Question 1

Which is the step of the nursing process in which the nurse determines the appropriate interventions for the identified nursing diagnosis?

Accepted Answer

The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out.

Question 2

A client in labor reports a feeling of burning pain during the second stage of labor. This type of pain is associated with:

Accepted Answer

This is an example of somatic pain experienced as a result of distention of the vagina and perineum during the second stage of labor. Visceral pain occurs in response to pressure on pelvic structures. Pain associated with ischemic tissue is a result of decreased blow flow to the uterus.
The pain of cervical dilation is a major pain source during labor but, during the second stage of labor, the client is already fully dilated so this would not be a factor.

Question 3

The nurse includes the addition of ice sitz baths for the postpartum patient. Which assessment finding indicates the treatment has been effective?

Accepted Answer

Sitz baths may be offered two to four times a day to women with episiotomies, painful hemorrhoids, or perineal edema. Sitz baths provide continuous circulation of water and cleanse and comfort the traumatized perineum. Cool water reduces pain caused by edema and may be most effective within the first 24 hours. Ice can be added to cool the water to a comfortable level as the woman sits in it. Approximation of the edges of a wound facilitate wound healing. The purpose of the cold sitz bath is to decrease the edema secondary to tissue trauma.

Question 4

If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

Accepted Answer

D&C allows examination of the uterine contents and removal of any retained placenta or membranes. Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus. Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.

Question 5

The primipara at 39 weeks gestation states to the nurse, I can breathe easier now. What is the nurses best response?

Accepted Answer

As the fetus descends toward the pelvic inlet (dropping), the woman notices that she breathes more easily because upward pressure on her diaphragm is reduced. However, increased pressure on her bladder causes her to urinate more frequently. Pressure of the fetal head in the pelvis also may cause leg cramps and edema. Lightening (descent of the fetus toward the pelvic inlet before labor) is most noticeable in primiparas and occurs about 2 to 3 weeks before the natural onset of labor. Instructions for labor, although correct, do not address the patients statement of being able to breathe easier. Fetal movement continues throughout the final weeks of gestation. A decrease in fetal movement is a concerning sign and the health care provider must be notified.

Question 6

A hospitalized toddler was drinking from a cup at home, but now refuses to drink from anything except his favorite bottle. This is because the toddler is:

Accepted Answer

Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital.

Question 7

The nurse should obtain informed consent for which situation?

Accepted Answer

Informed consent is required for invasive procedures that involve a risk to a child, such as lumbar puncture, chest tube insertion, and bone marrow aspirations. Informed consent is not required for procedures that are covered under the general consent to treat that is signed at admission by a parent or a guardian. Agreement with the procedure is obtained from children older than 7 years of age but does not preclude the need for informed consent from a parent. If a parent is not present and an emergency procedure requiring informed consent is needed, administrative consent must be obtained.

Question 8

Which nursing action is most appropriate when giving a child a sponge bath to decrease fever?

Accepted Answer

The procedure should be stopped immediately if the child begins to shiver. Shivering will increase the childs temperature. Alcohol is contraindicated because of skin irritation, the risk of neurological depression from the fumes or absorption through the skin, and shivering, which results from rapid cooling. Cold water can lead to rapid cooling. Tepid water should be used for a sponge bath to reduce fever. The procedure should be stopped immediately if the child begins to shiver. Shivering will increase the childs temperature.

Question 9

Which action is appropriate when the nurse is bathing a small child?

Accepted Answer

Bath water should be warm, not hot. Water temperature can be tested on the inside of the wrist or elbow. Young children can assist with bathing but cannot bathe independently. The temperature of the water should be less than 100 F. The nurse should never leave an infant or small child unattended in the bath.

Question 10

Which is the most reliable method that indicates the end of a nasogastric tube is correctly placed?

Accepted Answer

The pH of fluid aspirated from the stomach should be 5 or lower. This is the most reliable method for indicating that a nasogastric tube is properly placed. Intact swallowing, coughing, and gagging reflexes should not be used in the determination of nasogastric tube placement. Fluid aspirated from the stomach can have a grassy green, brown, or clear, mucoid-flecked appearance, but this is not the most reliable way to determine correct placement. A whooshing or gurgling sound can be heard as air injected into the tube enters the stomach, but this is not the most reliable method for determining tube placement.

Question 11

Where would the nurse locate the apical pulse on a 6-year-old child?

Accepted Answer

In children younger than 7 years of age, the apical pulse is located at the fourth intercostal space, lateral to the midclavicular line. The tricuspid valve is auscultated at the second right intercostal space. The pulmonic valve can be auscultated at the second intercostal space at the left sternal border. The apical pulse in a child older than 7 years of age is located at the fifth intercostal space in the midclavicular line.

Question 12

A nurse is totaling the intake of a child who is on oral feedings, enteral feedings, and parenteral IV fluids. During the 8 hour shift the child took 4 ounces of formula, by mouth. The child also had a supplemental feeding per gastrostomy tube that ran at 20 mL per hour for 4 hours. The childs IV ran continuously at 25 mL per hour for the whole 8 hours. What is the childs total intake for the 8 hour shift?

Accepted Answer

The answer of A nurse is totaling the intake of...

Question 13

A nurse is collecting a nasopharyngeal culture on a school-age child. Place the steps in order from the first step the nurse should take to the last step.

Accepted Answer

To obtain a nasopharyngeal culture on a school-age child the first step is to ask the child to look up. Bend the wire so that when the swab is inserted, the tip will go beyond the back of the nares and into the pharyngeal area. Dip the swab tip into saline and gently insert it into one nostril, down to the posterior nasopharynx. Leave it in place for several seconds and then remove it. After the specimen is obtained, place the swabs in the appropriate culture media. Remove gloves and perform hand hygiene. Label the specimen with the infant/childs name, birth date, medical record number, and the time and date of collection. Place it in a biohazard bag and send it to the laboratory with the requisition form for the test(s) to be performed.

Quiz 1: Nursing Process and Pediatric Care: Assessments, Interventions, and Informed Consent