The nurse is instructing the parents of a child who underwent a surgical repair of a myelomeningocele on how to change an occlusive dressing on the child’s back.
Which parental statement indicates understanding of the procedure?

A client at 38-weeks gestation reports experiencing severe abdominal pain.
Upon palpation, the nurse notes that the abdomen is rigid.
How should the nurse document the findings?

The current vital signs for a primipara who delivered vaginally during the previous shift are: temperature 100.4° F (38° C), heart rate 58 beats/minute, respiratory rate 16 breaths/minute, and blood pressure 130/74 mm Hg. Which action should the nurse implement?

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. According to his parents, he had sneezing and a runny nose last week but seemed to have recovered.
The child lives with 2 older, school-age siblings, his parents, and 3 dogs.
He was born at 37 weeks’ gestation.
The parents deny smoking, but his grandmother cares for him in the afternoons and smokes outside when she is at the house.
He has no significant medical history.
He has received all vaccines except for those due at 3 years.
Upon exam, the child is… Which two items must the nurse ensure are available before attempting to place the intravenous line?

A multiparous client with active herpes lesions is admitted to the unit with spontaneous rupture of membranes.
What action should the nurse take?

An adolescent client who has successfully managed hemophilia for the past 10 years is evaluated by the nurse.
Which behavior best evidences the client’s adjustment to the disorder as an adolescent?

The client is awake and alert, interacting with parents at the bedside.
She has thin, copious mucus from her nose and mouth and a cough.
She took her bottle in 20 minutes, with no issues.
The client’s monitor alarmed, oxygen saturation is 59%. She is cyanotic.
The client was placed in a knee-to-chest position, and the rapid response team was called.
What could be the potential cause of the client’s condition?

The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with ADHD.
Which statement(s) made by the caregiver demonstrates an understanding?

A patient was received one hour after delivering a 9 lb 1 oz (4.1 kg) female baby.

Her vital signs are as follows: Temperature 100.4° F (38° C) orally, Heart rate 86 beats/minute, Respiratory rate 16 breaths/minute, Blood pressure 102/12 mm Hg, Pain 4 on a 0 to 10 pain scale.

She was assisted to the bathroom where she voided 150 mL of clear yellow urine.

Lochia rubra is moderate with small clots, no foul odor noted.

The fundus is firm at the umbilicus.

The episiotomy edges are well approximated, with no redness, edema, drainage, or ecchymosis.

There is no pain, redness, or swelling in the calves.

A 1,000 mL bag of lactated Ringer’s solution containing 10 units of oxytocin is infusing via an 18-gauge peripheral IV in the left forearm at 125 mL per hour, with 500 mL remaining in the bag.

The IV is patent, without redness or swelling, and can be discontinued when this bag’s infusion is complete.

A 3-year-old male was brought into the emergency room this morning with a sudden onset of “fast and noisy breathing”. According to his parents, he had sneezing and a runny nose last week but seemed to have recovered.

The child lives with 2 older, school-age siblings, his parents, and 3 dogs.

He was born at 37 weeks’ gestation.

The parents deny smoking, but his grandmother cares for him in the afternoons and smokes outside when she is at the house.

He has no significant medical history.

He has received all vaccines except for those due at 3 years.

Upon exam, the child is… Which two items must the nurse ensure are available before attempting to place the intravenous line?