A nurse is assessing a 7-year-old boy and notes bruises in various stages of healing along with several small round burn marks on the child’s body. When the boy’s mother is questioned, she states “He’s so careless, falls all the time and plays with matches.” Which action by the nurse is appropriate?

The nurse is assessing a newborn born at 28 weeks gestation. Which of the following findings would be of greatest concern when planning nursing interventions?

A client is admitted to Labor and Delivery with an order for cephalexin 100 mg PO every 6 hours.  The drug is available as 125 mg/5 mL.  What volume would the nurse administer?

Last week, a client delivered their first pregnancy at 16 weeks gestation.  During the follow-up visit in the family health clinic today, the client notices the chart states they have had a spontaneous abortion. The client is upset over the use of the word abortion.  How can the nurse best explain this terminology to the client?

The nurse is caring for a 13-year-old boy diagnosed with cancer. He is experiencing feelings of powerlessness due to the effects of chemotherapy.  What intervention will best help improve his sense of control?

A nurse is assessing the face of a 5-year-old child and notes multiple areas of honey-colored crusted exudate from ruptured vesicles on the cheeks and around the mouth. Which of the following conditions is consistent with these signs and symptoms? 

You are administering heparin and following the protocol below for a client weighing 251 lbs. The order is to administer an initial heparin IV bolus followed by a titrated IV infusion.  Round to the tenths place. HEPARIN PROTOCOL Initial bolus- 60 units/kg Initial rate – 12 units/kg/h Obtain a PTT every 6 hours, and adjust dosage and rate as follows: If a PTT is less than 35 secs:      Repeat bolus with 40 units/kg and increase the rate by 4 units/kg/h. If a PTT is 36 to 44 seconds:       If a PTT is 36 to 44 seconds:          Repeat bolus with 20 units/kg and increase the rate by 2 units/kg/h. If a PTT is 45 to 75 seconds:       Continue current rate. If a PTT is 76 to 90 seconds:       Decrease rate by 2 units/kg/h. If a PTT is greater than 90 secs: Hold the heparin for 1 hour and decrease rate by 3 units/kg/h. Available (for bolus)  – heparin 1,000 units/mLAvailable (for infusion) –  heparin 25,000 units in 250 mL D5   6 hours later the PTT results from the lab are- PTT 80 secs.  The client is currently receiving 12units/kg/hr. What rate (mL/h) will the nurse set the pump at for the titrated heparin IV infusion in response to the PTT of 80 secs.

A Labor and Delivery nurse is assessing four clients on the unit who are expected to deliver within the next 24 hours. The nurse is concerned about risk factors for post-partum hemorrhage (PPH). Which client should the nurse assess as having the least likely risk for PPH?

A 34-year-old client visits the gynecologist. After examining the client, the HCP suspects cervical cancer. The nurse reviews the client’s history for risk factors for this disease. Which finding would not be a risk factor for cervical cancer? 

The nurse is administering RhoGAM (Rh Immunoglobulin) to a client who delivered 24 hours ago. The nurse reviews the indications for RhoGAM.  The client that is receiving RhoGAM is most likely which of the following?