Nokea
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which pain scales would be appropriate for this client? Select all that apply.
- A. FLACC Postoperative Pain Scale
- B. Riley Infant Pain Scale
- C. Poker Chip Tool
- D. Visual Analog Scale
- E. Numeric
- F. FACES
Correct Answer: A,B
Rationale: FLACC and Riley Infant Pain Scales assess behavioral cues in nonverbal infants, suitable for a 4-month-old post-surgery. Other scales require cognitive abilities beyond this age.
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The nurse is caring for a primigravida client who delivered vaginally 48-hours ago. The client's laboratory results are: hemoglobin 12.5 g/dL (125 g/L), hematocrit 34% (0.34 volume fraction), hepatitis B surface antigen negative, rubella non-immune, group B Streptococcus positive. Which prescription should the nurse prepare to administer?
- A. Hepatitis B immunoglobulin.
- B. Rubella vaccination.
- C. Blood transfusion.
- D. Penicillin G potassium.
Correct Answer: B
Rationale: The client's rubella non-immune status requires postpartum vaccination to prevent future congenital defects. Normal hemoglobin/hematocrit, negative hepatitis B, and post-delivery GBS status do not warrant other interventions.
History and Physical
Nurses' Notes
Flow Sheet
Vital signs
The client is a 9-month-old male who was born by cesarean section at 32 weeks gestation. He has been hospitalized once with respiratory syncytial virus at 2 months of age. He is up to date on vaccines.
Exhibits
Review H and P, nurse's note, and flow sheet.
Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Remove some of the baby's clothing
- B. Clean the area with warm water
- C. Alert child protective services
- D. Swab the area and send for a culture
- E. Hold the vaccines
- F. Temperature
- G. Parent's understanding of education
Correct Answer: A,B
Rationale: Miliaria, caused by overdressing, is addressed by removing clothing and cleaning with warm water. Monitoring temperature and parental education prevents recurrence.
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?
- A. Influenza.
- B. Chickenpox.
- C. Mumps.
- D. Sore throat.
Correct Answer: D
Rationale: A recent untreated Group A Streptococcus sore throat is the primary risk factor for acute rheumatic fever, triggering an autoimmune response.
A nurse is speaking with a client who is addicted to heroin and who just learned that she is pregnant. The client states, 'I just started taking methadone. Is there anything else I can do to make sure my baby is healthy?' Which information should the nurse provide?
- A. Describe genetic testing protocols.
- B. Sign up for group therapy sessions.
- C. Start a prenatal care plan as soon as possible.
- D. Discontinue the methadone right away.
Correct Answer: C
Rationale: Early prenatal care monitors methadone effects, fetal development, and complications like neonatal abstinence syndrome, ensuring a healthy pregnancy.
History and Physical
Nurses' Notes
Flow Sheet
Laboratory Results
38-year-old primiparous client is seen in the outpatient obstetric office 2 weeks postpartum after a spontaneous vaginal birth of a full-term infant after rupture of membranes for 16 hours. The client was discharged on day 2, exclusively breastfeeding.
Select the findings that will help the nurse determine what is causing the client's symptoms.
- A. Rupture of membranes for 16 hours
- B. Normal spontaneous vaginal birth
- C. Breastfeeding 7 to 8 times a day for 10 minutes
- D. Discharge hemoglobin of 9.2 g/dL (92 g/L)
- E. Current vital signs
- F. Shopping yesterday for 5 hours
- G. Foul-smelling lochia rubra
Correct Answer: A,D,E,F,G
Rationale: Prolonged rupture of membranes, low hemoglobin, fever, tachycardia, prolonged shopping, and foul-smelling lochia suggest postpartum infection risks like endometritis or mastitis. These findings indicate systemic inflammation, anemia, and potential milk stasis.