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Question 1 of 5

The nurse is assessing a client at 11 weeks gestation. The first day of the client's last menstrual period was September 7. Which of the following findings should the nurse expect to obtain?

Correct Answer: B,D,E

Rationale: At 11 weeks, increased urinary frequency (
B) is expected due to hormonal changes. The Naegele rule (LMP + 1 year - 3 months + 7 days) gives June 14 (
D). Fetal heart tones are detectable by Doppler (E). Fetal movement (
A) is felt later (16-20 weeks), and fundal height of 24 cm (
C) occurs around 24 weeks.

Question 2 of 5

The nurse is screening pediatric clients for developmental dysplasia of the hip (DDH). Which of the following findings would be consistent with DDH in a 3-week-old client?

Correct Answer: C

Rationale: Extra gluteal folds (
C) are a sign of DDH. The affected leg appears shorter, not longer (
A). Narrowing of the perineum (
B) and pelvic tilt (
D) are not typical.

Question 3 of 5

A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?

Correct Answer: C,E

Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back,
C) and suprapubic pressure (
C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (
A) can worsen impaction. Documentation (
B) is secondary to immediate action. Forceps (
D) are not typically used for shoulder dystocia.

Question 4 of 5

The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?

Correct Answer: A

Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (
A), requiring clarification. Urinating beforehand (
B), needle insertion (
C), and transient pain (
D) are correct.

Question 5 of 5

The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments?

Correct Answer: C

Rationale: Methylphenidate can affect growth (height/weight) and increase blood pressure (
C), making these priority assessments. Attention and activity (
A) are relevant but secondary. Dental health (
B) and social progress (
D) are less critical for medication monitoring.

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The unlicensed assistive personnel (UAP) reports to the nurse that during rounds a client has recently become pale. What is the nurse's first action?
A client admitted to the floor 3 days after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to:
The nurse is teaching a client with cardiac disease about the anatomy and physiology of the heart. Which is the correct pathway of blood flow through the heart?

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