Exam Review
- Which pregnant client is most at risk for ABO incompatibility?A)Mother is blood type A, father is blood type O, fetus is blood type AB)Mother is blood type AB, father is blood type O, fetus is blood type OC)Mother is blood type B, father is blood type B, fetus is blood type BD)Mother is blood type O, father is blood type A. fetus is blood type A
- A nurse is reviewing a newborn's chart and notes that the mother is blood type O and the baby is blood type A. Which of the following statements about ABO incompatibility is correct?A)ABO incompatibility occurs exclusively in Rh-negative mothers with Rh-positive infants, leading to mild anemia but not jaundice, and is easily prevented with Rh immunoglobulin.B)ABO incompatibility occurs when the mother's antibodies cross the placenta and attack fetal red blood cells, potentially causing mild hemolytic disease, jaundice. and anemia in the newborn, and it is more common than Rh incompatibility.C)ABO incompatibility only occurs if the mother has received multiple blood transfusions during pregnancy, causing maternal antibodies to attack fetal red blood cells, and it rarely affects newborns.D)ABO incompatibility occurs when the mother and infant have the same blood type, leading to severe hemolysis, kernicterus, and often requires immediate exchange transfusion.
- A nurse is caring for a 2-year-old toddler who is postoperative and nonverbal due to sedation. The child is grimacing and pulling at their IV site. Which pain assessment tool is MOST appropriate?A)Wong-Baker Faces ScaleB)Numeric Rating ScaleC)FLACCD)Visual Analog Scale
- A nurse is assessing a 4-year-old child who presents with symptoms suggestive of epiglottitis. Which of the following clinical manifestations would be most consistent with this condition?A)Difficulty swallowing drooling, hoarseness, and sitting in a tripod positionB)Rhinorrhea, congestion, mild sore throat, and hoarsenessC)Sudden onset of cough, wheezing, rapid breathing and difficulty swallowingD)Hoarseness, stridor, and a barking cough
Exam Review
- A 5-year-old child is scheduled for a vaccination. The nurse wants the child to self-report pain. The child can understand pictures but has difficulty with numbers. Which pain assessment tool is MOST appropriate?A)Numeric Rating Scale (0-10)B)FLACC scaleC)Visual Analog ScaleD)Oucher Pain Scale
- A 5-year-old preschooler is recovering from a tonsillectomy and is able to speak but has difficulty understanding numbers. Which pain assessment tool should the nurse use?A)Numeric Rating ScaleB)Visual Analog ScaleC)FLACCD)Faces Pain Scale-Revised (Wong-Baker)
- A 6-year-old child in the pediatric ward has had a minor laceration sutured on the forearm. Vital signs are within normal limits but the child is quiet. withdrawn, and refuses to play. The nurse suspects pain. What action should the nurse take FIRST?A)Use a developmentally appropriate pain assessment tool.B)Assume the child is fine because vital signs are stable.C)offer the child juice and a snack.D)Wait until pain is mentioned verbally by the child.
- A 5-year-old child presents to the emergency department with a stiff jaw, muscle spasms, and difficulty swallowing. The mother reports the child stepped on rusty nail 10 days ago. Which of the following is the priority nursing intervention?A)Apply a cold compress to the woundB)Encourage the child to ambulate to prevent stiffnessC)Provide a tetanus booster and tetanus immune globulinD)Administer oral antibiotics
Exam Review
- A pregnant client has a history of opioid dependence. Which of the following are appropriate nursing interventions for managing her care? Select all that apply.(SATA)A)Advise the client that occasional drug use is safe during pregnancyB)offer nonjudgmental counseling and referrals to support servicesC)Encourage abrupt discontinuation of all opioidsD)Monitor the newborn for signs of neonatal abstinence syndrome (NAS)E)Provide methadone therapy as prescribed
- Rho immune globulin will be ordered after birth if which situation occurs?A)Mother Rh-, baby Rh+B)Mother Rh+, baby Rh-C)Mother Rh+, baby Rh+D)Mother Rh-, baby Rh-
- A 13-year-old with juvenile arthritis has been experiencing persistent joint pain for the past 4 months. Which statement BEST defines this type of pain?A)Referred painB)Procedural painC)Chronic painD)Acute pain
- During a well-child visit, a parent asks why their 7-month-old has started to reach for objects with one hand before picking up smaller items with the fingers. Which explanation should the nurse give?A)"Your baby is demonstrating proximal-to-distal development, gaining control from the center outward"B)Your baby should use both hands equally at this age"C)"This is a sign of delayed fine motor development"D)"Your baby is skipping developmental milestones"
Exam Review
- A nurse is admitting a patient who is at 38 weeks gestation and has severe pre-eclampsia. When assessing the patient, the nurse should expect which finding?A)PolyuriaB)TachycardiaC)HeadacheD)Diplopia
- A 33-week pregnant client presents with severe right upper quadrant pain, nausea, and malaise. The provider suspects HELLP syndrome. Which combination of laboratory findings would confirm the diagnosis? (Select All that Apply.)(SATA)A)HemolysisB)Elevated liver enzymesC)Severe hypertensionD)HyperglycemiaE)Low platelets
- Which of the following findings in a pregnant client may indicate potential heart failure rather than normal pregnancy changes?A)Feeling tired at the end of a busy dayB)Shortness of breath with moderate exertionC)Mild swelling of ankles after standing all dayD)Swelling of face and hands, rapid breathing, and persistent cough
- A mother is Rh-negative, and her fetus is Rh-positive. She delivered her first Rh-positive baby without receiving Rho(D) immune globulin. Which complication may occur in a future pregnancy if sensitization has occurred?A)Neonatal hypoglycemiaB)MiscarriageC)Fetal macrosomiaD)Placenta previa
Exam Review
- A 10-year-old child presents with joint pain, low-grade fever, and a history of untreated strep throat 3 weeks ago. The nurse recalls that rheumatic fever is an autoimmune reaction following Group A Streptococcus infection. Which of the following complications should the nurse prioritize monitoring for?A)Pulmonary hypertension leading to increased peripheral resistanceB)Pancarditis leading to long-term valve damage, especially the mitral valveC)Acute kidney injury leading to bladder insufficiencyD)Coronary artery aneurysms arising from hypertension
- The nurse is assessing a newborn who is 12 hours old. Which symptoms would indicate the newborn is experiencing respiratory distress?(Select all that apply)(SATA)A)gruntingB)increased appetiteC)inspiratory stridorD)retractionsE)nasal flaring
- A pregnant client completes the 1-hour glucose tolerance test (GTT) at 26 weeks' gestation. The nurse explains that if the blood glucose result is above ____ to ____mg/dL. It is considered a positive screening and the client will need a 3-hour oral glucose tolerance test.
- A 12-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis. The child rates pain as 10/10 but refuses IV opioids due to fear of needles. Which intervention should the nurse implement FIRST?A)Document the refusal and delay analgesia.B)Explain that pain medication is mandatory.C)Ask the child to wait until the pain becomes severe.D)Offer nonpharmacologic pain.