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NCLEX Review: Maternity/Pediatrics/Psych

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shelby bruce

on 15 February 2016

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Transcript of NCLEX Review: Maternity/Pediatrics/Psych

Thank You!

Maternity NCLEX Review
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. A nurse determines the client is experiencing toxicity from the medication if which of the following is noted on assessment?

A. Presence of deep tendon reflexes
B. Serum magnesium level of 6 mEq/L
C. Proteinuria of 3+
D. Respirations of 10 per minutes

Magnesium Sulfate
Magnesium sulfate is the drug of choice used to prevent and treat seizure activity caused by preeclampsia
Therapeutic range: 4-7 mEq/L
Another nurse must be there for administration, as this is considered a high risk drug
Signs of toxicity
Decreased or absent deep tendon reflexes
Decreased urinary output
Slurred speech
Respiratory depression
Sudden drop in fetal heart rate and maternal heart rate and BP
Antidote: calcium gluconate
Changes in Fetal Heart Rate Patterns
Normal FHR: 110-160 BPM
Absent- undetectable from baseline
Minimal- change in baseline 5 BPM and under
Moderate- change in baseline from 6-25 BPM
Marked- change in baseline greater than 25 BPM

Changes in FHR patterns
Accelerations- visually apparent abrupt increase in FHR that returns to baseline in 2 minutes
Occurs in response to fetal movement, fetal scalp stimulation, or spontaneously
Indicative of fetal wellbeing
Early decelerations
In response to fetal head compression
Associated with contractions, "mirror image"
No nursing intervention required unless recurrent
Late decelerations
In response to uteroplacental insufficiency
An apparent, gradual decrease in FHR baseline after the contraction has started
The lowest point of the deceleration occurs after the peak of the contraction
Variable decelerations
In response to umbilical cord compression
Onset to nadir is <30 sec, must be at least 15 beats below baseline and last at least 15 sec
NCLEX Review:
Maternity/ Mental Health/ Pediatrics

A nurse in the labor room is caring for a client in the active phase of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to:

A. Place the mother in the supine position
B. Document the findings and contiue to monitor the fetal patterns
C. Administer oxygen via face mask
D. Increase the rate of pitocin IV infusion

Cultural Practices Regarding Maternity
Cool air in motion is thought to be dangerous while pregnant
Breastfeeding begun after the third day, colostrum is considered "spoiled"
Hot and cold theory- need warm fluids after delivery
Technology driven
Involvement of father valued
Native American
Herbal teas encouraged
Babies are not handled often

A woman from Southeast Asia has been in the United States for 6 months. She just delivered her first child. The nurse notices that the woman does not drink any of the fluids that are offered (ice water, iced tea, and juices) and mentions this concern at teh team meeting. The nurse manager states the problem may be cultural and that the woman may consider the postpartum period to be "cold". If this is corrct, which fluids may be acceptable to the woman? Select all that apply.

A. Hot tea
B. Lemonade
C. Lukewarm water
D. Hot water
E. Chocolate milk

Glucose in Newborns
Glucose levels drop when:
there is too much insulin
the baby is not producing enough glucose
the baby is using more glucose than it is producing (example: hypothermia)
the baby is not able to feed enough to keep glucose levels up
Risk factors:
Premature, serious infection, needs oxygen immediately after birth
Mother has diabetes, often resulting in macrosomia
Small for gestational age
bluish-colored or pale skin
breathig problems
loose or floppy muscles
poor feeding
problems keeping body warm
tremors, shakiness, sweating, or seizures
A newborn is jittery with irregular resirations and a weak, high pitched cry 30 minutes after admission to the nursery. Which of the following should be the priority nursing action?

A. Perform a heel stick to check serum glucose
B. Obtain an order for a drug screening blood test
C. Place a continuous pulse oximeter on the newborn
D. Evaluate the newborn's heart rate and temperature

Prioritization Questions
Consider the following principles:
Maslow's Hierarchy of Needs
Issues of safety
Assessment is a priority
Treat acute problems before chronic problems
A nurse is caring for a group of clients on a postpartum unit. Place the clients in order of priority to be seen by the nurse following report.

A. One day post vaginal delvery with urinary frequency
B. One day post Cesarean birth with pain of 8 on a 0-10 scale
C. Two day post vaginal delivery with 2 saturated perineal pads in one hour
D. Three days post Cesarean birth with breast engorgement
E. Three days post Cesarean birh preparing for discharge

Changes in Fetal Heart Rate Patterns

Early decelerations- head compression
No interventions needed unless they are recurrent
Late decelerations- placental insufficiency
Change maternal position
Correct hypotension
IV fluid bolus
Palpate uterus for tachysytole
Discontinue Pitocin
O2 at 10 L/min via facemask
Notify MD
Perform SVE/place fetal scalp electrode for more accurate reading
Assist with imminent birth if decelerations continue
Variable decelerations- cord compression
Change maternal position from side to side
Discontinue Pitocin
Administer O2 at 10L via facemask
Notify MD
Perform a vgainal exam
Assist with amnioinfusion per MD order
Assist with delivery if delerations continue
After a period of unsuccessful treatment with amitriptyline, a woman diagnosed with depression is switched to tranylcypromine. Which statement by the client indicates the client understands the side effects of tranylcypromine?
A. "I need to increase my intake of sodium."
B. "I must refrain from strenuous exercise."
C. "I must refrain from eating aged cheese or yeast products."
D. "I should decrease my intake of foods containing sugar."
Pharmacological Therapies
Pharmacological Therapies
C. The client was switched from amitriptyline (Elavil) to tranylcypromine (Parnate). Cheese and yeast products contain tyramine which the client should avoid to prevent a hypertensive crisis with tranylcypromine (Parnate), a monoamine oxidase (MAO) inhibitor. Sodium will not interact with Parnate and neither exercise nor sugar needs to be limited.

Evidence of an impending hypertensive crisis include: headaches, palpitations, and increased blood pressure.

Foods high in tyramine content include: aged cheese, red wine, beer, beef, chicken, liver, yeast, yogurt, soy sauce, chocolate, and bananas.
Psych NCLEX Review
Peds NCLEX Review
Developmental Stages
The mother of a toddler is concerned that the child is becoming antisocial because the child does not play with children but will sit next to another child and play alone. What should the nurse respond to this mother's concern?
The parents of a child hospitalized with sickle cell anemia tell the nurse that they are concerned about narcotic analgesics causing addiction. The nurse should explain which of the following concerning narcotics:
A. This is called parallel play and is expected.
B. This is called creative play and should be limited.
C. This is called isolated play and should be investigated.
D. This is called independent play and should be discouraged.
A. They are often ordered but not usually needed.
B. When they are medically indicated, children rarely become addicted.
C. They are given as a last resort because threat of addiction.
D. They are used only if other pain relieving measures are ineffective.
Erikson's Developmental Stages
Trust vs Mistrust
birth-18 months
focus: feeding, diaper changes
Children develop a sense of trust when caregivers provide reliability, care, and affection.
Cognitive Disorders
Sickle Cell Crisis
Autonomy vs Shame
Early Childhood: 2-3 years
focus: toilet training, parallel play
Children need to develop a sense of personal control over physical skills and a sense of independence.
A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first?
A. Pick up the fork and feed the client slowly
B. Say, "It's time for you to start eating your dinner."
C. Hand the fork to the client and say, "Use this fork to eat your green beans."
D. Save the client's dinner until her family comes in to feed her.
Initiative vs Guilt
Preschool: 3-5 years
Cognitive Disorders
focus: exploration
Children need to begin asserting control and power over the environment.
Industry vs Inferiority
School age: 6-11 years
focus: school
Children need to cope with new social and academic demands.
Identity vs Role Confusion
In providing nourishment for a child with cystic fibrosis, which of the following factors should the nurse keep in mind?

A. Fats and proteins must be greatly curtailed.
B. The diet should be high in calories and proteins.
C. Most fruits and vegetables are not well tolerated.
D. The diet should be high in easily digested carbohydrates and fats.
C. Agnosia: lack of recognition of objects and their purpose

The nurse should inform the client about about the fork and what to do with it. Feeding the client doesn't address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family is not appropriate unless identifying the fork or feeding the client is not successful.
Cystic Fibrosis
Adolescence: 12-18 years
focus: social relationships
Teens need to develop a sense of self and personal identity.
CF is a life-threatening, genetic disease that causes peristent lung infections and progressively limits the ability to breathe.

In people with CF, a defective gene causes a thick, buildup of mucus in the lungs, pancreas and other organs. In the lungs, the mucus clogs the airways and traps bacteria leading to infections, extensive lung damage and eventually, respiratory failure. In the pancreas, the mucus prevents the release of digestive enzymes that allow the body to break down food and absorb vital nutrients.

Children with CF require a well balanced, high protein, high calorie diet because of impaired intestinal absorption. Fats and proteins are a necessary part of a well-balanced diet.
Pediatric Vital Signs
The nurse is preparing to assess a 3-month old infant who is currently asleep. Which part of the assessment should the nurse complete at this time?
A. Eyes and ears
B. Nose and throat
C. Heart and lung sounds
D. Musculoskeletal system
Pediatric Vital Signs
ALWAYS observe first!
Use distraction.
Talk to the parents before you talk to the child.

Order of vital signs
heart rate
blood pressure

Normal Values:
newborn: HR 110-160 bpm, RR 30-60 breaths/min
gradually decrease as child ages
by age 12, normals same as adult

Count RR and HR for one full minute because of irregularities.

Always note where the temperature is taken and DO NOT add a degree.
Pain is the most common and debilitating symptom experienced by patients with sickle cell disease. The chronic nature of this pain can greatly affect the child’s development. A multidisciplinary approach is best for its management. Patient-controlled analgesia or continuous intravenous administration is usually effective. Pharmacologic intervention is necessary for the pain of sickle cell crisis.
A client with schizophrenia tells the nurse that he doesn't go out much because he doesn't have anywhere to go and he doesn't know anyone in the apartment where he's staying. Which of the following actions is most beneficial for the client at this time?
A. Encouraging him to call his family to visit more often.
B. Making an appointment for the client to see the nurse daily for 2 weeks.
C. Thinking about the need for rehospitalization for the client.
D. Arranging for the client to attend day treatment at the clinic.
D. Arranging for participation in day treatment is most beneficial at this time.
Because the client can live in an apartment setting, further development of independent functioning and the skills to gain as much independence as possible, including getting out and making new friendships. Family visits and daily nursing visits do not encourage the client to do this and making an appointment for 2 weeks later puts the needs of client off. Lack of social relationships is not a sufficent reason for rehospitalization.

Use Bleuler's four A's to remember important characteristics of schizophrenia: Autism (preoccupied with self), Affect (flat), Associations (loose), and Ambivalence (difficulty making decisions)

Remember: when evaluating these clients' behaviors, consider the medications they're receiving.
The nurse learns that a 7-year-old child with asthma uses a short acting beta2 agonist every morning before leaving the home to go to school. What does this finding suggest to the nurse
A. Asthma is well-controlled
B. Asthma is not well controlled
C. The client needs to take more of the medication
D. The medication should be taken after arriving to school
Asthma is inflammation and constriction of the airways resulting in obstruction.

Needing to use a short acting beta2 agonist two times in one week indicates need for further evaluation by a doctor.

shortness of breath
audible wheezing
prolonged expiratory wheezing
restlessness and cyanosis

Identify triggers.

either short (quick relief, used when asthma attack symptoms are present) or long acting (taken daily over a long period of time to gain control of the asthma)
Short: short acting beta agonists, anticholinergics, systemic corticosteroids
Long: long acting beta agonists, leukotriene modifiers, theophylline, immunomodulators

BONUS QUESTION: What would be a good pet for an asthma patient?
Cystic Fibrosis
Sickle Cell Anemia

Billings, D.M. & Hensel, D. (2015). Lippincott q&a review for nclex-rn. Philadelphia, Pennsylvania: Lippincott Williams & Wilkins.

Cystic Fibrosis Foundation. (2015). About cystic fibrosis. Retrieved from https://www.cff.org/What-is-CF/About-Cystic-Fibrosis/

Hurst Review Services (2016). Hurst Review. Pediatrics. Retrieved from http://www.hurstreview.com/my-account/videos/24

Easy Notecards. (2014). Maternal-child test 1 review questions. Retrieved from http://www.easynotecards.com/notecard_set/28783

Lowdermilk, D. L., Perry, S. E., Cashion, M. C., Alden, K. R. (2016).Maternity & Women’s Health Care (11th ed). St. Louis, MO: Mosby, Inc.

Upchurch, S., Henry, T., Pine, R., & Rickles, A. (2014). Comprehensive review for the nclex-rn examination. St. Louis, Missouri: Elsevier Inc.

Student Nursing Study Blog. OB/GYN2-antepartum. Retrieved from https://amy47.com/nclex-style-practice-questions/obgyn-nclex-type-questions/obgyn-2/

Student Nursing Study Blog. OB/GYN- intrapartum. Retrieved from https://amy47.com/nclex-style-practice-questions/obgyn-nclex-type-questions/

Your Best Grade (2016). Retrived from: http://www.yourbestgrade.com/hesi/specialty

Electroconvulsive Therapy

A nurse is caring for a client who is receiving electroconvulsive therapy (ECT) for a major depressive disorder. Which assessment finding would the nurse identify as an unexpected side effect of the ECT that requires notifying the physician?

A. Confusion
B. Memory Loss
C. Hypertension
D. Disorientation

Electroconvulsive Therapy

The major side effects of ECT are confusion, disorientation, and memory loss. A change in blood pressure would not be an anticipated side effect , and it would be a cause for concern. If hypertension occurred after ECT, the physician should be notified.

A nurse observes an anxious client blocking the hallway, walking three steps forward and then two steps backward. Other clients are agitated and trying to get past the client. The nurse intervenes by:

A. Standing alongside the client and saying, "You're very anxious today."
B. Attempting to stop the behavior and saying "You're going to get exhausted."
C. Taking the client to the lounge and saying "Relax and watch television now."
D. Walking alongside the patient and saying "You're not going anywhere very fast doing this."


An important consideration when alleviating anxiety is to assist the client with recognizing the behavior. Options 2 and 3 do not address the underlying behavior, and they may even escalate the behavior. Option 4 does not raise the client to a functioning level.
Postpartum Hemorrhage
leading cause of maternal mortaltity
Can be caused by:
uterine atony
lacerations of the vagina
hematoma devleopment
retained placental fragments
full bladder
Nursing Assessment:
look for excessive uterine bleeding (hemorrhage postpartum is considered more than one saturated pad per hour)
assess for signs of hypovolemic shock
assess for signs of hematomas
Postpartum Hemorrhage
Nursing Actions
perform fundal massage
notify HCP if fundus does not become firm
count pads and estimate blood loss
assess vital signs
increase IV fluids
administer oxytocin as prescribed
Vaso-occlusive crisis is the most common type.

Signs and Symptoms:
Severe pain, localized or general.
Low grade fever

Medical Management:
Provide bed rest
Hydration through oral and IV therapy
Electrolyte replacement
Blood Replacement

When a patient describes a physical problem ALWAYS assess because a client may be admitted for a psychological problem, but they may be experiencing a physiological problem as well.

If a patient asks if you're going to tell anyone what they disclose to you, you must tell them that some information must be shared to ensure the clients' safety and optimal therapy.

Monitor serum lithium levels carefully. Sign of toxicity are evident when more than 1.5 mEq/L. Blood levels should be drawn 12 hours after last dose.

When a client is taking Antabuse for alcohol dependency, be sure to teach to read ALL products to ensure they do not contain alcohol (such as cough medicine and shaving lotion)

A, C, D
As pregnancy advances, the uterus presses on abdominal vessels. Teach the woman that a left side-lying position relieves supine hypotension and increases perfusion to uterus, placenta, and fetus.
When deceleration patterns are associated with decreased or absent variablilty and tachycardia, the situation is ominous and requires immediate intervention and fetal assessment.
Client should void within 4 hours of delivery. Monitor closely for urine retention. Suspect retention if voiding is frequent and <100 mL per voiding.
Suction the mouth first and then the nose. Stimulating the nares can initaiate inspiration, which could cause aspiration of mucus in oral pharynx.
C, B, A , D, E
Urinary output for infants and children should be 1 to 2 mL/kg/hr

Typical parent and family reactions to a child with an obvious malformation such as cleft lip or palate are guilt, disappointment, grief, sense of loss, and anger

Hydration is very important in the treatment of sickle cell disease becuase it promotes hemodilution and circulation of red cells through the blood vessles

An infant with hypothyroidism is often described as a good, quiet baby by the parents
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