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2024/2025 PEDIATRICS NURSING ASSESSMENT WITH ANSWERS AND EXPLANATIONS. A+ GRADE PASSING LEVEL.
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2024/2025 PEDIATRICS NURSING ASSESSMENT WITH ANSWERS AND EXPLANATIONS. A+ GRADE PASSING LEVEL.
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2024/2025 PEDIATRICS NURSING ASSESSMENT WITHANSWERS AND EXPLANATIONS. A+ GRADE PASSING
LEVEL.
1. A nurse is admitting a client who is at 38 weeks of gestation
and is in the first stage of labor. Which of the following
assessment findings should the nurse report to the provider
first?
A. Expulsion of a blood-tinged mucous plug
B. Continuous contraction lasting 2 min
C. Pressure on the perineum causing the client to bear down
D. Expulsion of clear fluid from the vagina: B. Continuous
contraction lasting 2 min
i: A uterus contracting for more than 90 seconds is a sign of tetany and
could lead to uterine rupture, which is the greatest risk to the client at
this time. The nurse should report this finding immediately.
2. A nurse is providing teaching about nutrition to a client at her
first prenatal visit. Which of the following statements by the
nurse should be included in the teaching?
A. "You will need to increase your calcium intake during
breastfeeding." B. "Prenatal vitamins will meet your need
for increased vitamin D during pregnancy."
C. "Vitamin E requirements decline during pregnancy due to
the increase in body fat."
D. "You will need to double your intake of iron during
pregnancy.": D. "You will need to double your intake of iron
during pregnancy."
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, 2024/2025 PEDIATRICS NURSING ASSESSMENT WITH
ANSWERS AND EXPLANATIONS. A+ GRADE PASSING
LEVEL.
i: During pregnancy, the need for iron increases to allow transfer of the
appropriate amounts to the fetus and to support expansion of the
client's red blood cell volume.
3. A nurse is teaching about fetal development to a group of
clients in the antenatal clinic. Which of the following
statements should the nurse include in the teaching?
A. "The baby's heart beat is audible by a Doppler stethoscope at
12 weeks of pregnancy."
B. "The sex of the baby is determined by week 8 of pregnancy."
C. "Very fine hairs, called lanugo, cover your baby's entire body
by week 36 of pregnancy."
D. "You will first feel your baby move in week 24 of pregnancy.": A.
"The baby's heart beat is audible by a Doppler stethoscope at 12
weeks of pregnancy."
i: The fetal heartbeat is audible by Doppler stethoscope between 8
to 17 weeks of gestation.
4. A nurse on the labor and delivery unit is caring for a client
following a vaginal examination by the provider which is
documented as: -1. Which of the following interpretations of this
finding should the nurse make? A. The presenting part is lcm
above the ischial spines. B. The presenting art is lcm below the
ischial spines.
C. The cervix is lcm dilated.
D. The cervix is effaced lcm.: A. The presenting part is lcm above
the ischial spines.
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, 2024/2025 PEDIATRICS NURSING ASSESSMENT WITH
ANSWERS AND EXPLANATIONS. A+ GRADE PASSING
LEVEL.
i: Station is the relation of the presenting part to the ischial
spines of the maternal pelvis and is measured in centimeters
above, below, or at the level of the spines. If the station is minus
1, then the presenting part is lcm above the ischial spines. 5. A
nurse in a provider's office is caring for a client who is at 36
weeks of gestation and scheduled for an amniocentesis. The
client asks why she is having an ultrasound prior to the
procedure. Which of the following is an appropriate response by
the nurse?
A. "This will determine is there is more than one fetus."
B. "It is useful for estimating fetal age."
C. "It assists in identifying the location of the placenta and
fetus."
D. "This is a screening tool for spina bifida.": C. "It assists in identifying
the location of the placenta and fetus."
i: Identifying the positions of the fetus, placenta, and amniotic fluid
pockets immediately prior to the amniocentesis increases the safety of
this test by assisting with correct placement of the needle.
6. A nurse on a labor unit is admitting a client who reports
painful contractions. The nurse determines that the contractions
have a durtiong of Imin and a frequency of 3min.The nurse
obtains the following vitals: fetal heart rate 1301min, maternal
heart rate 1281min, and maternal blood pressure 92/54mmHg.
Which of the following is the priority action for the nurse to
take? A. Notify the provider of the findings.
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, 2024/2025 PEDIATRICS NURSING ASSESSMENT WITH
ANSWERS AND EXPLANATIONS. A+ GRADE PASSING
LEVEL.
B. Position the client with one hip
elevated. C. Ask the client if she
needs pain medication.
D. Have the client void.: B. Position the client with one hip elevated.
i: Based on Maslow's hierarchy of needs, the client's need for an
adequate blood pressure to perfuse herself and her fetus is a
physiological need that requires immediate intervention. Supine
hypotension is a frequent cause of low blood pressure
in clients who are pregnant. By turning the client on her side and
retaking her blood pressure, the nurse is attempting to correct
the low blood pressure and reassess. 7. A nurse is caring for a
group of clients on an intrapartum unit. Which of the following
findings should be reported to the provider immediately?
A. A tearful client who is at 32 weeks of gestation and is
experiencing irregular, frequent contractions.
B. A client who is at 28 weeks of gestation and receiving
terbutaline reports fine tremors.
C. A client who has a diagnosis of preeclampsia has 2+
proteinuria and 2+ patellar reflexes.
D. A client who has a diagnosis of preeclampsia reports epigastric
pain and unresolved headache.: D. A client who has a diagnosis of
preeclampsia reports epigastric pain and unresolved headache.
i: These findings indicate that the client's condition is worsening and are
signs of severe preeclampsia. They should be reported to the provider
immediately. Other manifestations of severe preeclampsia include:
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