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Hesi rn n404 maternity and pediatrics exam
Total Questions : 60
Showing 10 questions, Sign in for moreA client who is in labor states, "I think my water just broke?" The nurse notes that the umbilical cord is on the perineum. Which action should the nurse perform first?
A primigravida client at 32-weeks gestation presents to the clinic with a report of a pounding headache. The client demonstrates hyperreflexia. The nurse should recognize the client's symptoms may be caused by which condition?
3-month-old male infant is directly admitted to the pediatric unit from the outpatient pediatric cardiologist's office for evaluation and management of heart failure and failure to thrive. The client has a ventricular septal defect that was diagnosed at birth. Was born via an uncomplicated vaginal delivery. The client weighed 8 pounds and 2 ounces (3.64 kg) at birth and transitioned well after birth. Client has been followed by the pediatric cardiologist since birth. The parents brought the client to cardiologist reporting that in the last 3 days he has had a rapid heartbeat that is different from normal and that they have noticed that he seems more fatigued and sleeps more than before. Also, the parents have noticed small beads of sweat on the upper lip at times. Client is up to date on his vaccinations. The parents deny any exposure to any recent illnesses. Client has a family history of congenital heart disease (maternal aunt with atrial septal defect and cousin with coarctation of the aorta)
0900:
Client is admitted with parents being present and infant assessment is begun. It is observed that the client is listless and diaphoretic. Use of accessory muscles, tachypnea, and mild cyanosis are noted as well as flaring nares. Breath sounds are coarse bilaterally. The parents report that the infant has refused to eat today. There have been no diaper changes today. Infant is placed on a cardiac monitor and is allowed to remain in his parent's lap. Oxygen is given at 2 liters per minute via nasal cannula.
0920:
Assessment:
Cardiovascular: Loud holosystolic blowing murmur. Pulses 1+, equal in all extremities. Sinus tachycardia on monitor
Respiratory: Tachypnea, intercostal retractions through all lobes, mild cyanosis, coarse lung sounds through chest.
Neurological: Quiet, but arousable and listless infant. In parent's arm. Refusing to feed.
Gastrointestinal: Abdominal distension. Soft, bowel sounds active x 4 quadrants. Exclusively breastfed. Feeds 5 to 8 times a day for maximum of 5 minutes, fatigues with feeds. There has been half a pound weight loss in 3 days.
Genitourinary: 2 to 3 wet diaper changes a day on previous days. No urine output since 5 am.
The parents are at the client's bedside. They are teary eyed. The client is sleeping in his parent's arms with his head up. A 22-gauge peripheral IV line is started in the right hand.
0900:
Vital signs
- Temperature 101.5° F (38.6° C)
- Heart rate 155 beats/minute
- Respirations 55 breaths/minute
- Blood pressure 98/66 mm Hg
- Oxygen saturation 90% on room air
- Face Legs Activity Crying CONSOL ability (FLACC) Pain rated 0 out of 10 scale
- Weight 9 pounds, 10 oz. (4.37 kg)
1000:
Vital signs
- Temperature 101.5° F (38.6° C)
- Heart rate 159 beats/minute
- Respirations 50 breaths/minute .
- Blood pressure 98/60 mm Hg
- Oxygen saturation 98% on 2L nasal cannula
0900:
- Admit to pediatric unit
- Cardiology consultation
- Echocardiogram STAT
- Basic metabolic panel
- Peripheral IV access
- Strict input and output monitoring
- Diet breastmilk as tolerated
- Oxygen 2 liters per minute via nasal cannula
0920:
- Portable chest X-ray now
- Insert indwelling urinary catheter to continuous gravity drainage
0930:
Collect urine specimen for urinalysis (UA)
0945:
- Furosemide 8 mg IV push (IVP) every 12 hours
- Digoxin 0.06 mg IV once as digitalizing dose
- Captopril 2 mg IV every day
- Acetaminophen 40 mg liquid suspension PO x 1 now
1030:
- Start formula feeding. Infant formula 20 calloz (20 cal/30 mL). Add enteral nutritional formula to 24 calloz (24 cal/30 mL)
1000:
|
Laboratory Test |
Result |
Reference Range |
|
Glucose |
76 mg/dl (4.22 mmol/L) 14 mg/dL |
40 to 90 mg/dl. (2.2 to 5.0 mmol/L) |
|
Blood urea nitrogen |
14 mg/dL(0.78 mmol/L) |
5 to 18 mg/dL (1.8 to 6.4 mmol/L) |
|
Creatinine |
0.9 mg/dL (0.08 mmol/L) |
0.2 to 0.4 mg/dL (0.02 to 0.34 mmol/L) |
|
Sodium |
140 mEq/L (140 mmol/L) |
134 to 150 mEq/L (134 to 150 mmol/L) |
|
Potassium |
4.0 mEq/L (4.0 mmol/L) |
4.1 to 5.3 mEq/L (4.1 to 5.3 mmol/L) |
|
Chloride |
102 mEq/L (102 mmol/L) |
96 to 106 mEq/L (96 to 106 mmol/L) |
|
Carbon dioxide |
25 mEq/L (25 mmol/L) |
20 to 28 mEq/L (20 to 28 mmol/L) |
Patient Data
A 14-year-old female client comes into the clinic for an annual exam and expresses concern about not starting her menstrual cycle. Which finding should the nurse recognize as potential cause of delayed menstration?
Reference Range: Hemoglobin [10 to 15.5 g/dL (100 to 155 g/L)]
The nurse is caring for an infant with tetralogy of Fallot. During a blood draw the nurse observes the infant becoming pale and lethargic with circumoral cyanosis and diminished peripheral pulses. Which action should the nurse take next?
The nurse is developing a teaching plan for a school-aged child with AIDS. Which instruction should the nurse include in the teaching plan for the family of a school-aged child with AIDS?
How many mL of urine output should the nurse document for an infant's wet diaper weight of 85 grams compared to the dry diaper weight of 50 grams? (Enter numeric value only.)
Explanation
Calculation:
- Calculate the difference in weight between the wet and dry diaper.
Weight difference (grams) = Wet diaper weight (grams) - Dry diaper weight (grams)
= 85 grams - 50 grams
= 35 grams.
- Convert the weight difference in grams to milliliters (mL).
Conversion factor: 1 gram = 1 mL
Urine output (mL) = Weight difference (grams) x 1 mL/gram
= 35 grams x 1 mL/gram
= 35 mL.
The nurse is caring for a multiparous client who is in labor and observes a fetal heart rate (FHR) that decreases with the peak of a contraction and returns to baseline in 30 seconds. Which action should the nurse implement?
When inspecting the ears of a toddler without the use of an otoscope, which action should the nurse take?
A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish brown. Which intervention should the nurse implement first?
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