Tiêu đề RECALLS 4 - NP2 - SC ✅

2 | Page determine their baby’s sex via ultrasound. The nurse is correct when she said ______. A. At 10 weeks AOG B. 16 weeks AOG C. 20 weeks AOG D. 22 weeks AOG Situation: Nurse Bea is assisting pregnant mothers in their second trimester of pregnancy. The following questions apply 16. Nurse Bea is preparing to measure the fundal height of a client whose fetus is 28 weeks’ gestation. In what position should the nurse place the client to perform the procedure? A. In a standing position B. In the Trendelenburg position C. Supine with the head of the bed elevated to 45 degrees D. Supine with her head on a pillow and knees slightly flexed 17. Nurse Bea has just palpated the fundal height at the level of umbilicus. It is likely that the client is how many weeks pregnant? A. 12. B. 20. C. 28. D. 36 18. After doing Leopold’s maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: A. Above the umbilicus at the midline B. Above the umbilicus on the left side C. Below the umbilicus on the right side D. Below the umbilicus near the left groin 19. Which piece of equipment will the nurse routinely use to assess the fetal heart rate of a woman at 16 weeks’ gestation? A. Fetal heart monitor B. An adult stethoscope C. Bell of a stethoscope D. Ultrasound fetoscope 20. The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy? A. Hemorrhoids B. Postterm labor C. Maternal anemia D. Costovertebral angle tenderness Situation: Maris, who is in her first trimester of pregnancy, comes to the clinic for a prenatal check-up. Nurse Loisa is assigned to assist her. 21. Maris mentioned that she is experiencing nausea and vomiting each morning that she wakes up. Which of the following should not be included when giving health teachings to Maris? A. Eat dry crackers before arising B. Take small, frequent feedings C. Take antiemetic D. take low-fat diet 22. Maris also complains of urinary frequency. Which of the following should Nurse Loisa not instruct Maris to do? A. Limit fluid intake in the evening B. Perform Kegel exercises C. Increase intake of tea to control voiding D. Drink no less than 2000 mL of fluid during the day 23. Maris will undergo Alpha-fetoprotein level determination. Which of the following specimen us required? A. Maternal blood sample B. Blood from chorionic villi C. Amniotic fluid D. Cervical secretions 24. She asks Nurse Loisa, “What does the alpha fetoprotein test indicate?” The nurse bases a response on the knowledge that this test can detect: A. Kidney defects B. Cardiac defects C. Neural Tube defects D. Urinary tract defects 25. Nurse Loisa is giving health teaching to Maris on how to prevent neural tube defects to her baby. What supplement is needed to be taken by a pregnant women to prevent NTD? A. Folate B. Iron C. Vitamin C D. Vitamin A Situation: Nurse Yna is providing prenatal health teaching to a group of pregnant women in their first and second trimesters. She explains the normal discomforts of pregnancy, their causes, and how to manage them effectively. 26. Which of the following exercises should be taught to a pregnant woman who complains of backaches? A. Kegeling. B. Pelvic tilting. C. Leg lifting. D. Crunching. 27. A 36-week gestation gravid client is complaining of dyspnea when lying flat. Which of the following is the likely clinical reason for this complaint? A. Maternal hypertension. B. Fundal height. C. Hydramnios. D. Congestive heart failure. 28. During a prenatal visit, a gravid client is complaining of ptyalism. Which of the following nursing interventions is appropriate? A. Encourage the woman to brush her teeth carefully. B. Advise the woman to have her blood pressure checked regularly. C. Encourage the woman to wear supportive hosiery. D. Advise the woman to avoid eating rare meat 29. The nurse is measuring the fundal height on a client who is 36 weeks’ gestation when the client reports feeling lightheaded. What finding should the nurse expect to note when assessing the client? A. Fear B. Anemia C. A full bladder D. Compression of the vena cava 30. Which of the following skin changes should the nurse highlight for a pregnant woman’s health care practitioner? A. Linea nigra. B. Melasma. C. Petechiae. D. Spider nevi Situation: Nurse Lani is assigned in the labor room and is monitoring clients in active labor using an external fetal monitor. Understanding fetal heart rate patterns is vital in assessing fetal well-being. 31. The client is in active labor. Fetal heart monitoring is done. Bradycardia is noted at the start of uterine contraction. The nurse correctly interprets this finding as indicative of A. Head compression B. Prolapsed cord C. Uteroplacental insufficiency D. False labor 32. The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? A. Change the client’s position B. Prepare for emergency cesarean section C. Check for placenta previa D. Administer oxygen 33. The nurse, caring for a client in the active stage of labor, is monitoring the fetal status and notes that the monitor strip shows a late deceleration. Based on this observation, which action should the nurse plan to take immediately? A. document the findings B. prepare for immediate birth C. increase the rate of an oxytocin infusion D. administer oxygen to the client via face mask 34. The pregnant client tells the nurse that se felt wetness on her peripad and found some clear fluid. The nurse inspects the
3 | Page perineum and notes the present of umbilical cord. What is the immediate nursing action? A. Monitor the fetal heart rate B. Notify the primary health care provider C. Transfer the client to the delivery room D. Place the client in a Trendelenburg position 35. A laboring client has external electronic fetal monitoring in place. Which of the following assessment data can be determined by examining the fetal heart rate strip produced by the external electronic fetal monitor? A. Gender of the fetus B. Fetal position C. Labor progress D. Oxygenation Situation: Nurse Bianca is assigned to a high-risk OB ward. One of her clients is diagnosed with Pregnancy-Induced Hypertension. The following questions apply. 36. The clinic nurse is caring for a client with a suspected diagnosis of gestational hypertension. The nurse assesses the client, expecting to note which set of findings if gestational hypertension is present? A. Edema, ketonuria, and obesity B. Edema, tachycardia, and ketonuria C. Glycosuria, hypertension, and obesity D. Elevated blood pressure and proteinuria 37. Which of the following lab values should the nurse report to the physician as being consistent with the diagnosis of HELLP syndrome? A. Hematocrit 48%. B. Potassium 5.5 mEq/L. C. Platelets 75,000. D. Sodium 130 mEq/L. 38. The nurse is caring for a pregnant client with preeclampsia who is receiving a prescribed intravenous (IV) infusion of magnesium sulfate. To provide a safe environment, the nurse should ensure that which priority item is available? A. Tongue blade B. Percussion hammer C. Calcium gluconate injection D. Potassium chloride injection 39. Nurse Davis is monitoring a pregnant patient receiving magnesium sulfate for preeclampsia management. During her assessment, Nurse Davis suspects that the patient may be experiencing magnesium sulfate toxicity. Which of the following findings would most likely confirm her concern? A. Serum magnesium level of 7 mEq/L. B. Presence of active deep tendon reflexes. C. Urine output of 25 mL per hour. D. Respiratory rate of 10 breaths per minute 40.  Nurse Harris is caring for a pregnant patient in her third trimester who has been admitted with severe preeclampsia. While monitoring for potential complications, what should Nurse Harris assess for? A. Complaints of feeling warm despite a cool room temperature. B. Alternating periods of fetal movement and quietness. C. Signs of bleeding, such as in the gums, presence of petechiae, and purpura. D. Breast enlargement. Situation: Nurse Jasmine is assigned to the OB ward and is responsible for monitoring and educating several postpartum mothers who recently gave birth. The following questions apply: 41. A new mother was administered methylergonovine maleate intramuscularly after delivery. The nurse understands that this medication was administered for which action? A. Decrease uterine contractions B. Prevent postpartum hemorrhage C. Maintain a normal blood pressure D. Reduce the amount of lochia drainage 42. A postpartum nurse caring for a client who delivered vaginally 2 hours ago palpates the fundus and notes the character of the lochia. Which characteristic of the lochia should indicate to the nurse that the client’s recovery is normal? A. Pink-colored lochia B. White-colored lochia C. Serosanguineous lochia D. Dark red-colored lochia 43. Twelve hours after delivery, the nurse assesses the client for uterine involution. The nurse determines that the uterus is progressing normally towards its prepregnant state when palpation of the clients fundus is at which level? A. At the umbilicus B. One finger breaths below the umbilicus C. Two finger breaths below the umbilicus D. Midway between the umbilicus and the symphysis pubis 44. A 10-day postpartum breast-feeding client telephones the postpartum unit reporting a reddened, painful breast and elevated temperature. Based on assessment of the client’ s complaints, which action should the nurse tell the client to do? A. “Breast-feed only with the unaffected breast.” B. “Stop breast-feeding because you probably have an infection.” C. “Notify your health care provider because you may need medication.” D. “Continue breast-feeding since this is a normal response in breast-feeding mothers.” 45. The postpartum client who delivered her newborn 4 days ago has been observed by the nurse to have started assuming tasks of mothering. She has started doing tasks for herself, not asking assistance. In which postpartum stage of regeneration is the client? A. Taking-in phase B. Taking hold phase C. Letting-go phase D. Holding on phase 46. A pregnant client tests positive for the hepatitis B virus. The client asks the nurse if she will be able to breast-feed the baby as planned after delivery. Which therapeutic response should the nurse communicate to the client? A. “You will not be able to breast-feed the baby until 6 months after delivery .” B. “Breast-feeding is not advised, and you should seriously consider bottle-feeding the baby.” C. “Breast-feeding is not a problem, and you will be able to breast-feed immediately after delivery” D. “Breast-feeding is allowed if the baby receives prophylaxis treatment at birth and scheduled immunizations.” 47. The mother had breastfed her newborn. Which of the following actions of the mother indicates the need for further teaching? A. The mother inserts a clean finger into the baby’s mouth before removing him from the breast. B. The mother burps the baby after feeding from each breast. C. The mother places the baby on the left side after feeding D. The mother exposes her nipples to air for 10-20 minutes after feeding. 48. Which of the following factors might result in a decreased supply of breastmilk in a PP mother? A. Supplemental feedings with formula B. Maternal diet high in vitamin C C. An alcoholic drink D. Frequent feedings 49. A postpartum mother who chose not to breastfeed asks the nurse, "When will my menstrual period return?" The nurse correctly responds that: A. “It usually returns within 3-4 months postpartum.” B. “It will resume after your postpartum check-up at 4 weeks.” C. “It may resume as early as 6 to 8 weeks after delivery.” D. “It won’t return until your baby starts eating solid food.” 50. During a postpartum examination, the nurse notes that a client’s left calf is warm and swollen. Which of the following actions by the nurse is appropriate at this time? A. Notify the client’s physician. B. Teach the client to massage her leg. C. Apply ice packs to the client’s leg.
4 | Page D. Encourage the client to ambulate. Situation: Nurse Leah is caring for multiple pregnant clients in the antenatal ward. Some clients present with pregnancy- related problems. The following questions apply. 51. An ultrasound has identified that a client’s pregnancy is complicated by oligohydramnios. The nurse would expect that an ultrasound may show that the baby has which of the following structural defects? A. Dysplastic kidneys. B. Coarctation of the aorta. C. Hydrocephalus. D. Hepatic cirrhosis. 52. An ultrasound has identified that a client’s pregnancy is complicated by hydramnios. The nurse would expect that an ultrasound may show that the baby has which of the following structural defects? A. Pulmonic stenosis. B. Tracheoesophageal fistula. C. Ventriculoseptal defect. D. Developmental hip dysplasia. 53. Which of the following signs/symptoms would the nurse expect to see in a woman with abruptio placentae? A. Increasing fundal height measurements. B. Pain-free vaginal bleeding. C. Fetal heart accelerations. D. Bright red vaginal bleeding 54. The client is diagnosed to have placenta previa. What warning signs should be placed by the nurse in client’s unit? A. “No abdominal palpation” B. “No vaginal examination” C. “No BP-taking” D. “No cigarette smoking” 55. Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? A. Retained placental fragments B. Urinary tract infection C. Cervical laceration D. Uterine Atony Situation: Nurse Kathy is conducting research on the effectiveness of a new wound care protocol in a hospital setting. She needs to collect various types of data to analyze the results effectively. 56. Nurse Kathy is collecting data on the different categories of wounds (e.g., surgical, traumatic, pressure ulcers). What type of data is this? A. Interval B. Ratio C. Nominal D. Ordinal 57. Nurse Kathy records the pain levels of patients on a scale from 1 to 10. What type of data is this? A. Nominal B. Ordinal C. Interval D. Ratio 58. Nurse Kathy measures the weight of patients before and after implementing the new wound care protocol. What type of data is ‘weight’? A. Nominal B. Ordinal C. Interval D. Ratio 59. Nurse Kathy collects data on patients' ages to determine the average age of those participating in the study. What type of data is age? A. Nominal B. Ordinal C. Interval D. Ratio 60. Nurse Kathy uses a thermometer to measure patients' body temperatures. What type of data is body temperature in Celsius? A. Nominal B. Ordinal C. Interval D. Ratio Situation: Growth and Development 61. A 12-month-old boy weighed 8 lb 2 oz at birth. Understanding developmental milestones, what should the nurse caring for the child expect the current weight to be? A. 16 lb 4 oz B. 20 lb 5 oz C. 24 lb 6 oz D. 32 lb 8 oz 62. Nurse May is educating a mother on the proper sequence of food introduction for her 6-month-old infant. Which of the following reflects the correct order of introducing complementary foods? A. Vegetables, Cereals, Fruits, Meat, Egg, B. Cereal, Vegetables, Fruits, Meat, Egg, C. Cereal, Vegetables, Fruits, Egg, Meat D. Vegetables, Cereals, Fruits, Egg, Meat 63. Which finding would the nurse consider abnormal when performing a physical assessment on a 6-month-old? A. Posterior fontanel is open. B. Anterior fontanel is open. C. Beginning signs of tooth eruption. D. Able to track and follow objects. 64. Which type of play is most appropriate for a 10-month-old infant? A. Parallel play B. Solitary play C. Cooperative play D. Competitive (indoor) 65. Which of the following activities would best support a 7- month-old’s development of fine motor skills? A. Palmar grasp B. transfer objects between hands C. pincer grasp D. holds cup and spoon well Situation: The nurse in the pediatric ward is caring for several children with gastrointestinal disorders. The following questions apply. 66. The nurse is caring for a 14-year-old with celiac disease. The nurse knows that the patient understands the diet instructions by ordering which of the following meals? A. Eggs, bacon, rye toast, and lactose-free milk. B. Wheat bread, orange juice, and sausage links. C. Oat cereal, breakfast pastry, and nonfat skim milk. D. Cheese, banana slices, rice cakes, and whole milk. 67. Based on the diagnosis above, the nurse expects that the child’s stool will have which characteristic? A. Malodorous B. Dark in color C. Unusually hard D. Abnormally small in amount. 68. The mother explains that after meals her infant has been vomiting, and now it is becoming more frequent and forceful. During the assessment, the nurse notes visible peristaltic waves moving from left to right across the infant’ s abdomen. On the basis of these findings, which condition should the nurse suspect? A. Colic B. Intussusception C. Congenital megacolon D. Pyloric stenosis 69. Which of the following signs would MOST LIKELY suggest Hirschsprung disease in a newborn? A. Projectile vomiting B. Passage of meconium within 24 hours after birth C. Failure to pass meconium within 48 hours after birth D. Presence of currant jelly stools 70. Which of the following is the classic sign of Hirschsprung disease? A. Olive shaped mass B. Steatorrhea C. Ribbon-like stools D. Currant jelly-like stools