A nurse is providing care for an adolescent who was brought to the emergency department (ED) by their guardians due to pain in the left arm that started the previous evening.

The adolescent has a history of sickle cell disease diagnosed at age 4. They have a prescription for oral morphine sulfate and took one dose the previous evening at 1800 and another this morning at 0900.

The adolescent reports no relief from pain, rating it as 9 on a scale of 0 to 10. For each potential provider’s prescription, specify if the prescription is anticipated, nonessential, or contraindicated for the client.

A nurse is caring for a 7-year-old child who was brought in by parents due to unexplained bruising and red spots on the child’s shoulders, thighs, and back.

The parents report that the child has had a cold for more than 2 months and over-the-counter medications have not helped relieve the cold symptoms. The child had a small nosebleed “a few minutes ago” and reports “my arms and legs hurt all over.”. The nurse is reviewing the assessment findings and diagnostic results.

For each assessment finding, specify if the finding is consistent with sickle cell anemia or hemophilia.

A nurse is preparing to measure an infant’s vital signs.

Which of the following sites should the nurse use to assess the heart rate?

A nurse is caring for a laboring patient with an external fetal monitor. The nurse notices late decelerations on the monitor strip.

What does the nurse interpret this as indicating?

A nurse in the labor and delivery unit is attending to a client in labor. The nurse applies an external fetal monitor and toco transducer.

The FHR is around 140/min.

Contractions are every 8 min and 30 to 40 seconds in duration.

The nurse performs a vaginal exam and finds the cervix is 2 cm dilated, 50% effaced, and the fetus is at a -2 station.

Which stage and phase of labor is this client experiencing?

A nurse is preparing to administer digoxin to a 6-month-old infant. Before administering the dose, the nurse measures the apical heart rate.

The nurse should withhold the dose if the infant’s apical heart rate is less than what rate? .

A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor.

Which of the following findings confirm to the nurse that the client is in labor?

A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac.

Which of the following interventions should be incorporated into the care plan?

A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation.

Which of the following interventions should the nurse include in the plan of care?

A nurse is attending to a patient who is in preterm labor at 32 weeks of gestation. The patient asks the nurse, “Will my baby be okay?” What should the nurse respond?

A nurse is caring for a client who is at 28 weeks of gestation and received terbutaline. What findings should the nurse expect?