It is also not recommended when labor is progressing adequately. Choice D is incorrect. Even when there is cord compression, the situation states that compression is relieved, as indicated by the quick return of the heart rate to baseline. If the benchmark is reassuring, there is no need for immediate delivery or cesarean delivery.

Question 43

A client is about to go for a CT angiogram, which involves the administration of an intravenous radiopaque dye. In preparing the client for the procedure, the nurse’s responsibility is to educate him by saying: A. "You should expect some chest tightness during the procedure." B. " You should expect a burning sensation at the intravenous site." C. "You will likely experience flushing of the face." D. "An allergic reaction may cause a decline in your kidney function."

Answer 43

Explanation Choice C is correct. Flushing of the face is an expected response to the intravenous administration of contrast dye. Many diagnostic and imaging procedures (CT scans, angiograms, myelograms) involve the use of Intravenous radiocontrast (intravenous dye, iodinated contrast). These contrast dyes contain iodine. Most patients experience a warm sensation throughout the body shortly after contrast dye infusion. This is more pronounced in the face and throat and thereafter, moves to the pelvic area. Allergic reactions to intravenous contrast are seen only in about 5% to 8% of patients. Such reactions, therefore, are not expected responses. The contrast media acts directly to release histamine and other mediators from mast cells. There is no allergic antibody mediating this reaction. Hence, it is referred to as “pseudo-allergy.” Choice A is incorrect. Chest tightness may be experienced during a moderate to a severe hypersensitivity reaction and is not an expected response. Choice B is incorrect. Burning at the intravenous site is not a usual expected response with the use of IV contrast dye. Choice D is incorrect. Iodinated contrast is also toxic to the kidneys. This is not an allergy and is a direct toxic effect. It is important that the serum creatinine of the clients receiving iodinated contrast be checked before the procedure. If the estimated glomerular filtration rate (GFR) is less than 30ml/min, contrast dye must not be given. For those at-risk of renal toxicity, intravenous hydration must be given following contrast containing procedures.

Question 44

Upon gathering the lab results from your prenatal client’s recent blood draw. the nurse notes that the patient’s red blood cell levels have decreased since before pregnancy. The nurse believes that physiological anemia is likely occurring. a result from a/an: A. Decrease in circulating red blood cells B. Increase in plasma C. Increase in iron demands from the body D. Decrease in heart size

Answer 44

Explanation Choice B is correct. Physiological anemia occurs when there is an increase in plasma in the blood, thus “outweighing” the number of otherwise normal red blood cell levels. Physiological anemia is normocytic ( normal red cell size), whereas anemia caused by iron deficiency would be "microcytic." Choice A, C, and D are incorrect. In physiological anemia, there is no decrease in the circulating red blood cells; instead, there is an increase in plasma volume, causing dilutional anemia. While pregnancy does call for increased iron demands, this does not lead to physiological anemia; instead, iron deficiency leads to pathological microcytic anemia. Finally, pregnancy causes an increase in heart size, not a decrease. NCSBN client need |Topic: Health Promotion and Maintenance: Intrapartum care Reference: Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.

Question 45

An independent nursing intervention relating to the oral administration of opioid narcotic analgesics is to: A. Collect comparative pain assessment data just before the administration of the opioid narcotic analgesic. B. Collect comparative pain assessment data ½ hour after the administration of the opioid narcotic analgesic. C. Collect comparative pain assessment data just before and 1 hour after the administration of the opioid narcotic analgesic. D. Collect comparative pain assessment data just before and ½ hour after the administration of the opioid narcotic analgesic.

Answer 45

Explanation Choice C is correct. The independent nursing intervention relating to administering oral opioid narcotic analgesics is to collect comparative pain assessment data just before and 1 hour after administering the oral opioid. In the case of intravenous opioids, pain assessment must be performed 30 minutes after the opioid administration. This helps determine the effectiveness of these opioid narcotic analgesics in terms of pain reduction. Choice A, B, and D are incorrect. Although the nurse is expected to collect pain assessment data before and after administering the opioid narcotic analgesic, there are specific guidelines concerning the timing of pain assessments, and these must be adhered to. Pain assessment must be made 30 minutes after opioid if given by intravenous route whereas 1 hour after administration if given by oral route. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen.

Question 46

While working in the Neonatal Intensive Care Unit (NICU), you are notified that a "small for gestational age" infant is being brought to the unit. Being a NICU nurse, you understand that this means which of the following? A. The infant's weight is less than 2500 grams. B. The infant’s weight is below the 20th percentile. C. The infant’s weight is less than 1500 grams. D. The infant’s weight is below the 10th percentile.

Answer 46

Explanation Choice D is correct. The term "Small for Gestational Age (SGA)" is used when the infants are smaller than normal for the number of weeks of pregnancy (gestational age). When an infant’s weight is below the 10th percentile for the gestational age, it is considered small for gestational age. By definition, about 10 percent of all newborns are labeled as "SGA." Not all “Low Birth Weight” babies are SGA. Infants may be of low birth weight but may still fall above the 10th percentile for gestational age. It is important to distinguish SGA from other related terms, “Low Birth Weight (LBW)”, “Very Low Birth Weight (VLBW), and “Extremely Low Birth Weight (ELBW).” These definitions are based on the infant’s weight at the time of birth. These are not percentile scores and are defined on the absolute weight limit. An LBW infant is defined as an infant with a weight of less than 2500 grams (5 lb. and 8 ounces), regardless of gestational age at the time of birth. A VLBW infant is defined as the one with a weight less than 1500 grams at the time of birth. An ELBW infant is less than 1000 grams at the time of birth. Choice A is incorrect. When infants are born at less than 2500 grams, they are considered of low birth weight. A classification which considers only the weight and not the gestational age, is LBW, VLBW and ELBW whereas percentiles are used for the small/average/large for gestational age comparison. Choice B is incorrect. The 20th percentile is considered average for gestational age. Infant’s size falling between 10th - 90th percentile is considered average. One that is less than the 10th percentile is “small for gestational age”, and greater than 90th percentile is “large for gestational age”. Choice C is incorrect. When infants are born at less than 1500 grams, they are considered as “very low birth weight”. Percentile scores are used for the small/average/large for gestational age comparison. NCSBN Client Need: Topic: Health Promotion and Maintenance Reference:DeWit, S. C., & Williams, P. A. (2013).Fundamental concepts and skills for nursing. Elsevier Health Sciences.

Question 47

What is the sequence of action when you are mixing two insulins, such as NPH insulin and regular insulin, together in the same syringe? Place these steps in the correct order. Select the first step and then place that choice as the first letter of a series of letters in your response. For example, if the X choice is the first step; the Y choice is the second step, and the Z step is the last step of this procedure, you would fill “X. Y and Z” in that sequential order in the blank space below the steps for this procedure for mixing two insulins in the same syringe. Inject an amount of air equal to the regular insulin. Inject an amount of air equal to the ordered dosage of the NPH insulin. Withdraw the ordered dosage of the regular insulin. Withdraw the ordered dosage of the NPH insulin. Prep the top of the vials with an alcohol pad.

Answer 47

Explanation The Correct Answer Sequence is 5, 2, 1, 3 and 4 The Correct Answer is 5, 2, 1, 3, and 4. When you mix regular insulin with another type of insulin, always draw the regular insulin into the syringe first. When you combine two types of insulins other than regular insulin, it does not matter in what order you bring them into the syringe The correct procedure for drawing up and mixing two different insulins like NPH insulin and regular insulin, in the correct sequential order, is: A. Prep the top of the vials with an alcohol pad. B. Inject an amount of air equal to the ordered dosage of the NPH insulin C. Inject an amount of air equivalent to the ordered dosage of the regular insulin. D. Withdraw the ordered dosage of the regular insulin. E. Withdraw the ordered dosage of the NPH insulin. This sequencing prevents the contamination of regular insulin with the longer-acting NPH insulin.

Question 48

Your elderly female client has just begun a new medication for their impaired cardiac function. Which of the following is a high-priority nursing intervention, and what is the rationale for this client? A. You should closely monitor this client for the side effects of this medication because she is elderly. B. You should closely monitor this client for the side effects because this drug classification has more side effects than other drugs. C. You should closely monitor this client for adverse effects of this cardiac medication and dehydration. D. You should closely monitor this client for the adverse effects because she is elderly and adverse effects most commonly occur when a new medication is begun.

Answer 48

Explanation Correct Answer is D. You should carefully monitor this client for the adverse effects of this cardiac medication because they are elderly and adverse effects most commonly occur when a new drug is begun. This is the correct reasoning for the nurse's priority action of monitoring. Choice A is incorrect. Although you should closely monitor this client for the side effects of this medication because they are elderly, a more comprehensive rationale ( Choice D) exists among the options. The side effects may be more in this client because of the older age and this being a new medication. Choice B is incorrect. Although you should closely monitor this client for the side effects of this cardiac medication, it is not because this classification has more side effects than other drugs. This monitoring is necessary for the reason explained in Option D. Choice C is incorrect. Although you should closely monitor this client for the side effects of this cardiac medication, it is not indicated only because the client may be dehydrated. This monitoring is necessary for another reason, and there is no evidence in this question that the client is dehydrated. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice.

Question 49

The client admitted to the gynecology ward for premature labor is given terbutaline to arrest labor. The nurse should monitor which parameter when administering this medication? A. Breath sounds B. Urine output C. Pain D. Level of consciousness

Answer 49

Explanation A is correct. One of the most common side effects of terbutaline is pulmonary edema. The nurse should monitor the client’s breath sounds and assess for respiratory crackles and difficulty of breathing to detect if pulmonary edema is present. B is incorrect. Terbutaline does not have any effect on urine output. C is incorrect. Terbutaline is a tocolytic agent; it arrests labor and uterine contractions; it may decrease the client’s pain levels during contractions, but it is not the nurse’s priority assessment. D is incorrect. Terbutaline does not have any effect on the client’s level of consciousness. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family

Question 50

A pregnant client at 16 weeks gestation developed a Pulmonary Embolism and was initiated on intravenous heparin therapy two days ago. She is getting ready to be discharged. Which of the following medications do you expect the physician to order at discharge? A. Warfarin B. Rivaroxaban C. Apixaban D. Low Molecular Weight Heparin (LMWH)

Answer 50

Explanation Choice D is correct. The physician will most likely order Low Molecular Weight Heparin (LMWH) to be self-administered twice daily. The dosing schedule and monitoring of LMWH are more convenient than that of unfractionated heparin. LMWH does not cross the placenta and, therefore, does not cause fetal harm. LWMH and unfractionated heparin are the anticoagulants of choice during pregnancy. LMWH will provide therapeutic anticoagulation for the rest of the pregnancy. Most venous thromboembolism events need therapeutic anticoagulation for at least 3 to 6 months. However, pregnancy is a hypercoagulable state. The client, therefore, is at risk for recurrent thromboembolism throughout her pregnancy and at least six weeks post-partum. Choice A is incorrect. Warfarin is strictly contraindicated during pregnancy. Warfarin is a teratogen and can cross the placenta to reach the developing fetus. It may cause congenital disabilities (fetal warfarin syndrome), maternal/fetal bleeding, stillbirths, and miscarriages. Fetal warfarin syndrome is characterized by low birth weight, slower growth, mental retardation, deafness, small head size, and bone malformations. Pregnant women with venous thrombosis are anticoagulated with low molecular weight heparin or unfractionated heparin. Choices B and C are incorrect. Both Rivaroxaban and Apixaban belong to the class of Factor Xa inhibitors. These are newer oral anticoagulants that have mostly replaced warfarin in the treatment of venous thromboses; however, they are also not considered safe in pregnancy as they cross the placenta. Rivaroxaban is regarded as a Category C drug by the US FDA and is not a recommended drug in pregnancy if there is a safer alternative. Apixaban does not have much data in pregnancy and is not the anticoagulant of choice during pregnancy. NCSBN Client Need: Topic: Pharmacological and parenteral therapies; Sub-topic:Adverse Effects/Contraindications/Side Effects/Interactions

Question 51

You are caring for a client with chronic pain secondary to degenerative arthritis and osteoporosis. What data should you primarily consider in terms of this client’s pain assessment? A. The client’s performance in terms of their basic activities of daily living B. The client’s performance in terms of their instrumental activities of daily living C. The client’s value history D. The client’s vital signs

Answer 51

Explanation Correct Answer is A. The client’s performance in terms of their necessary activities of daily living should be primarily considered and collected in terms of this client’s chronic pain assessment. Other assessment data should include a complete pain history, the location, duration, character, and intensity of the pain in addition to assessing other characteristics of chronic pain, including client withdrawal, client depression, and indications that the parasympathetic nervous system is activated. Choice B is incorrect. You would not collect client data in terms of the client’s performance of their instrumental activities of daily living such as housekeeping, managing money, and food preparation because these activities are minimally impacted with chronic arthritic pain. Choice C is incorrect. You would not collect client data in terms of the client’s value history because this data is gathered for health care choices and beliefs and not chronic pain. Choice D is incorrect. You would not collect client data in terms of the client’s vital signs because this data is gathered for acute pain and not chronic pain. After all, vital signs remain healthy with chronic pain, and they increase with severe pain. Tachycardia, tachypnea, and blood pressure elevation may be seen with acute pain and distress. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management. Reference: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10thEdition)

Question 52

``` While assessing your patient in active labor, you evaluate the fetal monitor and note late decelerations and significantly decreased variability. The patient is on a Pitocin infusion. Upon observing this nonreassuring fetal heart rate, the nurse should take the following actions in what order? Administer oxygen Stop the Pitocin infusion Identify the cause Prepare for delivery if unresolved. Change the mother’s position ```

Answer 52

``` Correct Answer is: Identify the cause Stop the Pitocin infusion Change the mother’s position Administer oxygen Prepare for delivery if unresolved. ``` Explanation The first action the nurse should take is to identify the cause of the nonreassuring fetal heart rate. Is the patient lying on her back? Is the Pitocin drip inappropriately titrated? There are many causes of nonreassuring fetal heart rates, and sometimes a simple intervention can fix the problem. After the nurse tries to identify the cause, she should stop the Pitocin infusion. Remove the potential cause or contributing factor first. Even if the fetal heart rate seems to be improving, the Pitocin infusion should be stopped to prevent any further decelerations or decreased variability. Next, the nurse should change the mother’s position and lay the mother in left lateral position. If she is on her back, the fetus could be putting pressure on her descending aorta, or the fetus could be compressing the umbilical cord, and a simple change of position will resolve this. Next, the nurse should begin administering oxygen to the mother via a simple face mask at 8-10 L/min. This will optimize oxygenation to the fetus in the even the nonreassuring fetal heart rate has not yet been resolved. Lastly, if still unresolved, the nurse needs to prepare for an emergency delivery. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Medical Emergencies Reference: Lowdermilk D, Perry S, Cashion K, Alden K: Maternity & women’s health care, ed 10, St. Louis, 2012, Mosby, p. 428

Question 53

You are assigned to administer Dilaudid to a patient with post-operative pain. You should be aware of which of the following correct legal mandates in terms of controlled substances? Select all that apply. A. Signatures of 2 registered nurses but not of practical nurses when a narcotic is wasted. B. Prohibitions against the use of a placebo for pain management. C. The signatures of 3 registered nurses or practical nurses when a narcotic is wasted. D. The verification of the narcotic count at the beginning and the end of the shift. E. Checking the controlled substance at least 3 times prior to its administration. F. The secure locking of controlled substances to prevent diversion and theft.

Answer 53

Explanation Correct Answers are D and F The verification of the narcotic count at the beginning and the end of the shift (Choice D) and the secure locking of controlled substances to prevent diversion and theft (Choice F) are legal mandates in terms of narcotics and controlled substances. Nurses are responsible for ensuring that there is adequate documentation in the medical record to support the administration and the wasting of controlled substances. It’s legally mandated that controlled substances are securely locked to prevent diversion. Examples of storage systems for controlled substances include locked medication carts, locked cabinets, and automated dispensing systems. When controlled substances are removed from secure storage in quantities more than what needs to be administered, the nurse is responsible for wasting the excess/ unused portion in the presence of a witness. The best practices for the spending of controlled substances: Waste at the time of removal from the storage. Witnessing nurses must watch the administering nurse as the correct dose is drawn upper the order. Witnessing nurse must observe as the unneeded portion is wasted in the approved manner. Document the waste electronically or in writing. Witness to the wasting of controlled substances should verify product label, the number of wasted matches what is documented, and that the medication is wasted in an irretrievable location. Two nurses, both the administering nurse and the witness, are responsible for documenting the wastage. Either a Registered Nurse or a Licensed Practical Nurse can witness and sign. A nurse should never document seeing controlled substance wastage that was not observed. Choice A is incorrect. Although the signatures of two nurses are legally mandated when a narcotic is wasted, licensed practical nurses can also sign when an opiate is spent. Choice A claims practical nurses cannot endorse, which is an incorrect statement. Choice B is incorrect. Although there is a prohibition against the use of a placebo for pain management, this is an ethical and not a legal mandate. Choice C is incorrect. Although the signatures of more than one nurse are legally mandated when a narcotic is wasted, the names of 3 registered nurses or practical nurses are not legally required when an opiate is spent. Two signatures of RNs or LPNs will suffice. Choice E is incorrect. Although checking the controlled substance and all other medications, at least three times before its administration is appropriate, this is a standard of practice and not a legal mandate. NCSBN Client need: Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management. Reference: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10thEdition)

Question 54

While participating in interdisciplinary rounds on the Mother-Baby floor, the provider mentions that your 2-day old patient is at risk for phenylketonuria. Which of the following statements are true regarding this condition? Select all that apply. A. It is a genetic disorder that is autosomal dominant. B. Children with phenylketonuria commonly have a musty odor to their urine C. Hypopigmentation of the hair, skin, and irises is a prominent sign of the disorder. D. All 50 states require routine screening of newborns for phenylketonuria.

Answer 54

Explanation The correct answers are B, C, and D. Phenylketonuria, or PKU, is a genetic disorder that results in central nervous system damage from toxic levels of the essential amino acid phenylalanine. B, C, and D are all correct. The musty odor urine smell and hypopigmentation of the hair, skin, and irises are telltale signs of PKU. It is true that all 50 states require routine screening of newborns for this disorder! A is incorrect. The disease is inherited in an autosomal recessive manner. NCSBN client need: Topic: Physiological Adaptation Subtopic: Alterations in Body Systems Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 442

Question 55

A nurse is educating a student nurse about blood transfusion and transfusion reactions. Which of the following statements by student nurse indicate(s) need for additional teaching? Select all that apply. A. “Most common cause of fever during transfusion and transfusion reactions is Hemolysis” B. “Transfusion related Graft Versus Host disease occurs in immuno-suppressed patients.” C. “Transfusion Associated Circulatory Overload (TACO) is more common in patients with baseline renal failure.” D. “It is important to ask the patient about history of previous blood transfusions.” E. “Pre-medication with Diphenhydramine and Acetaminophen is always needed before transfusion.”

Answer 55

Explanation Correct answers are A and E. These two statements indicate that the student nurse needs further teaching on transfusion reactions. Choice A does not reflect correct understanding by the student nurse because the most common cause of fever during transfusion is “Febrile Non-hemolytic transfusion reaction” not hemolysis. Hemolysis also causes fever but it’s not common and often happens when there’s mismatching with donor blood product. On the other hand, Febrile Non-Hemolytic reactions are due to recipient antibodies reacting with donor leucocytes. Often, these patients have been sensitized with prior transfusions and develop antibodies. Therefore, it is important to get history regarding previous blood transfusions. (Choice D reflects a correct understanding by the student nurse). Physicians may decide to give pre-medication with Diphenhydramine and Acetaminophen only if the patient has a history of such febrile reactions or history of prior blood transfusions. Pre-medications are, therefore, not always required (Choice E does not reflect correct understanding by the student nurse). Transfusion reactions are adverse reactions that happen as a result of receiving a blood transfusion. The most common symptoms of transfusion reaction can be remembered by a Mnemonic – REACTION – Rash, Elevated temperature, Aching, Chills, Tachycardia, Increased pulse, Oliguria – low urine output, and Nausea. Transfusion reactions are various types and can include theallergic, hemolytic, and febrile type of reactions as well as GVHD (graft-versus-host-disease). Other transfusion-related complications include Circulatory overload which is more common in cardiac/ renal patients and septicemia due to contaminated blood products. Transfusion Associated Circulatory Overload (TACO) is more common in patients with baseline cardiac and renal disorders ( Choice C reflects a correct understanding by student nurse). Fluid overload can happen during transfusion if the patient already has underlying Congestive heart failure. If the patient is felt to be at risk for circulatory overload, a loop diuretic such as Furosemide may be ordered before, after, or in between PRBC units. Allergic type transfusion reactions occur when certain types of proteins (eg: IgA) interacts with antibodies in the recipient. For example, recipients with IgA deficiency may develop anaphylaxis if given transfusion from a normal donor with normal IgA levels. Such anaphylactic reactions may present with hives, rashes, wheezes, respiratory distress, abdominal pain, and angioedema (lip/oral swelling). Hemolytic type reaction can be occurring when the blood products are mistyped. Antibodies in the recipient's blood destroy the donor's blood cells. This can manifest as fever, chills, anxiety, back pain, chest pain, hemoglobinuria, increased heart rate, low blood pressure, disseminated intravascular coagulation, renal failure, and death. Febrile reactions can occur without hemolysis (Non-hemolytic). This is the most common type. It manifests with fever, chills, headache, and tachycardia. Often, these patients have received blood in the past with ready antibodies in their blood against WBCs. Recipient’s antibodies react with leucocytes within the donor blood products. An increase in temperature by 1’C or 1.8’F from baseline can be noted. Such febrile reactions may be minimized by a process called “leukodepletion” (removing WBCs from donor blood products). Graft-versus-host-disease (GVHD) is a rare transfusion reaction that occurs mostly in severely immunocompromised patients (post-bone-marrow transplant, Hodgkin disease, non-Hodgkin lymphoma, and acute myeloid and acute lymphoid leukemias). Choice B reflects a correct understanding of student nurses. In this condition, the donor’s T lymphocytes cause an immune response in the recipient by engrafting in the marrow of the recipient and attacking the recipient’s tissues/ blood cells. Under normal circumstances, donor T-cells are killed by the recipient’s immune system but in severe immunodeficiency, donor T-cells remain causing GVHD. Transfusion-related GVHD presents with fever, rash all over including feet and hands, diarrhea, nausea, and elevated Liver function tests. Such reactions can be limited by a process called “Cytoreduction” where the T-cells are removed from the donor blood products. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies Subtopic: Blood and Blood Products

Question 56

A nurse is caring for a client receiving digoxin. The client’s most recent digitalis level was 2.5 ng/mL. The nurse should take which priority action(s)? Select all that apply. A. Withhold the client's scheduled dose. B. Administer the dose as prescribed. C. Assess the client's urinary output. D. Assess the client's most recent sodium level. E. Assess the client's heart rate and rhythm. F. Call the physician and obtain an order for 2D Echocardiogram.

Answer 56

Explanation Correct answers are A and E. The client’s digitalis level of 2.5 ng/mL is indicative of toxicity. Digoxin has a narrow therapeutic index, which means it can cause significant side effects, such as cardiac arrhythmias (e.g., bradycardia, heart block, ventricular arrhythmias), even at plasma concentrations only twice the therapeutic plasma concentration range. Normal corrective serum digoxin levels range from 0.5–2 ng/mL. A level higher than two ng/mL is considered toxic. The nurse is correct to withhold the scheduled dose (Choice A) and assess the client’s heart rate and rhythm (Choice E) as the client is likely to be experiencing bradycardia. Choice B, C, D, and F are incorrect. It would be wrong to administer the next dose, as this would exacerbate the toxicity. An assessment of the urinary output and sodium is not relative to digitalis toxicity and is not the priority here. Calling the physician to notify regarding the toxic level is appropriate, but there is no reason to obtain a 2D echocardiogram. A 2D echocardiogram will not add any additional information at this point. Instead, an electrocardiogram must be obtained to look for any rhythm disturbances due to digoxin toxicity. NCSBN client need Topic: Pharmacological and parenteral therapies; Sub-Topic: Adverse effects of medications

Question 57

Your pregnant client with Diabetes is concerned about her sub-optimal blood sugar control and the potential harm to her baby. The infant of a diabetic mother is at risk for all of the following except: A. Prematurity B. Respiratory distress C. Pancreatic congenital malformation D. Hypoglycemia

Answer 57

Explanation Choice C is correct. The infant of a diabetic mother is not at an increased risk for pancreatic malformation. Pre-existing diabetes can increase the risk of congenital disabilities. Congenital heart defects ( Truncus arteriosus, Atrioventricular septal defect); Sacral agenesis ( a defect in which sacrum fails to form), Renal agenesis, Neural tube defects, and cleft lip/palate are some birth anomalies associated with maternal diabetes. Pancreatic malformation (Option C) is not one of those congenital disabilities. The risk of congenital disabilities can be reduced by improved glycemic control in the mother. Choices A, B, and D are incorrect. Infants born to diabetic mothers are indeed at an increased risk for premature birth, respiratory distress, and hypoglycemia. They may also be born large for gestational age ( macrosomia), experience hyperbilirubinemia, and thrombocytopenia. NCSBN client need |Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care Reference: Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014

Question 58

You are working in L&D and are assigned to a G4P3 patient in active labor. You note a nonreassuring fetal heart rate on the monitor and proceed to assess your patient. On exam, you can visualize umbilical cord protruding through the vaginia. Recognizing that this is an emergency, place the following priority nursing actions in the correct order: Apply pressure to lift the presenting fetal part. Stay with the patient and call for help Place the patient in Trendelenburg position Prepare for delivery Administer oxygen

Answer 58

Correct Answer is: Stay with the patient and call for help Apply pressure to lift the presenting fetal part. Place the patient in Trendelenburg position Administer oxygen Prepare for delivery Explanation The priority of nursing action is to stay with the patient and call for help. This is a medical emergency, and the nurse must remain with the patient to ensure safety. Next, the nurse needs to quickly don gloves and apply pressure to the presenting fetal part. This will lift the fetus off of the prolapsed umbilical cord and restore blood flow to the fetus. The nurse can not let go until the health care provider arrives to deliver the fetus. Next, the nurse needs someone to place the patient in Trendelenburg’s position. This will assist with keeping the presenting fetal part off of the umbilical cord, so that blood flow to the fetus continues. Next, the nurse needs someone to administer oxygen to the mother via a simple face mask at 8-10 L/min. This will optimize oxygenation to the fetus. Lastly, the nurse needs to prepare for the immediate delivery of the fetus. This is the only way to resolve this medical emergency. NCSBN Client Need Topic: Physiological Adaptation Subtopic: Medical Emergencies Reference: Lowdermilk D, Perry S, Cashion K, Alden K: Maternity & women’s health care, ed 10, St. Louis, 2012, Mosby, p. 619.

Question 59

The nurse is taking vital signs on a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action? A. Notify the healthcare provider. B. Document and continue to monitor C. Place the mother on her left side D. Administer 100% FiO2 via face mask

Answer 59

Explanation Answer: B A is incorrect. The nurse has observed an acceleration in the fetal heart rate, which is an increase in fetal heart rate by 15 bpm above the baseline. An acceleration lasts about 10-15 seconds, and then the heart rate returns to baseline, as the nurse observes in this question. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip. The nurse does not need to report this to the healthcare provider. B is correct. Because the nurse has noted a reassuring sign of the fetal heart rate, it is appropriate for her to document the finding and continue to monitor the mother. If the nurse had noticed a non-reassuring sign, other interventions would be necessary. C is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require repositioning of the mother to the left side. Repositioning the mother to the left-lateral position will be needed if a non-reassuring sign (e.g., fetal bradycardia, late decelerations) is noted. D is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require administration of 100% FiO2 via face mask. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Subject: Maternity Nursing Lesson: Problems with Labor and Delivery Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.

Question 60

The nurse is caring for a neonate with a decreased cardiac output. If noted in this patient, which of the following is not a sign of decreased cardiac output? A. Oliguria B. Difficulty breastfeeding C. Bradycardia D. Hypotension

Answer 60

Explanation Choice C is correct. Bradycardia is not a typical symptom of decreased cardiac output in neonates. Instead, a decreased cardiac output generally results in tachycardia as the heart pumps faster to compensate. Typical signs of decreased cardiac output in an infant include oliguria, difficulty feeding, hypotension, irritability, restlessness, pallor, and decreased distal pulses. Choice A is incorrect. Oliguria is an expected finding in an infant with a decreased cardiac output. As the kidneys are perfused less efficiently in an infant with decreased cardiac output, urination reduces or ceases altogether. Choice B is incorrect. Difficulty breastfeeding may be seen in infants with low cardiac output. Feeding is increasingly difficult for babies with poor circulation. Choice D is incorrect. Hypotension is an expected finding in an infant with low cardiac output. Normal cardiac output is required to keep blood pressure regulated. Reference: Kenner CLott J. Comprehensive Neonatal Care. 1st ed. St. Louis, Mo.: Saunders Elsevier; 2007.

Question 61

You are preparing for evening medication rounds and have a patient with the following order: 0.1 mg clonidine HS, PO The bottle you pull from the medication bin reads: 100 mcg/1mL How many mL’s of clonidine do you administer to your patient? Round to the nearest tenth of an mL. mL

Answer 61

Explanation Answer: 1 mL To calculate the proper amount of medication to administer to your patient, use the following formula: (Desired amount of medication ÷ Amount of medication you have) x vehicle (D÷H) x V Before you start your calculations for this problem, you need to convert the milligrams to micrograms so that your equation is all in the same unit. NEVER start calculating a dosage before all your units match! 1 mg = 1,000 mcg → 0.1 mg = 100 mcg So our order is for 100 mcg clonidine HS, PO. Your desired amount of medication is 100 mcg. D = 100. The amount of medication you have is 100 mcg. H = 100. The vehicle that this amount of medication comes in is 1 mL. V = 1 (100mcg ÷ 100mcg) x 1mL = 1 mL . Medication orders must always be written without trailing zeros. Here, the answer should be written as 1 mL, not 1.0 mL. Guidelines recommend never using a trailing zero while writing medication doses, as it can lead to significant medication dosing errors.

Question 62

The nurse is answering phones in the general practice clinic and receives a call from a patient who is experiencing leg pain after starting atorvastatin. Which of the following instructions, when given by the nurse, is the best course of action? A. Continue taking the medication as this is an expected side effect B. Discontinue the medication and schedule an appointment for the next week C. Stretch for 20 minutes or take a warm shower D. Discontinue the medication and visit the clinic as soon as possible

Answer 62

Explanation The correct answer is D. Leg pain, and muscle aches, which occur after taking atorvastatin, may indicate a severe muscular myopathy known as rhabdomyolysis. The nurse would be most accurate to have this patient discontinue their medication and come to the clinic as soon as possible. Choice A is incorrect. This patient should be seen in the clinic to rule out potentially fatal health problems like rhabdomyolysis. Choice B is incorrect. While this medication should be discontinued, waiting for treatment could delay necessary treatment. Choice C is incorrect. Stretching for 20 minutes or taking a warm shower could delay necessary treatment. NCSBN client need | Topic: Physiologic Integrity, pharmacology, and parenteral therapy Reference: Lilley L, Savoca D, Lilley L. Pharmacology And The Nursing Process. Maryland Heights, MO: Mosby; 2011

Question 63

The nurse gives discharge teaching to a patient going home on Doxycycline. Which of the following patient statements, if made by the patient to the nurse, requires further education? (Select all that apply): A. “I will use sunscreen when I plan on spending time outdoors.” B. “I am glad that, unlike most antibiotics, I won’t have to use a backup method of birth control.” C. “If I get a white coating on my tongue, I will immediately stop the medication.” D. “I should take this medication after I eat a meal.” E. “I will follow up with my doctor visits and get my labs checked.”

Answer 63

Explanation The correct answers are B, C, and D. These statements require further teaching. Doxycycline is a tetracycline antibiotic that fights bacteria in the body. It is used to treat many different bacterial infections, such as acne, urinary tract intestinal, respiratory, and eye infections, gonorrhea, chlamydia, syphilis, periodontitis. This patient will have to use a backup method of birth control (Option B). Birth control pills also may not work as well if the patient is taking doxycycline. The mechanism underlying this is felt to be due to antibiotics’ effects on reducing small intestinal bacteria. Decreased bacteria leads to decreased hydrolysis of the hormone, which in turn, results in increased fecal loss of the hormone and results in lower circulating levels of ethinylestradiol. This long-held belief has been challenged in recent studies. Still, until the availability of extensive studies, it is advised that patients take a backup method (other forms of birth control) when the patient is taking this medicine. The white coating (Option C) is glossitis, a common side effect of Doxycycline, but the patient should not stop the medication. This should not be confused with thrush since thrush presents more with painful whitish patches involving not just tongue but also the palate. The medication needs to be taken on an empty stomach because food can interfere with its absorption and reduces efficacy. The client should not take Doxycycline after eating (Option D). Choices A and E are incorrect. These statements reflect correct understanding and DO NOT need further teaching. Option A- This statement reflects a correct understanding by the client and does not need further teaching. With Doxycycline, there is increased photosensitivity/ Phototoxicity. When prescribing doxycycline, physicians usually advise patients on the use of a high sun protection factor (SPF) sunscreen. A broad-spectrum sunscreen to protect against UVB and UVA wavelengths should be recommended. Using a hat, avoiding sun are other teaching points. Option E- This patient needs to follow up and have their labs checked. No further teaching required. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Pharmacological & Parenteral Therapies. Reference: Core Concepts in Pharmacology (Holland/Adams); Chapter 32: Drugs for Skin Disorders; Lesson: Acne & Acne Related Disorders

Question 64

The nurse is caring for a client that is receiving Aspirin for acute pain. The nurse understands the associated adverse effects of the medication and includes all of the following nursing actions except: A. Administering the medication with food or milk. B. Monitoring the client's CBC C. Monitoring the client's liver and kidney function D. Administering another NSAID (Ibuprofen) when pain relief is inadequate.

Answer 64

Explanation Choice D is correct. The nurse should not administer another NSAID unless ordered since it increases the chances of the patient getting renal and hepatic impairment. A is incorrect. This is the correct nursing action. Giving aspirin with food or milk should be done by the nurse as it decreases gastric upset. B is incorrect. This is the correct nursing action. Sometimes, NSAIDs like ASA, Indomethacin can cause bone marrow depression ( agranulocytosis) and impaired coagulation. The client's CBC should be monitored for signs of pancytopenia. C is incorrect. This is the correct action. The client's liver and kidney function tests should be monitored by the nurse for the early detection of hepatic and renal impairment. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8th edition, Nebraska: Elsevier 2009

Question 65

A nurse is conducting pre-operative teaching to a client who will undergo surgery in 1 week. Which response by the client would prompt the nurse to give additional teaching? A. “Aspirin can possibly cause bleeding even after surgery.” B. "Aspirin can adversely affect my clotting ability" C. “I should stop Aspirin one day prior to my surgery.” D. “It is important that I talk to my physician about the possibility of stopping aspirin before the surgery.”

Answer 65

Explanation Choice C is Correct. This statement by the client (“I should stop Aspirin one day before my surgery.”) needs further education. Stopping Aspirin one day before surgery is not usually appropriate since platelet function would not recover enough in 1 day. Aspirin is an anti-platelet drug and can alter the platelet’s ability to aggregate and may increase the risk of bleeding after surgery. Aspirin irreversibly affects the platelet function, so; one should be aware that the effects of aspirin last for the duration of the life of the platelet (which is close to 10 days). After a single dose of aspirin, total body platelet activity recovers by 10% per day as a result of new platelets being produced – so approximately, by 5-7 days after the last aspirin dose, the majority of platelet activity would have recovered. Because of this, anti-platelet therapy is usually stopped 5 to 7 days before the scheduled surgery but should be done as directed by the physician. The client should, therefore, discuss this with the physician so that the client will be properly guided as to when the medication should be stopped before surgery. Choice C is, therefore, the correct answer because the nurse needs to reinforce teaching to correct his notion. Choices A, B, and D are incorrect because these statements reflect accurate understanding by the client about Aspirin, and these ideas do not need additional teaching. It is true that the client needs to consult his physician for guidance regarding stopping Aspirin (Choice D). It is true that Aspirin may increase post-operative bleeding risk (Choice A) and can adversely affect the clotting ability (Choice B). NCSBN Client Need: Topic: Physiological integrity; Sub-topic: Pharmacological and Parenteral Therapies

Question 66

The nurse is caring for a 1-day old newborn client diagnosed with jaundice. Which of the following statements is true regarding jaundice in newborns? Select all that apply. A. Jaundice within the first 24 hours of life is physiologic. B. Unconjugated bilirubin is excreted in the stool. C. Assessing a newborn for jaundice involves inspection of the skin, sclera, and mucous membranes. D. When treating a jaundiced infant with phototherapy, important nursing considerations are to ensure their eyes and genitals are covered.

Answer 66

Explanation Choices C and D are correct. When assessing an infant suspected to have jaundice, the most important thing to do will be to evaluate the skin, sclera, and mucous membranes (Choice C). When bilirubin levels are high, there will be a yellow tinge to these areas due to the high levels of the bilirubin pigment in the blood. Jaundice usually starts in the face and forehead area, so the nurse should begin her assessment there. The sclera and mucous membranes are a secure location to appreciate the yellow discoloration, especially in a patient with darker skin. When treating a jaundiced infant with phototherapy, important nursing considerations are to ensure their eyes and genitals are covered (Choice D). Phototherapy helps reduce serum bilirubin levels by converting bilirubin into water-soluble isomers that can be eliminated without conjugation in the liver. Phototherapy light can be harmful to the infant’s eyes and genitals. Nurses should ensure these areas are covered with an eye mask and a diaper. Choice A is incorrect. Jaundice, within the first 24 hours of life, is pathologic. This means that there is some other disease process or condition, causing jaundice that needs to be investigated. Often, etiology includes ABO incompatibility leading to hemolysis, liver pathology Physiologic jaundice is noted 2-3 days after birth and is simply due to the normal process of the infant’s liver taking over the processing of bilirubin. Since the liver is not mature enough to conjugate and excrete the bilirubin in the bile, predominantly unconjugated physiological jaundice appears. This type of disease should not be of any concern. Choice B is incorrect. It is the conjugated bilirubin that gets excreted in the stool, not unconjugated. Unconjugated bilirubin is the waste product that is released when the heme is released from hemoglobin in the process of red blood cell breakdown. It is transported to the liver to be converted into conjugated bilirubin. When converted to conjugated form, it can be excreted in bile and reaches the small intestine. Small bowel bacteria convert this conjugated form to Stercobilinogen and Urobilinogen. Stercobilinogen gives the yellow color to feces. Urobilinogen is water-soluble and is detected in the urine. In obstructive jaundice, conjugated bilirubin does not reach the intestine, and therefore, the result is the pale stools. In newborns with hemolysis or liver pathology, unconjugated form overwhelms the immature liver's capacity to conjugate. Hence, pathological jaundice ensues within 24 hours in such circumstances. NCSBN Client Need: Topic: Physiological Integrity; Subtopic: Basic care, comfort Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Question 67

The nurse assists a mother in labor to the bathroom and notes that the fetal heart rate increases from 130 to 190. She sits the mother back down in bed, and the fetal heart rate remains 190. Which of the following nursing actions would be appropriate? Select all that apply. A. Lie the mother down on her left side B. Decrease the rate of her IV fluids C. Administer oxygen D. Continue to just observe the mother.

Answer 67

Explanation Choices A and C are correct. The nurse has noted fetal tachycardia. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention. Any non-reassuring fetal heart rate will require intervention. One could remember these interventions with the mnemonic:- LION: lie the mother on her left side, increase IV fluids, oxygen, and notify the healthcare provider. In this case, the non-reassuring sign of fetal tachycardia necessitates intervention, and lying the mother on her left side is an appropriate intervention. Administering oxygen is an appropriate nursing intervention for the noted fetal tachycardia. The idea is to improve fetal oxygenation. This will go along with repositioning the mother on to her left side, increasing the rate of IV fluid administration, and notifying the healthcare provider. B is incorrect. Decreasing the rate of the mother's IV fluids is not appropriate. Instead, the nurse should increase the IV fluids' rate to help better facilitate blood perfusion to the placenta and fetus. D is incorrect. It is inappropriate to continue to observe the mother simply. The nurse has noted fetal tachycardia, a non-reassuring sign that requires intervention. The nurse should lie to the mother on her left side, increase her IV fluids, administer oxygen, and notify the healthcare provider. NCSBN Client Need: Topic: Effective, safe care environment; Subtopic: Coordinated care Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing; Subject:Maternity Nursing;Lesson:Problems with Labor and Delivery

Question 68

A 16-year-old adolescent is brought to the ER following an accident at a skating rink. The adolescent’s left knee is bruised and swollen. Upon interview, the nurse finds out that the adolescent has Hemophilia A. Which medication would be most appropriate for the client? A. Codeine phosphate B. Aspirin C. Ibuprofen D. Oxycodone terephthalate and Acetyl-salicylate

Answer 68

Explanation A is correct. Codeine phosphate is an analgesic that has no aspirin components and is used for moderate to severe pain. B is incorrect. Aspirin would aggravate the client’s condition by inhibiting platelet aggregation, increasing bleeding. C is incorrect. Ibuprofen also has aspirin components; aspirin is contraindicated in clients with bleeding disorders. D is incorrect. Oxycodone terephtalate and acetyl salicylic acid has aspirin components. Acetyl salicylic acid is a generic name for Aspirin. Aspirin is relatively contraindicated in clients with bleeding disorders because it increases the bleeding risk . Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier

Question 69

The nurse is caring for a client receiving Morphine sulfate for severe pain. The nurse should implement all of the following actions except: A. Administer Morphine only when the client complains of pain. B. Ensure Naloxone is always available. C. Check the client’s respirations before giving Morphine D. Provide a high fiber diet.

Answer 69

Explanation A is correct. Morphine should be given at times prescribed by the doctor to ensure adequate serum levels for optimum pain relief. Waiting to give it until the client experiences pain may lead to sub-optimal pain control. When specified by the physician, the nurse can provide Morphine for breakthrough pain, when the client complains of pain despite receiving round the clock morphine doses. B is incorrect. Naloxone should always be available as an antidote to morphine. C is incorrect. One of the significant side effects of morphine is respiratory depression. Checking the client’s respirations before giving Morphine should always be done. D is incorrect. Morphine results in constipation for most clients. A high fiber diet should be given to prevent illness.

Question 70

While reviewing the side effects of adjuvant analgesic medications, the nurse understands which of the following drugs is accurately paired with its most serious adverse side effect? A. Acetaminophen: Gastrointestinal tract bleeding B. Ibuprofen: Hepatic failure C. Clonidine: Renal failure D. Aspirin: Anaphylaxis

Answer 70

Explanation Choice D is correct. The most severe adverse effect of aspirin is an anaphylactic shock, which is life-threatening. Other side effects of aspirin include gastrointestinal ulcerations and hemolytic anemia. Choice A is incorrect. Acetaminophen is often used as adjuvant medication in treating pain. The most severe adverse effects of acetaminophen are hepatic failure, hepatotoxicity, and kidney damage. Gastrointestinal bleeding is not a side effect of acetaminophen. Choice B is incorrect. Ibuprofen is an NSAID ( Non Steroidal Anti-inflammatory Drug). NSAIDs can damage the gastrointestinal mucosa by inhibiting prostaglandins. Gastric and duodenal ulcers with bleeding are often seen with chronic NSAID use. Therefore, the most severe adverse effect of Ibuprofen is gastrointestinal tract bleeding and not hepatic failure. Choice C is incorrect. Clonidine is a centrally acting non-opioid analgesic drug. In addition to its use in treating refractory hypertension, it is also used as an adjuvant pain medication . The most serious adverse effect of Clonidine is rebound hypertension which can be severe in some cases. Rebound severe hypertension can occur due to sudden discontinuation of Clonidine. When it occurs, rebound hypertension can be treated with restarting Clonidine or with alpha blockers such as Phentolamine. Other less severe but common side effects of clonidine include dry mouth, sedation, constipation, and headache. Renal failure is not a usual side effect of Clonidine. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen; Kozier and Erb’s Fundamentals of Nursing: Concepts, Process and Practice

Question 71

You are working on L&D and are rounding on your three laboring patients. As you assess each patient you use _______________'s maneuvers to determine the fetal position.

Answer 71

Explanation Answer: Leopold Leopold's maneuvers: Refers to Four specific steps in palpating the uterus, which helps the nurse to determine the fetal lie and the fetal presentation. First maneuver (“Fundal Grip”): helps determine the size, consistency, shape, and mobility of the fundus. This helps assess the contents and, thereby, fetal lie. If the fetal head or buttocks (breech) are felt in the fundus, then the fetus is in “vertical lie.” If those parts are not perceived, the fetus is likely in a “transverse lie.” The second maneuver helps determine the direction to which fetal back is facing. The third maneuver helps assess the part of the fetus at the inlet and its mobility. It helps determine if the presenting part is engaged. In the absence of engagement, a movable body part will be felt. The fourth maneuver helps assess fetal descent. The nurse can determine the position of cephalic prominence (felt like a rounded body) about other body parts. In vertex presentation, the cephalic prominence is on the same side as the small pieces. In the face presentation, the cephalic prominence is on the same side as the back where the head is extended, and the face presents. https://player.vimeo.com/video/416169744

Question 72

Please match the correct description of each medication in the list below. Drag and drop each therapeutic response to the corresponding medication in that sequence. ``` Finasteride Tolterodine Potassium citrate Hydrochlorothiazide Furosemide ``` Alters the urinary pH to prevent the recurrence of urinary calculi. Decreases urinary calcium levels and may reduce recurrence of urinary calculi. Decreases urinary retention and increases the urinary stream. Decreases urinary frequency and urgency. Alters the urinary pH to prevent the recurrence of urinary calculi. Decreases urinary calcium levels and may reduce recurrence of urinary calculi. Increases urinary output and increases urinary calcium levels.

Answer 72

Correct Answer is: FINASTERIDE - Decreases urinary retention and increases the urinary stream. TOLTERODINE - Decreases urinary frequency and urgency. POTASSIUM CITRATE - Alters the urinary pH to prevent the recurrence of urinary calculi. HYDROCHLOROTHIAZIDE - Decreases urinary calcium levels and may reduce recurrence of urinary calculi. FUROSEMIDE - Increases urinary output and increases urinary calcium levels. Explanation Finasteride is a drug that reduces the size of the prostate and thereby decreases urinary retention. It is often used in patients with Benign Prostatic Hypertrophy related urinary retention. Tolterodine is an anticholinergic that is indicated for those with overactive bladder. An expected anticholinergic effect of this drug would be decreased urgency and urinary frequency. Potassium citrate is indicated for those with urinary calculi to reduce the recurrence because of its ability to alkalize the urine. Hydrochlorothiazide is a thiazide diuretic that increases urinary output while decreasing urinary calcium levels. Therefore, it may reduce renal calculi. Low-dose thiazides have been used to reduce the recurrence of calcium-containing kidney stones. Furosemide is a loop diuretic that increases urinary output and increases urinary calcium by increasing renal calcium excretion. Therefore, it is used in treating hypercalcemia. Please note the effect of Furosemide on calcium is opposite to that of Thiazide diuretics. Patients with hypercalcemic crisis and dehydration must always be given adequate fluids before they are given intravenous Furosemide. NCSBN Client need: Topic: Physiological integrity; Sub-topic: Pharmacological and parenteral therapies; expected actions/outcomes

Question 73

Calculate the equianalgesic of oral morphine when the client’s effective dosage of IV morphine was 75 mg per day. Fill in the blank. ______ mg of Oral Morphine

Answer 73

Explanation The Correct Answer is 225mg of oral morphine. The calculation of the equianalgesic of oral morphine when compared to IV morphine, which is always used to calculate equianalgesic, is done with a 3 to 1 ratio. In other words, the IV morphine is 3 times as potent as oral morphine. This calculation is shown below. Oral Morphine : IV Morphine = 3:1 ratio 75 mgof IV Morphine = (3x 75)= 225 mg of oral morphine. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation. Reference: Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition).

Question 74

A G3P3 client in labor tells the nurse, “I would like to breastfeed, but my breasts got so engorged last time. I could not take it. Do I have to go through that again?” Which of the following responses is most appropriate? A. “Keeping your baby on a 4 hourly schedule would help slow the milk production and lessen the engorgement.” B. “You can feed your baby formula milk until your milk comes in. This will reduce stimulation and prevent engorgement.” C. “You can take Parlodil to stop your milk production and prevent engorgement.” D. “You need to feed your baby as soon as possible. Also, feeding your baby often would prevent breast engorgement.”

Answer 74

Explanation Choice D is correct. Immediate and frequent breastfeeding is the key to decreasing breast engorgement in breastfeeding women. Also, the first step in treating engorgement is encouraging the mother to immediately breastfeed and continue to do so every 2 hours. Most common causes of engorgement include: A missed session of feeding or breast milk expression. Feeding the baby on a strict schedule. Less feeding by the baby due to illness/ sickness. Rapid weaning from breast milk. The mother should be educated to slow down the weaning process if she experiences engorgement during weaning. Choices A and B are incorrect. Feeding and emptying the breasts less often (Choice A) and substituting it with the formula (Choice B) increases the risk of engorgement. Having a strict feeding schedule increases the risk of breast engorgement. The amount of milk that can be stored in the breasts without causing engorgement varies from person to person. Therefore, following a fixed schedule of feeding/ expression may predispose the mother to breast engorgement and mastitis because of inadequate milk drainage. Choice C is incorrect. Parlodel (Bromocriptine) completely stops milk production; it also has serious side effects including stroke, when given to postpartum women. NCSBN Client Need Topic: Health Promotion and Maintenance; Sub-topic: Ante/Intra/Postpartum and Newborn Care Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 75

A nurse at an obstetric clinic has conducted a teaching class on sexuality during pregnancy. Which of the following comments from a participant would indicate that the teaching has been effective? A. “At around the time I would normally have my period, I should abstain from intercourse.” B. “I should no longer have sex during the last trimester of pregnancy.” C. “My sexual desire will remain the same for the entire pregnancy.” D. “The best time to enjoy sex is in the second trimester.

Answer 75

Explanation Correct Answer is D. Sexual pleasure is heightened during the second trimester of pregnancy. In the second trimester, most women experience significant relief from the discomforts of early pregnancy (nausea and vomiting, breast tenderness). The uterus is not too large to interfere with comfort and rest. The second trimester is also the time when pelvic organs are congested with blood, increasing pleasure in sexual activities. Choices A and B are incorrect. As long as risk factors such as preterm labor or incompetent cervix are not present, intercourse should not harm the pregnancy. Sexual intercourse should not be a cause of concern even in the third trimester unless risk factors such as preterm labor or placenta previa are present. Choice C is incorrect. Many women experience changes in sexual desire at different stages in pregnancy, depending on their general sense of well being and the presence of certain discomforts brought about by the pregnancy. It is not the same throughout pregnancy. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 76

Which of the following maternal deficiencies may result in neural tube defects in a fetus? A. Folic acid B. Vitamin B12 C. Vitamin E D. Iron

Answer 76

Explanation The correct answer is A.Folic acid is essential for the development of the neural tube and might prevent the defect or failure of the machine to close. B, C, and D are incorrect. Neither of these answer options is associated with neural tube defects. Neural tube defects are one of the most common congenital disabilities, occurring in approximately one in 1,000 live births in the United States. A neural tube defect is an opening in the spinal cord or brain that occurs very early in human development. The first spinal cord of the embryo begins as a flat region, which rolls into a tube (the neural tube) 28 days after the baby is conceived. When the neural tube does not close completely, a neural tube defect develops. Neural tube defects develop before most women know they are even pregnant. Neural tube defects are congenital disabilities of the brain, spine, or spinal cord. They happen in the first month of pregnancy, often before a woman even knows that she is pregnant. The two most common neural tube defects are spina bifida and anencephaly. Neural tube defects are considered a complex disorder because they are caused by a combination of multiple genes and multiple environmental factors. Known environmental factors include folic acid, maternal insulin-dependent diabetes, and maternal use of certain anticonvulsant (antiseizure) medications. While only a few environmental factors have been characterized, many different studies provide evidence that NTDs have a genetic component in their development. Studies of twins with NTDs have shown both identical twins have NTDs more than both fraternal twins. Studies of families show that the chance of having a second family member born with an NTD after one child is born with an NTD increase. For example, the general population’s chance of having an NTD is approximately 0.1% (1 in 1000). However, once the couple has one child with an NTD, their chance of having a second child with an NTD is increased to approximately 2-5%. Further studies have shown evidence for a genetic pattern of inheritance for NTDs. NTDs are a feature (or symptom) of known genetic syndromes, such as trisomy 13, trisomy 18, specific chromosome rearrangements, and Meckel-Gruber syndrome. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Physiological Adaptation Reference: Safe Maternal and Pediatric Nursing (Linnard-Palmer/Coats) Chapter 29: Child With a Neurological Condition; Lesson: Neural Tube Defects

Question 77

While reviewing fetal monitoring strips, the labor and delivery nurse notes that the piece is nonreassuring. What features characterize a fetal monitoring strip as nonreassuring? Select all that apply. A. Fetal heart rate less than 110 beats/minute. B. Increase in variability. C. Late decelerations D. Mild variable decelerations

Answer 77

Explanation Answer: A and C A is correct. A fetal heart rate less than 110 beats/minute or greater than 160 beats/minute is nonreassuring. B is incorrect. An increase in variability is a reassuring factor. A decrease in variability would be nonreassuring. C is correct. Late decelerations are an ominous sign, and immediate interventions should be taken to improve the fetal heart rate. They are characteristic of a nonreassuring heart rate. D is incorrect. Mild, variable decelerations are okay, only when the variable decelerations are severe are they nonreassuring. NCSBN Client Need Topic: Physiological AdaptationSubtopic: Alterations in Body Systems Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 363

Question 78

Expected fundal assessment findings of a woman who delivered a set of twins one hour ago via Cesarean section would be: A. Fundus 1-2 fingerbreadths above umbilicus, hard, and midline. B. Fundus need not be assessed because of the C-section. C. Fundus to the right of the umbilicus and soft. D. Fundus at the level of the umbilicus, hard, and in the midline.

Answer 78

Explanation Choice D is correct. Regardless of the mode of delivery, this is the normal postpartum fundus at one to two hours. Immediately after delivery and expulsion of the placenta, the uterus is about the size of a grapefruit and is located midline in the abdomen, halfway between the umbilicus and the symphysis pubis. Over the next several hours, the fundus will rise on the midline of the stomach to the level of or slightly above the umbilicus. Subsequently, the height of the fundus decreases by at least 1 cm or one fingerbreadth daily as the uterus goes through the process of involution. By the 10th day, the fundus is usually not palpable. Uterine “involution” refers to the return of the uterus to its pre-pregnancy size and condition. Involution begins soon after the expulsion of the placenta and occurs due to the contraction of the uterine smooth muscle. Assessing the fundus (top of the uterus) is a crucial component of post-delivery assessment—a lack of proper uterine involution results in complications such as postpartum hemorrhage. While assessing the fundus following delivery, you must evaluate for: Orientation: This represents the orientation of the fundus in relation to the umbilicus (referred by terms “to the left of the umbilicus,” “midline,” or “to the right of umbilicus”). Please note “midline” does not refer to the height of the fundus; instead, it refers to a side-to-side orientation in the midline (normal orientation). The fundus should immediately return to midline after delivery. If it deviates from the midline, it indicates “distended bladder.” Height: Assessing the height of the fundus is crucial to determine fundal descent because this is how the uterus returns to its original position in the true pelvis. Height is measured in fingerbreadths or centimeters (cm) in relation to the umbilicus (1 fingerbreadth = 1 to 1.5 centimeters). Please note immediately after delivery, the fundus is “below” the umbilicus- at midway between the symphysis pubis and umbilicus. Fundus then rises to the level of the umbilicus at about 1-2 hours post-delivery. At 12 hours, the fundus rises to 1 fingerbreadth above the umbilicus. Subsequently, it starts descending. In the next few days, fundus “descends” at a rate of 1 to 2 cm every 24 hours. Around the 6th day, the fundus is located halfway between the symphysis pubis and umbilicus. A week after birth, the uterus returns to the true pelvis. At 10 to 14 days, the fundus should not be palpable. By six weeks, the uterus returns to pre-pregnancy weight. Choice A is incorrect. The fundus is located at the level of or slightly above the umbilicus at 1 to 2 hours after delivery. At 12 hours, it is about one fingerbreadth above the umbilicus. Note that fundus rises within a few hours after birth before it begins its descent. Choice B is incorrect. The fundus must be assessed, regardless of the mode of delivery. Choice C is incorrect. The fundus should not be to the right of the midline or soft within a few hours after delivery. It should be in the midline and had. Right or leftward deviation indicates bladder distension. NCSBN Client Need Topic: Physiological Integrity; Subtopic: Reduction of Risk Potential Reference: Safe Maternity and Pediatric Nursing (Linnard-Palmer/Coats); Chapter12: Assessment and Care of the Family After Birth; Lesson: Uterine Assessment;

Question 79

While examining a client in the outpatient obstetric clinic during her first prenatal visit, the nurse looks for probable signs of pregnancy. When she palpates the abdomen, the nurse notes a rebounding of the fetus against her fingers. She documents this as __________, and knows that it is a probable sign of pregnancy.

Answer 79

Explanation Answer: Ballottement Ballottement is defined as the rebounding of the fetus against the examiner’s fingers on palpation. This is a probable sign of pregnancy. Other likely symptoms include Hegar’s sign, Goodell’s sign, and Chadwick’s sign. NCSBN Client Need Topic: Health Promotion and Maintenance Subtopic: Techniques of Physical Assessment Reference: Silvestri, L.; Saunders Comprehensive Review for the NCLEX-RN Examination, ed 6, St. Louis, 2014, Elsevier, p. 307

Question 80

A nurse is doing an assessment on a client who is 6-hours postpartum after delivering a full-term infant. The client verbalized feeling dizzy and faint. Which is the most appropriate nursing action? A. Place the client in Trendelenburg position B. Review the pre-delivery Hemoglobin and Hematocrit C. Instruct client to get out of bed slowly and ask for help when ambulating D. Inform the nursery nurse to delay rooming in until the client is stable

Answer 80

Explanation The Correct Answer is C. In the first 8 hours postpartum, orthostatic hypotension is a regular occurrence that may be manifested by feeling faint or dizzy. The nurse should reassure the client that this is normal and focus on the client’s safety. The client should always be instructed to get help when getting out of bed and ambulating until the symptoms subside. Choice A (Place the client in Trendelenburg position) is incorrect and is not an appropriate intervention currently. This position, when there is evidence of hypovolemia with shock or air embolism. Choice B (Review the pre-delivery hemoglobin and hematocrit) is incorrect. Hemorrhagic shock may manifest with blood-loss anemia and low blood pressure. However, there’s no suggestion in the question that severe intrapartum bleeding has occurred. Even if such intrapartum bleeding has occurred, reviewing pre-delivery hemoglobin is not reliable because examining the values obtained before the hemorrhagic event is of no help. Choice D (Inform the nursery nurse to delay rooming-in until the client is stable) is not necessary. The symptoms the client is experiencing are a regular occurrence in the first 8 hours postpartum and does not require delayed rooming-in. Keeping mother and baby together by rooming-in is recommended as a healthy birth practice. It promotes early breastfeeding and encourages maternal-infant bonding.

Question 81

The postpartum nurse is monitoring a new mother for signs of illness following vaginal delivery of a newborn infant. Which of the following is an early sign of excessive blood loss? A. Heart rate change from 80 bpm to 125 bpm B. Blood pressure change from 125/90 to 119/82 mm Hg C. A decrease in respiratory rate from 22 breaths per minute to 16 breaths per minute D. Reports of perineal soreness

Answer 81

Explanation The correct answer is A. An early sign of illness involves an increase in the patient’s heart rate. Tachycardia is a rapid response to hypovolemia. A heart rate change from 80 bpm to 125 bpm warrants further investigation into a possible illness. Choice B is incorrect. A blood pressure change from 125/90 to 119/82 mm Hg is not a significant drop enough to indicate hypovolemia or considerable hemorrhage. A shock is defined as mean arterial pressure less than 65 mm Hg or Systolic blood pressure less than 90 mm Hg. Choice C is incorrect. A respiratory rate decrease from 22 breaths per minute to 16 breaths per minute is an expected finding after delivery and is not alarming. Moreover, significant bleeding or hemorrhagic shock is associated with tachypnea (increase in the respiratory rate), not a decrease. Choice D is incorrect. Some perineal soreness is normal after delivery and does not necessarily indicate impending hemorrhage. NCSBN client need Topic: Health Maintenance and Promotion, Postpartum Care

Question 82

The mother of a 2-month old infant tells the nurse that her mother-in-law said to her that picking her baby up immediately when she cries, "spoils her baby". What would be the nurse's best response? A. “You can let your baby wait a while before picking her up.” B. “Babies need to be cuddled and comforted; this does not spoil your child.” C. “You need to feed her right away because crying means that they are hungry.” D. “You can just let your baby cry; she will stop once she gets tired.”

Answer 82

Explanation Choice B is correct. Infants need to have their security needs met by being held and cuddled. A is incorrect. Not picking up the baby after she has cried does not meet the baby's need for security. C is incorrect. Infants cry for many reasons. Assuming that the child is hungry and feeding them each time they cry may cause overfeeding problems such as obesity. D is incorrect. Letting the baby cry to sleep does not meet the baby's security needs. Reference Ignatavicius DD, Workman LM. Medical-Surgical Nursing: Patient-Centered Collaborative Care, 7th ed. St. Louis, MO: Elsevier; 2013

Question 83

Which of the following signs are indicative of respiratory distress in the newborn? Select all that apply. A. Respiratory rate of 48 breaths per minute B. Mild subcostal retractions C. Nasal flaring D. Head bobbing

Answer 83

Explanation Answer: C and D A is incorrect. A respiratory rate of 20 to 60 breaths per minute is standard in the newborn. B is incorrect. Mild subcostal retractions are not considered a normal finding in the newborn, but they are not enough to indicate respiratory distress. Because newborns breathe using their abdominal muscles, it is common to see some mild subcostal retractions, especially when they cry. Moderate to severe withdrawals, however, would indicate respiratory distress. C is correct. Nasal flaring is a sign of respiratory distress. If the newborn is working hard to breathe, they use extra effort when trying to pull air in through their nose, and their nares flare out with inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress. D is correct. Head bobbing is a severe sign of respiratory distress in the newborn. As they work harder and harder to breathe, they start using the muscles in their neck to pull their head forward with each inhalation. This is a sign that they are struggling to breathe and indicates respiratory distress. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Physiological adaptation Subject: Maternal and Newborn Health Lesson: Newborn Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D. (2013). Maternal child nursing care. Elsevier Health Sciences.

Question 84

The nurse is observing a client who has been in labor for 16 hours. For which of the following observations, should she notify the healthcare provider? Select all that apply. A. FHR 170-200 for 20 minutes B. Early decelerations C. Variable decelerations D. Moderate variability

Answer 84

Explanation Answer: A and C A is correct. A Fetal Heart Rate of 170-200 for 20 minutes is fetal tachycardia and should be reported to the healthcare provider. Any increase in fetal heart rate above 160 is considered tachycardia. When it persists for longer than 10 minutes, it is problematic and requires intervention. B is incorrect. Early decelerations do not need to be reported to the healthcare provider. They occur when the fetal heart rate decreases at the same time as a contraction, and are followed by a return to baseline. They occur due to the pressure of the fetus's head on the pelvis or soft tissue, and the nurse requires no intervention after an early deceleration. C is correct. Variable decelerations need to be reported to the healthcare provider immediately. They are sharp, and profound drops in the fetal heart rate unrelated to the time of contractions are a non-reassuring sign on a fetal heart rate strip. Variable decelerations are caused by cord compression, such as a prolapsed cord, and are an emergency requiring quick nursing intervention. D is incorrect. Moderate variability does not need to be reported to the healthcare provider. Variability on a fetal heart rate is defined as the fluctuations in the fetal heart rate from baseline. A moderate amount of variability is what is expected, and is considered a reassuring sign. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Reduction of Risk Potential Subject: Maternity Nursing Lesson: Problems with Labor and Delivery Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.

Question 85

When seeing a patient for her first prenatal appointment, she reports that her last menstrual period was on March 10th, 2020. Using Nägele’s rule, you estimate the date of delivery to be ___________ ( MM/DD/YYYY Format).

Answer 85

Explanation Correct Answer: 12/17/2020 (December 17th, 2020) Nägele’s rule is a simple way to estimate the expected date of delivery by using the time of a woman’s last menstrual period. Method: Obtain the date of the last day of the woman's menstrual period, add seven days, subtract three months, and then add one year. Using Nägele’s rule requires that a woman have a regular 28-day menstrual cycle, and is only an estimate.

Question 86

Which of the following are considered presumptive signs of pregnancy? Select all that apply. A. Frequent urination B. A positive home pregnancy test confirmed in the clinic C. Chloasma D. Fetal heart rate on ultrasound

Answer 86

Explanation Answer: A and C Any symptoms or signs of pregnancy reported by mother are considered "presumptive" whereas, those signs detected on a physician's exam are considered "probable". Those signs (imaging) related to fetal presence are clear "positive" signs of pregnancy. Choices A and C are correct. Frequent urination is a possible sign of pregnancy. Chloasma, or the "mask of pregnancy" is hyperpigmentation to the face, most commonly the cheeks and forehead. It is considered a possible sign of pregnancy. Choice B is incorrect. While a positive home pregnancy test reported by mother is considered "presumptive", the same is regarded as "probable" when confirmed by the physician. Choice B mentions confirmation of this finding by a physician/ clinic. Choice D is incorrect. The finding of a fetal heart rate on ultrasound is considered a positive sign of pregnancy. NCSBN Client Need: Topic: Health Promotion and Maintenance; Subject: Maternity; Lesson: Prenatal Reference: DeWit, S. C., & Williams, P. A. (2013). Fundamental concepts and skills for nursing. Elsevier Health Sciences.

Question 87

Upon noticing fetal bradycardia, the labor and delivery room nurse performs a vaginal examination on her client in labor. She discovers a pulsatile mass. What is the initial action of the nurse? A. Prepare for a Cesarean section. B. Tell the client not to push when contractions arrive. C. Escort the father out of the room. D. Place the client in Trendelenburg position.

Answer 87

Explanation Choice D is correct. Cord prolapse is a condition where the umbilical cord descends before or with the fetal presenting part. It should be suspected when there is a non-reassuring fetal heart rate tracing and absent membranes. A digital vaginal exam or external inspection will help the nurse confirm the suspicion of cord prolapse. The diagnosis is confirmed by palpating a pulsatile mass in the vaginal vault. In this condition, the presenting fetal part puts pressure on the prolapsed cord, compromising the fetal blood supply. Additionally, fetal blood flow is further compromised by umbilical vasospasm that occurs due to exposure to the cold atmosphere. Compromise of fetal blood supply results in fetal hypoxia and non-reassuring fetal heart rate pattern (Fetal bradycardia or recurrent, variable decelerations). The Trendelenburg position makes use of gravity to pull the embryo back into the uterus, relieving pressure off the umbilical cord from the presenting part. Cord prolapse is an obstetric emergency. The nurse should suspect it if fetal bradycardia or variable decelerations occur especially, immediately after the rupture of membranes. The nurse should: Call for help Avoid handling the cord, as it can cause further vasospasm and worsen outcomes. Manually lift the presenting part off the cord by vaginal digital exam. Do not push the cord back. Place the client in the left-lateral, Trendelenburg position, with head down and a pillow placed under the left hip. Prepare for immediate delivery ( usually via. emergency Cesarean section). If delivery is not immediately available and fetal decelerations persist, consider tocolysis ( eg: terbutaline)while awaiting the Cesarean section. Tocolytics relax the uterus, stop contractions, and therefore, relieve some pressure off the cord. Choice A is incorrect. With the fetus in distress, the nurse should prepare for an emergency C-section; however, this is not the first action of the nurse. Choice B is incorrect. In cord prolapse, the primary goal of the nurse is to ensure that the fetal blood supply and fetal oxygenation is restored. Telling the client not to push during contractions is an inappropriate action. Choice C is incorrect. The nurse may ask the client’s husband to leave, especially if they are disruptive. However, this is not the primary concern at this moment. Here is a short 2-minute video on Dos and Don'ts of umbilical cord prolapse : https://www.youtube.com/watch?v=iYDdB1K46wk&feature=youtu.be

Question 88

The nurse is evaluating the lab test results of one of her prenatal clients. She is eight weeks along and has a hematocrit level of 36% and hemoglobin of 11.7 gm/dL. These numbers are down from her pre-pregnancy H and H levels. The priority action of the nurse would be to: A. Call the mother and request that she have her levels redrawn. B. Record these normal findings and confirm that the client is on a prenatal vitamin during her next visit. C. Report this abnormal finding to the doctor immediately. D. Notify the lab that these results are not normal and need to be re-assessed.

Answer 88

Explanation The correct answer is B. These results are typical and should be recorded as such. A drop from pre-pregnancy values is an expected phenomenon if they remain within or close to normal range. Most women see a decrease in their hemoglobin and hematocrit levels during pregnancy. This phenomenon is known as physiological anemia and occurs as a result of increased plasma volume in the maternal bloodstream. It is essential to confirm that the client is taking the prenatal vitamins. Demand for iron is increased during pregnancy. Folic acid supplementation is necessary to prevent fetal neural tube defects. Prenatal vitamins will serve to address those needs. Choices A, B, and C are incorrect. This mother will not need emergent care, and thus the doctor does not need to be notified regarding this expected drop from pre-pregnancy values. No lab values will need to be redrawn at this time NCSBN client need Topic: Maintenance and Health Promotion, Ante / Intra /Postpartum Care Reference: Beckmann C. Obstetrics And Gynecology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014

Question 89

A G1P0 client in the first trimester of pregnancy informs the clinic nurse that she has replaced coffee with hot tea at breakfast. Her hemoglobin level was 10g/dL today, and she tells the nurse that she is taking her iron supplements twice daily. Which response by the nurse would be most appropriate? A. “You’re off to a great start! Tea has much less caffeine than coffee.” B. “A great addition to your cup of tea would be a little lemon. It’s going to help you absorb your iron pill better.” C. “Right now your iron levels are low. Please eliminate all caffeine.” D. “That’s alright. Drinking coffee or tea won’t affect the fetus.”

Answer 89

Explanation Choice B is correct.Tannins are polyphenolic compounds found in plants, wood, leaves, fruits, and tea. The tannin that is present in tea decreases the absorption of iron. But adding lemon juice, which is high in vitamin C, seems to cancel the inhibitory effect of tannin on iron absorption. There is also no evidence that caffeine affects the absorption of iron, but when consumed in large amounts during pregnancy, it may increase the risk of spontaneous abortion, preterm birth, and small-for-gestational-age newborns. It also affects calcium and zinc in terms of absorption and excretion. The correct answer, therefore, is option B, while statements A, C, and D are incorrect. Reference: Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins.

Question 90

The nurse is taking vital signs on a pregnant client in active labor. When she inflates the blood pressure cuff, she looks at the fetal monitor and notices that the fetal heart rate increases above baseline and then returns to baseline about 15 seconds later. What is the priority nursing action? A. Notify the healthcare provider. B. Document and continue to monitor C. Place the mother on her left side D. Administer 100% FiO2 via face mask

Answer 90

Explanation Answer: B A is incorrect. The nurse has observed an acceleration in the fetal heart rate, which is an increase in fetal heart rate by 15 bpm above the baseline. An acceleration lasts about 10-15 seconds, and then the heart rate returns to baseline, as the nurse observes in this question. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip. The nurse does not need to report this to the healthcare provider. B is correct. Because the nurse has noted a reassuring sign of the fetal heart rate, it is appropriate for her to document the finding and continue to monitor the mother. If the nurse had noticed a non-reassuring sign, other interventions would be necessary. C is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require repositioning of the mother to the left side. Repositioning the mother to the left-lateral position will be needed if a non-reassuring sign (e.g., fetal bradycardia, late decelerations) is noted. D is incorrect. Accelerations are a reassuring sign observed on a fetal heart rate monitoring strip and do not require administration of 100% FiO2 via face mask. NCSBN Client Need: Topic: Effective, safe care environment Subtopic: Coordinated care Subject: Maternity Nursing Lesson: Problems with Labor and Delivery Reference: Leifer, G. (2019). Introduction to maternity and pediatric nursing.

Question 91

Upon your arrival in the Labor and Delivery (L & D) department, the off-going nurse informs you that your patient is a G1P0, 18-year-old, and the fetus is in the ROA position. As an L&D nurse, you know that when you palpate your patient's abdomen, you will find <>

Answer 91

Explanation The Correct Answer is A. The image is showing the fetus in the ROA (Right Occiput Anterior) position. The presenting part (Occiput, back of the head) is directed rightwards and anterior to the mother’s pelvis. Fetal “Position” represents the orientation of the fetus in the mother’s womb, defined by the location of the presenting part of the embryo relative to the pelvis of the mother. When dealing with the presentation of the fetus, the fetal position is indicated with three letters. The first letter will be either R or L, indicating right or left orientation. The second letter will be either O, M, or S. This indicates the presenting part of the fetus: O for Occiput (head/ vertex presentation), M for Mentum (chin/ face presentation), or S for Sacrum (bottom/ breech presentation) or Scapula (Shoulder presentation). The last letter will be either A or P. This indicates if the presenting part of the fetus is oriented anterior or posterior or transverse to the mother’s pelvis. Choice B shows the fetus in the LOT (Left Occiput Transverse) position. The Occiput is facing felt and is transversely positioned about the mother’s pelvis. Choice C shows the fetus in the ROP (Right Occiput Posterior) position. Choice D shows the fetus in the LOA (Left Occiput Anterior) position.LOA is the most common fetal position. The Occiput-Anteriorposition is the most ideal for birth. NCSBN Client Need Topic: Health Promotion and Maintenance Subtopic: Ante/Intra/Postpartum and Newborn Care

Question 92

Which of the following obstetrical procedures can be used to assist the head of the fetus during vaginal delivery? Select all that apply. A. Amniotomy B. Forceps assisted delivery C. External version D. Vacuum assisted delivery

Answer 92

Explanation Choices B and D are correct. Forceps are tools used to help pull on the head of the baby to assist with the delivery. Vacuum-assisted delivery is a method where suction is applied to the head of the baby and pulled while the mother pushes. This helps to deliver the head of the infant. Choice A is incorrect. An amniotomy is the use of a hook or finger to break the amniotic sac. This helps to induce labor but does not assist in the delivery of the head of the fetus. Choice C is incorrect. The external version is a technique used when the baby is not in an appropriate position for vaginal delivery. The external cephalic version is used to turn a fetus from a breech position or side-lying (transverse) position into a more favorable head-down (vertex) position to help prepare the baby for a vaginal delivery. The external version is typically done before the labor begins, often around 37 weeks. Occasionally, it is done during the labor but before the membranes have ruptured. If the amniotic sac has ruptured or if there is not enough amniotic fluid around the fetus (oligohydramnios), version must not be done as it may end up injuring the fetus. Version does not directly assist in the delivery of the head of the fetus. NCSBN Client Need: Topic: Physiological Integrity Subtopic: Risk potential reduction Reference: Perry, S. E., Hockenberry, M. J., Lowdermilk, D. L., & Wilson, D.Maternal child nursing care. Elsevier Health Sciences.

Question 93

A 25-year-old female client at ten weeks gestation has mild fatigue. While reassuring her that this is expected, the nurse also knows all the following are regular changes during various trimesters of a healthy pregnancy? Select all that apply. A. Thyroid gland decreases in size B. Maternal blood volume increases C. Intestinal mobility increases D. Diastolic blood pressure decreases

Answer 93

Explanation Choices B and D are correct. To provide adequate nutrition and gas exchange for the developing fetus, a woman’s body undergoes several changes during pregnancy, including cardiovascular, hematologic, metabolic, renal, and respiratory changes. In a healthy pregnancy, maternal blood volume may increase by as much as 40 to 50% by week 32 of the pregnancy. Despite this increase in red blood cell production, the mother may develop dilutional physiological anemia. Mild to moderate fatigue may be experienced. During the second trimester, the nurse might note a decrease in diastolic blood pressure. Cardiac output may decrease as the mother changes positions. Choice A is incorrect. The thyroid and pituitary glands typically increase in size during pregnancy, not decrease. Reflecting the increased metabolic needs during pregnancy, TSH (thyroid-stimulating hormone) increases, and therefore, thyroid volume increases. Choice C is incorrect. Intestinalmobility decreases as progesterone levels increase to allow for increased absorption of nutrients. The nurse should be aware that this change may also increase the risk of constipation. NCSBN Client Need Topic: Health Promotion and Maintenance; Sub-topic: Ante/Intra/Postpartum Care Reference: Brown KP. Antenatal care. In: Management Guidelines for Nurse Practitioners Working with Women. 2nd ed. Philadelphia, PA: FA Davis; 2004:177–223.

Question 94

A mother in her first trimester of pregnancy is very upset that she feels constantly nauseous. You reassure her that the nausea is common in the first trimester. In addition, which of the following advice would you share with her? Select all that apply: A. Eat dry crackers before getting out of bed in the morning. B. Drink small sips of liquids throughout the day rather than large amounts with the meals. C. Eat only three moderate size meals a day. D. Brush teeth immediately after eating to avoid smells and tastes that trigger nausea.

Answer 94

Explanation Answer: A and B A is correct. Eating dry crackers in the morning before rising is standard advice to help decrease nausea. B is correct. It is recommended to drink small sips of liquids throughout the day rather than drinking large amounts with meals. C is incorrect. It would be better to recommend eating small frequent meals spread throughout the day. Low-fat meals are also advised to decrease nausea. D is incorrect. It is better to avoid brushing teeth immediately after a meal and shortly after getting out of bed in the morning to prevent nausea. NCSBN Client Need: Topic: Health Promotion and Maintenance Subtopic: N/A Reference: Lowdermilk et al. (2012), p. 326 Subject: Maternal health Lesson: Antepartum

Question 95

You are educating a 25-year-old obese client (Body Mass Index, BMI of 31) at 12 weeks gestation, who presents for a routine antenatal check-up. She gained 3 pounds compared to pre-pregnancy weight. Which of the following statement(s) by the client reflect correct understanding regarding recommended weight changes in pregnancy? Select all that apply. A. “Since I am obese, I should try to lose weight now to limit my risk of gestational diabetes.” B. “Typically, there is a 3 to 6 pounds of weight gain during the first trimester of pregnancy.” C. “In the third trimester, a weight gain of 2 pounds or more each week is considered high.” D. “I should aim to gain a total of 25 to 35 pounds during this pregnancy.” E. “Going forward in my pregnancy, I should aim to gain ½ pound per week.”

Answer 95

Explanation The Correct Answers are B, C, and E. Weight gain is considered crucial during pregnancy. A pregnant woman should be educated regarding what is deemed to be reasonable in terms of pregnancy weight gain and the implications of gaining too much or too little weight. The client needs to keep track of the rate of weekly weight gain. Guidelines have been proposed to assist with determining the rate of healthy weekly weight gain. Weight gain of 3 to 6 pounds during the entire first trimester (first three months) is considered normal and healthy (Choice B). Gaining 2 pounds or more per week at any time (Choice C) during pregnancy would be abnormally high, and such a client should focus on limiting the further rate of weight gain. The client in the question has already gained 3 pounds, which is healthy. Going forward, she should aim to learn about 8 to 17 pounds in the next six months ( about half a pound per week for the rest of her pregnancy). This is based on the recommended weight gain of 11-20 pounds during the entire pregnancy for someone with a BMI of 30 or above (obese).

Question 96

The nurse is taking care of a client with neuropathic pain. He is already on Acetaminophen and Gabapentin, but no relief. He rates his pain at six on a numerical pain rating scale of 0 to 10. According to the WHO Three-Step Analgesic Ladder, which of the following is indicated next? A. Ibuprofen plus Dexamethasone B. Tramadol plus Acetaminophen plus Gabapentin C. Hydromorphone plus Gabapentin D. Hydrocodone plus Gabapentin

Answer 96

Explanation Choice B is correct. On a numerical 0-10 pain scale, a rating of 0 represents “no pain,” 1-3 represents mild pain, a rating of 4-6 represents moderate pain, and a score of 7-10 represents severe pain. A pain rating of # 6 is considered reasonable on a numerical pain 0-10 rating scale. The client has already been given Step 1 medication (Acetaminophen) along with an adjuvant agent (gabapentin) and still has moderate pain. According to the Three-Step Analgesic Ladder that was developed by the World Health Organization (WHO), a step 2 analgesic medication (Tramadol) is indicated when the client is complaining of moderate pain that is not responding to non-opioid analgesics (Acetaminophen) plus adjuvant medication ( Gabapentin). The WHO three-step ladder is considered the pain treatment standard and provides a guideline for pain treatment. It presents a multifaceted approach to pain treatment in which opioids are considered secondary and not primary. The idea is not to restrict opioids but use them only as necessary. The ladder recommends maximizing non-opioid measures before moving to opioid agents. Non-opioid actions are grouped into two categories: non-opioid analgesics and adjuvant therapies. Adjuvant therapies include both adjuvant non-analgesic medications as well as non-pharmacologic tests. Examples of adjuvant medications in pain management include Gabapentin or Duloxetine for Neuropathic pain; Dexamethasone or Bisphosphonates for pain from bone metastases. Adjuvant non-pharmacologic therapies include acupuncture, physical measures, and psychotherapy. In WHO three-step ladder, opioids are added to the existing regimen of non-opioid analgesics and adjuvants and are not supposed to replace the current regimen. This strategy maximizes pain control by using the least amount of opioid possible. Choice B is incorrect. A step 1 medication (Ibuprofen) is not the category of analgesic to be used when the client is describing the pain as a # 6 (moderate). A step 2 strategy on the WHO ladder must be used. Choice C is incorrect. Hydromorphone is a potent opioid (Step 3, Analgesic). A step 3 strategy is not indicated before trying Step 2 strategy for moderate pain. For severe pain ( 7 to 10 on the numerical scale), step 3 agents can be given. Choice D is incorrect. Hydrocodone is a potent opioid (Step 3, Analgesic). A step 3 strategy is not indicated before trying Step 2 strategy for moderate pain. For severe pain ( 7 to 10 on a numerical scale), step 3 agents can be given. NCSBN Client Need: Topic: Pharmacological therapies; Sub-Topic: Pharmacological pain management

Question 97

Calculate the equianalgesic of oral morphine when the client’s effective dosage of IV morphine was 50 mg per day. Fill in the blank. ______ mg of Oral Morphine.

Answer 97

Explanation The Correct Answer is 150 mg of oral morphine. The calculation of the equianalgesic of oral morphine when compared to IV morphine, which is always used to calculate equianalgesic, is done with a 3 to 1 ratio. In other words, the IV morphine is three times as potent as oral morphine. So the dose of Oral Morphine to provide equianalgesic effect should be three times that of IV morphine dose. This calculation is shown below. Oral Morphine Equianalgesic Dose = 3 x ( Dose of IV Morphine) So 50 mg of IV morphine = 3 x (50) = 150 mg Oral Morphine. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation. Reference: Kozier and Erb’s Fundamentals of Nursing: Concepts, Process, and Practice (10th Edition)

Question 98

The nurse is caring for a client with premature labor receiving terbutaline infusion. All of the following manifestations would alert the nurse to stop the infusion, except: A. Blood pressure of 91/58 mm Hg B. Heart rate of 132 beats/minute C. Serum potassium level of 3.3 mEq/L D. Blood glucose level of 130 mg/dL

Answer 98

Explanation Choice D is correct. Terbutaline may increase the blood glucose level. The nurse should monitor the client’s blood sugar levels while on this drug. However, this client’s blood sugar level is at 130 mg/dL, an acceptable value to continue Terbutaline infusion. Choice A is incorrect. Terbutaline is a beta-agonist. By acting on beta-2 receptors in vascular smooth muscle, it causes vasodilation. Hypotension is a common side effect of Terbutaline. The nurse should stop the infusion when the blood pressure drops below 90/60 mm Hg. Choice B is incorrect. By acting on beta-1 receptors in the heart, Terbutaline increases the heart rate (Tachycardia). Tachycardia is also a common side effect of Terbutaline. The nurse should stop the infusion when the heart rate is more than 120 bpm. Choice C is incorrect. Hypokalemia is another common side effect of Terbutaline. The client's potassium is only 3.3 mEq/L. A serum potassium level less than 3.5 mEq/L is considered Hypokalemia. Hypokalemia should alert the nurse to stop the terbutaline infusion. Reference Pillitteri, A. Maternal and Child Health Nursing: Care of the Childbearing and Childbearing Family, 4th Edition; Lippincott, Williams & Wilkins, 2003

Question 99

SORRY EXACT NO EXACT QUESTION COPIED

Answer 99

06-01-2021 Last Updated Explanation B is the correct answer. Because of the shortness of breath, leg swelling, and patient’s age, the nurse can suspect this patient is suffering from Congestive Heart Failure (CHF). The drug of choice in managing fluid overload in CHF is a loop-acting diuretic, Furosemide, or Lasix. Furosemide acts on the ascending limb of Henle's loop and blocks the sodium-potassium-chloride cotransporter; thus, inhibiting sodium and chloride reabsorption. Decreased NaCl reabsorption will result in hypotonicity in the nephron's interstitial space, leading to significant free water excretion. Furosemide is also used in managing non-cardiac peripheral edema, fluid retention, and ascites. A is incorrect. Mannitol is a diuretic used for reduction in increased intracranial pressure. This is because mannitol is an osmotic diuretic that does not cross the blood-brain barrier. A gradient is developed between plasma and brain cells, causing a shift from the extracellular space into the blood vessels. C is incorrect. Hydrochlorothiazide is a thiazide diuretic. These diuretics also inhibit sodium/ chloride cotransporter, but their site of action is in the "distal convoluted tubule" of the nephron. Thiazide diuretics are used in treating hypertension. The amount of NaCl reabsorption in the distal tubule is small. Therefore, blocking this site alone does not cause large enough diuresis. Hence, thiazides are not the drug of choice in heart failure. In CHF, loop diuretics are most effective because their site of action is on Henle's loop, where 25% of NaCl reabsorption occurs. Hence, these agents promote the most effective diuresis in CHF. D is incorrect. Aldactone is a potassium-sparing diuretic. Aldactone helps treat high blood pressure, edema, ascites, and treat conditions with high hormone aldosterone levels ( conn's syndrome, primary hyperaldosteronism). NCSBN Client Need Topic: Pharmacological and Parenteral Therapies Reference: Lewis, Dirksen, Heitkemper, Bucher, 2013

Question 100

The nurse is providing education for a diabetic client who is given a Terbinafine (Lamisil) prescription for Onychomycosis. Which statement(s) by the client demonstrates a good understanding regarding his treatment with terbinafine? Select all that apply. A. “Following a successful course of treatment, my chance of getting cured is 90%.” B. “I will have to take Terbinafine for 3 to 6 months.” C. “I will need Liver function tests before starting Terbinafine.” D. “I will take this on empty stomach to help improve its absorption.” E. “It may cause taste or vision changes and, I will report vision changes to my doctor.” F. “Dark urine, pale stools, and persistent nausea may indicate a serious side effect.”

Answer 100

Explanation Choices B, C, E, and F are correct. Onychomycosis, also known as Tinea unguium, is a fungus infection of the nails (fingernails, toenails) that causes the nails to look thick, discolored, opaque, and crumbling. Dermatophytes cause 90% of these toenail infections. Remaining 10% are caused by non-dermatophytes (Saprophytes), and yeast (Candida). Treatment involves topical antifungals and systemic antifungals (Terbinafine, Lamisil). By inhibiting squalene epoxidase, Terbinafine blocks the synthesis of Ergosterol (Ergosterol is a crucial component of the fungal cell membranes). The nurse should be aware of the interactions and essential side effects of Terbinafine because it is one of the commonly prescribed antifungal drugs. Client education points include: Even after prolonged treatment, failure and recurrence rate is high (20 to 50% failure). The cure rate with TerbinafineTerbinafine is close to 50%. (Choice A is incorrect). Duration of treatment of toenail onychomycosis is typically much longer (3 to 6 months) compared to that of fingernails (1 month). Educate the client regarding the prolonged duration of treatment and instruct them to be compliant (Choice B is correct). Educate the client regarding essential side effects and when to contact the healthcare provider. Common side effects include headache, gastrointestinal side effects (abdominal pain, nausea, dyspepsia, diarrhea), rash, and taste changes. To minimize gastrointestinal side effects, Terbinafine should be taken with food. Taking it on an empty stomach may exacerbate gastrointestinal side effects (Choice D is incorrect). Vision changes may also occur. These may represent changes in the retina and must be reported immediately to the provider (Choice E is correct). Rarely, Terbinafine can cause severe liver toxicity. This can happen in even those without pre-existing liver disease. Yellow-colored urine, pale stools, jaundice, and persistent nausea may indicate acute liver damage (Choice F is correct). Baseline liver function tests (LFTs) must be checked before initiation of Terbinafine (Choice C is correct). In the past, LFTs have been monitored every 4 to 6 weeks while on Terbinafine, but new guidelines do not require routine monitoring of LFTs. NCSBN Client Need: Topic: Pharmacological and parenteral therapies; Sub-topic: Adverse Effects/Contraindications/Side Effects/Interactions

Question 101

A patient is prescribed a calcium channel blocker to treat primary hypertension. When teaching the patient about the medication, which of these foods will the healthcare provider advise the patient to avoid? A. Eggs B. Milk C. Grapefruit D. Bananas

Answer 101

Explanation Grapefruit and its juice contain furanocoumarins, which block the enzymes that are involved in metabolizing many drugs, including calcium channel blockers. Medication blood levels can increase, resulting in toxicity. The levels of calcium channel blockers are increased when grapefruit or grapefruit juice is consumed, potentially causing hypotension. The correct answer is C. Grapefruit can interfere with other drugs, as well, including statins (atorvastatin, lovastatin, simvastatin), some antibiotics, and some cancer drugs. A, B, and D are incorrect. Neither of these answer options adversely affect calcium channel blockers. NCSBN Client Need Topic: Physiological Integrity Subtopic: Pharmacological Therapies Chapter 15: Drugs for Hypertension Lesson: Calcium Channel Blockers Reference: Core Concepts in Pharmacology (Holland/Adams)

Question 102

Which of the following should the nurse include in education provided to a patient who is taking Lisinopril? (Select All That Apply.) A. “It may take several months for your blood pressure to return to normal.” B. “You must have your potassium monitored from time to time.” C. “This medication may change your color vision at times.” D. “You may notice a change in your sensation of taste.”

Answer 102

Explanation Answer and Rationale: Angiotensin-converting enzyme (ACE) inhibitors reduce the afterload on the heart and lower blood pressure. They are drugs of choice in the treatment of heart failure. ACE inhibitors have been shown to slow the progression of heart failure and to reduce deaths from heart disease. The first action of ACE inhibitors is to lower blood pressure and reduce blood volume. A, B, and D are correct. o A: Lisinopril may require 2-3 weeks of adjustment to reach maximum effectiveness, and several months of therapy may be needed for a patient’s functional status to return to normal. o B: High potassium levels may occur during treatment. The use of potassium supplements or potassium-sparing diuretics should be avoided. Electrolyte levels should be monitored periodically. o D: Other side effects that may be associated with Lisinopril include cough, taste disturbances, and hypotension. C is incorrect. Visual disturbances such as blurred vision may happen with Lisinopril but color vision changes are not an anticipated side effect associated with Lisinopril. NCSBN Client Need Topic: Physiological Integrity;Subtopic: Pharmacological Therapies Reference: Core Concepts in Pharmacology (Holland/Adams); Chapter15: Drugs for Hypertension;Lesson:AntihypertensiveMedications

Question 103

A nurse is caring for a client who has developed bradycardia. Which prescription should the nurse question? A. propranolol B. furosemide C. spironolactone D. valsartan

Answer 103

Explanation Choice A is correct. Propranolol is a non-selective beta-blocker. Propranolol is used in the management of hypertension and migraine prevention. While it reduces blood pressure, it can also decrease heart rate (bradycardia) by blocking beta-1 receptors. Therefore, if a client is experiencing bradycardia, the client should not receive any medications that can lower the heart rate further. Choices B, C, and D are incorrect. Furosemide, spironolactone, and valsartan lower blood pressure through different mechanisms, but they do not decrease heart rate.

Question 104

Your 75 year old female client complains of pain due to post-herpetic neuralgia. She is taking Naproxen. Which of the following coanalgesics should be added to her pain management regimen? A. Oxycodone B. Acetaminophen C. Ibuprofen D. Topical Lidocaine

Answer 104

Explanation Choice D is correct. Topical lidocaine, is a co-analgesic. Coanalgesics are also referred to as "adjuvant analgesics." It is crucial to use adjuvant analgesics for adequate pain control before moving to initiate opioid analgesics ( WHO pain ladder). Topical Lidocaine is very useful in local control of post-herpetic neuralgia pain. The lidocaine patch provides analgesia by reducing abnormal firing of sodium channels on injured pain nerve fibers directly under the piece. Topical patches are considered relatively safe because only less than 5% of the topically applied lidocaine is absorbed. Choice A is incorrect. Oxycodone is not a coanalgesic. It is an opioid analgesic. Choice B is incorrect. Acetaminophen is not a coanalgesic. It is classified under nonopioid analgesics. Choice C is incorrect. Ibuprofen not an analgesic. It's a nonopioid analgesic and an NSAID (a non-steroidal anti-inflammatory agent) like Naproxen. Berman, Audrey, Snyder, Shirlee, and Geralyn Frandsen. (2016). Kozier and Erb’s Fundamentals of Nursing.

Question 105

You are administering a transfusion of 1 unit of PRBCs to a 63-year-old client with hemoglobin of 8.9gm%. Listed in the Exhibit are his vital signs pre-transfusion, 5 minutes into the transfusion, and 10 minutes into the transfusion. What should the nurse do after 10 minutes of administering the transfusion? Select all that apply. << As shown in the exhibit, there is an increase in temperature and a drop in the blood pressure >>> A. Continue to monitor the patient’s response to the transfusion B. Notify the health care provider C. Stop the transfusion D. Take another set of vital signs at the next 10 minute interval

Answer 105

Explanation The correct answers are B and C. As shown in the exhibit, there is an increase in temperature and a drop in the blood pressure following the blood transfusion. Based on the vital signs the nurse has obtained, she expects that the patient is having a transfusion reaction. Transfusion reactions are adverse reactions that happen as a result of receiving a blood transfusion. Signs and symptoms of a transfusion reaction include fever, chills, diaphoresis, muscle aches, back pain, rashes, dyspnea, pallor, headache, nausea, apprehension, tachycardia, and hypotension. (Most common symptoms ca be remembered by a Mnemonic – REACTION – Rash, Elevated temperature, Aching, Chills, Tachycardia, Increased pulse, Oliguria – low urine output, and Nausea.) Most transfusion reactions occur during the first 15 minutes. While initiating blood transfusion, it should be started slowly at a rate of 2 mL/min (120 mL/hr) for the first 15 minutes – the idea here is to minimize the volume of the blood infused if the patient were to develop a reaction. The nurse should use 18 gauge or larger cannula to infuse because a smaller cannula may lead to mechanical lysis of red cells. The nurse should remain at the patient’s bedside for the first 15 minutes and if the blood is tolerated for 15 minutes without a reaction, the infusion rate can be increased. Blood transfusion units are usually at 250 ccs to 300 cc in volume. Transfusion must be completed within 4 hours. As per blood transfusion protocol used in most centers, vitals must be obtained at 5 minutes, 15 minutes, 30 minutes from the start of the infusion, 1 hourly until the infusion is completed, and then at 1 hour after the transfusion. Even if the patient is not complaining of the typical signs and symptoms, if their vital signs indicate a possible transfusion reaction, the transfusion should be stopped. In this client, the heart rate is trending up, blood pressure is trending down, and the temperature is trending up. At 10 minutes, he is tachycardic, hypotensive, and febrile. The patient is having a transfusion reaction. This requires immediate intervention. Therefore, the nurse should immediately stop the transfusion (Choice C); disconnect blood tubing from the intravenous site and notify the health care provider (Choice B). Choice A is incorrect. It is inappropriate to continue monitoring the patient’s response to the transfusion. Their vital signs are out of normal limits and an intervention is required. Choice D is incorrect. The nurse will begin continuously monitoring vital signs now that she suspects a transfusion reaction. It would be inappropriate for her to wait 10 minutes to take another set of vitals. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies Subtopic: Blood and Blood Products. Reference: Potter P, Perry A, Stockert P, Hall A: Fundamentals of nursing, ed 8, St. Louis, 2013, Mosby, p. 912 https://player.vimeo.com/video/409317953

Question 106

The nurse is providing discharge instructions to a client with accelerated hypertension who has been newly started on Nifedipine. His home medications include calcium supplements for osteoporosis, omeprazole for heartburn, furosemide, and lisinopril. Which statement(s) by the client demonstrates the need for additional teaching regarding Nifedipine? Select all that apply A. “If I get ankle swelling with this medication, furosemide will help.” B. “My gums may swell because of this medication.” C. “I will avoid getting up too quickly from sitting or lying position.” D. “I will check my pulse daily as the drug may significantly slow my heart rate.” E. “I will stop taking calcium supplements since they may negate the effects of Nifedipine.” F. “It is highly likely that I will get constipated from this drug.” G. “My heartburn may worsen with this medication.” H. “If I get cough and tongue swelling, I will hold Nifedipine”

Answer 106

Explanation Correct answers are A, D, E, F, and H. Calcium channel blockers (CCBs) are very commonly used to treat hypertension. The nurse needs to be aware of the common side effects of calcium channel blockers and educate the clients appropriately. There are two classes of calcium channel blockers: Dihydropyridines and Non-dihydropyridines. Dihydropyridines, including nifedipine and amlodipine, are more selective to blood vessels (potent vasodilators) and have little or no effect upon cardiac contractility/ conduction. These are used to treat hypertension or chronic stable angina. Significant side effects include dose-dependent pedal edema, headache, flushing, and orthostatic hypotension. Non-dihydropyridines, including verapamil and diltiazem, are less vaso-selective (less potent vasodilators) but more cardio-selective (depress cardiac conduction and contractility). These are used to treat cardiac arrhythmias, hypertension, chronic stable angina. Significant side effects include dose-dependent constipation, bradycardia, and reduced cardiac output. Their mechanisms of action explain their different side effect profiles. Dihydropyridines like Nifedipine cause peripheral edema in 20 to 30 percent of clients. The mechanism of this edema involves the redistribution of fluid from the intravascular compartment into the interstitial compartment. Therefore, this edema is not from fluid retention or increased plasma volume. Diuretic therapy with Furosemide will not help treat this pedal edema. Therefore, Choice A does not reflect correct understanding by the client and needs additional teaching. Since this edema is dose-dependent, it is often treated by a reduction in dose of the CCB. Rather than just taking other furosemide, the client needs to contact the healthcare provider so the edema can be addressed with dose adjustment. Dihydropyridines like Nifedipine have minimal effect on cardiac contractility or conduction. They do not cause bradycardia. On the contrary, they may cause reflex tachycardia due to vasodilation. Therefore, Choice D does not reflect correct understanding by the client and needs additional teaching. Please note that because of their cardo-selectivity and suppressive effect on contractility/ conduction, Verapamil and Diltiazem cause bradycardia and decreased cardiac output (seen in 25% patients on Verapamil). While IV calcium gluconate/ calcium chloride is often used to treat toxicity from calcium channel blockers, there is no evidence to say oral calcium supplements will reduce the effects of CCBs. Also, this client needs calcium supplements for his osteoporosis. Therefore, Choice E does not reflect correct understanding by the client and needs additional teaching. Constipation is a more common side effect with Non-Dihydropyridines like Verapamil (20% incidence). Illness is less common with Dihydropyridines. While there is a less than 2% chance that the person can get constipated from Nifedipine, it is not true that the client is highly likely to get constipated from Nifedipine. Therefore, Choice F does not reflect correct understanding by the client and needs additional teaching. It is those Clients that are on Verapamil that need to be instructed to increase their fiber intake significantly. Constipation with Verapamil is dose-dependent. Cough and tongue swelling (Angioedema) are common side effects seen with ACE inhibitors, not with CCBs. The client is also on Lisinopril (ACEI), which may lead to this side effect, so the nurse will need to explain this to the client. Therefore, Choice E does not reflect correct understanding by the client and needs additional teaching. Choice B is incorrect. Choice B reflects a correct understanding and does not need additional teaching. Gum/ gingival hyperplasia is familiar with extended-standing use of Nifedipine. Both Dihydropyridines and Non- Dihydropyridines may cause this. It is more common with Nifedipine than with Amlodipine. Choice C is incorrect. Because of peripheral vasodilation, Dihydropyridines like Nifedipine cause postural or orthostatic hypotension. So, the client should be aware of getting up slowly from the lying/ sitting position (Choice E), so they do not become dizzy. Choice E reflects a correct understanding and does not need additional teaching. Choice G is incorrect. All calcium channel blockers reduce the pressure in the lower esophageal sphincter exacerbating heartburn. This effect is seen more with Amlodipine/ Nifedipine. Of all the CCBs, Diltiazem is least likely to increase reflux symptoms. Therefore, it may be more appropriate to prefer diltiazem over other CCBs in patients with moderate to severe heartburn. Choice G reflects a correct understanding and does not need additional teaching.

Question 107

Your client is experiencing severe, acute anxiety prior to a scheduled endoscopy procedure. Which of the following medications is most likely to be ordered by the physician? A. Oxycodone B. Midazolam C. Clonazepam D. Haloperidol

Answer 107

Explanation The correct answer is B. Midazolam (Versed) is a benzodiazepine used for acute anxiety attacks. Midazolam is preferred in this setting because of “Rapid Onset” (2 to 5 minutes after IV administration) and “Short Duration” of action (3 to 8 hours). It can be administered intravenously or orally. Given these benefits, Midazolam would be the most useful for the patient experiencing an acute anxiety attack before or during endoscopic procedures, or before surgery. Additional benefits of Midazolam during procedures are sedation and amnesia. Midazolam as continuous IV infusion is also used in sedating mechanically ventilated patients in critical care settings. The nurse should keep Flumazenil as an antidote ready in case severe respiratory depression occurs with benzodiazepines. Choice A is incorrect. Oxycodone is an opioid pain medication. This is prescribed for severe pain. It is not indicated for the patient experiencing an acute anxiety attack. Choice C is incorrect. Clonazepam is a long-acting benzodiazepine often used in anxiety attacks after a traumatic event, panic disorders, or generalized anxiety disorder. Your client has pre-procedural anxiety and, therefore, does not need a long-acting anxiolytic. Your client needs an anxiolytic with a rapid onset of action and short duration. Midazolam fits that criteria among the above list. Choice D is incorrect. Haloperidol is an antipsychotic and is often used in mental health settings to address acute and severe agitation/ aggression associated with psychiatric disorders (Schizophrenia, Substance intoxication). It would not be useful for a patient experiencing pre-procedural acute anxiety.

Question 108

Calculate the equianalgesic of oral hydromorphone below. The equianalgesic chart on the wall of the medication room states that 10 mg of IV morphine is equivalent in terms of potency to 7.5 mg of oral hydromorphone and the client has been effectively treated with 60 mg of IV morphine. Fill in the blank. ______ mg of Oral Hydromorphone.

Answer 108

Explanation The Correct Answer is 45 mg of oral hydromorphone. The calculation of the equianalgesic of oral hydromorphone when compared to IV morphine, which is always used to calculate equianalgesic, is as shown below when 10 mg of IV morphine is equivalent in terms of potency to 7.5 mg of oral hydromorphone. 10 mg IV Morphine = 7.5 mg Oral Hydromorphone. 1 mg of IV Morphine then equals 0.75mg of Hydromorphone ( 7.5/10) so Equi-analgesic factor = 0.75. Multiply IV morphine dose with Equi-analgesic factor to arrive at oral hydromorphone dose. 60 mg IV Morphine = 60 x 0.75mg oral Hydromorphone= 45 mg of oral hydromorphone. NCSBN Client Need: Topic: Pharmacological and Parenteral Therapies; Sub-Topic: Pharmacological Pain Management; Dosage Calculation.

Question 109

The equianalgesic chart on the wall of the medication room states that 10 mg of IV morphine is equivalent to 7.5 mg of oral hydromorphone in terms of potency. Your client has been effectively treated with 80 mg of IV morphine. Calculate and fill in the blank with the equianalgesic dose of oral hydromorphone. ______ mg of Oral Hydromorphone ( Please enter numeric only).

Answer 109

Explanation The correct answer is 60mg of oral hydromorphone. The calculation of the equianalgesic of oral hydromorphone, when compared to IV morphine, should be made based on known equivalent potency. The potency of 10 mg of IV morphine is equivalent to that of 7.5 mg of oral hydromorphone. 10 mg IV Morphine = 7.5 mg Oral Hydromorphone. 1 mg of IV Morphine then equals 0.75mg of Hydromorphone ( 7.5/10) so Equi-analgesic factor = 0.75. Multiply IV morphine dose with Equi-analgesic factor to arrive at oral hydromorphone dose. 80 mg IV Morphine = 80 x 0.75mg oral Hydromorphone= 60 mg of oral hydromorphone.

Question 110

The nurse is caring for a 2 year old child with hypovolemic shock due to severe dehydration. The child weighs 11 kg. After obtaining appropriate IV access, the nurse prepares to administer 0.9% Normal Saline fluid bolus. Please enter the amount of initial fluid bolus to be administered in milliliters. Enter numerical value only. ____ milliliters. ml

Answer 110

Explanation The child should be given normal saline bolus at a dose of 20 ml/ kilogram over 5 to 15 minutes. The child’s weight is 11kg. IV fluid Bolus to be administered = 20 x 11 = 220 ml over 5 to 15 minutes. Repeat the blouses as necessary. Severe dehydration can present with impaired perfusion ( reduced capillary refill, loss of skin turgor, and reduced urinary output), hypovolemic shock, acute renal failure, and altered mental status. Rapid fluid resuscitation is the key. The principles of hypovolemic shock management per pediatric advanced life support (PALS) should be followed. Peripheral intravenous access should be obtained rapidly. If peripheral IV access unsuccessful, an intraosseous (IO) access should be obtained and resuscitation should begin immediately. A 20 mL/kg bolus of an isotonic crystalloid should be given over 5-15 minutes, followed by clinical evaluation of perfusion status, vital signs and mental status. Repeat boluses should be administered as necessary. In general, most children in hypovolemic shock will require at least 60 mL/kg of fluid in the first hour to achieve stabilization.

Question 111

The nurse is preparing to administer a prescribed dose of lactulose 20 grams orally QID to a client with portal-systemic encephalopathy. The medication is available at 3.33 grams per 5ml oral solution. She plans to administer 30 ml per dose to the client QID. When the nurse approaches the client, the client states, “I understand that I can not take other laxatives with lactulose.” After checking, the nurse should: A. Withhold the lactulose. B. Give only 3 ml lactulose instead of 30 ml. C. Give 30 ml lactulose with juice and monitor blood ammonia. D. Give 30ml lactulose and correct the client that he may take additional laxatives.

Answer 111

Explanation Choice C is correct. The client has been prescribed Lactulose for portal-systemic encephalopathy, not for constipation. The prescribed dose is 20 grams every 4 hours. Since each 5 ml has 3.33 grams in it, the accurate dosage to be administered is 30 ml every 4 hours. Lactulose does not have a palatable taste; therefore, it can be mixed with fruit juice, water, or milk to improve flavor. The nurse should monitor blood ammonia levels and watch for any side effects. Side effects include belching, flatulence, or abdominal cramping. Lactulose belongs to the class of "Osmotic Laxatives" and may be used to treat constipation. Being an osmotic laxative, it draws water into the colonic lumen and softens the stool. Lactulose is also used in hepatic (portal-systemic) encephalopathy because it inhibits intestinal ammonia production. Lactulose is metabolized by intestinal bacteria and converted to lactic acid. Because of lactic acid, the pH in the colonic lumen is reduced (acidified), and this promotes the conversion of ammonia (NH3) to ammonium (NH4+). This ionized form of the ammonia is unable to diffuse across the gut membrane into the blood, and thereby, blood ammonia levels decrease. Additionally, the acidic pH suppresses the urease-producing gut bacteria involved in the production of ammonia. Decreasing blood ammonia levels results in improved mental status in PSE. When used in hepatic encephalopathy, the Lactulose dose needs to be carefully adjusted so the client averages 2 to 3 loose stools per day. This is the dose at which Lactulose is expected to show good benefit in PSE. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of Lactulose using the above definition of 2-3 loose stools/ day. Therefore, the client should be educated not to use additional laxatives. Choice A is incorrect. The client needs his prescribed dose Lactulose for his portal-systemic encephalopathy. Choice B is incorrect. The prescribed dose is 20 grams, which is equivalent to 30 ml as per the calculation above. Administering 3ml instead of 30ml is inappropriate. Choice D is incorrect. The client has correct understanding already. It is inappropriate to tell the client with hepatic encephalopathy to take additional laxatives while on Lactulose. Lactulose dose needs to be carefully adjusted, so the client averages 2 to 3 loose bowel movements per day. If other laxatives are used in conjunction, it gets challenging to determine the optimal dose of Lactulose. Reference: Black, JM, Hawkes, JH; Medical-Surgical Nursing: Clinical Care for Positive Outcomes 8thedition, Nebraska: Elsevier 2009