TEST BANK for Introduction to Maternity and Pediatric Nursing, 9th Edition by Leifer Gloria

Chapter 01: The Past, Present, and Future Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A patient chooses to have the certified nurse-midwife (CNM) provide care during her

pregnancy. What does the CNM‘s scope of practice include? a. Practice independent from medical supervision b. Comprehensive prenatal care c. Attendance at all deliveries d. Cesarean sections ANS: B

The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures that a backup physician is available in case of unforeseen problems.

DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5 TOP: Advance Practice Nursing Roles KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. Which medical pioneer discovered the relationship between the incidence of puerperal fever

and unwashed hands? a. Karl Credé b. Ignaz Semmelweis c. Louis Pasteur d. Joseph Lister ANS: B

Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students.

DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 TOP: The Past KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. A pregnant woman who has recently immigrated to the United States comments to the nurse,

―I am afraid of childbirth. It is so dangerous. I am afraid I will die.‖ What is the best nursing response reflecting cultural sensitivity? a. ―Maternal mortality in the United States is extremely low.‖ b. ―Anesthesia is available to relieve pain during labor and childbirth.‖ c. ―Tell me why you are afraid of childbirth.‖ d. ―Your condition will be monitored during labor and delivery.‖ ANS: C

Asking the patient about her concerns helps promote understanding and individualizes patient care.

DIF: Cognitive Level: Application REF: pp. 6-8 OBJ: 8 TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation

4. An urban area has been reported to have a high perinatal mortality rate. What information

does this provide? a. Maternal and infant deaths per 100,000 live births per year b. Deaths of fetuses weighing more than 500 g per 10,000 births per year c. Deaths of infants up to 1 year of age per 1000 live births per year d. Fetal and neonatal deaths per 1000 live births per year ANS: D

The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.

DIF: Cognitive Level: Comprehension REF: p. 13 | Box 1.6 OBJ: 9 TOP: The Present-Child Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 5. What is the focus of current maternity practice? a. Hospital births for the majority of women b. The traditional family unit c. Separation of labor rooms from delivery rooms d. A quality family experience for each patient ANS: D

Current maternity practice focuses on a high-quality family experience for all families, traditional or otherwise.

DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5 TOP: The Present-Maternity Care KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 6. Who advocated the establishment of the Children‘s Bureau? a. Lillian Wald b. Florence Nightingale c. Florence Kelly d. Clara Barton ANS: A

Lillian Wald is credited with suggesting the establishment of a federal Children‘s Bureau.

DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: 1 | 2 TOP: The Past KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. What was the result of research done in the 1930s by the Children‘s Bureau? a. Children with heart problems are now cared for by pediatric cardiologists. b. The Child Abuse and Prevention Act was passed. c. Hot lunch programs were established in many schools. d. Children‘s asylums were founded.

ANS: C

School hot lunch programs were developed as a result of research by the Children‘s Bureau on the effects of economic depression on children.

DIF: Cognitive Level: Knowledge

REF: p. 4

OBJ: 2 | 3

TOP: The Past KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 8. What government program was implemented to increase the educational exposure of

preschool children? a. WIC b. Title XIX of Medicaid c. The Children‘s Charter d. Head Start ANS: D

Head Start programs were established to increase educational exposure of preschool children.

DIF: Cognitive Level: Knowledge REF: p. 3 OBJ: 3 TOP: Government Influences in Maternity and Pediatric Care KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. What guidelines define multidisciplinary patient care in terms of expected outcome and

timeframe from different areas of care provision? a. Clinical pathways b. Nursing outcome criteria c. Standards of care d. Nursing care plan ANS: A

Clinical pathways, also known as critical pathways or care maps, are collaborative guidelines that define patient care across disciplines. Expected progress within a specified timeline is identified.

DIF: Cognitive Level: Knowledge REF: p. 13 OBJ: 10 TOP: Health Care Delivery Systems KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 10. A nursing student has reviewed a hospitalized pediatric patient chart, interviewed her mother,

and collected admission data. What is the next step the student will take to develop a nursing care plan for this child? a. Identify measurable outcomes with a timeline. b. Choose specific nursing interventions for the child. c. Determine appropriate nursing diagnoses. d. State nursing actions related to the child‘s medical diagnosis.

ANS: C

The nurse uses assessment data to select appropriate nursing diagnoses. Outcomes and interventions are then developed to address the relevant nursing diagnoses.

DIF: Cognitive Level: Application REF: p. 12 OBJ: 7 TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 11. A nursing student on an obstetric rotation questions the floor nurse about the definition of the

LVN/LPN scope of practice. What resource can the nurse suggest to the student? a. American Nurses Association

b. State‘s Board of Nursing c. Joint Commission d. Association of Women‘s Health, Obstetric and Neonatal Nurses ANS: B

The scope of practice of the LVN/LPN is published by the state‘s board of nursing.

DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 2 TOP: Critical Thinking KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12. What was recommended by Karl Credé in 1884? a. All women should be delivered in a hospital setting. b. Chemical means should be used to combat infection. c. Podalic version should be done on all fetuses. d. Silver nitrate should be placed in the eyes of newborns.

ANS: D

In 1884 Karl Credé recommended the use of 2% silver nitrate in the eyes of newborns to reduce the incidence of blindness.

DIF: Cognitive Level: Knowledge REF: p. 2 OBJ: 1 TOP: Use of Silver Nitrate KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. What is the purpose of the White House Conference on Children and Youth? a. Set criteria for normal growth patterns. b. Examine the number of live births in minority populations. c. Raise money to support well-child clinics in rural areas. d. Promote comprehensive child welfare.

ANS: D

White House Conferences on Children and Youth are held every 10 years to promote comprehensive child welfare.

DIF: Cognitive Level: Knowledge REF: p. 4 OBJ: 2 TOP: White House Conferences KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. How many hours of hospital stay does legislation currently allow for a postpartum patient

who has delivered vaginally without complications? a. 24 b. 48 c. 36 d. 72 ANS: B

Postpartum patients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have had a cesarean delivery usually stay 4 days.

DIF: Cognitive Level: Knowledge REF: p. 6 TOP: Hospital Terms for Postpartum Patients KEY: Nursing Process Step: Planning

OBJ: 5

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. How does the clinical pathway or critical pathway improve quality of care? a. Lists diagnosis-specific implementations b. Outlines expected progress with stated timelines c. Prioritizes effective nursing diagnoses d. Describes common complications ANS: B

Critical pathways outline expected progress with stated timelines. Any deviation from those timelines is called a variance.

DIF: Cognitive Level: Comprehension REF: p. 13 OBJ: 10 TOP: Critical Pathway KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 16. A patient asks the nurse to explain what is meant by ―gene therapy.‖ What is the nurse‘s best

response? a. Gene therapy can replace missing genes. b. Gene therapy evaluates the parent‘s genes. c. Gene therapy can change the sex of the fetus. d. Gene therapy supports the regeneration of defective genes.

ANS: A

Gene therapy can replace missing or defective genes.

DIF: Cognitive Level: Knowledge REF: p. 8 OBJ: 5 TOP: Gene Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. The nurse is clarifying information to a patient regarding diagnosis-related groups (DRGs).

What is the nurse‘s best response when the patient asks how DRGs reduce medical care costs? a. By determining payment based on diagnosis b. By requiring two medical opinions to confirm a diagnosis c. By organizing HMOs d. By defining a person who will require hospitalization ANS: A

DRGs determine the amount of payment and length of hospital stay based on the diagnosis.

DIF: Cognitive Level: Comprehension REF: p. 8 OBJ: 3 TOP: DRGs KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 18. How does electronic charting ensure comprehensive charting more effectively than

handwritten charting? a. Provides a uniform style of chart. b. Requires certain responses before allowing the user to progress. c. All documentation is reflective of the nursing care plan. d. Requires a daily audit by the charge nurse.

ANS: B

Comprehensive electronic documentation is ensured by requiring specific input in designated categories before the user can progress through the system.

DIF: Cognitive Level: Comprehension REF: pp. 16-17 OBJ: 12 TOP: Computer Charting KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 19. The nurse reminds family members that the philosophy of family-centered care is to provide

control to the family over health care decisions. What is the appropriate term for this type of control? a. Empowerment b. Insight c. Regulation d. Organization ANS: A

The term empowerment refers to the control a family has over its own health care decisions.

DIF: Cognitive Level: Knowledge REF: p. 1 OBJ: 13 TOP: Empowerment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. A patient in the prenatal clinic is concerned about losing her job because of her pregnancy.

The nurse instructs her that the Family Medical Leave Act (FMLA) allows an employee to be absent from work without pay. How many weeks does the FMLA allow a woman to recover from childbirth or care for a sick family member without loss of benefits or pay status? a. 4 b. 6 c. 10 d. 12 ANS: D

The FMLA allows for employees to leave work for up to 12 weeks to recover from childbirth or to care for an ill family member without losing benefits or pay status.

DIF: Cognitive Level: Knowledge REF: p. 3 OBJ: 5 TOP: FMLA KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. What term appropriately describes the nurse who is able to adapt health care practices to meet

the needs of various cultures? a. Culturally aware b. Culturally sensitive c. Culturally competent d. Culturally adaptive ANS: C

The nurse who is able to adapt health care to meet the needs of various cultures is said to be culturally competent.

DIF: Cognitive Level: Knowledge TOP: Cultural Competency

REF: p. 6 OBJ: 6 KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A 22. What is one major advantage to the application of critical thinking? a. Problem-free care b. Limitation of approaches to care c. Decreased need for assessment d. Problem prevention ANS: D

Critical thinking results in problem prevention in designing nursing care.

DIF: Cognitive Level: Comprehension TOP: Critical Thinking MSC: NCLEX: N/A

REF: p. 15 OBJ: 11 KEY: Nursing Process Step: N/A

MULTIPLE RESPONSE 1. What services are birthing centers able to provide? (Select all that apply.) a. Prenatal care b. Labor and delivery services c. Classes for new mothers d. Adoption referrals e. Family planning ANS: A, B, C, E

Birthing centers are capable of providing full-service obstetric care, classes for new mothers, and family planning. Birthing centers do not offer adoption services.

DIF: Cognitive Level: Comprehension REF: p. 6 OBJ: 5 TOP: Birthing Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 2. What developments in the early 20th century encouraged women to seek hospitalization for

childbirth? (Select all that apply.) a. Use of specialized obstetric instruments b. Use of anesthesia c. Physicians‘ closer relationships with hospitals d. Focus on family-centered care e. Insurance coverage ANS: A, B, C

In the early 1900s, the development of specialized obstetric instruments, better modes of anesthesia, and the physician‘s reliance on hospital services were instrumental in encouraging women to seek hospitalization for childbirth.

DIF: Cognitive Level: Comprehension REF: pp. 2-3 OBJ: 5 TOP: Hospitalization for Childbirth KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. What non–family-centered policies were prevalent in the 1960s? (Select all that apply.) a. Waiting room for fathers b. Sedation of mother during labor

c. Delay of reunion of mother and infant d. Lenient visiting hours e. Restrictions of visitations by minor children ANS: A, B, C, E

Hospital policies in the 1960s provided a separate waiting room for fathers while the mother went through labor in a sedated state. The reunion of mother and infant was delayed for several hours because of the sedation. Visiting hours were rigid and disallowed the visitation of minor children.

DIF: Cognitive Level: Comprehension REF: p. 3 OBJ: 5 TOP: Non–Family-Centered Practices KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. The nurse is aware that there is a legal responsibility to report certain diseases and conditions

to county or state health authorities. Which would be included? (Select all that apply.) a. Tuberculosis b. Child abuse c. Industrial accidents d. Sexually transmitted diseases e. Foodborne infections ANS: A, B, D, E

The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and sexually transmitted diseases), foodborne infections, child abuse, and threats of suicide.

DIF: Cognitive Level: Comprehension REF: p. 4 | Legal and Ethical Considerations Box OBJ: 4 TOP: Reportable Diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. Practical nursing students are using critical thinking skills to study for an upcoming test. What

will these students include when studying? (Select all that apply.) a. Memorization of facts first b. Prioritizing information c. Relating facts to other facts d. Making assumptions e. Reviewing before the test ANS: B, C, E

Using critical thinking when studying involves understanding facts before memorizing, prioritizing information to be memorized, relating facts to other facts, using all five senses, reviewing before tests, and reading critically. Critical thinking does not involve assumption as does general thinking.

DIF: Cognitive Level: Comprehension REF: p. 16 OBJ: 8 TOP: Critical Thinking KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 6. What factors have played a role in meeting the goals of Healthy People 2030 as it relates the

goals for outcomes of pregnancy? (Select all that apply.) a. Early prenatal care

b. c. d. e.

Increased number of surgical births NICU care Use of prenatal glucocorticoids Fetal surgery

ANS: A, C, D, E

Early prenatal care, fetal surgery, use of prenatal glucocorticoids, technology, and NICU care have played a role in increasing the positive outcome of pregnancy, and the goals of Healthy People 2030 may well be met. Increase in surgical births and multiple gestations do not work toward meeting the goals of Healthy People 2030.

DIF: Cognitive Level: Comprehension REF: p. 17 OBJ: 13 TOP: Healthy People 2030 KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 7. A community health nurse is providing specialized care to patients in the home setting. What

kind of specialized care may this nurse be providing? (Select all that apply.) a. Glucose monitoring b. Heparin therapy c. Family education d. Total parenteral nutrition e. Provision of referral services ANS: A, B, D

Glucose monitoring, heparin therapy, and total parenteral nutrition are categorized as specialized care that may be provided by the community health nurse. Family education and provision of referral are categorized as therapeutic care.

DIF: Cognitive Level: Application REF: p. 20 OBJ: 14 TOP: Community Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Chapter 02: Human Reproductive Anatomy and Physiology Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A 14-year-old boy is at the pediatric clinic for a checkup. What physical changes of puberty

will the nurse indicate are related to the production of testosterone?

a. b. c. d.

Stimulation of production of white cells and platelets Promotion of growth of small bones Increase in muscle mass and strength Decrease in production of sebaceous gland secretions

ANS: C

Testosterone increases muscle mass, promotes strength and growth of long bones, and enhances production of red blood cells.

DIF: Cognitive Level: Knowledge REF: p. 25 OBJ: 1 | 2 | 5 TOP: Male Reproductive System KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is educating high school students about puberty. What will the nurse indicate

regulates the production of sperm and secretion hormones? a. Testes b. Vas deferens c. Ejaculatory ducts d. Prostate gland ANS: A

The testes have two functions: manufacture of spermatozoa and secretion of androgens.

DIF: Cognitive Level: Knowledge REF: p. 24 OBJ: 3 | 5 TOP: Male Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The nurse is speaking with a couple trying to conceive a child. What will the nurse remind the

couple is a factor that can decrease sperm production? a. Infrequent sexual intercourse b. The man not being circumcised c. The penis and testes being small d. The testes being too warm ANS: D

The scrotum is suspended away from the perineum to lower the temperature of the testes for sperm production.

DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: 3 TOP: Male Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 4. When describing the female reproductive tract to a pregnant woman, the nurse would explain

that which uterine layer is involved in implantation? a. Perimetrium b. Endometrium c. Myometrium d. Internal os ANS: B

The endometrium is the inner mucosal layer of the uterus that is governed by cyclical hormonal changes. It is functional during menstruation and during the implantation of a fertilized ovum.

DIF: Cognitive Level: Knowledge REF: p. 27 OBJ: 7 TOP: Female Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A group of nursing students plans to teach a class of sixth-grade girls about menstruation.

What correct information will the nursing students teach to the class? a. Menarche usually occurs around 12 years of age. b. Ovulation occurs regularly from the very first cycle. c. A regular cycle is established by the third period. d. Typically, menstrual flow is heavy and lasts up to 10 days.

ANS: A

The beginning of menstruation, called menarche, occurs at about 12 years of age. Early cycles are irregular and anovulatory.

DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: 1 | 9 TOP: Female Reproductive Cycle and Menstruation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. A 10-year-old girl asks the nurse, ―What is the first sign of puberty?‖ What is the correct

nursing response? a. An increase in height b. Breast development c. Appearance of axillary hair d. The first menstrual period ANS: B

The first outward change of puberty in girls is the development of breasts at about 10 to 11 years of age.

DIF: Cognitive Level: Knowledge REF: p. 24 OBJ: 1 | 2 TOP: Puberty—Female KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. A 12-year-old female patient experienced menarche 3 months ago. Her mother voices concern

to the pediatric office nurse regarding the irregularity of her daughter‘s menstrual cycle. What is the nurse‘s best response? a. ―Worrying is not the answer.‖ b. ―I will talk to the pediatrician about a gynecological referral.‖ c. ―I can only discuss this with your daughter.‖ d. ―Early cycles are often irregular.‖ ANS: D

Early cycles are often irregular and may be anovulatory. Regular cycles are usually established within 6 months to 2 years of the menarche. In an average cycle, the flow (menses) occurs every 28 days, plus or minus 5 to 10 days.

DIF: Cognitive Level: Application REF: p. 30 OBJ: 9 TOP: Menstrual Cycle KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. Which hormone initiates the maturation of the ovarian follicle? a. Estrogen b. Follicle-stimulating hormone c. Progesterone d. Luteinizing hormone ANS: B

Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle.

DIF: Cognitive Level: Knowledge REF: p. 30 OBJ: 1 | 9 TOP: Female Reproductive Cycle KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. What statement indicates a woman has correct information about oogenesis? a. ―Women make fewer ova as they age.‖ b. ―Women have all of their ova at the time they are born.‖ c. ―Ova production begins at birth and continues until puberty.‖ d. ―New ova are made every month from puberty to climacteric.‖ ANS: B

Oogenesis (formation of immature ova) does not occur after fetal development. Females are born with about 2 million immature ova, which rapidly reduce by adulthood.

DIF: Cognitive Level: Comprehension REF: p. 28 OBJ: 9 TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. A pregnant woman asks the nurse, ―Will I be able to have a vaginal delivery?‖ The nurse

knows that which is the most favorable pelvic type for vaginal birth? a. Gynecoid b. Android c. Anthropoid d. Platypelloid ANS: A

The gynecoid pelvis is the typical female pelvis and is most favorable for vaginal birth.

DIF: Cognitive Level: Knowledge REF: p. 28 OBJ: 8 TOP: Female Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. A mother is anxious about her ability to breastfeed after her child is born because of her small

breast size. What would be an important point to teach this mother? a. Milk is produced in ducts and lobules regardless of breast size. b. Supplementing breastfeeding with formula allows the infant to receive adequate nutrition. c. Breast size can be increased with exercise. d. Drinking extra milk during pregnancy allows breasts to produce adequate amounts

of milk.

ANS: A

Breast size does not influence the ability to secrete milk.

DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: 6 TOP: Female Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. For what is the decrease in estrogen and progesterone during the menstrual cycle responsible? a. Degeneration of the corpus luteum b. Ovulation c. Follicle maturation d. Shedding of the endometrium ANS: D

The fall in estrogen and progesterone causes the endometrium to break down, resulting in menstruation.

DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: 9 TOP: Female Reproductive Cycle KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. The nurse is assisting with pelvic inlet measurements on a pregnant woman. What

measurement will provide the nurse with information about whether the woman can deliver vaginally? a. Diagonal conjugate b. Obstetric conjugate c. Transverse diameter d. Anteroposterior diameter ANS: B

This measurement determines if the fetus can pass through the birth canal.

DIF: Cognitive Level: Comprehension REF: p. 29 OBJ: 8 TOP: Female Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse has explained menstruation to a 13-year-old girl. What statement indicates the girl

needs additional education? a. ―Periods last about 5 days.‖ b. ―My cycle should get regular in 6 months.‖ c. ―I should expect heavy bleeding with clots.‖ d. ―Periods come about every 4 weeks.‖ ANS: C

Clots are not normally seen in menstrual discharge. A normal menstrual flow is 30 to 40 mL blood and 30 to 50 mL serous fluid.

DIF: Cognitive Level: Comprehension REF: p. 30 OBJ: 9 TOP: Female Reproductive Cycle KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

15. A mother asks the nurse, ―When will I know my child has entered puberty?‖ What will the

nurse state based on an understanding of changes associated with puberty? a. ―Your daughter will have her first period.‖ b. ―You‘ll recognize puberty by the mood swings.‖ c. ―The child becomes interested in the opposite sex.‖ d. ―Secondary sex characteristics, such as pubic hair, appear.‖ ANS: D

Puberty begins when the secondary sex characteristics appear. Puberty ends when mature sperm are formed in the male and when regular menstrual cycles occur in the female.

DIF: Cognitive Level: Comprehension REF: p. 23 OBJ: 1 | 2 TOP: Puberty KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. A nurse is planning to teach couples about the physiology of the sex act. What correct

information will the nurse provide? a. ―Fertilization of an ovum requires penetration by several sperm.‖ b. ―An ovum must be fertilized within 24 hours of ovulation.‖ c. ―It takes 4 to 5 days for sperm to reach the fallopian tubes.‖ d. ―Sperm live for only 24 hours following ejaculation.‖ ANS: B

After ovulation, the egg lives for only 24 hours. Sperm must be available during that time if fertilization is to occur.

DIF: Cognitive Level: Comprehension REF: p. 32 OBJ: 6 | 7 TOP: Physiology of the Sex Act KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A newly married couple tells the nurse they would like to wait a few years before starting a

family. Which statement made by the man indicates an understanding about sexual activity and pregnancy? a. ―My wife can‘t get pregnant if I withdraw before climax.‖ b. ―A man can secrete semen before ejaculation.‖ c. ―If we don‘t have intercourse very often, my wife won‘t get pregnant.‖ d. ―It is safe to ejaculate outside the vagina.‖ ANS: B

Semen may be secreted during sexual intercourse before ejaculation.

DIF: Cognitive Level: Comprehension REF: p. 25 OBJ: 4 TOP: Male Reproductive System KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. The nurse is aware that the diagonal conjugate is 12 cm. What is the measurement in

centimeters of the obstetric conjugate? a. 10 to 10.5 b. 11 to 11.5 c. 12.5 to 13 d. 14 to 14.5

ANS: A

The obstetric conjugate is approximately 1.5 to 2 cm shorter than the diagonal conjugate.

DIF: Cognitive Level: Knowledge REF: p. 29 OBJ: 1 | 8 TOP: Obstetric Conjugate KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. The nurse uses a diagram to demonstrate the fimbriae when teaching nursing students about

the female anatomy. What is true about fimbriae? a. They form the passageway for the sperm to meet the ovum. b. They are the site of fertilization. c. They are fingerlike projections that ―capture‖ the ovum. d. They propel the egg through the fallopian tube.

ANS: C

Fimbriae are the fingerlike projections from the infundibulum that ―capture‖ the ovum at ovulation and conduct it into the fallopian tube.

DIF: Cognitive Level: Comprehension REF: p. 28 OBJ: 6 | 7 TOP: Fimbriae KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. What will the nurse explain to a 12-year-old patient when describing what characterizes

nocturnal emissions? a. A drop in testosterone level b. Sexual stimulation c. Absence of sperm in ejaculate d. Association with violent dreams ANS: C

Nocturnal emissions, also known as ―wet dreams,‖ occur without sexual stimulation and contain no sperm. Testosterone levels are constant until midlife.

DIF: Cognitive Level: Comprehension REF: p. 24 OBJ: 2 TOP: Nocturnal Emissions KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The nurse is educating a pregnant patient who expects to breastfeed. The nurse knows that

when a patient breastfeeds, which portions of the breast secrete milk? a. Lactiferous sinuses b. Lobes c. Montgomery‘s glands d. Alveoli lobules ANS: D

The alveoli secrete milk.

DIF: Cognitive Level: Knowledge REF: p. 30 OBJ: 6 | 7 TOP: Milk Secretion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. Where are the secretions responsible for nourishing sperm excreted from?

a. b. c. d.

Vas deferens Epididymis Cowper‘s gland Scrotum

ANS: C

The Cowper‘s gland secretions nourish the sperm.

DIF: Cognitive Level: Knowledge REF: p. 25 OBJ: 4 TOP: Cowper‘s Gland KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 23. What signifies the end of puberty for a male? a. Facial hair is evident. b. Erections can be sustained. c. Ejaculate is greater than 5 mL. d. Mature sperm are formed.

ANS: D

Puberty ends for a male when mature sperm are formed by the testes.

DIF: Cognitive Level: Knowledge REF: p. 23 OBJ: 1 | 2 TOP: End of Puberty KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. How long does sperm remain viable in the female reproductive tract? a. 12 hours b. 1 day c. 2 days d. 4 days ANS: D

Sperm can remain viable in the reproductive tract of the female for as long as 4 to 5 days.

DIF: Cognitive Level: Knowledge REF: p. 32 OBJ: 5 TOP: Viability of Sperm KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. The nurse encourages the members of a prenatal class to seriously consider breastfeeding.

What does breast milk provide in addition to nourishment for the infant? a. Maternal antibodies b. Stimulus for red blood cell production c. Endorphins that soothe the infant d. Hormones that stimulate growth ANS: A

Breast milk provides maternal antibodies to the infant that give the child acquired immunity from some diseases for several months.

DIF: Cognitive Level: Comprehension REF: p. 29 OBJ: 7 TOP: Properties of Breast Milk KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

26. A female patient reports her menstrual cycle consistently occurs every 32 days. What day of

her cycle can the woman anticipate ovulation? a. 14 b. 16 c. 18 d. 20 ANS: C

Ovulation occurs when a mature ovum is released from the follicle about 14 days before the onset of the next menstrual period.

DIF: Cognitive Level: Analysis REF: p. 30 OBJ: 9 TOP: Menstrual Cycle KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. The nurse conducting a sex education class for junior high students describes some cultural

rites celebrating the entry to adulthood. What information would the nurse include? (Select all that apply.) a. Bar mitzvah b. Displays of bravery c. Receiving part of their inheritance d. Ritual circumcision e. Displays of self-defense ANS: A, B, D, E

Some cultures celebrate the entry to adulthood with rites such as displays of strength, bravery, self-reliance, and self-defense. Ritual circumcisions and bar and bat mitzvahs are also entry rites to adulthood. Lack of such rituals can sometimes confuse young people because there is no evidence of acceptance as an adult.

DIF: Cognitive Level: Knowledge REF: p. 23 OBJ: 2 TOP: Rites of Passage KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is reading a pregnant patient‘s history and physical. What information does the

nurse recognize might indicate the need for a cesarean delivery? (Select all that apply.) a. History of childhood rickets b. Immobile coccyx c. Prepregnant weight of 100 pounds d. Avid horse rider e. Pelvic fracture 3 years ago ANS: A, B, E

Pelvic conditions that may predispose to a cesarean delivery are childhood rickets, pelvic fracture, and immobile coccyx.

DIF: Cognitive Level: Comprehension REF: pp. 28-29 TOP: Pelvic Conditions Predisposing Cesarean Delivery KEY: Nursing Process Step: Data Collection

OBJ: 8

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What are considered to be functions of the fallopian tubes? (Select all that apply.) a. Passage for sperm to meet ova b. Passage for ovum to uterus c. Safe environment for zygote d. Restriction for only one ovum to enter uterus e. Site for fertilization ANS: A, B, C, E

The fallopian tube provides passage for both sperm and ova, offering an optimum place for fertilization and a safe environment for the zygote.

DIF: Cognitive Level: Knowledge REF: p. 28 OBJ: 7 TOP: Function of Fallopian Tubes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse is providing an in-service to students beginning their obstetric clinical rotation.

Using a diagram, the nurse points out parts of the female pelvis. What will the nurse include?

(Select all that apply.) a. Two innominates b. Obstetric conjugate c. Sacrum d. Perimetrium e. Coccyx ANS: A, C, E

The bones of the pelvis are two innominates, the sacrum, and the coccyx.

DIF: Cognitive Level: Knowledge REF: p. 28 OBJ: 6 | 8 TOP: Bones of the Pelvis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse explains that testosterone is responsible for males exceeding females in which

aspects? (Select all that apply.) a. Strength b. Height c. Mental concentration d. Hematocrit levels e. Agility ANS: A, B, D

Testosterone has the following effects not directly related to sexual reproduction: increases muscle mass and strength, promotes growth of long bones, increases basal metabolic rate, enhances production of red blood cells, produces enlargement of vocal cords, and affects the distribution of body hair. These effects result in greater strength and stature and a higher hematocrit level in males than in females.

DIF: Cognitive Level: Knowledge REF: p. 25 OBJ: 2 TOP: Effects of Testosterone KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

6. A patient is being seen by her health care provider for a suspected vaginal infection. What will

the nurse include when educating this patient on factors that affect the vaginal pH? (Select all that apply.) a. Antibiotic therapy b. Frequent douching c. Exercise d. Jet lag e. Use of vaginal sprays ANS: A, B, E

The vagina is self-cleansing and during the reproductive years maintains a normal acidic pH of 4 to 5. The self-cleansing activity may be altered by antibiotic therapy, frequent douching, and excessive use of vaginal sprays, deodorant sanitary pads, or deodorant tampons.

DIF: Cognitive Level: Application REF: p. 26 OBJ: 7 TOP: Female Reproductive Organs KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 03: Fetal Development Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What is the total number of chromosomes contained in a mature sperm or ovum? a. 22 b. 23 c. 44 d. 46 ANS: B

Gametes (sex cells) contain 23 chromosomes.

DIF: Cognitive Level: Knowledge REF: p. 34 OBJ: 2 TOP: Gametogenesis KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A pregnant woman states, ―My husband hopes I will give him a boy because we have three

girls.‖ What will the nurse explain to this woman? a. The sex chromosome of the fertilized ovum determines the gender of the child. b. When the sperm and ovum are united, there is a 75% chance the child will be a girl. c. When the pH of the female reproductive tract is acidic, the child will be a girl. d. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.

ANS: D

When a Y-bearing sperm fertilizes an ovum, a male child is produced.

DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 3 TOP: Sex Determination KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. What is the most common site for fertilization?

a. b. c. d.

Lower segment of the uterus Outer third of the fallopian tube near the ovary Upper portion of the uterus Area of the fallopian tube farthest from the ovary

ANS: B

Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.

DIF: Cognitive Level: Knowledge REF: pp. 35-36 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The embryo is termed a fetus at which stage of prenatal development? a. 2 weeks b. 4 weeks c. 9 weeks d. 16 weeks ANS: C

The fetus (third stage of prenatal development) begins at the ninth week and continues until the 40th week of gestation or until birth.

DIF: Cognitive Level: Knowledge REF: p. 39 OBJ: 4 TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse is reviewing fetal circulation with a pregnant patient and explains that blood

circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries ANS: A

The umbilical vein transports richly oxygenated blood from the placenta to the fetus.

DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 7 TOP: Fetal Circulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. Where is the usual location for implantation of the zygote? a. Upper section of the posterior uterine wall b. Lower portion of the uterus near the cervical os c. Inner third of the fallopian tube near the uterus d. Lateral aspect of the uterine wall ANS: A

The zygote usually implants in the upper section of the posterior uterine wall.

DIF: Cognitive Level: Knowledge REF: p. 38 OBJ: 3 TOP: Implantation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

7. What is the embryonic membrane that contains fingerlike projections on its surface, which

attach to the uterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis ANS: C

The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.

DIF: Cognitive Level: Knowledge REF: p. 38 OBJ: 4 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. Which hormone is responsible for converting the endometrium into decidual cells for

implantation? a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone ANS: D

At high levels, progesterone maintains the endometrial lining for implantation of the zygote.

DIF: Cognitive Level: Knowledge REF: p. 42 OBJ: 6 TOP: Placenta KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A pregnant patient asks the nurse when her infant‘s heart will begin to pump blood. What will

the nurse reply? a. By the end of week 3 b. Beginning in week 8 c. By the end of week 16 d. Beginning in week 24 ANS: A

The fetal heart begins to pump by week 3 of gestation.

DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. What organ does the ductus venosus shunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs d. Kidneys ANS: A

Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.

DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 7 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. What complication can result from untreated respiratory distress in the newborn? a. Esophageal atresia b. Gastric dilation c. Cold stress d. Reopening of the foramen ovale ANS: D

Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.

DIF: Cognitive Level: Comprehension REF: p. 43 OBJ: 7 TOP: Fetal Circulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. During an ultrasound, two amnions and two placentas are observed. What will be the most

likely result of this pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High–birth weight twins ANS: A

Dizygotic twins always have two amnions and two chorions (placentas).

DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 8 TOP: Multifetal Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the

nurse explain is one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin that is pink and smooth d. Eyes that are closed ANS: A

By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus has definite periods of movement and sleeping.

DIF: Cognitive Level: Comprehension REF: p. 41 | Table 3.1 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. At what point in prenatal development do the lungs begin to produce surfactant? a. 17 weeks b. 20 weeks

c. 25 weeks d. 30 weeks ANS: C

During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur.

DIF: Cognitive Level: Knowledge REF: p. 41 | Table 3.1 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. A woman missed her menstrual period 1 week ago and has come to the doctor‘s office for a

pregnancy test. Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen ANS: C

Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.

DIF: Cognitive Level: Knowledge REF: p. 42 OBJ: 6 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. When preparing to teach a class about prenatal development, the nurse would include

information about folic acid supplementation. What is folic acid known to prevent? a. Congenital heart defects b. Neural tube defects c. Mental retardation d. Premature birth ANS: B

It is now known that folic acid supplements can prevent neural tube defects such as spina bifida.

DIF: Cognitive Level: Comprehension REF: p. 39 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse is educating a class of expectant parents about fetal development. What is

considered fetal age of viability? a. 14 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: B

By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of viability).

DIF: Cognitive Level: Knowledge REF: p. 39 OBJ: 5 TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse is presenting a conference on gene dominance. What does the nurse report as the

percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not? a. 10% b. 25% c. 50% d. 100% ANS: C

If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.

DIF: Cognitive Level: Comprehension REF: p. 37 OBJ: 4 TOP: Dominant Traits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. The nurse explains that the birth weight of monozygotic twins is frequently below average.

What is the most likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition ANS: D

The single placenta may not be able to provide adequate nutrition to two fetuses.

DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 8 TOP: Low Birth-Weight Twins KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The school nurse is counseling a group of adolescent girls. What does the nurse explain about

sperm ejaculated near the cervix? a. They are destroyed by the acidic pH of the vagina. b. They survive up to 5 days and can cause pregnancy. c. They lose their motility in about 12 hours after intercourse. d. They are usually pushed out of the vagina by the muscular action of the vaginal wall.

ANS: B

Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.

DIF: Cognitive Level: Comprehension REF: p. 36 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. What does the nurse explain can affect the survival of the X- and Y-bearing sperm after

intercourse?

a. b. c. d.

Age Estrogen level Body temperature Level of feminine hygiene

ANS: B

Estrogen levels and the pH of the female reproductive tract can affect the survival of the Xand Y-bearing sperm as well as their motility.

DIF: Cognitive Level: Knowledge REF: p. 36 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. Of what is the normal umbilical cord comprised? a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the

fetus ANS: C

The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus.

DIF: Cognitive Level: Knowledge REF: p. 43 OBJ: 6 TOP: Fetal Circulation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 23. What part of the fetal body derives from the mesoderm? a. Nails b. Oil glands c. Muscles d. Lining of the bladder ANS: C

The mesoderm is responsible for the development of muscles. Nails and oil glands derive from the ectoderm. The lining of the bladder derives from the endoderm.

DIF: Cognitive Level: Knowledge REF: p. 39 | Box 3.1 OBJ: 4 TOP: Embryonic Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. A couple just learned they are expecting their first child and are curious if they are having a

boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound? a. 4 weeks‘ gestational age b. 6 weeks‘ gestational age c. 10 weeks‘ gestational age d. 16 weeks‘ gestational age ANS: C

The fetal period begins at the 9th week, and by the 10th week the external genitalia are visible to ultrasound examination.

DIF: Cognitive Level: Knowledge REF: p. 39 OBJ: 5 TOP: Fetal Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. A nurse is teaching a lesson on fetal development to a class of high school students and

explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm ANS: A, B, C

The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm.

DIF: Cognitive Level: Knowledge REF: p. 39 | Box 3.1 OBJ: 4 TOP: Primary Germ Layers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus ANS: A, E

The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin; allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for the fetus. Although the fetus does swallow amniotic fluid, it has no nutritional value.

DIF: Cognitive Level: Knowledge REF: p. 38 OBJ: 6 TOP: Amniotic Fluid KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What

facts will the nurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twins share a placenta. c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases with maternal age.

ANS: C, D

Dizygotic twins tend to repeat in families and have separate chorions. They can be the same sex or different sexes and have their own placenta. Incidence increases with maternal age.

DIF: Cognitive Level: Comprehension REF: p. 45 OBJ: 8 TOP: Dizygotic Twins KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 1. The normal volume of amniotic fluid is approximately _______________ mL at 37 weeks‘

gestation.

ANS:

1000 The volume of amniotic fluid steadily increases from about 30 mL at 10 weeks of pregnancy to 350 mL at 20 weeks. The volume of fluid is about 1000 mL at 37 weeks. In the latter part of pregnancy, the fetus may swallow up to 400 mL of amniotic fluid per day and normally excretes urine into the fluid.

DIF: Cognitive Level: Knowledge REF: p. 38 OBJ: 6 TOP: Amniotic Fluid KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 04: Prenatal Care and Adaptations to Pregnancy Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a

2-year-old son and had one previous spontaneous abortion. How would the nurse document the patient‘s obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110 ANS: C

Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para.

DIF: Cognitive Level: Application REF: p. 51 | Box 4.1 OBJ: 1 TOP: Definition of Terms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A woman calls her health care provider to schedule prenatal visits in an uncomplicated

pregnancy. How frequently will the nurse assist the patient to schedule these appointments? a. Every 3 weeks until the 6th month, then every 2 weeks until delivery b. Every 4 weeks until the 7th month, after which appointments will become more frequent

c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy ANS: B

Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 weeks through 36 weeks. From 36 weeks until delivery, visits are weekly.

DIF: Cognitive Level: Application REF: p. 49 OBJ: 2 | 3 TOP: Prenatal Visits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. During the physical examination for the first prenatal visit, it is noted that Chadwick‘s sign is

present. What is Chadwick‘s sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline ANS: A

Chadwick‘s sign is the purplish or bluish discoloration of the cervix, vulva and vagina.

DIF: Cognitive Level: Knowledge REF: p. 53 OBJ: 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After the examination is completed, the patient asks the nurse why Chadwick‘s sign occurs

during pregnancy. What would the nurse explain as the cause of Chadwick‘s sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area ANS: D

Chadwick‘s sign is caused by increased vascular congestion in the cervical and vaginal area.

DIF: Cognitive Level: Comprehension REF: p. 53 OBJ: 6 | 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse has explained physiological changes that occur during pregnancy. Which statement

indicates that the woman understands the information? a. ―Blood pressure goes up toward the end of pregnancy.‖ b. ―My breathing will get deeper and a little faster.‖ c. ―I‘ll notice a decreased pigmentation in my skin.‖ d. ―There will be a curvature in the upper spine area.‖ ANS: B

The pregnant woman breathes more deeply, and her respiratory rate may increase slightly.

DIF: Cognitive Level: Comprehension REF: p. 57 TOP: Normal Physiological Changes in Pregnancy

OBJ: 7 | 13

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman reports that her last normal menstrual period began on August 5, 2013. What is this

woman‘s expected delivery date using Nägele‘s rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014 ANS: C

To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary.

DIF: Cognitive Level: Analysis REF: p. 52 | Box 4.2 OBJ: 5 TOP: Determining Estimated Date of Delivery KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an

electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks ANS: C

The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device.

DIF: Cognitive Level: Knowledge REF: p. 54 OBJ: 3 | 6 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that

the fetal heart rate (FHR) has dropped to 120 beats/minute from a rate of 160 beats/minute earlier in the pregnancy. What is the nurse‘s first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding.

ANS: D

The FHR at term ranges from a low of 110 to 120 beats/minute to a high of 150 to 160 beats/minute. This should be recorded as normal. The FHR drops in the late stages of pregnancy.

DIF: Cognitive Level: Application REF: p. 54 OBJ: 3 TOP: Assessing Fetal Heart Tone KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. A woman‘s prepregnant weight is determined to be average for her height. What will the

nurse advise the woman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds ANS: C

The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds.

DIF: Cognitive Level: Knowledge REF: p. 63 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during

pregnancy, the woman responds, ―I don‘t like milk.‖ What dietary adjustments could the nurse recommend? a. Increase intake of organ meats. b. Eat more green leafy vegetables. c. Choose more fresh fruits, particularly citrus fruits. d. Include molasses and whole-grain breads in the diet.

ANS: B

For women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables, and canned salmon and sardines that contain bones.

DIF: Cognitive Level: Application REF: p. 64 OBJ: 8 | 13 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A pregnant woman is experiencing nausea in the early morning. What recommendations

would the nurse offer to alleviate this symptom? a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets.

ANS: C

The nurse can recommend eating dry toast or crackers before getting out of bed in the morning to alleviate nausea during pregnancy.

DIF: Cognitive Level: Application REF: p. 70 | Table 4.6 OBJ: 10 TOP: Common Discomforts in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What

is the nurse‘s initial action? a. Assess food intake. b. Weigh the patient again. c. Take the blood pressure.

d. Notify the physician.

ANS: C

The marked weight gain may be an indication of pre-eclampsia. The blood pressure should be assessed before notifying the physician.

DIF: Cognitive Level: Application REF: p. 49 OBJ: 4 TOP: Pre-eclampsia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The patient remarks that she has heard some foods will enhance brain development of the

fetus. The nurse replies that foods high in docosahexaenoic acid–omega 3 fatty acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables ANS: C

Foods rich in DHA are red meat, flounder, halibut, and soybean and canola oil. Frying fish negatively alters the DHA. DIF: Cognitive Level: Application REF: p. 61 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse encourages adequate intake of folic acid for women of childbearing age before and

during pregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neural tube defects ANS: D

Folic acid can reduce the incidence of neural tube defects such as spina bifida and anencephaly.

DIF: Cognitive Level: Knowledge REF: p. 65 OBJ: 8 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 15. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a

positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCG detected in the urine d. Fetal heartbeat ANS: D

Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner.

DIF: Cognitive Level: Knowledge REF: p. 54 OBJ: 6 | 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. At her initial prenatal visit, a woman asks, ―When can I hear the baby‘s heartbeat?‖ At what

gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope? a. 4 weeks b. 12 weeks c. 18 weeks d. 24 weeks ANS: C

The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy.

DIF: Cognitive Level: Knowledge REF: p. 54 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A woman pregnant for the first time asks the nurse, ―When will I begin to feel the baby

move?‖ What is the nurse‘s best response? a. ―You may notice the baby moving around the 4th or 5th month.‖ b. ―Quickening varies with every woman.‖ c. ―You‘ll feel something by the end of the first trimester.‖ d. ―The baby will be big enough for you to feel in your 8th month.‖ ANS: A

Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of gestation.

DIF: Cognitive Level: Knowledge REF: p. 53 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. A pregnant woman inquires about exercising during pregnancy. What information should the

nurse include when planning to educate this woman? a. Exercise elevates the mother‘s temperature and improves fetal circulation. b. Exercise increases catecholamines, which can prevent preterm labor. c. A regular schedule of moderate exercise during pregnancy is beneficial. d. Pregnant women should limit water intake during exercise.

ANS: C

In general, moderate exercise several times a week, from the 8th week through delivery, is advised during pregnancy.

DIF: Cognitive Level: Comprehension TOP: Exercise During Pregnancy

REF: p. 67 OBJ: 9 | 13 KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal

care and counseling for adolescents differ from other age populations? a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurse‘s advice.

ANS: A

The pregnant adolescent must cope with two of life‘s most stress-laden transitions simultaneously: adolescence and parenthood.

DIF: Cognitive Level: Comprehension REF: p. 65 TOP: Psychological Adaptations to Pregnancy KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

OBJ: 12

20. At what age is a woman who becomes pregnant for the first time described as an ―elderly

primip‖? a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old ANS: D

A woman over the age of 35 who becomes pregnant for the first time is described as an ―elderly primip.‖ DIF: Cognitive Level: Knowledge REF: p. 75 OBJ: 12 TOP: Elderly Primip KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physical Adaptation 21. The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy.

What is the appropriate term for this sign? a. Chadwick‘s b. Hegar‘s c. McDonald‘s d. Goodell‘s ANS: D

Goodell‘s sign is one of the probable signs of pregnancy and describes a softened cervix and vagina.

DIF: Cognitive Level: Knowledge REF: p. 53 OBJ: 1 | 6 | 7 TOP: Goodell‘s Sign KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physical Adaptation 22. When obtaining a prenatal history on a pregnant patient the nurse notes a family history of

sickle cell disease. Given this information, what lab test can the nurse anticipate the physician will order?

a. b. c. d.

Endovaginal ultrasound Pap test Complete blood count Hemoglobin electrophoresis

ANS: D

Hemoglobin electrophoresis identifies the presence of sickle cell trait or disease (in women of African or Mediterranean descent). It is ordered in the first trimester, if indicated.

DIF: Cognitive Level: Comprehension REF: p. 50 | Table 4.1 OBJ: 3 TOP: Prenatal Laboratory Tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care 23. A pregnant woman is attending her second prenatal visit. Prenatal lab work indicates she is

not immune to the rubella virus. What is the most appropriate nursing intervention? a. Provide the rubella vaccine as ordered by the physician immediately. b. Inform the woman she should receive the vaccine in the hospital after delivery. c. Hold all immunizations until 1 month postpartum. d. Encourage the patient to decide whether or not to get the rubella vaccine prenatally.

ANS: B

The rubella vaccine is contraindicated during pregnancy. A woman should be instructed to avoid pregnancy for at least 1 month following rubella immunization. It is not necessary to hold all immunizations until 1 month postpartum.

DIF: Cognitive Level: Application REF: p. 78 OBJ: 4 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care 24. A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does

the nurse explain as the most likely cause of this symptom? a. Supine hypotension syndrome b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition ANS: A

Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. Symptoms of supine hypotension syndrome include faintness, lightheadedness, dizziness, and agitation.

DIF: Cognitive Level: Comprehension REF: p. 57 OBJ: 7 TOP: Physiological Changes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care MULTIPLE RESPONSE

1. A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to

Hawaii. What would the nurse recommend that the patient do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return. b. Eat a large meal before boarding the flight. c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently.

ANS: C, D, E

Because of the increase in clotting potential, the pregnant patient is prone to a thromboembolism. Adequate hydration, frequent position changes, and movement decrease the risk.

DIF: Cognitive Level: Application REF: p. 69 OBJ: 10 TOP: Flight Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic

joints relax. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine ANS: A, B

A waddling gait and joint instability are the only signs that relate to joint changes. The other discomforts are related to the enlarging uterus with its attendant weight.

DIF: Cognitive Level: Comprehension REF: p. 59 OBJ: 7 TOP: Joint Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse assesses the progress from the announcement stage of fatherhood to the acceptance

stage when the patient reports which actions by the father? (Select all that apply.) a. Goes fishing every afternoon. b. Has revised his financial plan. c. Spends leisure time with his friends. d. Traded his sports car for a sedan. e. Helped select a crib.

ANS: B, D, E

Active planning for an infant is an indication of the acceptance stage. Concentration on a hobby and spending time away from home are indicators of nonacceptance.

DIF: Cognitive Level: Comprehension REF: pp. 73-74 OBJ: 11 TOP: Stages of Fatherhood KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. What nursing interventions are appropriate for the prenatal patient in terms of prenatal care?

(Select all that apply.)

a. b. c. d. e.

Offer nutritional counseling.

Reinforce responsibility of parenthood.

Reduce risk factors.

Improve health practices.

Make financial arrangements for delivery.

ANS: A, B, C, D

Nutritional counseling, reinforcing and discussing the responsibility of parenthood, reducing risk factors for the pregnant woman and the fetus, and improving health practices are all goals of prenatal care.

DIF: Cognitive Level: Comprehension REF: pp. 48-49 OBJ: 2 | 3 TOP: Goals of Prenatal Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. The nurse recognizes which behavior characteristic(s) of women in their first trimester of

pregnancy? (Select all that apply.) a. Showing off her sonogram photos b. Ambivalence about pregnancy c. Emotional and labile mood d. Focusing on her infant e. Fatigue ANS: A, B, C, E

Showing off photos, feeling ambivalence about the pregnancy, fragile emotions, and fatigue and sleepiness are all characteristic of behaviors seen in the first trimester. Women are not focused on their infant; they are focused on themselves and the physical changes they are experiencing.

DIF: Cognitive Level: Comprehension REF: p. 73 OBJ: 11 TOP: Behaviors of First Trimester KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse reminds the prenatal patient that she should add ________ kcal to her daily intake

to nourish the fetus.

ANS:

300 The recommended dietary intake increase is 300 kcal a day.

DIF: Cognitive Level: Comprehension REF: p. 64 OBJ: 8 TOP: Nutrition During Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 05: Nursing Care of Women with Complications During Pregnancy Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE

1. A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the

nurse explain that hyperemesis gravidarum is distinguished from morning sickness? a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy. b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances. c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum. d. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.

ANS: B

Dehydration and electrolyte imbalances result from persistent nausea and vomiting associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta.

DIF: Cognitive Level: Comprehension REF: p. 90 OBJ: 3 TOP: Hyperemesis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports

passing some tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms? a. Inevitable abortion b. Incomplete abortion c. Complete abortion d. Missed abortion ANS: B

Signs and symptoms of an incomplete abortion are similar to those of an inevitable abortion, but some tissue is passed.

DIF: Cognitive Level: Comprehension REF: pp. 90-92| Table 5.2 | Figure 5.2 OBJ: 3 TOP: Incomplete Abortion KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for

a missed abortion. What is the most appropriate statement by the nurse? a. ―There is usually something wrong with the fetus when this happens early in pregnancy.‖ b. ―Now there. You can try to conceive on your next cycle.‖ c. ―I‘m here if you need to talk.‖ d. ―You are young and strong. I know you can have a healthy pregnancy.‖ ANS: C

An effective technique when communicating with a woman experiencing pregnancy loss is to say, ―I‘m here if you need to talk.‖ The nurse listens and acknowledges the woman‘s grief.

DIF: Cognitive Level: Application REF: p. 93, Communication Box OBJ: 3 TOP: Dilation and Evacuation (D&E) KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

4. A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding

accompanied by abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman understands the explanation of an ectopic pregnancy? a. ―The chorionic villi develop vesicles within the uterus.‖ b. ―The placenta develops in the lower part of the uterus.‖ c. ―The fetus dies in the uterus during the first half of the pregnancy.‖ d. ―The embryo is implanted in the fallopian tube.‖ ANS: D

Ectopic pregnancy occurs when the fertilized ovum is implanted outside of the uterine cavity.

DIF: Cognitive Level: Comprehension REF: p. 95 OBJ: 3 TOP: Ectopic Pregnancy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the

entire cervical os. What does the nurse understand best describes this condition? a. Low-lying placenta b. Marginal placenta previa c. Partial placenta previa d. Total placenta previa ANS: D

A total placenta previa describes a condition in which the placenta completely covers the cervical opening.

DIF: Cognitive Level: Comprehension REF: pp. 96-98 OBJ: 3 TOP: Placenta Previa KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. What symptom presented by a pregnant women is indicative of abruptio placentae? a. Painless vaginal bleeding b. Uterine irritability with contractions c. Vaginal bleeding and back pain d. Premature rupture of membranes ANS: C

Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae.

DIF: Cognitive Level: Knowledge REF: pp. 98-99 OBJ: 3 TOP: Abruptio Placenta KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. What situation would concern the nurse about the presence of Rh incompatibility? a. Rh-negative mother, Rh-positive fetus b. Rh-positive mother, Rh-negative fetus c. Rh-negative mother, Rh-negative fetus d. Rh-positive mother, Rh-positive fetus ANS: A

Rh incompatibility can occur only if the mother is Rh negative and the fetus is Rh positive.

DIF: Cognitive Level: Analysis REF: p. 103 OBJ: 3 TOP: Rh Incompatibility KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. A primigravida in her first trimester is Rh negative. What will this woman receive to prevent

anti-Rh antibodies from forming? a. Rh immune globulin during labor b. Intrauterine transfusions with O-negative blood c. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant d. Rh immune globulin now and again in the last trimester ANS: C

An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after the birth of an Rh-positive infant or abortion.

DIF: Cognitive Level: Comprehension REF: p. 104 OBJ: 3 TOP: Rh Incompatibility KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and

polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest? a. Toxoplasmosis b. Abruptio placentae c. Hydatidiform mole d. Diabetes mellitus ANS: D

Large (macrosomic) infants over 9 pounds are linked to gestational diabetes.

DIF: Cognitive Level: Comprehension REF: p. 105 OBJ: 4 TOP: Diabetes Mellitus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose

metabolism in what way? a. Placental hormones increase the resistance of cells to insulin. b. Insulin cells cannot meet the body‘s demands as the woman‘s weight increases. c. There is a decreased production of insulin during pregnancy. d. The speed of insulin breakdown is decreased during pregnancy.

ANS: A

Hormones and enzymes produced by the placenta increase the resistance of cells to insulin.

DIF: Cognitive Level: Knowledge REF: p. 105 OBJ: 4 TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Why does the woman taking oral hypoglycemic agents to control diabetes mellitus need to

take insulin during pregnancy?

a. b. c. d.

Insulin can cross the placental barrier to the fetus.

Insulin does not cross the placental barrier to the fetus.

Oral agents do not cross the placenta.

Oral agents are not sufficient to meet maternal insulin needs.

ANS: B

Oral hypoglycemic agents are not used during pregnancy, because they can cross the placenta, possibly resulting in fetal birth defects or hypoglycemia.

DIF: Cognitive Level: Comprehension REF: p. 107 OBJ: 4 TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is

afraid that her infant will also contract hepatitis B. What will the nurse explain to this woman? a. The infant will be given a single dose of hepatitis immune globulin after birth. b. The infant will be able to use the antibodies from the immunizations given to the patient before delivery. c. The infant will not have hepatitis B because the virus does not pass through the placental barrier. d. The infant will be immune to hepatitis B because of the mother‘s infection.

ANS: A

The infant will be given immune globulin immediately after birth for temporary immunity followed by hepatitis B vaccine. Immunization is not recommended for women who are pregnant.

DIF: Cognitive Level: Comprehension REF: p. 112 OBJ: 4 TOP: Hepatitis B KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. What will the nurse begin with when asking a patient about drug use during a prenatal

history? a. ―Do you smoke, drink alcohol, or use drugs?‖ b. ―Do you ever use prescription or street drugs?‖ c. ―What over-the-counter and prescription drugs have you taken in the past 3 months?‖ d. ―We need to know if you take drugs so we can help your baby.‖ ANS: C

Screening for drug use should begin in a nonthreatening way by asking about prescription and OTC medications and how the information can help provide safe and appropriate prenatal care.

DIF: Cognitive Level: Application REF: pp. 115-116 | Table 5.9 OBJ: 5 TOP: Interviewing Relative to Drug Use KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first

sign of fluid retention suggestive of this complication? a. Abdominal enlargement

b. Facial swelling c. Sudden weight gain d. Swelling of the feet and ankles ANS: C

Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs, and hands follow weight gain.

DIF: Cognitive Level: Knowledge REF: p. 102 OBJ: 3 TOP: Hypertension KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A patient with gestational hypertension is exhibiting all of the signs below. What should the

nurse report immediately? a. Diarrhea b. Urticaria c. Blurred vision d. Backache ANS: C

Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for effective intervention to prevent preeclampsia and convulsion.

DIF: Cognitive Level: Application REF: p. 90, Patient Teaching Box OBJ: 3 TOP: Hypertension KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. A patient who is 28 weeks pregnant presents with consistent hypertension. What need would

the home health nurse make the first priority? a. Activity restriction b. Balanced nutrition c. Increased fluid intake to ensure adequate hydration d. Instruction about the effect of diuretics ANS: A

Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and enhancing fetal oxygenation.

DIF: Cognitive Level: Application REF: p. 102 OBJ: 3 TOP: Hypertension KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse

explain is the objective of magnesium sulfate therapy for this patient? a. To prevent convulsions b. To promote diaphoresis c. To increase reflex irritability d. To act as a saline cathartic ANS: A

Magnesium sulfate is a central nervous system depressant given to prevent seizures.

DIF: Cognitive Level: Knowledge REF: p. 102 OBJ: 3 TOP: Magnesium Sulfate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium

sulfate. What is the highest priority nursing intervention? a. Count respirations and report a rate of less than 12 breaths/minute. b. Count respirations and report a rate of more than 20 breaths/minute. c. Check blood pressure and report a rate of less than 100/60 mm Hg. d. Monitor urinary output and report a rate of less than 100 mL/hr.

ANS: A

Excessive magnesium sulfate may cause respiratory depression.

DIF: Cognitive Level: Application REF: p. 102 OBJ: 3 TOP: Magnesium Sulfate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 19. What drug will the nurse plan to have available for immediate IV administration whenever

magnesium sulfate is administered to a maternity patient? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline) ANS: C

Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a woman receives magnesium sulfate.

DIF: Cognitive Level: Comprehension REF: p. 102 OBJ: 3 TOP: Calcium Gluconate KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 20. A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, ―Will I be

able to deliver vaginally?‖ What explanation by the nurse is the most appropriate? a. ―Yes, you can deliver vaginally until 36 weeks.‖ b. ―A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done.‖ c. ―A cesarean section is performed when the mother has a total placenta previa.‖ d. ―There is no reason why you cannot have a vaginal delivery.‖ ANS: C

A cesarean delivery is done for a partial or total placenta previa.

DIF: Cognitive Level: Application REF: p. 98 OBJ: 3 TOP: Placenta Previa KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the

developing fetus. What can result from maternal rubella during pregnancy? a. Facial abnormalities

b. Mental retardation c. Liver failure d. Limb deformities ANS: B

Rubella can have devastating effects on the developing fetus. Some effects of rubella on the embryo or fetus include microcephaly, mental retardation, cardiac defects, cataracts, and deafness.

DIF: Cognitive Level: Knowledge REF: p. 111 OBJ: 4 TOP: Rubella KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis? a. Frequency and urgency of urination b. Nausea and weight loss c. Burning sensation when voiding d. Tenderness in the flank area ANS: D

Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills, flank pain or tenderness, nausea, and vomiting.

DIF: Cognitive Level: Comprehension REF: p. 114 OBJ: 4 TOP: Pyelonephritis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 23. The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best

position for this patient? a. Flat on her back with knees flexed to help prevent hemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowler‘s position to prevent supine hypotension d. In the knee-chest position to reduce pressure on the placenta ANS: B

The prenatal patient with placenta previa is best placed on her side with a pillow for support.

This position not only reduces stress on the placenta but also reduces the possibility of supine hypotension.

DIF: Cognitive Level: Application REF: p. 98 OBJ: 3 TOP: Placenta Previa KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 24. The young prenatal patient with gestational diabetes mellitus (GDM) says, ―I am frightened

that I will have to deal with insulin injections for the rest of my life.‖ What is the best response by the nurse? a. ―After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections.‖ b. ―Have you considered an insulin pump?‖ c. ―After a while those insulin injections won‘t seem so bad.‖ d. ―It will most likely resolve 6 weeks or so after the baby is born.‖

ANS: D

GDM usually resolves by 6 weeks after delivery.

DIF: Cognitive Level: Application REF: p. 104 OBJ: 3 TOP: GDM KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 25. The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks‘ gestation.

What intervention will the nurse implement before this diagnostic test? a. Instruct the patient to take nothing by mouth after midnight the night before the test. b. Initiate an IV. c. Encourage the patient to drink 1 to 2 quarts of water before the test. d. Instruct the patient to remove all jewelry.

ANS: C

Ultrasound uses high-frequency sound waves to visualize structures within the body; the examination may use a transvaginal probe or an abdominal transducer; abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination).

DIF: Cognitive Level: Application REF: p. 86 | Table 5.1 OBJ: 2 TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care 26. The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will

the nurse assess for in the newborn? a. Meconium ileus b. Diarrhea c. Hypoglycemia d. Muscle tremors ANS: C

The fetus responds to the hyperglycemia from the mother‘s blood and produces increased insulin. This insulin may cause hypoglycemia in the infant after it is no longer exposed to the mother‘s blood.

DIF: Cognitive Level: Application REF: p. 105 | Box 5.4 OBJ: 4 TOP: Hypoglycemia in Macrosomic Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. The nurse educates prenatal patients about the threat of TORCH infections. Which infections

are included in this classification? (Select all that apply.) a. Toxoplasmosis b. Toxemia c. Cytomegalovirus d. Rubella

e. Herpes simplex ANS: A, C, D, E

The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.

DIF: Cognitive Level: Knowledge REF: p. 111 OBJ: 5 TOP: TORCH Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a

pregnancy might result in which problems? (Select all that apply.) a. Disruption of family roles b. Financial pressures c. Excessive attachment to infant d. Frustration with activity restriction e. Alteration in child care practices ANS: A, B, D, E

High-risk pregnancies may produce problems such as disruption of family roles, financial pressures, delayed attachment to the infant, alteration in child care practices, and frustration with activity restriction.

DIF: Cognitive Level: Comprehension REF: pp. 119-120 OBJ: 7 TOP: Impact of High-Risk Pregnancies KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department

(ED). What should the ED nurse offer the patient? (Select all that apply.) a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) e. A warm beverage ANS: A, B, C, D

The patient should be offered privacy, an opportunity to hold the infant, support group information, and a memento. A warm beverage is not a priority at this time.

DIF: Cognitive Level: Application REF: p. 120 OBJ: 7 TOP: Stillborn Infant KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. What would the nurse include in a teaching plan for the pregnant patient who has iron

deficiency anemia and has been placed on iron supplements? (Select all that apply.) a. Citrus fruits enhance absorption of iron. b. Bran products support iron deficiency. c. Milk will disguise the taste of the iron. d. The iron therapy will continue for about 3 months. e. Tea should be avoided while taking iron.

ANS: A, D, E

Calcium, bran, and milk interfere with the absorption of iron. Vitamin C helps with the absorption of iron, the therapy usually lasts 3 months, and the tannic acid in tea does interfere with the absorption of iron.

DIF: Cognitive Level: Application REF: p. 109 OBJ: 4 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 5. The nurse takes into consideration that the patient with placenta previa is at risk for

postpartum infection for what reasons? (Select all that apply.) a. Vaginal organisms can invade the placenta. b. The undernourished placenta becomes necrotic. c. The amniotic fluid can become infected. d. The placenta is an excellent growth medium. e. The misplaced placenta weakens the uterine wall.

ANS: A, D

Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the nutrient-rich environment of the placenta. The weak musculature of the lower segment of the uterus will cause postpartum hemorrhage rather than infection.

DIF: Cognitive Level: Comprehension REF: p. 98 OBJ: 3 TOP: Infection with Placenta Previa KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The nurse is obtaining history and physical information on a new patient attending her first

prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH incompatibility c. Hypertension d. Pre-eclampsia e. Infection ANS: A, C, D

The obese woman who is pregnant has a high risk for developing complications during pregnancy such as gestational diabetes, hypertension, cardiac problems, pre-eclampsia, and respiratory problems.

DIF: Cognitive Level: Comprehension REF: p. 108 OBJ: 3 TOP: Obesity KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 7. A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse

that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.) a. Tell the husband that authorities will be notified immediately. b. Provide privacy for the assessment. c. Determine if children are being hurt.

d. Communicate in a nonjudgmental way. e. Determine factors that increase the risk of injury.

ANS: B, C, D, E

The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The nurse also determines whether children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she intends to leave.

DIF: Cognitive Level: Application REF: pp. 116-119 OBJ: 6 TOP: Battering KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Injury Prevention

Chapter 06: Nursing Care of Mother and Infant During Labor and Birth Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What does the nurse note when measuring the frequency of a laboring woman‘s contractions? a. How long the patient states the contractions last b. The time between the end of one contraction and the beginning of the next c. The time between the beginning and the end of one contraction d. The time between the beginning of one contraction and the beginning of the next ANS: D

The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.

DIF: Cognitive Level: Comprehension REF: p. 126 OBJ: 3 TOP: Frequency of Contractions KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Why is the relaxation phase between contractions important? a. The laboring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward delivery at these times.

ANS: C

Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

DIF: Cognitive Level: Comprehension REF: p. 127 OBJ: 3 TOP: Interval KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What contraction duration and interval does the nurse recognize could result in fetal

compromise? a. Duration shorter than 30 seconds, interval longer than 75 seconds b. Duration shorter than 90 seconds, interval longer than 120 seconds c. Duration longer than 90 seconds, interval shorter than 60 seconds

d. Duration longer than 60 seconds, interval shorter than 90 seconds ANS: C

Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

DIF: Cognitive Level: Comprehension REF: p. 127 | Safety Alert OBJ: 4 TOP: Contraction/Fetal Compromise KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 4. Vaginal examination reveals the presenting part is the infant‘s head, which is well flexed on

the chest. What is this presentation? a. Vertex b. Military c. Brow d. Face ANS: A

In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

DIF: Cognitive Level: Comprehension REF: p. 129 OBJ: 3 TOP: Fetal Position KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. What does meconium-stained amniotic fluid indicate when the infant is in a vertex

presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in the mother ANS: A

Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.

DIF: Cognitive Level: Comprehension REF: p. 143 OBJ: 4 TOP: Meconium-Stained Amniotic Fluid KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. It is determined that the presenting part of the fetus is the buttocks. At delivery the fetus‘s hips

are flexed and the knees are extended. How would the nurse record this presentation? a. Complete breech b. Frank breech c. Double footling d. Buttocks presentation ANS: B

When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.

DIF: Cognitive Level: Application

REF: pp. 128-129 | Figure 6.7

OBJ: 3 | 4 TOP: Components of the Birth Process KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The

nurse knows that what indicates the beginning of true labor? a. Contractions that are relieved by walking b. Discomfort in the abdomen and groin c. A decrease in vaginal discharge d. Regular contractions becoming more frequent and intense ANS: D

In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

DIF: Cognitive Level: Application REF: p. 133 OBJ: 6 TOP: Initiation of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse

when she should go to the hospital. What is the nurse‘s most informative response? a. ―When you feel increased fetal movement‖ b. ―When contractions are 10 minutes apart‖ c. ―When membranes have ruptured‖ d. ―When abdominal or groin discomfort occurs‖ ANS: C

Ruptured membranes are an indication that the woman should go to the hospital or birthing center.

DIF: Cognitive Level: Application REF: p. 133 OBJ: 5 TOP: Admission to the Hospital or Birth Center KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse is caring for a woman in the first stage of labor. What will the nurse remind the

patient about contractions during this stage of labor? a. They get the infant positioned for delivery. b. They push the infant into the vagina. c. They dilate and efface the cervix. d. They get the mother prepared for true labor.

ANS: C

The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

DIF: Cognitive Level: Comprehension REF: p. 149 | Table 6.5 OBJ: 5 TOP: First Stage of Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing

at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the woman‘s change in behavior? a. Labor has progressed to the transition phase. b. She lacked adequate preparation for the labor experience. c. The woman would benefit from a different form of analgesia. d. The contractions have increased from mild to moderate intensity.

ANS: A

If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

DIF: Cognitive Level: Analysis REF: p. 149 | Table 6.5 OBJ: 5 TOP: Transition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. What is the function of contractions during the second stage of labor? a. Align the infant into the proper position for delivery. b. Dilate and efface the cervix. c. Push the infant out of the mother‘s body. d. Separate the placenta from the uterine wall.

ANS: C

The contractions push the infant out of the mother‘s body as the second stage of labor ends with the birth of the infant.

DIF: Cognitive Level: Knowledge REF: p. 149 | Table 6.5 OBJ: 5 TOP: Second Stage of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. What marks the end of the third stage of labor? a. Full cervical dilation b. Expulsion of the placenta and membranes c. Birth of the infant d. Engagement of the head ANS: B

The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.

DIF: Cognitive Level: Knowledge REF: p. 149 | Table 6.5 OBJ: 5 TOP: Third Stage of Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. Why should the nurse encourage the mother to void during the fourth stage of labor? a. A full bladder could interfere with cervical dilation. b. A full bladder could obstruct progress of the infant through the birth canal. c. A full bladder could obstruct the passage of the placenta. d. A full bladder could predispose the mother to uterine hemorrhage.

ANS: D

A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.

DIF: Cognitive Level: Comprehension REF: p. 149 | Table 6.5 OBJ: 5 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 14. The nurse observes the patient bearing down with contractions and crying out, ―The baby is

coming!‖ What is the best nursing intervention? a. Find the physician. b. Stay with the woman and use the call bell to get help. c. Send the woman‘s partner to locate a registered nurse. d. Assist with deep breathing to slow the labor process.

ANS: B

If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

DIF: Cognitive Level: Application REF: p. 134 OBJ: 5 TOP: Imminent Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate

that lasts 15 to 20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency ANS: A

Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

DIF: Cognitive Level: Analysis REF: p. 141 OBJ: 4 TOP: Fetal Accelerations KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What is the most appropriate statement from the nurse when coaching the laboring woman

with a fully dilated cervix to push? a. ―At the beginning of a contraction, hold your breath and push for 10 seconds.‖ b. ―Take a deep breath and push between contractions.‖ c. ―Begin pushing when a contraction starts and continue for the duration of the contraction.‖ d. ―At the beginning of a contraction, take two deep breaths and push with the second exhalation.‖ ANS: D

When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.

DIF: Cognitive Level: Application

REF: p. 148

OBJ: 8

TOP: Instructions for Pushing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. What is the most important nursing intervention during the fourth stage of labor? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding.

ANS: C

Immediately after giving birth, every woman is assessed for signs of hemorrhage.

DIF: Cognitive Level: Comprehension REF: p. 149 | Table 6.5 OBJ: 8 TOP: Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What

is the most appropriate nursing action? a. Check the fundus for position and firmness. b. Report to the doctor immediately. c. Change the pads and chart the time. d. Time how long it takes to soak one pad.

ANS: A

Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

DIF: Cognitive Level: Application REF: p. 153 OBJ: 8 TOP: Nursing Postdelivery Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in

fetal heart rate with uterine contractions. What is the nurse‘s initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula.

ANS: C

Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

DIF: Cognitive Level: Application REF: p. 142 OBJ: 8 TOP: Variable Decelerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. How should the nurse intervene to relieve perineal bruising and edema following delivery? a. Place an ice pack on the area for 12 hours. b. Place a warm pack on the perineal area for 24 hours. c. Administer aspirin to relieve inflammation.

d. Change the perineal pad frequently.

ANS: A

An ice pack can be placed on the mother‘s perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours after delivery.

DIF: Cognitive Level: Application REF: p. 153 OBJ: 8 TOP: Ice Pack/Bruising KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. At 1 and 5 minutes of life, a newborn‘s Apgar score is 9. What does the nurse understand that

a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in stable condition.

ANS: D

Apgar scoring is a system for evaluating the infant‘s need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is stable.

DIF: Cognitive Level: Comprehension REF: p. 158 | Table 6.6 OBJ: 9 TOP: Care of the Infant After Birth KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. A nursing student assisting a woman in labor asks the instructor, ―What does it mean when the

baby is at minus 1 station?‖ After being given an explanation by the nursing instructor, what statement by the student indicates an accurate understanding of station? a. ―Fetal head is above the ischial spines.‖ b. ―Fetal head is below the ischial spines.‖ c. ―Fetal head is engaged in the mother‘s pelvis.‖ d. ―Fetal head is visible at the perineum.‖ ANS: A

Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines. Minus stations are above the ischial spines.

DIF: Cognitive Level: Comprehension REF: p. 132 | Figure 6.10 OBJ: 5 TOP: Mechanisms of Labor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the

most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions b. Fear related to the probable need for cesarean delivery c. Dysuria related to prolonged labor and decreased intake d. Risk for injury related to hemorrhage ANS: D

In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.

DIF: Cognitive Level: Application REF: p. 152 OBJ: 5 | 8 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse

attempt to stimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warm fluids to drink b. By helping the patient to ambulate in the room c. By seating the patient upright in a straight-back chair d. By positioning the patient on her right side ANS: B

Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.

DIF: Cognitive Level: Application REF: p. 136 OBJ: 6 | 7 | 8 TOP: Differentiating Between True and False Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 25. What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine. b. Decrease flow of intravenous (IV) fluids. c. Increase oxygen to 10 L/minute. d. Prepare to increase oxytocin drip.

ANS: C

The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.

DIF: Cognitive Level: Application REF: p. 142 OBJ: 8 TOP: Late Decelerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. What is the nurse primarily concerned about maintaining in the initial care of the newborn? a. Fluid intake b. Feeding schedule c. Thermoregulation d. Parental bonding ANS: C

Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low.

Hypothermia can cause cold stress, which leads to hypoxia.

DIF: Cognitive Level: Comprehension REF: p. 154 OBJ: 9 TOP: Thermoregulation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

27. A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after

cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth? a. Eclampsia b. Placental abruption c. Congestive heart failure d. Uterine rupture ANS: D

Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous cesarean birth.

DIF: Cognitive Level: Comprehension REF: p. 149 OBJ: 7 TOP: VBAC KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 28. The physician performs an amniotomy on a laboring woman. What will be the nurse‘s priority

assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes ANS: A

The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed.

Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.

DIF: Cognitive Level: Application REF: p. 143 OBJ: 8 TOP: Rupture of Membranes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. While caring for an Arab woman in labor, the nurse should provide cultural sensitivity

through which interventions? (Select all that apply.) a. Provide for extreme modesty. b. Assign a male caregiver. c. Arrange for the husband/partner to participate in labor. d. Provide adequate pain control. e. Respect protective amulets.

ANS: A, D, E

Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and religious amulets. The husband is in attendance but not as a participant. Arabs prefer female caregivers. If a male is in attendance, then the husband will remain in the room as long as the male is there.

DIF: Cognitive Level: Application REF: p. 124 OBJ: 2 TOP: Cultural Considerations KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. What are the advantages of a freestanding birth center? (Select all that apply.) a. Homelike setting b. Designed for high-risk pregnancies c. Lower costs d. Attended by certified obstetricians e. Immediate emergency access ANS: A, C

Advantages of a freestanding birth center include a homelike setting and lower costs, because the center does not require expensive departments such as emergency or critical care.

Freestanding birth centers are not designed for high-risk patients, are not attended by certified obstetricians, and do not have immediate emergency access.

DIF: Cognitive Level: Comprehension REF: p. 125 OBJ: 2 TOP: Free-Standing Birth Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. What do late decelerations indicate? (Select all that apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression ANS: A, B, C

This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression.

Prolonged decelerations indicate cord compression and early decelerations indicate head compressions.

DIF: Cognitive Level: Comprehension REF: p. 141 OBJ: 4 | 5 TOP: Late Decelerations KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After

a thorough examination and diagnostic testing, it is determined to be false (prodromal) labor.

What signs and symptoms would lead the nurse to suspect false (prodromal) labor? (Select all that apply.) a. Leaking of vaginal fluid b. Contractions intensify with ambulation c. Pink spotting d. Painless tightening of abdominal muscles e. Cervix thick and not effaced

ANS: D, E

Painless tightening of abdominal muscles (Braxton Hicks contractions) and cervix thick and not effaced lend to the determination of false (prodromal) labor. Leaking of vaginal fluid may indicate rupture of membranes and is a sign of true labor. Contractions that intensify with ambulation and pink spotting (bloody show) are signs of true labor.

DIF: Cognitive Level: Comprehension REF: pp. 136-137 OBJ: 6 | 7 TOP: False Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care

Chapter 07: Nursing Management of Pain During Labor and Birth Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse is teaching a childbirth preparation class. The group is discussing individual

expression of labor pain. What statement is accurate about a patient‘s expression of pain? a. It reduces the patient‘s perception of pain. b. It is intensified by the vertex position of the fetus. c. It is influenced by culture. d. It can be completely controlled by nonpharmacological techniques.

ANS: C

Culture influences how women feel about birth and what is an acceptable response to pain.

DIF: Cognitive Level: Comprehension REF: p. 168 OBJ: 4 TOP: Cultural Influences on Pain KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What chemical substance(s) produced in the body acts as a natural pain reliever? a. Endorphins b. Morphine c. Codeine d. Atropine ANS: A

Endorphins are natural body substances that are similar to morphine and may explain why laboring women need smaller doses of analgesia.

DIF: Cognitive Level: Knowledge REF: p. 167 OBJ: 1 | 4 TOP: Endorphins KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A nurse instructs a woman‘s labor coach to comfort her by firmly pressing on her lower back.

What is this technique? a. Sacral pressure b. Distraction c. Effleurage d. Conscious relaxation ANS: A

Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labor.

DIF: Cognitive Level: Knowledge REF: p. 169 | Box 7.1 OBJ: 6 TOP: Nonpharmacological Pain Management KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to

do during the contraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing.

ANS: C

If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down.

DIF: Cognitive Level: Application REF: p. 170 OBJ: 3 | 6 TOP: Stair-Step Breathing Pattern KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Several hours into labor, a woman complains of dizziness, numbness, and tingling of her

hands and mouth. What does the nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation ANS: D

Hyperventilation is sometimes a problem if a woman is breathing rapidly.

DIF: Cognitive Level: Comprehension REF: p. 170 | Box 7.2 OBJ: 4 TOP: Hyperventilation KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. What is the most appropriate nursing action to take when a laboring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 liters via mask. d. Notify the doctor.

ANS: A

Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.

DIF: Cognitive Level: Application REF: p. 171 | Box 7.2 OBJ: 4 TOP: Nonpharmacological Pain Management KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

7. A woman in the transition phase of labor requests a narcotic analgesic medication for pain

relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor? a. It can cause medication given at later stages to be ineffective. b. It will have no complications for the mother or infant. c. It may result in respiratory depression to the newborn. d. It will speed up labor and increase pain.

ANS: C

The risk of narcotic analgesics is that they cross the placenta and can cause fetal respiratory depression.

DIF: Cognitive Level: Comprehension REF: p. 172 OBJ: 7 TOP: Opioids KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 8. What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with

contractions? a. Offer warm liquids to the patient. b. Encourage the patient to pant. c. Engage the patient in conversation. d. Assist the patient to the knee-chest position.

ANS: B

Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt conversation during contractions. Walking intensifies contractions.

DIF: Cognitive Level: Application REF: p. 170 OBJ: 3 | 4 TOP: Panting KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds

the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent? a. Nausea and vomiting b. Vomiting and aspiration c. Abdominal cramping d. Intestinal obstruction ANS: B

The major adverse effect of general anesthesia is aspiration of stomach contents.

DIF: Cognitive Level: Comprehension REF: p. 173 | Table 7.2 OBJ: 7 TOP: General Anesthesia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Reduction of Risk 10. What assessment should be taken immediately after the anesthesiologist administers an

epidural block to a laboring woman? a. Bladder for distention b. Blood pressure

c. Sensation in the lower extremities d. Intravenous fluid flow rate ANS: B

Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also important but not an initial assessment.

DIF: Cognitive Level: Application REF: p. 173 OBJ: 8 TOP: Epidural Block KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A woman in labor has had an epidural block for pain relief. The nurse will be assessing

carefully for what associated side effect of this type of regional anesthesia? a. Reduced fetal heart rate b. Long, intense contractions c. Sudden leg cramps d. Bladder distention ANS: D

A side effect of an epidural block is urine retention, because the anesthesia interferes with the woman‘s ability to have an urge to void. The patient may have to be catheterized.

DIF: Cognitive Level: Knowledge REF: pp. 173-174, Safety Alert Box OBJ: 8 TOP: Epidural Block KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. Which narcotic antagonist is used to reverse narcotic-induced respiratory depression? a. Hydroxyzine (Vistaril) b. Phenobarbital c. Naloxone (Narcan) d. Nitrous oxide ANS: C

Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics.

DIF: Cognitive Level: Knowledge REF: p. 173 OBJ: 7 | 8 TOP: Narcotic Antagonist KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before

delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia? a. Restrict oral fluids. b. Keep legs flexed. c. Walk with assistance as soon as possible. d. Lie flat for several hours.

ANS: D

The woman would be advised to remain flat for several hours after the block to decrease the chance of postspinal headache.

DIF: Cognitive Level: Application

REF: p. 175

OBJ: 7 | 8

TOP: Subarachnoid Block KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 14. A woman requests a pudendal block to manage her labor pain. What statement by the woman

indicates a need for further explanation about the pudendal block? a. ―I‘m having a contraction. Can I get the pudendal block now?‖ b. ―I‘ll get the pudendal block right before I deliver.‖ c. ―The nurse-midwife will insert the needles into my vagina.‖ d. ―It takes a few minutes after the medicine is administered to make me feel numb.‖ ANS: A

The pudendal block does not block pain from contractions and is given just before birth.

DIF: Cognitive Level: Comprehension REF: p. 176 OBJ: 7 | 8 TOP: Pudendal Block KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She

received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, ―Please give me something for the pain. I can‘t take the pain!‖ What is the priority nursing diagnosis? a. Pain related to uterine contractions b. Knowledge deficit related to the birth experience c. Ineffective coping related to inadequate preparation for labor d. Risk for injury related to lack of prenatal care ANS: A

The most important issue for this woman, at this time, is effective pain management.

DIF: Cognitive Level: Analysis REF: p. 177, Nursing Care Plan 7.1 OBJ: 4 TOP: Pain as a Priority KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. The nurse who encourages the gate control theory of pain control would advise a woman in

labor and her partner to use which nonpharmacological method of pain management? a. Slow abdominal breathing b. Guided relaxation c. Listening to music d. Massage ANS: D

According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter fibers and ―closes the gate.‖ DIF: Cognitive Level: Analysis REF: p. 166 OBJ: 6 TOP: Gate Control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an

epidural for delivery. What is a contraindication to an epidural block?

a. b. c. d.

Abnormal clotting Previous cesarean delivery History of migraine headaches History of diabetes mellitus

ANS: A

An epidural block is not used if a woman has abnormal blood clotting.

DIF: Cognitive Level: Comprehension REF: p. 173 OBJ: 7 TOP: Epidural Block KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. The nurse coaches the primigravida not to bear down until the cervix is completely dilated.

What may premature bearing down cause? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression of the cord ANS: B

Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.

DIF: Cognitive Level: Comprehension REF: p. 170 OBJ: 4 TOP: Cervical Laceration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. What is the Dick-Read method of childbirth preparation based on? a. Mild sedation throughout labor b. Relaxation techniques c. Skin stimulation d. Deep massage ANS: B

The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.

DIF: Cognitive Level: Knowledge REF: p. 168 OBJ: 5 TOP: Dick-Read Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her

baseline respiratory rate is 22 breaths per minute. What should be the patient‘s rate while performing slow breathing? a. 9 b. 11 c. 15 d. 20 ANS: B

The range of respirations should be no lower than half of the base rate and no more rapid than double the base rate.

DIF: Cognitive Level: Comprehension REF: p. 170 OBJ: 3 TOP: Lamaze Method KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. What is the least amount of sensation that one perceives as pain? a. Tolerance b. Threshold c. Level d. Abatement ANS: B

Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.

DIF: Cognitive Level: Knowledge REF: p. 166 OBJ: 1 TOP: Pain Threshold KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the

nurse of the need for pain relief? a. Frequently asking for ice chips b. Facial grimacing c. Changing positions in bed d. Covering her face with her hands ANS: B

Facial grimacing may be an indicator of unexpressed pain.

DIF: Cognitive Level: Comprehension REF: p. 171 OBJ: 4 | 6 | 8 TOP: Nonverbal Pain Expressing KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 23. A patient who received an epidural block asks why her blood pressure is taken so often. What

is the nurse‘s best response to explain the frequent blood pressure assessments? a. They ensure that unsafe levels of hypertension do not occur. b. They help assess for the need for further pain relief. c. They monitor the progress of labor. d. They ensure adequate placental perfusion.

ANS: D

The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading to fetal hypoxia.

DIF: Cognitive Level: Comprehension REF: p. 173 OBJ: 7 | 8 TOP: Disadvantage of Epidural Block KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 24. A laboring patient requests hot and cold applications be applied to her abdomen for pain

control. How will this intervention act to control pain? a. By increasing endorphin production b. By facilitating effacement and dilation c. By producing increasing pain tolerance

d. By stimulation of large nerve fibers ANS: D

The gate control theory explains how pain impulses reach the brain for interpretation. It supports several nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the conduction of impulses through small-diameter fibers. Techniques to stimulate large-diameter fibers and ―close the gate‖ to painful impulses include massage, palm and fingertip pressure, and heat and cold applications.

DIF: Cognitive Level: Comprehension REF: p. 166 OBJ: 5 | 6 TOP: Nonpharmacological Pain Relief KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 25. When caring for the laboring patient, the nurse determines that the fetus is located in the right

occiput posterior (ROA). What will the nurse anticipate? a. Urinary retention b. Severe lower back pain c. A shorter labor process d. Nausea ANS: B

If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mother‘s sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.

DIF: Cognitive Level: Application REF: p. 168 OBJ: 4 TOP: Maternal Condition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 1. What typical types of classes are available to help expectant parents prepare for parenthood?

(Select all that apply.) a. Infant care b. Breastfeeding c. Gestational diabetes d. Sources of financial aid e. Yoga ANS: A, B, C

Prenatal classes include such topics as infant care, breastfeeding, gestational diabetes, exercising, and sibling and grandparent preparation. Yoga and financial information are not traditional content for prenatal instruction.

DIF: Cognitive Level: Knowledge REF: p. 164 OBJ: 2 TOP: Prenatal Classes KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 2. What breathing techniques would the nurse teach the prenatal patient to help her focus during

labor in order to reduce pain? (Select all that apply.)

a. b. c. d. e.

First-stage breathing Abdominal breathing Fourth-stage breathing Modified paced breathing Patterned paced breathing

ANS: A, B, D, E

First-stage breathing includes the techniques of modified paced breathing and patterned paced breathing, which are types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus and reduce pain perception. The fourth stage of labor is the woman‘s recovery stage and does not require a breathing technique.

DIF: Cognitive Level: Comprehension REF: p. 170 OBJ: 3 | 5 TOP: Breathing Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. How does the pain of childbirth differ from other types of pain? (Select all that apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs narcotic relief. c. Position changes relieve pain and facilitate delivery. d. Childbirth pain declines following birth. e. Childbirth pain is self-limited.

ANS: A, C, D, E

Childbirth pain differs from other types of pain, because it is part of a normal, natural, and expected process, can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with narcotics in many cases.

DIF: Cognitive Level: Comprehension REF: p. 166 OBJ: 3 | 4 TOP: Childbirth Pain KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. Which are nonpharmacological forms of pain relief? (Select all that apply.) a. Skin stimulation b. Diversion and distraction c. Breathing techniques d. Exercise e. Yoga ANS: A, B, C

Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain control. Although exercise and practices such as yoga and Pilates are beneficial, they are not means of pain control.

DIF: Cognitive Level: Knowledge REF: pp. 168-169 OBJ: 6 TOP: Nonpharmacological Pain Control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort

in the later stages of pregnancy? (Select all that apply.) a. Leg lifts

b. c. d. e.

Pelvic rock Tailor sitting Sit-ups Shoulder curling

ANS: B, C, E

Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial, because they both increase intra-abdominal pressure.

DIF: Cognitive Level: Comprehension REF: p. 165 OBJ: 6 TOP: Helpful Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse is providing a conference on nonpharmacological pain control methods. What

major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.) a. They sedate the mother. b. They do not slow labor. c. They do not dull the excitement of the birth experience. d. They do not have the potential to cause allergic reactions. e. They do not have to be delayed until labor is well established.

ANS: B, C, D, E

All the options mentioned are benefits of nonpharmacological pain control methods with the exception of sedating the mother.

DIF: Cognitive Level: Knowledge REF: p. 168 OBJ: 5 | 6 TOP: Advantages of Nonpharmacological Pain Control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal

delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis?

(Select all that apply.) a. Assess leg movement and sensation before ambulating. b. Administer antibiotic as ordered. c. Observe for signs of impending birth. d. Provide sacral pressure as needed. e. Assess fetal position frequently.

ANS: A, C

To prevent the risk for injury related to epidural anesthesia, the nurse should assess for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.

DIF: Cognitive Level: Application REF: p. 173 OBJ: 8 TOP: Epidural Anesthesia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

8. The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse

to provide patient education. What will the nurse include in the educational plan? (Select all that apply.) a. Onset is slow. b. Duration is short. c. Administration is by mouth. d. No known side effects. e. It is not the same drug as sufentanil.

ANS: B, E

Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same drugs. Fentanyl can cause respiratory depression but less than meperidine. It is not administered by mouth.

DIF: Cognitive Level: Comprehension REF: p. 172 | Table 7.1 OBJ: 8 TOP: Narcotic Analgesia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

Chapter 08: Nursing Care of Women with Complications During Labor and Birth Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is regular at 154 beats/minute. b. Amniotic fluid is clear with flecks of vernix. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8C. ANS: C

Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.

DIF: Cognitive Level: Application REF: p. 186 TOP: Obstetric Procedures—Amniotomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

OBJ: 3

2. A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce

labor and begins to have contractions every 90 seconds. What is the nurse‘s initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the physician. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by mask.

ANS: A

Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

DIF: Cognitive Level: Application REF: p. 186 TOP: Obstetric Procedures—Induction of Labor KEY: Nursing Process Step: Implementation

OBJ: 3

MSC: NCLEX: Physiological Integrity 3. What nursing care should be provided to a woman with a third-degree laceration immediately

after delivery? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema ANS: B

Ice is applied to the perineum to reduce bruising and edema.

DIF: Cognitive Level: Application REF: p. 188 OBJ: 3 TOP: Obstetric Procedures—Lacerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. After several hours of labor, a nursing assessment reveals that a woman‘s cervix is 5 cm

dilated, but contractions are becoming shorter and less frequent. What is this labor pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False ANS: B

The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.

DIF: Cognitive Level: Comprehension REF: p. 196 | Table 8.2 OBJ: 5 TOP: Abnormal Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to

5 cm with membranes intact. What action by the physician will the nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency cesarean section.

ANS: A

Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact.

DIF: Cognitive Level: Comprehension TOP: Abnormal Labor MSC: NCLEX: Physiological Integrity

REF: p. 196 OBJ: 2 | 5 KEY: Nursing Process Step: Implementation

6. An infant is delivered with the use of forceps. What should the nurse assess for in the

newborn? a. Loss of hair from contact with forceps

b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation ANS: C

Pressure from forceps may injure the infant‘s facial nerve, which is evidenced by facial asymmetry.

DIF: Cognitive Level: Application REF: p. 190 OBJ: 3 TOP: Obstetric Procedures—Forceps Delivery KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. A new mother is distressed and tearful about the elevated dome over her infant‘s posterior

fontanelle. The nurse responds, ―This condition will resolve itself in a few days.‖ What is the cause? a. Prolonged pressure against the partially dilated cervix b. Small leak of fluid through the posterior fontanelle c. Pressure of the forceps during delivery d. The effect of the vacuum extractor ANS: D

The ―chignon‖ is due to the effect of the vacuum extractor and will disappear in a few days.

DIF: Cognitive Level: Comprehension REF: p. 190 OBJ: 2 TOP: Chignon KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A frustrated patient in labor has been affected by decreased uterine muscle tone and reports,

―My doctor won‘t induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need?‖ What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12 ANS: A

The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American College of Obstetricians and Gynecologists (ACOG).

DIF: Cognitive Level: Comprehension REF: p. 184 | Table 8.1 OBJ: 2 TOP: Bishop Scoring for Vaginal Delivery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 9. A woman is having a difficult labor because the fetus is presenting in the right occipital

position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported and give her a back massage b. Supine with legs bent at the knee

c. Standing with support d. Sitting up and leaning forward on the overbed table ANS: D

A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.

DIF: Cognitive Level: Application REF: p. 199 OBJ: 7 TOP: Abnormal Labor KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 10. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is

dilated 9 cm. The panicked woman begs the nurse, ―Please give me something.‖ What is the most appropriate pain-relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery.

ANS: C

The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.

DIF: Cognitive Level: Application REF: p. 201 OBJ: 3 | 5 TOP: Abnormal Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance 11. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes

ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism ANS: A

Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture, because the barrier to the uterine cavity is broken.

DIF: Cognitive Level: Application REF: p. 201 OBJ: 3 | 6 TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm

labor. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Maternal hypertension c. Fetal bradycardia d. Fetal hypokalemia ANS: A

Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol.

DIF: Cognitive Level: Comprehension REF: p. 203 OBJ: 6 | 7 | 8 TOP: Preterm Labor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. Which statement indicates a woman understands activity limitations for the management of

preterm labor? a. ―After my shower in the morning, I do the laundry and straighten up the house; then I rest.‖ b. ―I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day.‖ c. ―I have a 2-year-old to care for, but I try to rest as much as I can.‖ d. ―I get really bored at home, so I go to the shopping mall for just a little while.‖ ANS: B

Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

DIF: Cognitive Level: Comprehension REF: p. 202 OBJ: 7 TOP: Preterm Labor KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. A student nurse questions the instructor regarding what alteration should be made for the

assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by ―walking‖ fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift.

ANS: B

Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.

DIF: Cognitive Level: Comprehension REF: p. 194 OBJ: 4 TOP: Cesarean Postoperative Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. A pulsating structure is felt during a vaginal examination of a woman in labor. How would the

nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. On her back with her head lower than the rest of her body d. Supine with her legs elevated and bent at the knee ANS: C

The Trendelenburg‘s (head down) position displaces the fetus upward to stop compression of the prolapsed cord.

DIF: Cognitive Level: Application REF: p. 205 OBJ: 8 TOP: Emergencies During Childbirth—Prolapsed Umbilical Cord KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. Several hours after delivery, the nurse finds a woman crying. The woman says repeatedly,

―My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section.‖ What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency cesarean section d. Grieving related to loss of expected birth experience ANS: D

Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger, because the expected course of birth did not occur.

DIF: Cognitive Level: Application REF: p. 203 OBJ: 8 TOP: Cesarean Section KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. A pregnant woman‘s membranes ruptured prematurely at 34 weeks. She will be discharged to

her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her obstetrician if she has a temperature above 37.8C (100F). c. Massage her breasts to promote uterine relaxation. d. Rest in a side-lying Trendelenburg‘s position with hips elevated.

ANS: B

For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8C (100F).

DIF: Cognitive Level: Application REF: p. 186 OBJ: 6 TOP: Premature Rupture of Membranes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium

sulfate. What side effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency ANS: C

Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

DIF: Cognitive Level: Knowledge TOP: Preterm Labor MSC: NCLEX: Physiological Integrity

REF: p. 203 OBJ: 6 KEY: Nursing Process Step: Implementation

19. When a woman is admitted to the labor and delivery unit, she tells the nurse that she is

anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor? a. By decreasing a woman‘s pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension ANS: B

Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

DIF: Cognitive Level: Comprehension REF: p. 200 OBJ: 5 TOP: Factors That Influence Labor Pain KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance 20. During a strenuous labor, the woman asks for some pain remedy for the sudden pain between

her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub.

ANS: B

Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture.

This should be reported immediately.

DIF: Cognitive Level: Application REF: p. 206 OBJ: 3 TOP: Uterine Rupture KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. What does the nurse explain is used to soften the cervix with a ―cervical ripening‖ agent? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation ANS: A

Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.

DIF: Cognitive Level: Knowledge REF: p. 185 OBJ: 3 TOP: Cervical Ripening KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 22. The nurse is caring for a patient who is threatening preterm labor and has been given

glucocorticoids. What is the purpose of glucocorticoid administration? a. Prevent infection. b. Increase fetal lung maturity. c. Increase blood flow from placenta. d. Relax the cervix.

ANS: B

Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

DIF: Cognitive Level: Comprehension REF: p. 203 OBJ: 6 TOP: Fetal Lung Maturity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse arrives at the start of a shift on the labor unit to find a census of four patients in

active labor. Which laboring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous cesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy ANS: C

A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression.

Contractions may be frequent and intense, often from the onset. If the woman‘s tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth.

DIF: Cognitive Level: Analysis REF: p. 201 OBJ: 7 TOP: Precipitate Birth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 24. The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the

nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction d. Use of frequent position changes ANS: D

A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor.

DIF: Cognitive Level: Comprehension REF: p. 196 OBJ: 5 | 6 TOP: Hypotonic Labor Dysfunction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. What sign(s) of infection should the nurse assess for after an amniotomy? a. Oral temperature of 37C (99.8F) b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain ANS: B

Increase in the FHR above 160 beats/minute frequently precedes a woman‘s temperature elevation. All the other options are normal findings for late pregnancy.

DIF: Cognitive Level: Application REF: p. 186 OBJ: 3 TOP: Postamniotomy Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. What are the rationales for labor induction? (Select all that apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency ANS: D, E

Maternal diabetes and placental insufficiency are rationales for induction. The other options are contraindications for labor induction.

DIF: Cognitive Level: Comprehension REF: pp. 183-184 OBJ: 2 TOP: Rationales for Labor Induction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration ANS: A, B, C

Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor.

Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor.

DIF: Cognitive Level: Application REF: p. 184 OBJ: 3 TOP: Hypotonic Labor KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What complications of overstimulation of uterine contractions may occur? (Select all that

apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture ANS: A, B, E

The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.

DIF: Cognitive Level: Comprehension TOP: Complication of Oxytocin

REF: p. 186 OBJ: 6 KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the

quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Press the palms of her hands down on her breasts.

ANS: B, C, D

Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction to nipples with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions.

DIF: Cognitive Level: Application REF: p. 184 OBJ: 5 TOP: Nipple Stimulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at

term. What conditions would contraindicate labor induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal cesarean incision d. Prolapsed cord e. Gestational diabetes ANS: B, D

Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord.

Gynecoid pelvis is the most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labor induction.

DIF: Cognitive Level: Comprehension REF: p. 184 OBJ: 2 TOP: Induction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. A woman is preparing for administration of a cervical ripening agent. What nursing actions

will the nurse anticipate implementing? (Select all that apply.) a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. d. Instruct patient to ambulate immediately afterward. e. Ensure a tocolytic is available.

ANS: A, B, C

The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.

DIF: Cognitive Level: Application REF: pp. 184-185 OBJ: 3 TOP: Cervical Ripening KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

Chapter 09: The Family After Birth Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is assessing a newborn. Which sign would indicate hypoglycemia? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry ANS: D

There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.

DIF: Cognitive Level: Comprehension REF: p. 231 OBJ: 9 TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. What would the nurse expect to find when assessing the fundus of the uterus immediately

after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus ANS: A

Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.

DIF: Cognitive Level: Comprehension REF: p. 211 OBJ: 2 TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What statement made by a new mother indicates she needs additional information about

breastfeeding? a. ―I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast.‖ b. ―The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.‖ c. ―The baby has been nursing every 2 to 3 hours.‖ d. ―If the baby gets fussy between feedings, I give her a bottle of water.‖ ANS: D

Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.

DIF: Cognitive Level: Comprehension

REF: p. 240

OBJ: 14

TOP: Breastfeeding—Supplemental Feedings KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After delivery, the nurse‘s assessment reveals a soft, boggy uterus located above the level of

the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat.

ANS: B

A poorly contracted uterus should be massaged until firm to prevent hemorrhage.

DIF: Cognitive Level: Application REF: p. 214 OBJ: 9 TOP: Boggy Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. What type of lochia will the nurse assess initially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis ANS: B

The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum.

DIF: Cognitive Level: Knowledge REF: p. 214 OBJ: 4 TOP: Lochia Rubra KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge

teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity.

ANS: C

A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.

DIF: Cognitive Level: Application REF: pp. 214-215 OBJ: 19 TOP: Hemorrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back. c. Remove perineal pads from the rectal area toward the vagina. d. Use cool water to decrease edema of the perineum.

ANS: B

Cleansing from front to back prevents contamination from the rectal area.

DIF: Cognitive Level: Application REF: p. 216 OBJ: 2 TOP: Perineal Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. A postpartum woman is not immune to rubella. What will the nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum

checkup. c. The woman should be instructed not to get pregnant until she receives the rubella

vaccine. d. No intervention is indicated at this time because the woman is not at risk for

rubella.

ANS: A

The woman who is not immune to rubella is immunized in the immediate postpartum period, because there is no danger of her being pregnant.

DIF: Cognitive Level: Comprehension REF: p. 220 OBJ: 2 TOP: Rubella KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. Which statement indicates the new mother is breastfeeding correctly? a. ―I will alternate breasts when feeding the baby.‖ b. ―I keep the baby on a 4-hour feeding schedule.‖ c. ―I let the baby stay on the first breast only 5 minutes.‖ d. ―I put only the nipple in the baby‘s mouth when I am breastfeeding.‖ ANS: A

Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.

DIF: Cognitive Level: Comprehension REF: p. 236| Table 9.4 OBJ: 10 TOP: Breastfeeding KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is counseling a lactating mother about diet. What would the nurse include with this

information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet.

ANS: A

To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet.

DIF: Cognitive Level: Comprehension REF: p. 242 TOP: Breastfeeding—Maternal Nutrition

OBJ: 18

KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A woman asks about resumption of her menstrual cycle after childbirth. What should the

nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed.

ANS: B

Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.

DIF: Cognitive Level: Comprehension REF: p. 217 OBJ: 4 TOP: Return of Menses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. In what situation will the physician order RhoGAM? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs.

ANS: A

The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.

DIF: Cognitive Level: Analysis REF: p. 220 OBJ: 2 TOP: RhoGAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action

prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convection ANS: C

Newborns lose heat quickly after birth as fluid evaporates from their bodies.

DIF: Cognitive Level: Comprehension REF: p. 227 | Table 9.3 OBJ: 2 TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What will the nurse‘s instructions for a new mother to care for the infant‘s umbilical cord

include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off

ANS: C

Diaper placement below the umbilical stump allows for drying by air circulation.

DIF: Cognitive Level: Application REF: p. 230 OBJ: 2 TOP: Umbilical Cord Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A new mother states her preference to formula feed her newborn. What will the nurse

planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache.

ANS: A

When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.

DIF: Cognitive Level: Application REF: pp. 241-242 OBJ: 14 | 19 TOP: Suppression of Lactation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. On the second postpartum day, a mother bathed her newborn for the first time. She tells the

nurse, ―I don‘t think I did it right.‖ What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down ANS: B

In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.

DIF: Cognitive Level: Analysis REF: p. 226 OBJ: 6 TOP: Postpartum Psychological Stages KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation 17. A primipara tells the nurse, ―My afterpains get worse when I am breastfeeding.‖ What is the

most appropriate nursing response? a. ―I‘ll get you some aspirin to relieve the cramping that you feel.‖ b. ―Afterpains are more intense with your first baby.‖ c. ―Breastfeeding releases a hormone that causes your uterus to contract.‖ d. ―A change of position when you‘re breastfeeding might help.‖ ANS: C

Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus.

DIF: Cognitive Level: Application REF: p. 235 OBJ: 2 TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. A new mother has decided not to breastfeed her newborn. What information will the nurse

include when planning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple is full of formula during the entire feeding b. Heating the infant formula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding ANS: A

The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.

DIF: Cognitive Level: Comprehension REF: p. 244 | Skill 9.7 OBJ: 17 TOP: Formula Feeding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. In the recovery room, the nurse checks the newly delivered woman‘s fundus following a

cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion.

ANS: C

The fundus is checked gently by walking the fingers from the side of the uterus to the midline.

DIF: Cognitive Level: Application REF: p. 220 OBJ: 5 TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. The nurse instructed a postpartum woman about storing and freezing breast milk. What

statement by the woman leads the nurse to determine that the teaching was effective? a. ―I can thaw frozen breast milk in the microwave.‖ b. ―I‘ll put enough breast milk for one day in a container.‖ c. ―Breast milk can be stored in glass containers.‖ d. ―Breast milk can be kept in the refrigerator for up to 3 months.‖ ANS: C

Breast milk can be safely stored in glass or clear hard plastic containers.

DIF: Cognitive Level: Comprehension REF: p. 241 OBJ: 14 TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. What should the nurse implement for security purposes when bringing the infant from the

nursery to the mother? a. Ask, ―Is this your band number?‖ b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother.

ANS: D

The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.

DIF: Cognitive Level: Application REF: p. 228 OBJ: 8 TOP: Security Identification Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL ANS: D

A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.

DIF: Cognitive Level: Comprehension REF: p. 231 OBJ: 8 TOP: Hypoglycemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 23. The nurse is caring for a woman of Middle Eastern descent on the first postpartum day.

Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction? a. Patient correctly performed return demonstration. b. Patient indicated understanding by nodding head with instruction. c. Patient verbalizes ―I understand.‖ d. Family member indicates patient understands procedure.

ANS: A

The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement.

DIF: Cognitive Level: Application REF: p. 211 OBJ: 3 TOP: Cultural Influences KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Cultural Awareness 24. A woman has given birth to an unresponsive newborn that NICU staff are attempting to

revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse‘s most appropriate action? a. Contact the hospital chaplain. b. Request the couple‘s clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn.

ANS: C

If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However, this is an emergency, so the nurse may perform the baptism by pouring water on the infant‘s forehead while saying, ―I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.‖ If there is any doubt as to whether the infant is alive, the baptism is given conditionally: ―If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit.‖ The physician is attending to the patient‘s immediate health needs.

DIF: Cognitive Level: Application REF: p. 225 OBJ: 7 TOP: Grieving Parents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Grief and Loss 25. A woman required a cesarean section for safe delivery of her newborn. She is planning to

breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. ―Consider formula feeding for the first few days.‖ b. ―Pumping breast milk would be best for now.‖ c. ―Take pain medication 30 to 40 minutes prior to nursing.‖ d. ―Use the football hold when breastfeeding.‖ ANS: D

The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding.

DIF: Cognitive Level: Application REF: p. 236 OBJ: 13 TOP: Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 1. Which assessments would lead the nurse to determine the gestational age of the infant as

preterm? (Select all that apply.) a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole ANS: A, C

The only signs of preterm are the thin skin and the slowly responding ear.

DIF: Cognitive Level: Application REF: p. 229 OBJ: 2 TOP: Gestational Age Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What

interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove.

d. Provide a shower chair. e. Confirm ambulation ability.

ANS: B, C, D, E

The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.

DIF: Cognitive Level: Application REF: p. 222 OBJ: 5 TOP: Postpartum Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. What postpartum exercises should the nurse teach a patient who had a vaginal delivery

yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D

Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.

DIF: Cognitive Level: Comprehension REF: p. 220 OBJ: 19 TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. While instructing a new mother on formula preparations, the nurse would include what types?

(Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cow‘s milk e. Canned evaporated milk ANS: A, B, C

Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infant‘s needs, and powdered formula that is mixed as needed. Cow‘s milk and canned evaporated milk are unsuitable, because they are nutritionally inadequate and stress the kidneys.

DIF: Cognitive Level: Comprehension REF: p. 243 OBJ: 17 TOP: Formula Choices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse is instructing a woman at 6 months postpartum on weaning her infant from

breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborn‘s favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding.

e. Pump breasts in place of eliminated feeding.

ANS: B, C, D

When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.

DIF: Cognitive Level: Comprehension REF: p. 242 OBJ: 16 TOP: Weaning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

Chapter 10: Nursing Care of Women with Complications After Birth Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output ANS: B

Tachycardia is usually the first sign of inadequate blood volume.

DIF: Cognitive Level: Knowledge REF: p. 251 | Safety Alert OBJ: 2 TOP: Hypovolemic Shock KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the

patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine hypoplasia d. Uterine dysfunction ANS: A

Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.

DIF: Cognitive Level: Comprehension REF: p. 253 OBJ: 2 TOP: Atony KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What should the nurse‘s first action be when postpartum hemorrhage from uterine atony is

suspected? a. Teach the patient how to massage the abdomen and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the physician.

d. Ask the patient to void and reassess fundal tone and location.

ANS: C

When the uterus is boggy, the nurse should immediately massage it until it becomes firm.

DIF: Cognitive Level: Application REF: p. 254 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the

side. What should the nurse‘s next assessment be? a. Fullness of the bladder b. Amount of lochia c. Blood pressure d. Level of pain ANS: A

Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied.

DIF: Cognitive Level: Application REF: p. 254 OBJ: 6 TOP: Bladder Distention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Massage and putting the infant to the breast of a postpartum patient have been ineffective in

controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician? a. Ritodrine b. Magnesium sulfate c. Oxytocin d. Bromocriptine ANS: C

Oxytocin (Pitocin) is the most common drug ordered to control uterine atony.

DIF: Cognitive Level: Comprehension REF: p. 254 OBJ: 5 TOP: Oxytocin (Pitocin) for Hemorrhage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed.

What is the nurse‘s most helpful response? a. ―Stop breastfeeding until the infection clears.‖ b. ―Pump the breasts to continue milk production, but do not give breast milk to the infant.‖ c. ―Begin all feedings with the affected breast until the mastitis is resolved.‖ d. ―Breastfeeding can continue unless there is abscess formation.‖ ANS: D

The woman with mastitis can continue to breastfeed unless an abscess forms.

DIF: Cognitive Level: Application TOP: Mastitis and Breastfeeding MSC: NCLEX: Physiological Integrity

REF: pp. 258-259 OBJ: 6 KEY: Nursing Process Step: Implementation

7. A woman had a vaginal delivery two days ago and is preparing for discharge. What will the

nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Contractions d. Fatigue and irritability ANS: A

Increased temperature is a sign of infection. The other choices are normal in the postpartum period.

DIF: Cognitive Level: Application REF: p. 256 OBJ: 4 TOP: Puerperal Infections KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. One day after discharge, the postpartum patient calls the clinic complaining of a reddened area

on her lower leg, temperature elevation of 37°C (99.8°F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Phlebitis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis ANS: A

The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient.

DIF: Cognitive Level: Analysis REF: p. 256 OBJ: 2 TOP: Phlebitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. Which statement indicates to the nurse on a postpartum home visit that the patient understands

the signs of late postpartum hemorrhage? a. ―My discharge would change to red after it has been pink or white.‖ b. ―If I have a postpartum hemorrhage, I will have severe abdominal pain.‖ c. ―I should be alert for an increase in bright red blood.‖ d. ―I would pass a large clot that was retained from the placenta.‖ ANS: A

When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage.

DIF: Cognitive Level: Comprehension REF: p. 255 OBJ: 2 TOP: Color Change in Lochia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. During a postpartum assessment, a woman reports her right calf is painful. The nurse observes

edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants for 6 weeks

b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day ANS: A

Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism.

DIF: Cognitive Level: Analysis REF: p. 256 OBJ: 5 TOP: Anticoagulant Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 11. What statement by the patient leads the nurse to determine a woman with mastitis understands

treatment instructions? a. ―I will apply cold compresses to the painful areas.‖ b. ―I will take a warm shower before nursing the baby.‖ c. ―I will nurse first on the affected side.‖ d. ―I will empty the affected breast every 8 hours.‖ ANS: B

Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.

DIF: Cognitive Level: Comprehension REF: p. 259 OBJ: 6 TOP: Mastitis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. What is the best response to a postpartum woman who tells the nurse she feels ―tired and sick

all of the time since I had the baby 3 months ago‖? a. ―This is a normal response for the body after pregnancy. Try to get more rest.‖ b. ―I‘ll bet you will snap out of this funk real soon.‖ c. ―Why don‘t you arrange for a babysitter so you and your husband can have a night out?‖ d. ―Let‘s talk about this further. I am concerned about how you are feeling.‖ ANS: D

If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive.

DIF: Cognitive Level: Application REF: pp. 259-260 OBJ: 6 | 7 TOP: Depression KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are

visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Have the woman sit in a chair for meals. b. Monitor vital signs every 4 hours and report any changes. c. Tell the woman to remain in bed with her legs elevated. d. Assist the woman with ambulation for short periods of time.

ANS: D

Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman.

DIF: Cognitive Level: Application REF: p. 257 OBJ: 4 TOP: Thrombus Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. Five days after a spontaneous vaginal delivery, a woman comes to the emergency room

because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis ANS: C

Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.

DIF: Cognitive Level: Analysis REF: p. 257 | Table 10.2 OBJ: 2 TOP: Puerperal Infections KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and

is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this woman‘s symptoms? a. Bipolar disorder b. Major depression c. Postpartum blues d. Postpartum depression ANS: B

Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep, and appetite disturbances, and sometimes delusions about the infant being dead.

DIF: Cognitive Level: Analysis REF: pp. 259-260 OBJ: 7 TOP: Major Depression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. Three weeks after delivering her first child, a woman tells the nurse, ―I waited so long for this

baby and now that she is here, I can‘t believe how different my life is from what I expected.‖ What is the best nursing response to the woman‘s statement? a. ―How is your partner adjusting to the change?‖ b. ―I hear this from a lot of first-time mothers.‖ c. ―Have you told anyone else about your feelings?‖ d. ―Tell me how things are different.‖ ANS: D

The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mother‘s feelings about motherhood and her infant.

DIF: Cognitive Level: Application REF: pp. 259-260 OBJ: 6 | 7 TOP: Disorders of Mood KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. After a prolonged labor, a woman vaginally delivered a 10-pound, 3-ounce infant boy. What

complication should the nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments ANS: B

Delivering a large infant and a prolonged labor are risk factors for hematoma formation.

DIF: Cognitive Level: Analysis REF: p. 255 OBJ: 3 TOP: Hematoma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing

pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy ANS: C

Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall.

DIF: Cognitive Level: Knowledge TOP: Subinvolution of the Uterus MSC: NCLEX: Physiological Integrity

REF: p. 255 OBJ: 2 KEY: Nursing Process Step: Implementation

19. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of

breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the physician of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with antipyretic remedy for elevated temperature.

ANS: B

Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication.

DIF: Cognitive Level: Application REF: p. 256 OBJ: 2 | 6 TOP: Pulmonary Embolus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses

a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding?

a. b. c. d.

Concerned and reports a probable cervical laceration Attentive and massages the uterus to expel retained clots Distressed and reports a possible clotting disorder Satisfied with the normal early postpartum finding

ANS: A

The bright trickle of blood with a firm uterus suggests a cervical laceration.

DIF: Cognitive Level: Application REF: p. 255 OBJ: 2 | 6 TOP: Laceration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse assesses a positive Homans‘ sign when the patient‘s leg is flexed and foot sharply

dorsiflexed. Where does the patient report that the pain is felt? a. Groin b. Achilles tendon c. Top of the foot d. Calf of the leg ANS: D

A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans‘ sign. Homans‘ sign is suggestive of a deep vein thrombosis.

DIF: Cognitive Level: Comprehension REF: p. 256 OBJ: 2 TOP: Homans Sign KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000

cells/dL. What action should the nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further.

ANS: D

The patient should be assessed further for other signs of infection, because a white blood cell (WBC) count of 20,000 to 30,000 cells/dL is normal in the early postpartum period.

DIF: Cognitive Level: Analysis REF: p. 257 OBJ: 6 TOP: Elevated WBC KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. A postpartum patient experiences anaphylactic shock. What is the most likely cause? a. Pulmonary embolism b. Hypertension c. Allergy d. Blood clotting disorder ANS: C

Anaphylactic shock is caused by allergic responses to drugs administered. Cardiogenic shock may be caused by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders.

DIF: Cognitive Level: Comprehension REF: p. 250 OBJ: 3 TOP: Shock KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the

nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K ANS: D

The antidote for warfarin overdose is vitamin K. DIF: Cognitive Level: Knowledge REF: p. 256|Safety Alert OBJ: 5 TOP: Warfarin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 1. A nurse is discussing risk factors for postpartum shock with a childbirth preparation class.

What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage ANS: B, C, D, E

Hypertension is not a cause for postpartum shock; all the other options can cause shock.

DIF: Cognitive Level: Application REF: p. 250 OBJ: 3 TOP: Postpartum Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that

there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus ANS: B, E

Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.

DIF: Cognitive Level: Analysis REF: p. 253 OBJ: 4 TOP: Cessation of Lochia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

3. The nurse instructs the postpartum patient that her nutritional intake should include which

food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe ANS: A, C, E

Legumes and foods containing vitamin C are conducive to healing. Starches are not.

DIF: Cognitive Level: Comprehension REF: p. 258 OBJ: 4 TOP: Foods Conducive to Healing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that

apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying.

ANS: B, C, D, E

Nursing mothers should take in about 3 liters of fluid a day. All the other options are interventions to reduce the risk of mastitis and milk accumulation in the breast.

DIF: Cognitive Level: Comprehension REF: p. 259 OBJ: 4 TOP: Reduction of the Risk of Mastitis KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can

the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples ANS: A, B, C, D

Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine.

DIF: Cognitive Level: Comprehension REF: p. 258 | Table 10.2 OBJ: 4 TOP: Urinary Tract Infection KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse

anticipate? (Select all that apply.) a. Provision of IV fluids

b. c. d. e.

Placement of an indwelling Foley catheter Assessment of oxygen saturation Administration of anticoagulants Blood transfusion

ANS: A, B, C, E

Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given.

DIF: Cognitive Level: Application REF: p. 251 OBJ: 5 TOP: Hypovolemic Shock KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 1. The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware

that this indicates a blood loss of _____ mL. ANS:

15 The weight of 1 g in a perineal pad is equal to 1 mL of blood loss.

DIF: Cognitive Level: Comprehension REF: p. 251 OBJ: 2 TOP: Weighing Perineal Pad KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 11: The Nurse’s Role in Women’s Health Care Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is preparing a community education program on preventive health care for women.

What common screening test will the nurse plan on explaining to the women attending the program? a. Breast examination by a health professional b. Breast self-examination c. Breast biopsy d. Mammography ANS: D

Mammography is a screening test used to detect breast cancer. A breast examination is a focused assessment, not a test. A breast self-examination is important, but not a screening test.

A breast biopsy is a diagnostic test versus a test performed for basic screening purposes.

DIF: Cognitive Level: Comprehension REF: p. 264 OBJ: 2 TOP: Mammography KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. The nurse reviews the procedure for breast self-examination (BSE) with a 25-year-old woman

who has a family history of breast cancer. When reviewing the procedure, when will the nurse indicate as the best time for a woman to perform a breast self-examination? a. A few days before her period b. During her menstrual period c. On the last day of menstrual flow d. One week after the beginning of her period ANS: D

The best time for BSE is 1 week after the beginning of the menstrual period.

DIF: Cognitive Level: Knowledge REF: p. 264 OBJ: 2 TOP: Breast Self-Exam KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. A woman asks the nurse, ―How do oral contraceptives prevent pregnancy?‖ What will the

nurse explain about the combination of estrogen and progesterone in oral contraceptives? a. Makes cervical mucus hostile to sperm b. Prevents ovulation c. Prohibits implantation of the egg d. Acts as a barrier by destroying sperm ANS: B

Oral contraceptives contain a combination of estrogen and progesterone that suppresses ovulation.

DIF: Cognitive Level: Comprehension REF: p. 275 OBJ: 5 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. What should a woman expect after insertion of an intrauterine device (IUD)? a. Menstrual flow will be lighter. b. Menstrual cramps will be eliminated. c. A string should be felt in the vagina. d. The device should be changed every 2 years.

ANS: C

A woman should feel for the string periodically, especially after her period, to confirm the presence of the IUD. DIF: Cognitive Level: Comprehension REF: p. 277 OBJ: 5 TOP: IUDs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. What information will the nurse provide when educating a woman about the correct use of a

diaphragm? a. Use of a spermicidal cream or jelly is not recommended. b. Leave in place for at least 6 hours after intercourse. c. Remove immediately after intercourse for douching. d. It is effective for up to 48 hours if positioned properly.

ANS: B

To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to, but no more than 24 hours.

DIF: Cognitive Level: Comprehension REF: p. 278 OBJ: 5 TOP: Diaphragm KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The nurse is providing sexual education to a group of high school students. What will the

nurse explain is the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases? a. Abstain from sex. b. Use the male condom. c. Use the female condom. d. Use the barrier method.

ANS: A

Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases.

DIF: Cognitive Level: Comprehension REF: p. 275 OBJ: 5 TOP: Abstinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. On day 13 of a 28-day cycle, a woman‘s basal body temperature is 36.5C (97.7F). What will

her temperature measurement most likely be if ovulation takes place on day 14? a. 35.9C (96.7F) b. 36.3C (97.3F) c. 36.7C (98.1F) d. 37.1C (98.9F) ANS: C

At the time of ovulation, body temperature will increase slightly, about 0.2C (0.4F).

DIF: Cognitive Level: Analysis REF: p. 274 OBJ: 6 TOP: Ovulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse tells a woman who is trying to conceive to check her cervical mucus for changes.

What will she expect the characteristic of cervical mucus to be a few days before ovulation? a. Cloudy and tacky b. Scant and thick c. Thin and white d. Clear and slippery ANS: D

Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage of sperm into the cervix.

DIF: Cognitive Level: Knowledge REF: p. 274 OBJ: 6 TOP: Ovulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The nurse is discussing cervical mucus changes with a woman who wishes to use natural

family-planning methods. What information about cervical mucus at ovulation will the woman indicate to the nurse, demonstrating that learning has taken place? a. Cervical mucus enhances the motility of the sperm. b. Cervical mucus indicates endometrial readiness for implantation. c. Cervical mucus facilitates movement of the ovum through the fallopian tube. d. Cervical mucus provides vaginal lubrication during intercourse.

ANS: A

Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm.

DIF: Cognitive Level: Comprehension REF: p. 274 OBJ: 6 TOP: Cervical Mucus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. In the week before her menstrual period, a woman experiences irritability, anxiety, and

difficulty concentrating. What remedy might the nurse suggest to relieve these symptoms? a. Drink tea or hot chocolate before going to bed. b. Take a daily folic acid and vitamin C supplement. c. Include complex carbohydrates and fiber in the diet. d. Avoid exercise when symptoms occur.

ANS: C

A diet rich in complex carbohydrates and fiber is recommended for premenstrual dysmorphic disorder.

DIF: Cognitive Level: Application REF: p. 268 OBJ: 3 TOP: Premenstrual Dysmorphic Disorder KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. At her regular gynecological examination, a woman tells the nurse that she is concerned about

osteoporosis. What suggestion can the nurse make to this patient? a. Take a vitamin E supplement daily. b. Do isometric exercises that can be practiced every day. c. Include more dairy products and green, leafy vegetables in her diet. d. Try to limit her intake of caffeine.

ANS: C

Foods rich in calcium include milk, dairy products, and green, leafy vegetables.

DIF: Cognitive Level: Application REF: p. 285 OBJ: 7 | 8 TOP: Prevention of Osteoporosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. A 48-year-old woman tells the nurse, ―I missed my period last month. Am I in menopause?‖

The nurse knows that at which point is a woman considered to be menopausal? a. Her periods have stopped for 1 year. b. Her periods have been irregular and light for 12 months. c. She has symptoms of vasomotor instability. d. She experiences symptoms of decreased estrogen, such as dyspareunia.

ANS: A

When a woman‘s menstrual periods have stopped for 1 year, she is considered menopausal.

DIF: Cognitive Level: Comprehension REF: pp. 285-286 OBJ: 7 | 8 TOP: Menopause KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The nurse is planning to teach a woman about perimenopause. What would the nurse include

regarding lowered estrogen level? a. It prevents osteoporosis. b. It decreases vaginal lubrication. c. It raises the level of low-density lipoproteins. d. It raises the level of high-density lipoproteins.

ANS: C

Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver for excretion. With lowered levels of estrogen, low-density lipoproteins increase, causing an increase in the incidence of heart attacks and strokes.

DIF: Cognitive Level: Knowledge REF: p. 284 OBJ: 7 TOP: Menopause KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What side effect would the nurse instruct a woman to look for when starting hormone

replacement therapy (HRT)? a. Fatigue b. Headache c. Weight loss d. Amenorrhea ANS: B

Patients initiating HRT are reminded to have regular follow-up care and report headaches, vision changes, symptoms of thrombophlebitis, and cardiac symptoms.

DIF: Cognitive Level: Comprehension REF: p. 286 OBJ: 8 TOP: HRT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. What will the nurse advise when a woman asks what she can do to reduce the discomfort of

hot flashes? a. ―Aerobic exercise helps control hot flashes.‖ b. ―Increase the amount of calcium and vitamin D in your diet.‖ c. ―Dress in layers of cotton clothing.‖ d. ―Drink plenty of fluids, particularly caffeinated beverages.‖ ANS: C

Cotton allows easier passage of air than synthetic fabrics. Layering allows the woman to take off or put on clothes when symptoms occur.

DIF: Cognitive Level: Application REF: p. 285 | NCP 11.1 OBJ: 8 TOP: Prevention of Hot Flashes KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. Which statement made by the nurse would teach an adolescent using tampons how to prevent

toxic shock syndrome (TSS)? a. Super-absorbency tampons are effective for overnight absorption. b. Tampons should be changed at least every 4 hours. c. Gloves should be worn when changing tampons. d. TSS can be prevented by using a pad for the first 2 days of menstrual flow.

ANS: B

Tampons should be changed every 4 hours, because a blood-soaked tampon is an excellent environment for bacteria.

DIF: Cognitive Level: Comprehension REF: p. 269 OBJ: 4 TOP: TSS KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. What statement by a man considering a vasectomy indicates a need for further information? a. ―Sterility does not occur immediately after the procedure.‖ b. ―We will need to use some form of birth control for about a month afterward.‖ c. ―The procedure involves the use of local anesthesia.‖ d. ―I‘ll need to remain in the hospital for a few days.‖ ANS: D

A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia.

DIF: Cognitive Level: Analysis REF: p. 282 OBJ: 5 TOP: Vasectomy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. At her 6-week postpartum checkup, a woman states, ―I am wondering about birth control. I

used oral contraceptives before, and I‘m breastfeeding now. Can I use the pill again?‖ What is the nurse‘s best response? a. ―You should know that oral contraceptives increase your milk production.‖ b. ―Oral contraceptives can be taken once lactation is well established.‖ c. ―You don‘t need to use any form of birth control as long as you are breastfeeding.‖ d. ―Oral contraceptives are contraindicated for the lactating woman.‖ ANS: B

Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established. Women who breastfeed their infants usually will not ovulate for 10 weeks and do not need contraception until that time.

DIF: Cognitive Level: Application REF: p. 276 OBJ: 5 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal

infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. With what are these findings consistent? a. Candidiasis

b. Trichomoniasis c. Bacterial vaginosis d. Chlamydia ANS: A

The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese appearance to the vaginal discharge.

DIF: Cognitive Level: Analysis REF: p. 271 | Table 11.1 OBJ: 4 TOP: Candidiasis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. The nurse is providing an informational session on oral contraceptives. Which of the

following decrease effectiveness of oral contraceptives? a. Antihistamines for seasonal allergies b. Iron preparations for treatment of anemia c. Appetite suppressants for weight reduction d. Anticonvulsants for treatment of epilepsy ANS: D

Anticonvulsants decrease the effectiveness of oral contraceptives.

DIF: Cognitive Level: Comprehension REF: p. 276 OBJ: 5 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. The nurse is instructing a man considering a vasectomy. What instruction will the nurse

provide to address the postoperative time period? a. Intercourse should be delayed for 6 weeks. b. Sperm will still be ejaculated for a month. c. Erections will be difficult to maintain. d. Monthly sperm counts for a year will be necessary.

ANS: B

Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for about a month. A sperm count after that period of time should be performed to confirm the absence of sperm. Intercourse does not have to be delayed, but an alternate method of contraception should be used. Erections and sexual pleasure are not affected by a vasectomy.

DIF: Cognitive Level: Comprehension REF: p. 282 OBJ: 5 TOP: Vasectomy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A woman diagnosed with endometriosis reports ―painful intercourse.‖ What is the appropriate

medical term for the nurse to document when describing this symptom? a. Dyspnea b. Dysmenorrhea c. Dyspareunia d. Dysrhythmia ANS: C

Dyspareunia is the term for painful sexual intercourse. Dyspnea is shortness of breath.

Dysmenorrhea is painful menstruation. Dysrhythmia is irregular heart rhythm.

DIF: Cognitive Level: Knowledge REF: p. 283 OBJ: 1 TOP: Dyspareunia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse is educating a woman diagnosed with premenstrual dysphoric disorder (PMDD).

What is the best type of diet for the nurse to recommend? a. High protein, low fat b. High carbohydrate, high fiber c. Low calorie, low fat d. Low carbohydrate, high protein ANS: B

Treatment of PMDD includes a diet rich in complex carbohydrates and fiber (to lengthen effects of the carbohydrate meal).

DIF: Cognitive Level: Application REF: p. 268 OBJ: 3 TOP: PMDD KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse instructs a woman taking oral contraceptives to report which possible side effects?

(Select all that apply.) a. Abdominal pain b. Weight gain c. Headache d. Eye or visual problems e. Speech disturbances ANS: A, C, D, E

The memory aid ACHES is helpful: abdominal pain, chest pain, headaches, eye problems, and speech disturbances. Weight gain is an expected side effect of oral contraceptives.

DIF: Cognitive Level: Comprehension REF: p. 276 OBJ: 5 TOP: Oral Contraceptives KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. The nurse cautions that women with a history of which disorders are not candidates for HRT?

(Select all that apply.) a. Melanoma b. Estrogen-dependent breast cancer c. Hepatitis C d. Thromboembolic disease e. Hyperthyroidism ANS: A, B, C, D

Persons who are absolutely restricted from HRT are those with melanoma, estrogen-dependent breast cancers, chronic liver disorders, thromboembolic disease, and seizure disorders.

DIF: Cognitive Level: Comprehension REF: p. 284 OBJ: 9 TOP: HRT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 3. A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What

information will the nurse provide when educating this patient on alendronate (Fosamax)?

(Select all that apply.) a. Drink 8 oz. of water following dosage. b. Lay down for 30 minutes after taking. c. This medication has no known side effects. d. Avoid weight-bearing exercises.

ANS: A

Alendronate (Fosamax) may be prescribed. Esophageal and gastric irritation are common side effects of alendronate, and the woman should be instructed to drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating a meal. Weight-bearing exercises such as walking, hiking, stair climbing, and dancing are advisable. High-impact exercises should be avoided.

DIF: Cognitive Level: Comprehension REF: p. 285 OBJ: 2 | 8 TOP: Osteoporosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

Chapter 12: The Term Newborn Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. While inspecting a newborn‘s head, the nurse identifies a swelling of the scalp that does not

cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle ANS: C

A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.

DIF: Cognitive Level: Comprehension REF: p. 291 OBJ: 1 TOP: Newborn Assessment—Head KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What is the nurse‘s best response to a mother who is voicing concern about the molding of her

2-day-old infant? a. ―Molding doesn‘t cause any problems. Don‘t worry about it.‖ b. ―Did you deliver vaginally or by cesarean section?‖

c. ―The baby‘s head conformed to the shape of the birth canal. It will go away soon.‖ d. ―A traumatic delivery can cause molding.‖ ANS: C

The newborn‘s head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal.

DIF: Cognitive Level: Application REF: p. 291 OBJ: 1 TOP: Newborn Assessment—Head KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions ANS: D

Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.

DIF: Cognitive Level: Analysis REF: p. 298 OBJ: 3 TOP: Newborn Assessment—Respiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When the newborn‘s crib was moved suddenly, the nurse noticed that his legs flexed and arms

fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality ANS: A

The Moro reflex is a normal neonatal reflex. It is elicited when the infant‘s crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.

DIF: Cognitive Level: Analysis REF: p. 290 | Figure 12.3 OBJ: 2 TOP: Newborn Reflexes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn.

Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck ANS: B

The rooting reflex causes the infant‘s head to turn in the direction of anything that touches the cheek in anticipation of food.

DIF: Cognitive Level: Application REF: p. 308 OBJ: 2 TOP: Newborn Reflexes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term

newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped ANS: D

The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age.

DIF: Cognitive Level: Comprehension REF: p. 291 OBJ: 3 TOP: Newborn Assessment—Head KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What statement indicates the parent understands the guidelines for bathing a newborn? a. ―I‘ll use a mild soap to clean all of the body parts.‖ b. ―I am going to add bath oil to the water to keep the baby‘s skin soft.‖ c. ―I should shampoo the head after washing the rest of the body.‖ d. ―I‘ll wash from the feet upward and change the washcloth for the face.‖ ANS: C

The shampoo is done last, because the large surface area of the head predisposes the infant to heat loss.

DIF: Cognitive Level: Comprehension REF: pp. 305-306 |Skill 12.5 OBJ: 8 TOP: Home Care—Bathing the Infant KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse is measuring the vital signs of a calm, full-term newborn. Which finding is

abnormal? a. An axillary temperature of 36.6°C (98°F) b. An apical pulse rate of 178 beats/minute c. Respirations of 35 breaths/minute d. Blood pressure of 80/50 mm Hg ANS: B

The normal range for a newborn‘s pulse rate is 110 to 160 beats/minute. A pulse rate outside of this range should be reported.

DIF: Cognitive Level: Comprehension REF: p. 298 TOP: Newborn Assessment—Vital Signs KEY: Nursing Process Step: Data Collection

OBJ: 3

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool

color to be 2 days after birth? a. Yellow b. Brown c. Greenish brown d. Black and tarry ANS: A

The stool of a breastfed infant is bright yellow, soft, and pasty.

DIF: Cognitive Level: Application REF: p. 307 OBJ: 8 TOP: Newborn Assessment—Gastrointestinal System KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The mother of a 2-week-old infant tells the nurse, ―I think the baby is constipated. I‘ve

noticed she strains when she has a bowel movement.‖ What is nurse‘s most helpful response? a. ―Give the baby one serving of fruit per day.‖ b. ―Increase the amount and frequency of her feedings.‖ c. ―It sounds like the baby is uncomfortable because she is constipated.‖ d. ―Newborns might strain with bowel movements because their muscles aren‘t fully developed.‖ ANS: D

Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.

DIF: Cognitive Level: Application REF: p. 307 OBJ: 8 TOP: Newborn Assessment—Gastrointestinal System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to

weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800 ANS: C

In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

DIF: Cognitive Level: Analysis REF: p. 300 OBJ: 3 TOP: Newborn Assessment—Weight KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The parents of a newborn girl express concern about the infant‘s vaginal discharge, which

appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation of the ovarian hormones by the pituitary system b. Cessation of female sex hormones transferred in utero from mother to infant

c. The increased amount of circulating blood from the mother throughout pregnancy d. Trauma to the genitalia during the birth process ANS: B

Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.

DIF: Cognitive Level: Comprehension REF: p. 302 OBJ: 8 TOP: Newborn Assessment—Genitourinary KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much.

What is the most appropriate nursing response to this mother? a. ―Tell me how many hours per day your baby sleeps.‖ b. ―It is normal for newborns to sleep most of the day.‖ c. ―Newborns generally sleep 12 to 15 hours per day.‖ d. ―You will find as the baby gets older, he sleeps less.‖ ANS: A

Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by ―too much‖ before giving any information.

DIF: Cognitive Level: Application REF: p. 295 OBJ: 8 TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. Which statement indicates the parents understand when to contact the pediatrician or nurse

practitioner? a. Infant refuses a feeding. b. Infant has an axillary temperature of 97°F. c. Infant has three pasty, yellow-brown stools in 24 hours. d. Infant‘s diaper is not wet after 8 hours.

ANS: D

Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.

DIF: Cognitive Level: Comprehension REF: p. 300 OBJ: 8 TOP: Discharge Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A mother asks the nurse, ―Do you think my baby recognized my voice?‖ The nurse should

consider which correct information when responding? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mother‘s voice from other sounds in the first days of life.

ANS: D

The ability to discriminate between a mother‘s voice and other voices may occur as early as in the first 3 days of life.

DIF: Cognitive Level: Knowledge REF: p. 294 OBJ: 3 | 8 TOP: Newborn Assessment—Hearing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The nurse compared the birth weight of a 3-day-old with her current weight and determined

the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infant‘s feedings. d. Try feeding the infant a different type of formula.

ANS: A

It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

DIF: Cognitive Level: Application REF: p. 300 OBJ: 3 TOP: Newborn Assessment—Weight KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. Parents express concern about the milia on the face and nose of their infant. What is the

nurse‘s most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infant‘s face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed.

ANS: D

Milia require no treatment. This skin manifestation will disappear spontaneously.

DIF: Cognitive Level: Application REF: p. 302 OBJ: 5 TOP: Newborn Assessment—Skin KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse is going to use a bulb syringe to clear mucus from a newborn‘s nose and mouth.

What is the nurse‘s first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretions from the nose before the mouth. c. Depress the bulb before inserting the syringe tip into the mouth. d. Insert the tip into the back of the mouth to reach mucus.

ANS: C

The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

DIF: Cognitive Level: Application REF: p. 297| Skill 12.2 OBJ: 3 TOP: Newborn Assessment—Respiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. The mother of a 4-day-old calls the pediatrician‘s office because she is concerned about her

infant‘s skin. Which finding needs to be reported promptly to the child‘s pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infant‘s body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infant‘s skin has a yellowish tinge.

ANS: D

Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.

DIF: Cognitive Level: Analysis REF: p. 305 OBJ: 6 TOP: Newborn Assessment—Skin (Jaundice) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. What action does the nurse implement to protect newborns from infection while in the

nursery? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8°C (75°F) and 26.6°C (80°F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care.

ANS: C

Hand washing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.

DIF: Cognitive Level: Application REF: p. 309 OBJ: 7 TOP: Preventing Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. Which assessment of the newborn should be reported? a. Head circumference is 5 cm greater than the chest circumference. b. Hands and feet are warm with a blue color. c. Temperature is 36.6°C (97.8°F). d. Head has a longer than normal shape to it.

ANS: A

The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm.

DIF: Cognitive Level: Analysis REF: p. 291| Skill 12.1 OBJ: 3 TOP: Newborn Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does

the nurse explain this transitory skin discoloration is called? a. Epstein‘s pearls b. Milia c. Stork bites d. Mongolian spots

ANS: D

Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.

DIF: Cognitive Level: Comprehension REF: pp. 302-305| Table 12.2 OBJ: 5 TOP: Mongolian Spots KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The pediatric clinic nurse receives lab results on several newborn patients. Which of the

following should be brought to the physician‘s attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15 ANS: D

A bilirubin of 15 is elevated and requires further immediate investigation.

DIF: Cognitive Level: Analysis REF: p. 305 | Table 12.3 OBJ: 3 TOP: Labwork KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that

apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight ANS: A, B, C, D

The Apgar score is a standardized method of evaluating the newborn‘s condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes.

DIF: Cognitive Level: Application REF: p. 297 OBJ: 3 TOP: Apgar Score KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all

that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling ANS: A, B, C, E

Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.

DIF: Cognitive Level: Comprehension REF: p. 296 OBJ: 8 TOP: Noninvasive Pain Relief KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse reminds new parents that newborns must be protected from environments that are

too cold or too hot because of which aspects of the newborn‘s physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts ANS: A, C

Newborns have very little subcutaneous fat, which offers little insulation against cold.

Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

DIF: Cognitive Level: Comprehension REF: p. 298 OBJ: 4 TOP: Environmental Thermal Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which interventions would be included in the nursing care of the newly circumcised infant?

(Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage.

ANS: A, D

Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely.

DIF: Cognitive Level: Application REF: pp. 301-302 | Patient Teaching Box OBJ: 7 TOP: Circumcision Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Pincer grasping ANS: A, B, C, D

Blinking, sneezing, gagging, and sucking reflexes are present in the full-term newborn. Pincer grasp does not occur until between 8 and 12 months.

DIF: Cognitive Level: Knowledge REF: p. 290 OBJ: 2 TOP: Reflexes KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. The nurse takes into consideration that newborns are especially prone to dehydration because

of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine ANS: A, B, E

The newborn‘s glomeruli are small and have only one-third of the blood circulation of an adult, and they are unable to effectively concentrate urine. The GI tract is active. The infant‘s sweat glands do not work effectively and allow very little fluid loss through sweat.

DIF: Cognitive Level: Comprehension REF: p. 300 OBJ: 8 TOP: Dehydration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Growth and Development

Chapter 13: Preterm and Postterm Newborns Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is assessing a preterm infant. To what does the infant‘s level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infant‘s weight as compared to the gestational age d. Ability of the organs to function outside of the uterus ANS: D

Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.

DIF: Cognitive Level: Knowledge REF: p. 321 OBJ: 1 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this

infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure ANS: C

The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.

DIF: Cognitive Level: Comprehension REF: p. 328 OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage

during the first few days of life? a. Weak or absent sucking or swallowing reflex b. Inability to digest food properly c. Refusal to take formula by mouth d. Need for a larger quantity of formula at each feeding ANS: A

When the preterm infant‘s sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

DIF: Cognitive Level: Comprehension REF: p. 326 OBJ: 4 TOP: Preterm Infant—Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant ANS: D

The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.

DIF: Cognitive Level: Knowledge REF: p. 324 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting air into the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents. d. Check serum glucose level.

ANS: C

When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.

DIF: Cognitive Level: Application REF: p. 331 OBJ: 6 TOP: Preterm Infant—Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse explains to a patient in preterm labor that what may be ordered by the physician to

accelerate fetal lung maturity? a. Prostaglandins b. Oxytocin

c. Magnesium sulfate d. Corticosteroids ANS: D

Surfactant production can be increased by administering corticosteroids to the mother before delivery.

DIF: Cognitive Level: Comprehension REF: p. 324 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The apnea monitor indicates that a preterm infant is having an apneic episode. What is the

most appropriate nursing action in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infant‘s feet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning.

ANS: B

Gently rubbing the infant‘s back, ankles, or feet may stimulate the infant to breathe.

DIF: Cognitive Level: Application REF: p. 325 OBJ: 4 TOP: Preterm Infant—Apnea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. What would the nurse assess for in a preterm infant receiving an intravenous infusion

containing calcium gluconate? a. Seizures b. Bradycardia c. Dysrhythmias d. Tetany ANS: B

The infant receiving intravenous calcium gluconate should be monitored for bradycardia.

DIF: Cognitive Level: Application REF: p. 327 OBJ: 4 TOP: Hypocalcemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. What is the rationale for placing a preterm infant born at 34 weeks of gestation in an

incubator? a. The infant has a small body surface-to-weight ratio. b. Heat increases the flow of oxygen to the extremities. c. The infant‘s temperature control mechanism is immature. d. Heat within the incubator facilitates drainage of mucus.

ANS: C

The preterm infant is at risk for heat loss for several reasons, one of which is that the heat regulating center in the brain is immature.

DIF: Cognitive Level: Comprehension REF: p. 329 OBJ: 9 TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

10. What nursing action is appropriate to prevent possible retinopathy in a preterm infant

requiring oxygen therapy? a. Monitor arterial oxygen levels with a pulse oximeter. b. Position the head slightly lower than the body. c. Administer low concentrations of oxygen. d. Keep the infant‘s eyes covered at all times.

ANS: A

Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority in the neonatal intensive care unit (NICU).

DIF: Cognitive Level: Application REF: p. 327 OBJ: 4 TOP: Retinopathy of Prematurity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and

expiratory grunting. What do these findings indicate? a. Respiratory distress syndrome b. Postmaturity syndrome c. Apneic episode d. Cold stress ANS: A

Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.

DIF: Cognitive Level: Analysis REF: p. 324 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. What nursing action will the nurse implement for a preterm infant who is being gavage fed

and has a bloody stool? a. Assess for abdominal distention. b. Decrease the amount of the next feeding. c. Institute enteric precautions. d. Get a culture of the next stool.

ANS: A

Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.

DIF: Cognitive Level: Application REF: p. 328 OBJ: 4 TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. Parents of a preterm infant come to the NICU every day to see their infant, who is being

gavage fed. What will the nurse teaching about stimulating the infant tell the parents? a. To bring in colorful pictures and toys to place in the incubator b. That stimulating the infant during feedings increases intake c. To stroke the infant during feeding to increase intake

d. Not to disturb the infant between feedings ANS: C

During gavage feedings, stroking the infant gently can provide stimulation.

DIF: Cognitive Level: Application REF: p. 333 OBJ: 8 TOP: Family Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry.

The nurse is aware that these symptoms indicate what? a. Respiratory distress syndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure ANS: B

The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infant‘s glycogen stores are not adequate.

DIF: Cognitive Level: Analysis REF: p. 327 |Nursing Tip OBJ: 4 TOP: Postterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will

always be small for her age. What is the most appropriate nursing response? a. ―Preterm infants usually remain smaller than term infants throughout childhood.‖ b. ―Your daughter will be the same size as other children by the time she is 1 year old.‖ c. ―Prematurity is associated with short stature but does not affect weight gain.‖ d. ―It takes about two years for the preterm infant to catch up to a full-term infant.‖ ANS: D

In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the second year.

DIF: Cognitive Level: Application REF: p. 333 OBJ: 8 TOP: Preterm Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The nurse caring for a preterm infant will record the intake and output. The nurse is aware that

what is the optimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr ANS: A

The optimum output for a preterm infant is 1 to 3 mL/kg/hr.

DIF: Cognitive Level: Comprehension TOP: Immature Kidneys

REF: p. 328 OBJ: 4 KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic

might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin ANS: D

The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.

DIF: Cognitive Level: Comprehension REF: p. 322 OBJ: 2 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse in a pediatrician‘s office is preparing to do a developmental assessment on a

3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth? a. 1st b. 2nd c. 3rd d. 4th ANS: B

The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.

DIF: Cognitive Level: Analysis REF: p. 333 OBJ: 2 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. The mother of a postterm infant asks the nurse why the infant is being watched so closely.

What is the nurse‘s most appropriate response? a. ―The placenta does not function adequately as it ages.‖ b. ―Infants born postmaturely are generally large.‖ c. ―Delivery of the postterm infant is more difficult.‖ d. ―There is less amniotic fluid.‖ ANS: A

Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with maturity.

DIF: Cognitive Level: Comprehension REF: p. 334 OBJ: 9 TOP: Postterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. What symptoms of cold stress might the nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature

d. Increased respiratory rate and periods of apnea ANS: D

Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.

DIF: Cognitive Level: Comprehension REF: p. 326 | Nursing Tip OBJ: 5 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse is caring for an infant born at 42 weeks. What would the physical assessment

reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body ANS: A

Loss of vernix caseosa leaves the skin dry, causing peeling.

DIF: Cognitive Level: Comprehension REF: p. 334 OBJ: 9 TOP: Postterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. What term describes the age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age ANS: B

The gestational age is the age based on the actual time in the uterus.

DIF: Cognitive Level: Knowledge REF: p. 321 OBJ: 1 TOP: Gestational Age KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Growth and Development 23. How often will the nurse caring for a preterm infant in an incubator record the temperature of

the infant and the incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours ANS: B

The temperature of the incubator is adjusted to a level that will maintain an optimal body temperature in the infant. Smaller infants may require higher incubator temperatures. The nurse records the temperature of the infant and the incubator every 2 hours. The infant‘s temperature is monitored with a heat-sensitive probe that is taped to the abdomen.

DIF: Cognitive Level: Comprehension TOP: Thermoregulation

REF: p. 329 OBJ: 5 KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk 24. Why is the postterm neonate at risk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fat stores have been used in utero for nourishment ANS: D

Fat stores have been used in utero for nourishment during the extended pregnancy.

DIF: Cognitive Level: Comprehension REF: p. 334 OBJ: 9 TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8

pounds, 10 ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. Late preterm ANS: C

Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks.

DIF: Cognitive Level: Analysis REF: p. 321 OBJ: 2 TOP: Gestational Age KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory

distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. At least 1 month ANS: B

In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours.

DIF: Cognitive Level: Comprehension REF: p. 324 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse knows that a postterm infant may experience which potential problems? (Select all

that apply.)

a. b. c. d. e.

Seizures Asphyxia Paralysis Visual defects Polycythemia

ANS: A, B, E

The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.

DIF: Cognitive Level: Comprehension REF: p. 334 OBJ: 9 TOP: Potential Problems of the Postterm Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that

what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma ANS: A, B, C

The predisposing causes of preterm birth are numerous; in many instances, the cause is unknown. Prematurity may be caused by multiple births, illness of the mother (e.g., malnutrition, heart disease, diabetes mellitus, or infectious conditions), or the hazards of pregnancy itself, such as gestational hypertension, placental abnormalities that may result in premature rupture of the membranes, placenta previa (in which the placenta lies over the cervix instead of higher in the uterus), and premature separation of the placenta. Studies also indicate the relationships between prematurity and poverty, smoking, alcohol consumption, and abuse of cocaine and other drugs. Hyperemesis gravidarum and chloasma are not risk factors for preterm birth.

DIF: Cognitive Level: Comprehension REF: p. 321 OBJ: 3 TOP: Preterm Birth KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 3. The nurse assesses a preterm infant in the NICU. What signs should be reported to the

physician? (Select all that apply.) a. Paleness b. Transparent skin c. Superficial scalp veins d. Vomiting e. Bulging fontanelles ANS: A, D, E

Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent skin and superficial scalp veins are expected findings.

DIF: Cognitive Level: Application REF: p. 332 |Table 13.1 OBJ: 4 TOP: Potential Problems of the Preterm Infant

KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of _____

weeks.

ANS:

34 Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.

DIF: Cognitive Level: Knowledge REF: p. 324 OBJ: 4 TOP: Surfactant KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 14: The Newborn with a Perinatal Injury or Congenital Malformation Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What occurrence results from obstruction within the ventricles of the brain or inadequate

reabsorption of cerebrospinal fluid? a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus ANS: D

Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.

DIF: Cognitive Level: Knowledge REF: p. 338 OBJ: 1 | 2 | 4 TOP: Hydrocephalus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is caring for an infant with hydrocephalus. What nursing action is most important

for this nurse to implement? a. Align the limbs. b. Support the head. c. Keep the head lower than the hip. d. Check intake and output.

ANS: B

The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the child to prevent injury to the neck.

DIF: Cognitive Level: Application TOP: Hydrocephalus

REF: p. 340 OBJ: 5 KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse observes that the infant‘s anterior fontanelle is bulging after placement of a

ventriculoperitoneal shunt. How should the nurse position this infant? a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In a semi-Fowler‘s position ANS: D

If the fontanelles are bulging, the child will be positioned in a semi-Fowler‘s position to promote drainage from the ventricles through the shunt.

DIF: Cognitive Level: Application REF: p. 340 OBJ: 5 TOP: Hydrocephalus KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. What nursing action will the nurse implement after feeding an infant with hydrocephalus? a. Position the infant sitting upright in an infant seat. b. Place the infant over the shoulder to burp. c. Leave the infant in a side-lying position. d. Stimulate the infant by rubbing its feet.

ANS: C

Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-lying position in a quiet atmosphere to reduce the incidence of vomiting.

DIF: Cognitive Level: Application REF: p. 340 OBJ: 5 TOP: Feeding a Hydrocephalic Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele.

What is the priority preoperative nursing care of this newborn? a. Keep the sac dry. b. Diaper snugly. c. Position prone in an incubator. d. Move from side to side every hour.

ANS: C

The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The infant‘s hips are kept lower than the lesion, and the infant is usually not in diapers.

DIF: Cognitive Level: Analysis REF: p. 342 OBJ: 7 TOP: Myelodysplasia and Spina Bifida KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for

hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response? a. Elevate the child‘s head.

b. Check bowel sounds. c. Record retention of feeding. d. Notify the charge nurse of possible malabsorption.

ANS: D

An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum.

DIF: Cognitive Level: Application REF: p. 340 OBJ: 5 TOP: VP Shunt KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. The nurse is providing education to parents of a child with cleft palate. What will the nurse

instruct the parents to report immediately? a. Facial paralysis b. Ear infections c. Increased intracranial pressure (ICP) d. Drooling ANS: B

Children with cleft palate are at risk of ear infections and dental disorders. Parents should be instructed to take the child to the health care provider at the first sign of earache.

DIF: Cognitive Level: Application REF: p. 344 OBJ: 8 TOP: Complication of Cleft Palate KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. Postoperative nursing care of the infant following surgical repair of a cleft lip would include: a. Feeding the infant with a spoon to avoid sucking b. Positioning the infant on the abdomen to facilitate drainage c. Applying elbow restraints to protect the surgical area d. Providing minimal stimulation to prevent injury to the incision ANS: C

Elbow restraints are used postoperatively to prevent the infant from damaging the operative area.

DIF: Cognitive Level: Application REF: p. 344 OBJ: 8 TOP: Cleft Lip and Palate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. Which statement indicates that parents understand how to feed their infant who had a surgical

repair for a cleft lip? a. ―We are feeding the baby with a dropper for 2 weeks.‖ b. ―We resumed bottle feeding after discharge.‖ c. ―We started the baby on solid food yesterday.‖ d. ―The baby is drinking well from a straw.‖ ANS: A

The infant is fed with a dropper until the incision is completely healed about 1 to 2 weeks after surgery.

DIF: Cognitive Level: Application REF: p. 344 OBJ: 8 TOP: Cleft Lip and Palate KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. An 18-month-old child had a surgical repair of a cleft palate and is now allowed to eat a

regular diet. What nursing action is the most appropriate? a. Feed solid foods with the spoon at the side of the mouth. b. Puree foods and offer them through a straw. c. Place small bites of food in the mouth with a tongue blade. d. Offer small, frequent meals of finger foods.

ANS: A

The primary concern with feeding is to protect the operative site. The child can be fed with a spoon, but only the side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of the mouth.

DIF: Cognitive Level: Application REF: p. 345 OBJ: 8 TOP: Cleft Lip and Palate KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. When bathing an infant, what sign does the nurse recognize as a sign of developmental hip

dysplasia? a. Hypotonicity of the leg muscles b. One leg is shorter than the other c. Broadening and flattening of the buttocks d. Two skinfolds on the back of each thigh ANS: B

When developmental hip dysplasia is present, the leg on the affected side will appear shorter than the leg on the unaffected side.

DIF: Cognitive Level: Comprehension REF: pp. 346-347 |Figure 14.9 OBJ: 9 TOP: Developmental Hip Dysplasia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse knows that

what is the usual treatment for an infant with this diagnosis? a. A Pavlik harness b. A body spica cast c. Traction d. Triple-diapering ANS: A

In infants who are more than 2 months of age, longer-term immobilization with a Pavlik harness is required.

DIF: Cognitive Level: Comprehension REF: p. 347 | Figure 14.10 OBJ: 9 TOP: Developmental Hip Dysplasia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. After delivery, a mother asks the nurse about newborn screening tests. The nurse explains that

what is the optimal time for testing for phenylketonuria? a. In the first 24 hours of life b. After 2 to 3 days c. At 4 to 6 weeks of age d. At 2 months of age ANS: B

Blood tests for phenylketonuria should be obtained 48 to 72 hours after birth. The newborn will have had enough time to ingest protein through feedings, and the chance of false-negative results will be reduced.

DIF: Cognitive Level: Comprehension REF: p. 350 OBJ: 10 TOP: PKU KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse is advising parents about feeding their infant with phenylketonuria. What formula

and/or diet should the nurse suggest? a. Lifelong high-protein diet b. A formula that is low in the amino acid leucine c. A soy-based formula d. Substitute Lofenalac for some protein foods ANS: D

A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted for natural protein foods.

DIF: Cognitive Level: Comprehension REF: p. 350 OBJ: 10 TOP: PKU KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 15. Parents of a 2-month-old infant with Down syndrome are attending a well visit at the pediatric

clinic. What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child? a. Preventing hyperthermia b. Respiratory care c. Prevention of diarrhea d. Incontinence care ANS: B

The child with Down syndrome has generalized hypotonicity, which caused mucus accumulation and respiratory problems.

DIF: Cognitive Level: Application REF: p. 353 OBJ: 11 TOP: Down Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. What would the nurse include when instructing parents about positioning their toddler who

has just had a body spica cast applied? a. Prop the child upright with pillows for meals. b. Use the bar between the legs to turn the child. c. Put the child on her abdomen to sleep.

d. Change the child‘s position frequently.

ANS: D

The child‘s position must be changed frequently to relieve pressure and promote circulation.

DIF: Cognitive Level: Application TOP: Developmental Hip Dysplasia MSC: NCLEX: Physiological Integrity

REF: p. 348 OBJ: 9 KEY: Nursing Process Step: Implementation

17. The nurse is caring for an Rh-negative mother on the labor and birth unit. What scenario

indicates this patient will require RhoGAM administration? a. She has had one Rh-negative child and is pregnant with an Rh-negative child. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative child. d. She is a primipara with an O-negative child.

ANS: B

The only woman with antibodies against the Rh-positive infant is the Rh-negative woman who has had one Rh-positive child and is now pregnant with another.

DIF: Cognitive Level: Analysis REF: p. 354 OBJ: 12 TOP: Rh Concerns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurse‘s

best response? a. ―The light increases the infant‘s metabolism.‖ b. ―The light stimulates liver function.‖ c. ―The light dilates blood vessels.‖ d. ―The light breaks down bilirubin.‖ ANS: D

Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted.

DIF: Cognitive Level: Application REF: p. 355 OBJ: 14 TOP: Hemolytic Disease of the Newborn KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired.

The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time? a. Immediately after birth b. By 3 months of age c. After 12 months of age d. Varies in every case ANS: B

A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.

DIF: Cognitive Level: Comprehension REF: p. 343 OBJ: 8 TOP: Cleft Lip KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. Phototherapy is instituted for an infant. What is the most appropriate nursing action for the

infant having phototherapy? a. Cover the infant‘s head with a hat. b. Dress the infant lightly in a T-shirt. c. Keep the infant‘s eyes covered. d. Reposition the infant at least every 4 to 8 hours.

ANS: C

The infant‘s eyes are protected with patches to prevent damage from the high-intensity lights.

DIF: Cognitive Level: Application REF: p. 357 |NCP 14.2 OBJ: 13 TOP: Phototherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the

nurse assess for with this neonate? a. Hypoglycemia b. Erythroblastosis fetalis c. Intracranial hemorrhage d. Pancreatic failure ANS: A

The newborn of a mother with diabetes is prone to hypoglycemia.

DIF: Cognitive Level: Application REF: p. 360 OBJ: 15 TOP: Infant of a Diabetic Mother KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 22. What assessment made by the nurse would lead the nurse to suspect hip dysplasia? a. Asymmetrical gluteal folds b. Limited adduction of the affected side c. Foot turned inward d. Deep inguinal creases ANS: A

The gluteal folds are asymmetrical because the head of the femur has slipped out of the acetabulum. There is also limited abduction of the affected side, and when the legs are flexed the affected leg seems to be shorter.

DIF: Cognitive Level: Comprehension REF: p. 346 OBJ: 9 TOP: Hip Dysplasia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 23. The nurse is providing care to a child with Down syndrome. What body system has the

highest risk of congenital anomaly in a child with Down syndrome? a. Reproductive system

b. Genitourinary system c. Cardiovascular system d. Gastrointestinal system ANS: C

Down syndrome children are prone to deformities of the cardiovascular system.

DIF: Cognitive Level: Knowledge REF: p. 352 OBJ: 11 TOP: Down Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder.

What is the most appropriate response? a. ―Cystic fibrosis is a chromosomal defect.‖ b. ―Cystic fibrosis is a metabolic defect.‖ c. ―Cystic fibrosis is a malformation present at birth.‖ d. ―Cystic fibrosis is a blood disorder.‖ ANS: B

Inborn errors of metabolism include a number of inherited diseases that affect body chemistry.

There may be an absence or a deficiency of a substance necessary for cell metabolism. The deficient substance is usually an enzyme. Almost any organ of the body may be damaged.

Examples of inborn errors of metabolism include cystic fibrosis and phenylketonuria (PKU).

In disorders of the blood, there is a reduced or missing blood component or an inability of a component to function adequately. Sickle cell disease, thalassemia, and hemophilia fall into this category. Chromosomal abnormalities number in the thousands. Most involve some type of mental retardation, and others are incompatible with life. The newborn with Turner‘s syndrome or Klinefelter‘s syndrome may have impaired physical growth and sexual development. Malformations at birth include several types of structural defects.

DIF: Cognitive Level: Knowledge REF: p. 337 | Box 14.1 OBJ: 3 TOP: Classification of Birth Defects KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. What characteristics are typical in a child diagnosed with Down syndrome? (Select all that

apply.) a. Close-set eyes b. Simian creases c. Wide-spaced front teeth d. Protruding tongue e. Curved, small fingers ANS: A, B, D, E

Children with Down syndrome have close-set upturned eyes, simian creases in palms of hands, protruding tongue, and curved, small fingers. They also have a wide space between their first and second toe and a high incidence of heart defects.

DIF: Cognitive Level: Knowledge

REF: p. 351 | Figure 14.12

OBJ: 11 TOP: Features of Down Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What will the nurse include in the plan of care when caring for an infant with an intracranial

hemorrhage? (Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often to maintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe for increased intracranial pressure.

ANS: A, B, E

These children should be kept positioned with the head elevated, fed slowly, and monitored for increased intracranial pressure. Children with intracranial hemorrhages are not stimulated and are kept in a quiet environment.

DIF: Cognitive Level: Comprehension REF: p. 359 OBJ: 2 TOP: Intracranial Hemorrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. What would be included in the plan of care for a child just returned to the floor from surgery

in which a clubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying. b. Check toes for capillary refill. c. Circle with a pen any area of bleeding on the cast. d. Keep casted leg lowered. e. Observe for skin irritation.

ANS: A, B, C, E

The casted leg should be kept elevated. All the other options are necessary nursing interventions for a child who is freshly casted.

DIF: Cognitive Level: Comprehension REF: pp. 345-346 OBJ: 2 TOP: Repair of Clubfoot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the

newborn of a mother who took opioids during pregnancy. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite ANS: A, B, C

The neonate with abstinence syndrome will have tremors, be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite.

DIF: Cognitive Level: Knowledge TOP: Neonatal Abstinence

REF: p. 360 OBJ: 2 KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Physiological Integrity: Reduction of Risk 5. What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware

of? (Select all that apply.) a. High-pitched cry b. Unequal pupils c. Bulging fontanelles d. Diarrhea e. Hiccups ANS: A, B, C

Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles.

DIF: Cognitive Level: Knowledge REF: p. 340 | Nursing Tip OBJ: 4 TOP: Signs of ICP KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse is obtaining intake information on a new patient being seen for preconception care

and notes a family history of neural tube defects. What interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid drug use. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the first trimester.

ANS: A, C

The use of drugs during early pregnancy and poor nutrition may contribute to the development of a neural tube defect. The American Academy of Pediatrics (AAP) recommends that all women of childbearing age take a daily multivitamin that contains 0.4 mg of folic acid and continue the intake of folic acid until the 12th week of pregnancy, when basic neural tube development is completed. Studies have shown that the intake of folic acid before conception dramatically decreases the occurrence of neural tube defects such as spina bifida. Daily exercise and bed rest do not decrease the risk of neural tube anomalies.

DIF: Cognitive Level: Comprehension REF: p. 341 OBJ: 6 TOP: Prevention of Neural Tube Defects KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 7. The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational

diabetes immediately after birth. What assessment findings can the nurse anticipate? (Select all that apply.) a. High blood glucose levels b. Weight of 9 pounds or more c. Decreased subcutaneous fat d. Hypocalcemia e. Hyperbilirubinemia ANS: B, D, E

Many newborn infants of diabetic mothers have serious complications. When the mother is hyperglycemic, large amounts of glucose are transferred to the fetus. After delivery the infant often has low blood glucose levels because of the abrupt loss of maternal glucose and hypertrophy of the pancreatic islet cells, which results in a temporary overproduction of insulin. Hyperinsulinism, along with excess production of protein and fatty acids, often results in a newborn infant who weighs more than 4082 g (9 lb). These infants suffer from hypoglycemia, hypocalcemia, and hyperbilirubinemia.

DIF: Cognitive Level: Comprehension REF: p. 360 OBJ: 15 TOP: Macrosomic Newborn KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 8. The home health nurse is educating parents on home phototherapy. What will the nurse

include when providing information to these parents? (Select all that apply.) a. b. c. d. e.

Cover the infant‘s eyes when under the light.

Use a three-prong plug.

Keep a diaper in place.

Place the light source on an absorbent surface.

Expose as much skin as possible.

ANS: B, C, E

Parents should be instructed to use a three-prong plug for safety, keep a diaper in place, and expose as much skin as possible. The light source should be placed on a nonabsorbent surface, not on carpet or in a crib. It is not necessary to cover the infant‘s eyes when under the light.

DIF: Cognitive Level: Application REF: p. 360 | Box 14.4 OBJ: 14 TOP: Home Phototherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention

Chapter 15: An Overview of Growth, Development, and Nutrition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What type of development is the nurse assessing when an infant can lift his or her head before

he or she can sit? a. Specific to general b. Proximodistal c. Cephalocaudal d. General to specific ANS: C

Cephalocaudal development proceeds from head to toe.

DIF: Cognitive Level: Comprehension REF: p. 365 OBJ: 1 TOP: Cephalocaudal Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What is a unique organization of characteristics that determines an individual‘s pattern of

behavior?

a. b. c. d.

Environment Heredity Personality Experience

ANS: C

One definition of personality states that it is a unique organization of characteristics that determines the individual‘s typical or recurrent pattern of behavior.

DIF: Cognitive Level: Knowledge REF: p. 374 OBJ: 1 TOP: Personality Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. An infant‘s birth weight is 7 pounds, 8 ounces. What can the nurse project the weight to be at

6 months? a. 12 pounds b. 15 pounds c. 18 pounds d. 22 pounds ANS: B

An infant usually doubles his or her birth weight by 5 to 6 months.

DIF: Cognitive Level: Analysis REF: p. 366 OBJ: 4 TOP: Weight Prediction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What would the nurse further investigate when assessing patterns of growth in a child? a. Previous weight was in the 75th percentile, and present weight is in the 25th

percentile. b. Height is in the 90th percentile, and weight is in the 75th percentile. c. Last weight was in the 5th percentile, and present weight is in the 10th percentile. d. Weight is in the 50th percentile, and sibling‘s weight at the same age was in the

75th percentile.

ANS: A

The child showing a difference of two or more percentile levels from an established growth pattern should undergo further evaluation.

DIF: Cognitive Level: Analysis REF: p. 369 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A mother reports that she and her husband have had one child together, but both have children

from previous marriages living in their home. The nurse will base the care planning on what type of family? a. Nuclear b. Blended c. Alternate d. Extended ANS: B

A blended family involves the remarriage of persons with children.

DIF: Cognitive Level: Comprehension REF: p. 372 | Table 15.1 OBJ: 6 | 7 TOP: The Family KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The mother of a 7-month-old infant reports that the first lower central incisor has erupted. She

asks the nurse, ―How many teeth will he have by his first birthday?‖ The nurse explains that the infant will have how many teeth by 1 year of age? a. 2 b. 4 c. 6 d. 8 ANS: C

The 1-year-old infant usually has about 6 teeth, 4 above and 2 below.

DIF: Cognitive Level: Knowledge REF: p. 388 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. At a well-baby visit, parents of a 6-month-old infant ask when to take the infant for the first

dental visit. What is the nurse‘s best response? a. ―If the teeth are brushed regularly, the child should see a dentist by 3 years of age.‖ b. ―The first dental visit should be arranged after the first tooth erupts.‖ c. ―The child should have a dental examination when all deciduous teeth have erupted.‖ d. ―A dental visit by 1 year of age is recommended by the American Academy of Pediatric Dentistry.‖ ANS: D

The Academy of Pediatric Dentistry recommends that the first dental visit occur by 1 year of age.

DIF: Cognitive Level: Application REF: p. 388 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse is planning anticipatory guidance for a caregiver of a preschool-age child. The

nurse will explain that permanent teeth begin erupting at what age? a. 4 years old b. 6 years old c. 8 years old d. 10 years old ANS: B

Permanent teeth do not erupt through the gums until the sixth year.

DIF: Cognitive Level: Knowledge REF: p. 389 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

9. A mother asks the nurse how much food should be offered to her 2-year-old child. What is a

good rule of thumb for serving size (in tablespoons) per year of age? a. 2 b. 3 c. 4 d. 5 ANS: A

The rule of thumb for serving sizes is to offer 1 tablespoon of each food group per year of age.

DIF: Cognitive Level: Comprehension REF: p. 387 OBJ: 9 TOP: Rule of Thumb for Serving Sizes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. An assessment of a child‘s nutritional status reveals the child is alert, with shiny hair, firm

gums, firm mucous membranes, and regular elimination. How would this child‘s nutritional status be described? a. Overnourished b. Undernourished c. Well nourished d. Borderline ANS: C

Well-nourished children show steady gains in height and weight and have shiny hair, firm gums and mucous membranes, and regular elimination.

DIF: Cognitive Level: Analysis REF: p. 385 OBJ: 9 TOP: Nutrition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse encourages a Puerto Rican family to bring food to a child because he is not eating

the food served on his hospital tray. What can the nurse expect the child to eat? a. Dried beans mixed with rice b. Crisp vegetables c. Spaghetti and meatballs d. Wild berries, roots, and seeds ANS: A

A common food choice of Americans of Puerto Rican descent is dried beans mixed with rice.

DIF: Cognitive Level: Comprehension REF: p. 383 | Table 15.6 OBJ: 7 TOP: Feeding the Ill Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. The nurse observes that a 2-year-old toddler is able to use a spoon steadily at mealtime. What

does self-feeding help to develop in the toddler? a. Good nutrition b. A sense of independence c. Adequate height and weight d. Healthy teeth

ANS: B

By the end of the second year, toddlers can feed themselves. This helps them to develop a sense of independence.

DIF: Cognitive Level: Comprehension REF: p. 384 OBJ: 2 TOP: Feeding the Healthy Child KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. What activity would the nurse choose to meet Erikson‘s developmental task of industry when

caring for a 7-year-old child? a. Completing a 50-piece jigsaw puzzle b. Looking at a comic book c. Playing a game of ―I Spy‖ with the nurse d. Coloring a picture in a coloring book ANS: A

In the developmental period of late childhood, children are striving to develop a sense of industry. The completion of a jigsaw puzzle is industrious play.

DIF: Cognitive Level: Analysis REF: p. 374 | Table 15.4 OBJ: 11 TOP: Personality Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. What does the nurse recognize as an example of Piaget‘s concrete operational thinking? a. A 2-year-old child says, ―It‘s nighttime‖ when his room is darkened. b. A 4-year-old child refers to the hospital as ―my house.‖ c. A 5-year-old child coloring a picture of a puppy says, ―This is my puppy.‖ d. A 7-year-old child says, ―I am sick because I have germs in my chest.‖ ANS: D

The 7-year-old child‘s remark reflecting the cause and effect of germs and illness is an example of operational thinking. All other options are examples of preoperational thought, which is egocentric and symbolic.

DIF: Cognitive Level: Analysis REF: p. 374 | Table 15.3 OBJ: 8 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse has discussed with a mother the process of introducing solid foods to her

6-month-old infant. What statement by the mother leads the nurse to determine that learning has taken place? a. ―I will give my infant rice cereal first.‖ b. ―I will give my infant yellow vegetables first.‖ c. ―I will give my infant egg yolks first.‖ d. ―I will give my infant fruits first.‖ ANS: A

Solid foods are usually introduced at about 6 months of age, starting with rice cereal, which is the least allergenic.

DIF: Cognitive Level: Comprehension REF: p. 383 | Table 15.6 OBJ: 9 TOP: Feeding the Healthy Child KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. What is the best nursing action when an 8-year-old child comes to the school nurse with his

central incisor in his hand and reports he knocked his tooth out on the water fountain? a. Give him an ice cube to suck on. b. Have him wash his mouth out with peroxide and water. c. Wrap the tooth in a clean tissue. d. Wash off the tooth and place it in a container of milk.

ANS: D

The tooth should be washed off and put in a container of milk to preserve it for possible reimplantation.

DIF: Cognitive Level: Application REF: p. 390 OBJ: 10 TOP: Loss of Tooth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 17. The mother of a 7-month-old infant states, ―The baby is eating food now. Should I give him

regular milk, too?‖ What is the nurse‘s best response? a. ―You should give the baby low-fat milk.‖ b. ―Try the milk. See if he has any digestive problems.‖ c. ―Continue breast milk or iron-fortified formula until 1 year of age.‖ d. ―At this age, infants can tolerate lactose-free or soy-based milk.‖ ANS: C

Whole milk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2 years of age.

DIF: Cognitive Level: Application REF: p. 380 OBJ: 9 TOP: Nutrition and Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. When a small group of preschool-age children were playing house, each child was pretending

to be a particular family member. What type of play does the nurse recognize these children are participating in? a. Parallel b. Cooperative c. Symbolic d. Fantasy ANS: B

In cooperative play, children play with each other, each taking a specific role.

DIF: Cognitive Level: Analysis REF: p. 391| Table 15.8 OBJ: 11 TOP: Play KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. When the nurse asks a 10-year-old Native American if he is ready to go to therapy, he does

not answer immediately. How does the nurse interpret this response?

a. b. c. d.

Indecision Considering the answer in silence Shyness with strangers Fear of medical personnel

ANS: B

Native Americans value silence. They need to sit and consider matters before replying to questions.

DIF: Cognitive Level: Analysis REF: p. 370 | Table 15.2 OBJ: 7 TOP: Ethnic Considerations—American Indian KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. A mother tells the nurse, ―My 11-month-old son is not as active as my other children were at

this age. He is the youngest of four and the older children love to dote on him.‖ Which factor is influencing this child‘s language development? a. Heredity b. Sex c. Mother‘s health during pregnancy d. Ordinal position ANS: D

Motor development of the youngest child may be prolonged if the child is babied by others in the family.

DIF: Cognitive Level: Analysis REF: p. 369 OBJ: 5 TOP: Factors Influencing Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. A mother tells her 4-year-old child that balls should be played with outside and not inside the

house. Why is the child likely to obey the rule? a. The child does not want to be punished. b. The child wants to please her mother. c. The child respects authority figures. d. The child believes that following the rules is right.

ANS: A

According to Kohlberg, children in the preconventional stage (4 to 7 years) are obedient to their parents for fear of punishment.

DIF: Cognitive Level: Comprehension REF: p. 374 | Table 15.3 OBJ: 8 TOP: Moral Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. What should the nurse avoid when demonstrating a bath procedure to parents of Vietnamese

origin? a. Talking directly to the mother b. Exposing the child‘s genitals c. Touching the child‘s head d. Using cool water

ANS: C

The Vietnamese are very sensitive about anyone touching a child‘s head because that is where consciousness lies.

DIF: Cognitive Level: Application REF: p. 367 | Table 15.2 OBJ: 7 TOP: Ethnic Considerations—Vietnamese KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 23. What does the nurse calculate the basal metabolic index (BMI) of an 8-year-old child who is

48 inches tall (1.2 meters) and weighs 100 pounds (45.4 kg) to be? a. 28.9 b. 32.4 c. 34.8 d. 37.6 ANS: B

The formula for BMI calculation is weight in kg divided by height in meters (squared): 45.4 (weight in kg) divided by 1.4 (1.2 squared) = 32.4. A BMI of over 30 is classified as obese.

DIF: Cognitive Level: Analysis REF: p. 385 | Skill 15.2 OBJ: 9 TOP: Calculation of BMI KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. What toy is developmentally appropriate for the nurse to suggest to entertain a 5-year-old

child? a. Jack-in-the-box b. Book of nursery rhymes c. Model airport with toy planes d. Model car construction kit ANS: C

At this age children are into creative play. The model airport with toy planes is the most developmentally appropriate.

DIF: Cognitive Level: Application REF: p. 391 | Table 15.8 OBJ: 11 TOP: Play Activities KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. The nurse caring for a 4-year-old postoperative patient instructs him to blow bubbles. What

nursing intervention is the nurse most likely implementing by using this form of therapeutic play? a. Providing pain relief b. Encouraging deep breathing c. Decreasing risk of infection d. Maintaining body temperature ANS: B

Play can also be therapeutic and aid in the recovery process. An example of therapeutic play is the game of having the child blow bubbles to promote deep breathing.

DIF: Cognitive Level: Application REF: p. 391 | Table 15.8 OBJ: 14 TOP: Therapeutic Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 26. The mother of a 7-year-old pediatric patient asks the nurse about her child‘s sleep

requirement. What is the most accurate response by the nurse? a. ―7 to 10 hours a night‖ b. ―5 to 7 hours a night with one daytime nap‖ c. ―11 to 13 hours a night‖ d. ―4 to 6 hours a night with two daytime naps‖ ANS: C

Sleep patterns vary with age. The neonate sleeps 8 to 9 hours per night and naps an equal amount of time during the day. The 2-year-old child may sleep 10 hours during the night and have only one short daytime nap. The 7-year-old child usually requires 11 to 13 hours of sleep and rarely has a daytime nap. These patterns may be altered by cultural practices.

DIF: Cognitive Level: Comprehension REF: p. 368 OBJ: 5 TOP: Sleep KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention MULTIPLE RESPONSE 1. How do children differ from adults? (Select all that apply.) a. Higher metabolic rate b. Greater surface area in relation to their weight c. Less mature organ systems d. More fluid reserves e. Continuously changing growth and development pattern ANS: A, B, C, E

Children are in a continuous growth and development pattern. Children have a greater surface area and a higher metabolic rate. All of their organ systems are not mature.

DIF: Cognitive Level: Comprehension REF: p. 363 OBJ: 3 TOP: Adult Versus Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What approaches should the nurse suggest for introducing a toddler to new foods? (Select all

that apply.) a. Serve one food at a time. b. Avoid showing personal likes or dislikes. c. Offer foods in small amounts, less than a teaspoon. d. Entice the toddler to eat with sweets. e. Serve food warm.

ANS: A, B, C, E

Foods should be introduced in small, warm servings, one food at a time. Sweets and milk should not be offered until after solid food.

DIF: Cognitive Level: Comprehension REF: pp. 384-385 OBJ: 9 TOP: Solid Food KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. Which healthy snack foods would the school nurse suggest to a group of adolescents? (Select

all that apply.) a. Bubble gum b. Chocolate-covered peanuts c. Raw vegetables d. Cheese e. Dried fruits ANS: C, D

Cheese and raw vegetables are acceptable healthy snacks. Bubble gum, chocolate-covered peanuts, and dried fruits all contain high amounts of sugar.

DIF: Cognitive Level: Comprehension REF: p. 378 OBJ: 9 TOP: Healthy Snacks KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse suggests to the parents of an obese 10-year-old child that they use the Portion Plate

for Kids place mat. How does this tool help with selection of portion sizes? (Select all that apply.) a. Cartoon characters eating healthy foods b. Tips on healthy food choices c. Portion measurement in tablespoons for common food d. Calorie values for cup-size portions of common foods e. Familiar objects such as a deck of cards to measure servings ANS: B, E

The Portion Plate for Kids is a place mat that uses common objects such as a deck of playing cards or a baseball to measure serving portions.

DIF: Cognitive Level: Comprehension REF: p. 378 OBJ: 9 TOP: Portion Plate for Kids KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. An educational program is being presented to pediatric nurses on the relationship of play to

childhood development. What information should be included in this presentation? (Select all that apply.) a. Art play should be used sparingly. b. Use of computer/video games is detrimental. c. Understanding of child–parent relationships can be gained by observing play. d. Play encourages self-expression. e. Play provides a sense of accomplishment.

ANS: C, D, E

Art is an appropriate play activity at almost any age and provides an avenue for experimentation as well as for creative expression and a feeling of accomplishment in the child. Observing the child at play can aid in assessing growth and development and understanding the child‘s relationships with family members. Any plan of care for a hospitalized child of any age should include a play activity that either encourages growth and development or encourages the expression of thoughts and feelings. Computer programs are popular with all age groups, providing problem-solving skills, manipulative skills, and opportunities for new learning.

DIF: Cognitive Level: Comprehension REF: p. 391 OBJ: 11 | 13 | 15 TOP: Play KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. Parents attending a well visit for their 11-year-old son verbalize concern over his computer

use. When asked about it, the boy states, ―I play games on my computer for 1 hour a day.‖ The nurse knows that computer games can provide what opportunities to childhood development? (Select all that apply.) a. Problem-solving skills b. Gross motor development c. Manipulative skills d. Learning opportunities e. Increased self-worth ANS: A, C, D

Computer programs are popular with all age groups, providing problem-solving skills, manipulative skills, and opportunities for new learning.

DIF: Cognitive Level: Comprehension REF: p. 392 OBJ: 13 TOP: Computer Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 16: The Infant Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A mother calls the pediatrician‘s office because her infant is ―colicky.‖ What is the most

helpful measure the nurse can suggest to the mother? a. Sing songs to the infant in a soft voice. b. Place the infant in a well-lit room. c. Walk around and massage the infant‘s back. d. Rock the fussy infant slowly and gently.

ANS: D

One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements.

DIF: Cognitive Level: Application REF: p. 403 OBJ: 7 TOP: Colic KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

2. When does the posterior fontanelle close? a. 2 to 3 months b. 3 to 6 months c. 6 to 9 months d. 9 to 12 months ANS: A

The posterior fontanelle closes between 2 and 3 months of age.

DIF: Cognitive Level: Knowledge REF: p. 392 | Box 16.1 OBJ: 5 TOP: Fontanelle KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. At what age does an infant‘s birth weight triple? a. 9 months b. 1 year c. 18 months d. 2 years ANS: B

The infant usually triples his or her birth weight by about 12 months of age.

DIF: Cognitive Level: Knowledge REF: p. 403 | Box 16.1 OBJ: 5 TOP: Development and Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What is the earliest age at which an infant is able to sit steadily alone? a. 4 months b. 5 months c. 8 months d. 15 months ANS: C

The infant can sit alone without support at about 8 months of age.

DIF: Cognitive Level: Knowledge REF: p. 401 | Box 16.1 OBJ: 5 TOP: Sitting Alone KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. What is the earliest age at which the infant should be able to walk independently? a. 8 to 10 months b. 12 to 15 months c. 15 to 18 months d. 18 to 21 months ANS: B

For the majority of children, the milestone of walking alone is achieved between 12 and 15 months.

DIF: Cognitive Level: Knowledge REF: p. 403 | Box 16.1 OBJ: 4 TOP: Walk Independently

KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. The parent of a 3-month-old infant asks the nurse, ―At what age do infants usually begin

drinking from a cup?‖ What is the nurse‘s most accurate response? a. 5 months b. 9 months c. 1 year d. 2 years ANS: B

The infant can usually drink from a cup when it is offered at about 9 months.

DIF: Cognitive Level: Comprehension REF: p. 395 | Box 16.1 OBJ: 9 | 14 TOP: Drink from Cup KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. What would the nurse expect a 4-month-old infant to be able to accomplish? a. Hold a cup. b. Stand with assistance. c. Lift head and shoulders. d. Sit with back straight.

ANS: C

Because development is cephalocaudal, of these choices, lifting the head and shoulders is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months.

DIF: Cognitive Level: Comprehension REF: p. 400 | Box 16.1 OBJ: 4 TOP: Development and Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. What is an abnormal finding in an evaluation of growth and development for a 6-month-old

infant? a. Weight gain of 4 to 7 ounces per week b. Length increase of 1 inch in 2 months c. Head lag present d. Can sit alone for a few seconds ANS: C

The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.

DIF: Cognitive Level: Analysis REF: p. 401 | Box 16.1 OBJ: 4 TOP: Head Control KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

9. A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her

birth weight was 8 pounds, 2 ounces. What will the nurse weighing the infant today expect her weight to be? a. At least 12 pounds b. At least 16 pounds c. At least 20 pounds d. At least 24 pounds ANS: B

Birth weight is usually doubled by 6 months of age.

DIF: Cognitive Level: Application REF: p. 400 | Box 16.1 OBJ: 4 TOP: Development and Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. What will the nurse advise a parent to do when introducing solid foods? a. Begin with one tablespoon of food. b. Mix foods together. c. Eliminate a refused food from the diet. d. Introduce each new food 4 to 7 days apart.

ANS: D

Only one new food is offered in a 4- to 7-day period to determine tolerance.

DIF: Cognitive Level: Comprehension REF: p. 410 OBJ: 9 | 13 TOP: Solid Food KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. The nurse is talking with a parent about tooth eruption. What teeth will the nurse explain are

the first deciduous teeth to erupt? a. Lower central incisors b. Upper central incisors c. Lower lateral incisors d. Upper lateral incisors ANS: A

The first teeth to erupt, usually at about 7 months, are the lower central incisors.

DIF: Cognitive Level: Knowledge REF: p. 401 | Box 16.1 OBJ: 5 TOP: Development and Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. The nurse is assessing development in a 9-month-old infant. What would the nurse expect to

observe? a. Speaking in 2-word sentences b. Grasping objects with palmar grasp c. Creeping along the floor d. Beginning to use a spoon rather sloppily ANS: C

The 9-month-old infant tries to creep, has developed pincer movement, and can grasp a spoon without keeping food on it.

DIF: Cognitive Level: Analysis REF: p. 401 | Box 16.1 OBJ: 4 TOP: Development and Care KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. What statement made by a parent indicates correct understanding of infant feeding? a. ―I‘ve been mixing rice cereal and formula in the baby‘s bottle.‖ b. ―I switched the baby to low-fat milk at 9 months.‖ c. ―The baby really likes little pieces of chocolate.‖ d. ―I give the baby new foods before he takes his bottle.‖ ANS: D

New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.

DIF: Cognitive Level: Comprehension REF: p. 410 | Nursing Tip OBJ: 9 TOP: Nutrition Counseling KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A mother is concerned because her 10-month-old infant is lethargic. What is the best action

the nurse can advise this mother to implement? a. Keep the infant‘s room well lit. b. Rub the infant‘s soles vigorously. c. Offer the infant a pacifier. d. Handle the infant slowly and gently.

ANS: D

Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently.

DIF: Cognitive Level: Application REF: p. 404 OBJ: 6 TOP: Lethargy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. The nurse discusses child-proofing the home for safety with the mother of a 9-month-old

infant. Which statement made by the mother would indicate an unsafe behavior? a. ―I put covers on all of the electrical outlets.‖ b. ―In the car, she rides in a front-facing car seat.‖ c. ―There are locks on all of the cabinets in the house.‖ d. ―I have a gate at the top and bottom of the stairs.‖ ANS: B

A rear-facing infant car seat should be used for infants younger than 1 year of age.

DIF: Cognitive Level: Analysis REF: p. 412 OBJ: 16 TOP: Infant Safety KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

16. The nurse observes a 10-month-old infant using her index finger and thumb to pick up pieces

of cereal. What does this behavior indicate the infant has developed? a. The pincer grasp b. A grasp reflex c. Prehension ability d. The parachute reflex ANS: A

By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

DIF: Cognitive Level: Comprehension REF: p. 396 OBJ: 4 TOP: General Characteristics KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A parent is concerned because her infant has a diaper rash. What is the best action the nurse

would advise the parent to implement? a. Use commercial diaper wipes to clean the area. b. Apply a protective ointment on the area. c. Change the infant‘s diaper less frequently. d. Keep the diaper area covered all of the time.

ANS: B

A protective ointment can be applied when the skin in the diaper area appears pink and irritated.

DIF: Cognitive Level: Application REF: p. 405 OBJ: 6 TOP: Diaper Rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 18. The mother of an infant born prematurely tells the nurse, ―The baby is irritable. She cries

during diaper changes and feedings. Can you make some suggestions about what I should do to soothe her?‖ What is the most appropriate recommendation to help this parent? a. Play the radio or TV while you feed the infant. b. Put the infant in a room with sunlight. c. Wrap the infant snugly when you hold them. d. Change the infant‘s position quickly.

ANS: C

A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face.

DIF: Cognitive Level: Application REF: p. 404 OBJ: 7 TOP: Infant Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. What is the most appropriate activity to recommend to parents to promote sensorimotor

stimulation for a 1-year-old infant? a. Ride a tricycle. b. Spend time in an infant swing. c. Play with push-pull toys. d. Read large picture books.

ANS: C

Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old infant.

DIF: Cognitive Level: Analysis REF: p. 413 | Table 16.3 OBJ: 17 TOP: Infant Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. Which statement indicates the mother of an 8-month-old infant understands infant sleep

patterns? a. ―I put the baby in my bed until she falls asleep, then I put her in her crib.‖ b. ―I let the baby skip an afternoon nap so that she will fall asleep earlier.‖ c. ―I put the pacifier in the crib so that she can find it when she wakes up.‖ d. ―I rock the baby back to sleep if she wakes up at night.‖ ANS: C

The parent should assist the infant to develop self-soothing behaviors so that the infant can get back to sleep on her own.

DIF: Cognitive Level: Analysis REF: p. 404 OBJ: 8 TOP: Sleep Patterns KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. How might the nurse demonstrate the parachute reflex with an infant? a. Lifting the infant high in the air above her head b. Holding the infant in a football hold, cradling the head c. Seating the infant in a stroller in an upright position d. Placing the infant downward into the crib ANS: D

The infant, when placed downward in a prone position, will protectively extend the arms.

DIF: Cognitive Level: Comprehension REF: p. 396 OBJ: 4 TOP: Parachute Reflex KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. Parents of a 6-month-old infant ask the nurse why it is necessary to offer iron-rich formula to

their child. What is the correct response? a. ―The infant has limited ability to produce red blood cells.‖ b. ―The infant has ineffective digestive enzymes.‖ c. ―The infant has exhausted maternal iron stores.‖ d. ―The infant has need of the iron to support dentition.‖ ANS: C

It is necessary to offer iron-rich formula to the children when they exhausted maternal iron stores.

DIF: Cognitive Level: Comprehension REF: p. 407 OBJ: 12 TOP: Iron Supplement KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

23. The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the

nurse report to the physician immediately? a. Respiratory rate of 60 breaths/minute b. Pulse rate of 100 beats/minute c. Minimal verbalization d. Fussy behavior ANS: A

Respirations of a 1-year-old infant should be 20 to 40 breaths/minute. Increased respiratory rate can lead to distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal verbalization and fussy behavior are not emergency situations or abnormal for this age.

DIF: Cognitive Level: Application REF: p. 403 | Box 16.1 OBJ: 3 TOP: 12-Month-Old Physical Characteristics KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. A new mother is voicing concern she is breastfeeding her newborn too frequently. How often

does the nurse instruct this mother she should expect her newborn to feed? a. Every 2 to 3 hours b. Every 4 to 6 hours c. Every 6 to 8 hours d. Every 8 to 10 hours ANS: A

Breastfed infants may require feedings at 2- to 3-hour intervals because breast milk is more easily digested. A flexible but regular schedule that provides a rest period between feedings is best for the parent and infant.

DIF: Cognitive Level: Application REF: p. 407 OBJ: 12 TOP: 12-Month-Old Physical Characteristics KEY: Nursing Process Step: Intervention MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. The nurse cautions that children who have unmet hunger needs will likely display which

characteristic(s)? (Select all that apply.) a. Irritability b. Ineffective feeding patterns c. No predictable sleep–wake cycle d. Distrust e. Effective parent bonding ANS: A, B, C, D

Children who experience frequent hunger do not have effective parental bonding. All other options are probable outcomes for a child who has unmet hunger needs.

DIF: Cognitive Level: Comprehension REF: p. 395 OBJ: 9 TOP: Hunger KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is preparing to outline principles of discipline for parents of an infant. What

information should the nurse include? (Select all that apply.) a. Firmly say ―No.‖ b. Distract the child to another activity. c. Bribe the child with a sweet treat. d. Remain consistent. e. Ignore the child until behavior improves.

ANS: A, B, D

Parental approval is important to the infant, and setting limits early is essential. Principles of discipline at this age include the following: lowering the voice to say no firmly, removing the child from the situation, distraction, and consistency.

DIF: Cognitive Level: Comprehension REF: p. 398 | Nursing Tip OBJ: 2 TOP: Discipline KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. What should the teaching plan include about infant fall precautions? (Select all that apply.) a. Remove all unsteady furniture. b. Keep crib rails up and in locked position. c. Steady infant with hand when on changing table. d. Use tray attachment on high chair as restraint. e. Keep infant seat on the floor while indoors.

ANS: A, B, C, E

The tray attachment to a high chair is an inadequate restraint. All other options are good precautions to prevent an infant from a fall.

DIF: Cognitive Level: Comprehension REF: p. 412 OBJ: 16 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 4. The nurse is aware that the 7-month-old infant can signal feeding readiness by which

action(s)? (Select all that apply.) a. Pulling spoon toward mouth b. Biting at spoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement at sight of food e. Manipulating finger foods ANS: A, E

The 7-month-old infant pulls the spoon toward his or her mouth and can manipulate finger foods. The 7-month-old infant does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food.

DIF: Cognitive Level: Comprehension REF: p. 401 | Box 16.1 OBJ: 14 TOP: Feeding Skills KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

5. The nurse is educating parents of a 2-month-old infant about immunizations. What

immunizations against illness should their child receive? (Select all that apply.) a. Pertussis (whooping cough) b. Influenza c. Diphtheria d. Tetanus e. Polio ANS: A, B, C, D, E

The first DPT, polio, and flu immunizations are given at the age of 2 months.

DIF: Cognitive Level: Knowledge REF: p. 399| Box 16.1 OBJ: 6 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. What will the nurse take into consideration when educating parents regarding infant nutrition?

(Select all that apply.) a. Cultural practices b. Sex of the infant c. Parental knowledge d. Infant‘s developmental level e. Parent–child interaction ANS: A, C, D, E

Parents have many concerns about feeding their infant during the first year of life. This is a period when readiness to receive nutrition education is usually high; therefore, the nurse looks for opportunities to provide accurate information. Assessment of parental knowledge; infant development, behavior, and readiness; parent–child interaction; and cultural and ethnic practices is important. Sex of the infant does not enter into nutritional education.

DIF: Cognitive Level: Comprehension REF: p. 406 OBJ: 10 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. Parents of an infant inform the nurse they are planning home preparation of solid foods. What

directions should the nurse provide? (Select all that apply.) a. Boil foods in a large amount of water. b. Do not freeze foods. c. Add 1 teaspoon of salt per cup. d. Puree food in electric blender. e. Add sugar sparingly.

ANS: D, E

Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly. Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foods may be frozen in ice cube trays and defrosted for use.

DIF: Cognitive Level: Comprehension REF: p. 409 |Health Promotion OBJ: 13 TOP: Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 17: The Toddler

Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. Which behavior reported by a parent of an 18-month-old toddler would the nurse report to the

pediatrician as a cause for concern? a. Has temper tantrums. b. Feeds self sloppily. c. Walks by holding onto furniture. d. Speaks in short sentences.

ANS: C

By 18 months, a toddler should have been walking alone for several months. The toddler who walks holding onto furniture should be evaluated by a developmental specialist.

DIF: Cognitive Level: Analysis REF: p. 415 | Table 17.1 OBJ: 2 TOP: Delayed Walking KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What would the nurse assessing growth and development of a 2-year-old child expect to find? a. The child jumps with both feet. b. Twenty deciduous teeth have erupted. c. The child can hop on one foot. d. The child has a vocabulary of 900 words.

ANS: A

The 2-year-old child can jump with both feet. The remaining achievements occur after 2 years of age.

DIF: Cognitive Level: Comprehension REF: p. 415 | Table 17.1 OBJ: 2 TOP: Jumping KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A parent remarks, ―My 18-month-old daughter carries her blanket around everywhere. Is this

normal?‖ What is the best explanation a nurse who has an understanding of toddler development might give? a. She carries her blanket because she is ritualistic. b. Carrying her favorite blanket is self-consoling behavior. c. This behavior can be discouraged by offering new toys to the child. d. This could be indicative of emotional distress.

ANS: B

Favorite possessions and repetitive rituals are self-consoling behaviors for the toddler.

DIF: Cognitive Level: Application REF: p. 419 OBJ: 2 TOP: Self Consoling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse observed three toddlers playing side by side with dolls. Closer observation revealed

that the children were not interacting with one another. What type of play is this?

a. b. c. d.

Solitary Parallel Associative Cooperative

ANS: B

Toddlers engage in parallel play. Children play next to, but not with, each other.

DIF: Cognitive Level: Comprehension REF: p. 423 OBJ: 11 TOP: Play KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. What instruction would the nurse include when planning anticipatory guidance for parents of

a toddler? a. Adhere to a rigid schedule because the toddler is ritualistic. b. Limit-setting should include praise. c. Shoes should fit snugly at the toe and arch. d. Dress the toddler in pants with a zipper so that he or she can learn to zip and unzip clothes.

ANS: B

Limit-setting should include praise as well as disapproval for undesired behavior.

DIF: Cognitive Level: Application REF: p. 419 OBJ: 6 TOP: Limit Setting KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. What is the best advice the nurse can offer a parent concerned because her 2-year-old child is

very active and does not eat much? a. Insist that the child eat one food on the plate. b. Help the child wind down with a quiet activity before mealtime. c. Maintain a consistent eating schedule for the family. d. Serve the meal with a variety of interesting plates, cups, and utensils.

ANS: B

Quiet time before meals provides an opportunity for the active toddler to wind down.

DIF: Cognitive Level: Application REF: p. 422 OBJ: 9 TOP: Quiet Time KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. How would the nurse advise a parent who states, ―I never know how much food to feed my

child‖? a. Serving sizes should not exceed 1 teaspoon of each type of food. b. Food quantities must be carefully measured to avoid overfeeding. c. Use 1 tablespoon of each food for each year of age as a guideline. d. A toddler should eat three balanced meals. Snacks are not necessary.

ANS: C

A tablespoon of each type of food for each year of age is a good guideline to follow when determining serving sizes.

DIF: Cognitive Level: Application REF: p. 422 OBJ: 9 TOP: Food Portions KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The nurse is discussing toilet training with parents. What behavior by the child would identify

toilet training readiness? a. Willing to sit on the potty for 15 to 20 minutes b. Dry in the daytime for 4-hour periods c. Able to communicate that he or she is wet d. Curious about bathroom activities ANS: C

Children are ready for toilet training when they can communicate in some fashion that they are wet or need to urinate or defecate.

DIF: Cognitive Level: Comprehension REF: p. 419 OBJ: 8 TOP: Toilet Independence KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. What is the most appropriate toy for the nurse to select for a normal 2-year-old child? a. Bicycle with training wheels b. Dump truck c. Wind-up toy d. Building block set ANS: B

The 2-year-old child enjoys playing with objects that can be pushed or pulled.

DIF: Cognitive Level: Application REF: p. 427 OBJ: 11 TOP: Toys and Play KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. What could the nurse recommend to a child‘s mother to encourage a toddler to practice

independence? a. Offer a variety of items to choose from to stimulate his mind. b. Allow the child to determine his own daily routine. c. Offer him a choice between two items. d. Set the routine herself, but discuss with her toddler how he or she would have done it differently.

ANS: C

The toddler can be allowed to make choices as the situation warrants, but the number of choices should be limited because too many confuse the toddler.

DIF: Cognitive Level: Application REF: p. 415 OBJ: 4 TOP: Offering Choices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. On a home visit, the nurse notes that the parents require teaching intervention to protect the

15-month-old child who lives there. What observation would lead the nurse to this conclusion? a. The fireplace has a screen.

b. The dining room table has a tablecloth on it. c. There are paintings on the wall. d. The kitchen floor is clean but not shiny.

ANS: B

A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it.

The toddler could be injured if items on the table are moved when the tablecloth is pulled.

DIF: Cognitive Level: Analysis REF: p. 424 | Health Promotion Box OBJ: 10 TOP: Injury Prevention KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. What does the nurse consider as an appropriate snack for a 2-year-old child? a. Hot dog sections b. Grapes c. Popcorn d. Applesauce ANS: D

Applesauce is a healthy and safe snack food for the toddler. The toddler is at risk for choking on foods such as grapes, hot dogs, and popcorn.

DIF: Cognitive Level: Analysis REF: p. 424 | Health Promotion Box OBJ: 10 TOP: Injury Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. Which finding would concern the nurse assessing vital signs on a 2-year-old child? a. Temperature of 37.1C (98.8F) b. Pulse at 100 beats/minute c. Respirations of 36 breaths/minute d. Blood pressure of 90/60 mm Hg ANS: C

In the toddler period, the respiratory rate decreases to 25 breaths/minute.

DIF: Cognitive Level: Analysis REF: pp. 416-417 OBJ: 2 TOP: Vital Signs KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What would be an expected finding when assessing language development in a 2-year-old

child? a. A 900-word vocabulary b. Use of two-word sentences c. Use of pronouns and prepositions d. 100% of speech is understandable ANS: B

The 2-year-old child should be using two-word sentences.

DIF: Cognitive Level: Analysis REF: p. 418 | Table 17.2 OBJ: 5 TOP: Speech Development

KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse is planning to explain the use of time-outs to the parent of a 3-year-old child. How

many minutes will the nurse indicate is appropriate for a child of this age? a. 3 b. 6 c. 10 d. 15 ANS: A

Timing for time-out is usually based on 1 minute per year of age.

DIF: Cognitive Level: Comprehension REF: p. 419 OBJ: 6 TOP: Guidance and Discipline KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The parent of a toddler tells the nurse, ―My daughter‘s appetite has decreased. Thank

goodness she loves to drink milk.‖ What is the most appropriate response by the nurse? a. ―Has your daughter been sick recently?‖ b. ―How much milk does she drink in a day?‖ c. ―Has she become a fussy eater, too?‖ d. ―Have you tried offering her finger foods?‖ ANS: B

Milk should be limited to 24 ounces a day. Too few solid foods can lead to dietary deficiencies of iron.

DIF: Cognitive Level: Application TOP: Nutrition Counseling MSC: NCLEX: Physiological Integrity

REF: p. 422 OBJ: 9 KEY: Nursing Process Step: Data Collection

17. How many hours should toddlers be able to stay dry for the nurse to suggest they are ready to

begin bladder training? a. 1 b. 2 c. 3 d. 4 ANS: B

If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective.

DIF: Cognitive Level: Comprehension REF: p. 421 OBJ: 8 TOP: Bladder Training KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. Parents tell the nurse they are frustrated with their toddler‘s recent behavior and refusal to

agree with anything they ask of them. What does the nurse explain as the term for when a toddler tests their own power? a. Negativism b. Dawdling c. Tantrums

d. Food fads ANS: A

By refusing to eat, dress, sleep, or anything else by saying ―No,‖ toddlers test their own power to control. Because toddlers are also egocentric, they come to believe that their negativism is absolute. This is especially true if the adults give into it.

DIF: Cognitive Level: Comprehension REF: p. 415 OBJ: 1 | 2 TOP: Negativism KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. The nurse is assessing a 3-year-old toddler. What is the expected weight gain for this age

child? a. 2 times the birth weight b. 2.5 times the birth weight c. 3 times the birth weight d. 4 times the birth weight ANS: D

The expected weight of a

-year-old toddler is four times the birth weight.

DIF: Cognitive Level: Comprehension REF: p. 415 OBJ: 2 TOP: Weight Prediction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. What guideline should an adult follow when speaking to a toddler? a. Be at eye level with the child. b. Hold by the shoulders to keep the child‘s attention. c. Seat the child to focus on conversation. d. Speak in a firm strong voice.

ANS: A

Being at eye level is helpful to hold the child‘s attention and is especially important when the child is frightened.

DIF: Cognitive Level: Comprehension REF: p. 421 OBJ: 2 TOP: Conversing with Toddler KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. Why does day care for the toddler differ from that of the preschooler? a. Toddlers have a shorter attention span. b. Toddlers need more group play. c. Toddlers are less prone to environmental dangers. d. Toddlers require less outdoor space.

ANS: A

Toddlers have a shorter attention span than preschoolers and are prone to investigate other opportunities in the environment that may put them in harm‘s way. Toddlers are more interested in parallel play.

DIF: Cognitive Level: Comprehension REF: p. 423 TOP: Day Care KEY: Nursing Process Step: N/A

OBJ: 2

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. A 16-month-old child is attending a well-child visit at a pediatric clinic. Which assessment

would indicate the biggest cause for concern? a. Does not walk independently b. Prefers finger feeding c. Limited to single words d. Is unable to climb steps ANS: A

A child should be walking independently by 16 months. It is normal for a child this age to prefer finger feeding and to be limited to single words. Many children do not climb steps until 24 months of age.

DIF: Cognitive Level: Comprehension REF: p. 416 | Table 17.1 OBJ: 2 TOP: Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. When selecting a potty chair, the parents are encouraged to select one that has which

characteristic(s)? (Select all that apply.) a. Small enough for the child‘s feet to touch floor b. Sturdy and stable c. Supportive of child‘s back and arms d. Made of plastic or fiberglass e. Capable of being taken apart easily ANS: A, B, C

Potty chairs should be small and sturdy and supportive of the child‘s back and arms. The composition is not important as long as it is stable.

DIF: Cognitive Level: Comprehension REF: p. 421 OBJ: 8 TOP: Potty Chairs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse suggests offering which food(s) to support the toddler‘s desire to self-feed? (Select

all that apply.) a. Pureed foods b. Finger foods c. Foods served cold d. Foods in colorful dishes e. Foods that are varied and colorful ANS: B, D, E

Finger foods that are varied and colorful and served in colorful dishes at a moderate temperature are all attractive. Foods can be chopped into small pieces but not pureed.

DIF: Cognitive Level: Comprehension REF: p. 422 OBJ: 9 TOP: Self-Feeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

3. The nurse points out which physiological change(s) in the toddler that serve(s) as protection

against disease? (Select all that apply.) a. Toughening of the skin b. Increased capillary response for thermoregulation c. Stabilization of body temperature d. Elevation in white blood cell count e. Enlarged adenoids and tonsils ANS: A, B, C, E

With the exception of an increased white blood cell (WBC) count, which is always pathological, the other options are all maturing changes that equip the toddler to better fight disease.

DIF: Cognitive Level: Comprehension REF: p. 416 OBJ: 2 TOP: Physiological Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. Parents of a toddler are discussing the emotion of fear with the pediatric nurse. What

information can the nurse offer regarding fear and the toddler? (Select all that apply.) a. Stress increases fear. b. Rituals help deal with fear. c. Teasing the child can decrease fear. d. Once fear is learned it is difficult to eliminate. e. Adults should openly share their fears.

ANS: A, B, D

Once a fear has been learned, it is more difficult to eliminate. Clinging to favorite possessions and repetitive rituals are self-consoling behaviors for the toddler, particularly at bedtime and during separation from parents. Stress increases fear of separation. Adults should attempt to control their own fears in the presence of young children. Respect and understanding should always be accorded to children who are afraid. Making fun of the fear or shaming the child in front of others is detrimental to self-esteem.

DIF: Cognitive Level: Comprehension REF: p. 419 OBJ: 7 TOP: Fear KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 1. The nurse assessing a 2-year-old is satisfied to see that the present weight of the child is

_____________ times their birth weight.

ANS:

3 The birth weight has usually tripled by the time the child is 2 years of age.

DIF: Cognitive Level: Comprehension REF: p. 415 OBJ: 2 TOP: Tripled Birth Weight KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 18: The Preschool Child Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. Which statement best describes the 3-year-old child? a. Boisterous, tattles on others b. Aggressive, shows off c. Helpful, wants to assist with chores d. Talkative, inquisitive about the environment ANS: C

Three-year-old children are helpful and can assist in simple household chores.

DIF: Cognitive Level: Comprehension REF: p. 434 OBJ: 3 TOP: Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The parents of a 4-year-old boy are concerned because they have noticed him frequently

touching his penis. What knowledge would act as the basis for the nurse‘s response? a. This behavior indicates a normal curiosity about sexuality. b. Masturbation suggests the boy has an excessive fear of castration. c. It is usually a result of discomfort from a penile rash or irritation. d. The behavior is abnormal and the child should be referred for counseling.

ANS: A

Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality.

DIF: Cognitive Level: Comprehension REF: p. 434 OBJ: 10 TOP: Masturbation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A preschool child is asked, ―Why do trees have leaves?‖ Which response would be an

example of animism? a. ―So I can have shade over my sandbox.‖ b. ―Because God made them that way.‖ c. ―To hide behind when they are scared.‖ d. ―For the squirrels to play in.‖ ANS: C

Animism describes the tendency of preschool children to attribute human characteristics to nonhuman objects.

DIF: Cognitive Level: Application REF: p. 431 OBJ: 1 | 3 | 4 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What tasks would be appropriate to expect of a 5-year-old child? a. Setting the table with paper plates b. Washing the dirty knives

c. Carrying glasses from the table to the sink d. Scrubbing out the sink with cleanser ANS: A

Parents must consider developmental level and safety when asking the 5-year-old child to help with chores.

DIF: Cognitive Level: Application REF: p. 437 OBJ: 3 TOP: Development—Safety KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A 3-year-old child, while playing with his favorite toy in the playroom of the pediatric unit, is

approached by another child who also wants to play with the same toy. What behavior will the nurse anticipate from this child? a. Will play well with the other child. b. Will give the toy up and then not play anymore. c. Will become angry and a physical response might ensue. d. Will ignore the toy and go on to something else.

ANS: C

The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her possessions.

DIF: Cognitive Level: Application REF: p. 432 | Table 18.1 OBJ: 3 TOP: Display of Aggression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. A parent is concerned about her children‘s reaction should their grandmother die. What

understanding will guide the nurse‘s response? a. Children are unlikely to notice their grandmother‘s absence if no one reminds them. b. Young children often understand that other people die, but do not equate it with themselves. c. The children‘s response will depend entirely on whether they have been acquainted with death before this. d. Children can understand the concept of a higher being much like adults can.

ANS: B

Between 3 and 4 years of age, the children become curious about death and dying. They may realize that others die, but they do not relate death to themselves.

DIF: Cognitive Level: Comprehension REF: p. 435 OBJ: 7 TOP: Concept of Death KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. What is the most appropriate intervention when dealing with occasional aggression in a

4-year-old child? a. Have the child take a time-out in the corner for 4 minutes. b. Spank the child at the time of the incident. c. Take away television privileges for the day. d. Send the child to his room for 30 minutes.

ANS: A

Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique.

DIF: Cognitive Level: Application REF: pp. 436-437 OBJ: 3 TOP: Limit Setting KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. A father is concerned about how long his preschool-age child will continue sucking his

thumb. What is the most helpful response from the nurse? a. ―Most children will stop thumb-sucking naturally by school age.‖ b. ―Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice.‖ c. ―Consistently touching the child‘s fingers whenever he sucks his thumb is most effective.‖ d. ―Thumb-sucking is detrimental to the eruption of the child‘s teeth and must be stopped as soon as possible.‖ ANS: A

Most children give up the habit of thumb-sucking by the time they reach school.

DIF: Cognitive Level: Application REF: p. 438 OBJ: 10 TOP: Thumb-Sucking KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. How does the nurse characterize the play of 5-year-old children? a. Enjoying rough and tumble play b. Playing well-organized games c. Following rules d. Preferring inside activities ANS: C

The 5-year-old child wants to play by the rules but cannot accept losing. The rules may be very strict or change as the game progresses.

DIF: Cognitive Level: Comprehension REF: p. 432 | Table 18.1 OBJ: 13 TOP: Play KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The nurse is discussing preschoolers‘ sexual curiosity with the parent. What statement by the

mother leads the nurse to determine that the mother understands the information? a. ―Make up funny words for body parts.‖ b. ―Distract the child with a toy if they ask about sex.‖ c. ―Answer their questions when they ask.‖ d. ―Tell them to ask you again when they are 6 years old.‖ ANS: C

Parents should provide sex education at the time the child asks about sex.

DIF: Cognitive Level: Analysis REF: pp. 432-434 OBJ: 10 TOP: Sexual Curiosity KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

11. What type of play is most appropriate when planning care for a child with moderate

intellectual deficiency? a. Exercise leg and arm muscles. b. Be educationally oriented to make up for lost time. c. Be adjusted to mental age rather than chronological age. d. Involve contact sports and aggressive physical activity with other children.

ANS: C

The nurse must consider the child‘s mental age rather than her chronological age when selecting toys for play.

DIF: Cognitive Level: Application REF: p. 442 OBJ: 14 TOP: Play KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. What is the nurse‘s best advice to a parent about a preschooler‘s ―imaginary friend‖? a. Having imaginary friends is a sign that the child has low self-esteem. b. It is common for preschoolers to have imaginary friends. c. Preschoolers invent an imaginary friend when they feel overwhelmed. d. The best approach to dealing with an imaginary friend is to ignore them.

ANS: B

Imaginary friends are common and normal during the preschool period and serve many purposes, such as relief from loneliness, mastery of fears, and acting as a scapegoat.

DIF: Cognitive Level: Comprehension REF: pp. 441-442 OBJ: 3 | 13 TOP: Imaginary Friend KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. What intervention might the nurse suggest as helpful for the child with enuresis? a. Applying an electric pad that gently shocks the child b. Waking the child several times during the night to urinate c. Decreasing fluid intake after the evening meal d. Increasing dietary fiber intake ANS: C

If a child is experiencing enuresis, liquids after dinner should be limited and the child should routinely void before going to bed.

DIF: Cognitive Level: Application REF: p. 439 OBJ: 10 TOP: Enuresis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. What should the nurse suggest as the most appropriate toy choice for a 3-year-old? a. A board game b. A small pet, such as a goldfish c. A large construction set d. Push-pull toys ANS: C

Large construction sets are suitable toys for the preschool-age child.

DIF: Cognitive Level: Application REF: p. 441 OBJ: 13 TOP: Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

-year-old child tells the nurse, ―My daughter points instead of speaking whenever she wants me to get something for her, but she understands me when I ask her to do something.‖ Based on the parent‘s comment, what does the nurse suspect? a. Age-appropriate language development b. An expressive language delay c. A receptive language delay d. A potential hearing deficit

15. The parent of a

ANS: B

An expressive language delay is suspected when the child understands spoken language but is not talking.

DIF: Cognitive Level: Application REF: p. 434 | Table 18.3 OBJ: 5 TOP: Language Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

-year-old child tells the nurse, ―Bedtime is difficult. I can‘t get my son to go to bed at night.‖ The nurse and the child‘s mother discuss options. What intervention is the most appropriate choice? a. Allow the child to put himself to bed when he is tired. b. Let the child read in his room until he falls asleep. c. Establish a bedtime routine and use it consistently. d. Tire him out with physical activity before bedtime.

16. The parent of a

ANS: C

Parents should engage the child in quiet activities before bedtime and establish a ritual that signals readiness for bedtime.

DIF: Cognitive Level: Application REF: p. 434 OBJ: 6 TOP: Bedtime Habits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. What fear is unique to the preschool period? a. Water b. Animals c. Bodily harm d. Death ANS: C

The fear of bodily harm, particularly the loss of body parts, is unique to this stage.

DIF: Cognitive Level: Knowledge REF: p. 435 OBJ: 3 TOP: Fear KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

18. A 4-year-old child tells the nurse she will not eat peas because they are green. Of what is this

an example? a. Egocentrism b. Artificialism c. Animism d. Centering ANS: D

The tendency to concentrate on a single outstanding characteristic of an object while excluding other features is known as centering.

DIF: Cognitive Level: Application REF: p. 431 OBJ: 3 TOP: Centering KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. A 4-year-old child insists he has more money with a nickel than his father has with a dime.

What is this perception, as described in Piaget‘s theory? a. Egocentrism b. Artificialism c. Animism d. Intuition ANS: D

The intuitive stage, as described by Piaget, is prelogical thinking that is based on the outside appearance of objects. A nickel is larger than a dime and therefore more valuable.

DIF: Cognitive Level: Comprehension REF: p. 431 OBJ: 4 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. What will children who are unable to express themselves with words often do? a. Become reclusive and introspective. b. Develop other methods of verbal communication. c. Engage in more creative play. d. Have tantrums and act out.

ANS: D

Children with delayed communication skills will frequently have tantrums and act out when they are unable to make their needs known.

DIF: Cognitive Level: Comprehension REF: p. 431 OBJ: 5 TOP: Tantrums KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. Which is an example of associative play? a. Two children playing in house, one playing the role of the dad and the other

playing the role of the mom b. Two children playing in a sand box, one building a wall and the other digging a

hole c. Two children playing with sports-associated items, one with a football and the other with a bat d. Two children playing with a coloring book, one coloring pictures and the other

looking at pictures ANS: A

Associative play allows the preschoolers to use their enlarged vocabulary in play with other children to carry on conversations and describe scenarios for each to play.

DIF: Cognitive Level: Analysis REF: p. 435 OBJ: 13 TOP: Associative Play KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. The nurse is educating a group of preschool parents about the importance of safety. Which

statement by a parent indicates the need for further education? a. ―I continue to provide a great deal of indirect supervision for my child.‖ b. ―My stairway is always free of clutter.‖ c. ―I only leave my child in the car for brief moments.‖ d. ―Medications are kept in a locked cabinet.‖ ANS: C

Children must not play in or around the car or be left alone, even for a brief moment, in the car. Preschool children still require a good deal of indirect supervision to protect them from dangers that arise from their immature judgment or social environment. Stairways should be free of clutter and medications kept out of reach.

DIF: Cognitive Level: Comprehension REF: p. 440 OBJ: 12 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 23. Parents of a 5-year-old child tell the nurse they are concerned about their child‘s speech

development by stating, ―No one can understand him but us.‖ What clinical classification of speech disorder does the nurse suspect? a. Global language delay b. Expressive language delay c. Language loss d. Articulation disorder ANS: D

When parents are the only people to understand their preschool child, an articulation disorder is suspected (see Table 18-3).

DIF: Cognitive Level: Application REF: p. 434 | Table 18.3 OBJ: 5 TOP: Speech Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. What does including play in the plan of care for a 5-year-old allow the child to do? (Select all

that apply.) a. Exercise his imagination. b. Assume a role and act it out. c. Offer an emotional outlet.

d. Avoid magical thinking. e. Interact with other children.

ANS: A, B, C, E

Benefits of play for the preschooler include exercising imagination, assuming a role and acting it out, offering an emotional outlet, and interacting with other children. Play employs the use of magical thinking.

DIF: Cognitive Level: Knowledge REF: p. 440 OBJ: 13 TOP: Purpose of Play KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What developmental milestone(s) assist the 5-year-old boy toward developing his sexual

identity? (Select all that apply.) a. Begins to be less focused on his mother. b. Ignores both parents totally. c. Regresses to a more infantile level. d. Forms a romantic attachment to the mother. e. Identifies with the parent of the same sex.

ANS: A, D, E

Children of this age become less focused on the mother as the central person and begin to identify with the parent of the same sex, forming a romantic attachment to the parent of the opposite sex. This little boy might say, ―I‘m going to marry my mother.‖ A little girl might say, ―I‘m going to marry my daddy.‖ DIF: Cognitive Level: Application REF: p. 435 OBJ: 2 TOP: Romantic Attachment to Parent KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. Which bedtime preparation rituals are the most appropriate for the nurse to suggest? (Select

all that apply.) a. Telling a story b. Placing a favorite toy in bed c. Placing a glass of water at the bedside d. Turning on a night-light e. Playing energetically ANS: A, B, C, D

All options are soothing bedtime rituals except energetic playing, which would be stimulating and counterproductive to sleep.

DIF: Cognitive Level: Comprehension REF: p. 434 OBJ: 6 TOP: Bedtime Habits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse points out what advantage(s) of a nursery school or preschool experience? (Select

all that apply.) a. Increasing self-confidence b. Fostering group cooperation c. Detecting adjustment problems d. Attainment of toilet training skills

e. Playing experiences with other children ANS: A, B, C, E

Nursery school increases self-confidence, group cooperation, social skills, and cooperative play. Objective observations by a nursery school instructor can detect early adjustment problems. The child is usually toilet trained prior to the start of preschool.

DIF: Cognitive Level: Comprehension REF: p. 439 OBJ: 12 TOP: Advantages of Nursery School KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. Which major developmental tasks will the nurse expect a child to accomplish by the end of

the preschool years? (Select all that apply.) a. Development of parallel play b. Acceptance of separation c. Increased communication skills d. Consistent appetite e. Control of bodily functions ANS: B, C, E

The major tasks of the preschool child include preparation to enter school, development of a cooperative type of play, control of body functions, acceptance of separation, and increase in communication skills, memory, and attention span. Appetite remains inconsistent.

DIF: Cognitive Level: Comprehension REF: p. 430 OBJ: 2 TOP: Major Developmental Tasks KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 1. When planning an activity for a 3-year-old child, the nurse bases the plan on the average

attention span of _____ minutes.

ANS:

15 The average attention span of the preschooler is about 15 minutes.

DIF: Cognitive Level: Comprehension REF: p. 432 | Table 18.1 OBJ: 3 TOP: Attention Span of Preschooler KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 19: The School-Age Child Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is assessing a school-age child. What will the nurse expect in regard to physical

development of this child? a. Growth of 3 to 6 inches per year

b. Gain of 5 to 7 pounds per year c. Increase of head circumference by 1 inch per year d. A visual acuity of 20/20 by 9 years of age ANS: B

During the school-age period, the average weight gain per year is generally 5.5 to 7 pounds.

DIF: Cognitive Level: Knowledge REF: pp. 445-446 OBJ: 3 TOP: Physical Growth KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What should the nurse keep in mind when planning to teach a class on nutrition to

fourth-grade students? a. School-age children can concentrate on only one aspect of a situation. b. School-age children can think abstractly. c. School-age children are egocentric in their thinking. d. School-age children think logically and concretely.

ANS: D

Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and an understanding of cause and effect.

DIF: Cognitive Level: Comprehension REF: p. 445 OBJ: 3 TOP: Cognitive Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. What type of relationships are the preferred social interactions for the school-age child? a. Heterosexual interest groups b. Association with one ―best friend‖ c. Rigidly organized groups with complex rules d. Same-sex peer groups ANS: D

The preferred social interaction of the school-age child is in same-sex peer groups or cliques.

DIF: Cognitive Level: Analysis REF: p. 445 OBJ: 3 TOP: Social Development—Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse is advising parents of a 10-year-old boy about the most developmentally supportive

experiences for their son. What is the best experience for this child according to Erikson‘s theory? a. Constant variety of activities b. Successful performance in Little League c. Feeling healthy and strong d. Having a girlfriend ANS: B

The child who is successful in activities will feel positively about himself or herself.

DIF: Cognitive Level: Analysis REF: p. 446 | Box 19.1 OBJ: 3 TOP: Psychosocial Development KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The parents of an 8-year-old child tell the nurse the child wakes the household crying out

during his frequent nightmares. What is the nurse‘s most helpful response to explain nightmares? a. They are a normal extension of the child‘s fear of mutilation. b. They are an abnormal response to repressed feelings. c. They are a common result of latent sexuality. d. They are a side effect of overactivity and stimulation.

ANS: A

The nightmares experienced by an 8-year-old child are an extension of their characteristic fear of mutilation.

DIF: Cognitive Level: Comprehension REF: p. 455 | Table 19.3 OBJ: 3 TOP: Eight-Year-Old KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. What is the best suggestion by the nurse for an appropriate toy for a hospitalized 6-year-old

boy? a. Handheld video game b. MP3 player c. Adventure book d. Jigsaw puzzle ANS: A

The 6-year-old child can perform numerous feats that require muscle coordination. At this age, the handheld video game will offer competition without overexertion.

DIF: Cognitive Level: Analysis REF: p. 449 OBJ: 3 TOP: Six-Year-Old KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon

be starting first grade. What statement by the girl‘s father leads the nurse to determine that the parents understood the information? a. ―We should put a stop to her thumb-sucking.‖ b. ―We‘ll have a talk about what school is like.‖ c. ―We will let her walk to the bus stop by herself.‖ d. ―We‘ll have her meet some children who will be in her class.‖ ANS: D

To prepare a child for school, parents can arrange for the child to meet other children who will be entering school with her.

DIF: Cognitive Level: Application REF: p. 449 | Parent Teaching Box OBJ: 4 TOP: Parental Guidance for Starting School KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

8. A 9-year-old boy is often cranky and irritable, and his school performance has declined. What

is the most probable factor causing this behavior? a. He sleeps only 6 to 7 hours a night. b. He eats eggs every day. c. He has a new dog. d. He plays about 1 to 3 hours each evening.

ANS: A

The 9-year-old child requires about 10 hours of sleep per night.

DIF: Cognitive Level: Application REF: p. 452 OBJ: 3 TOP: Nine-Year-Old KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A parent asked the nurse, ―At what age are children capable of assuming more responsibility

for personal belongings?‖ What is the nurse‘s best response based on knowledge of growth and development? a. 6 years b. 7 years c. 9 years d. 12 years ANS: C

The 9-year-old child is dependable and assumes more responsibility for personal belongings.

DIF: Cognitive Level: Comprehension REF: p. 452 OBJ: 3 TOP: Nine-Year-Old KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. The school nurse is preserving a tooth that was knocked out on the school playground. What

will the nurse be especially careful to do? a. Wrap the tooth loosely in a clean cloth. b. Rinse the tooth with alcohol. c. Handle the tooth only by the crown. d. Place the tooth in a warm environment.

ANS: C

When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage to the root and placed in milk until the child can be examined by a dentist.

DIF: Cognitive Level: Application REF: p. 450 | Nursing Tip OBJ: 7 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A parent states, ―My 7-year-old really wants a dog. His 10-year-old brother has allergies to

animal dander. I don‘t know what to do.‖ What type of pet should the nurse suggest as the best choice? a. A small breed of dog because the large dogs produce more allergens. b. An older unneutered dog that produces fewer allergens than a younger one. c. A cat because it requires less care and is less allergenic. d. A poodle, which does not shed, making it a good choice for people with allergies.

ANS: D

The poodle does not have a shed cycle and so it may be the least offensive pet for the allergic child.

DIF: Cognitive Level: Analysis REF: p. 460 OBJ: 8 TOP: Pet Ownership KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. When asked about her activities, a 10-year-old girl responded, ―I like school. I play the flute

in the school band, and I take tennis lessons.‖ What does the nurse know these activities will help this child develop? a. Initiative b. Industry c. Identity d. Intimacy ANS: B

The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities facilitates the child‘s sense of industry.

DIF: Cognitive Level: Application REF: p. 445 OBJ: 3 TOP: Psychosocial Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. A mother reports that she has a new job and her 12-year-old child is home alone for a time

after school. Which statement made by the parent alerts the nurse to a potentially unsafe situation for this child? a. ―I told him that he could invite a few friends after school.‖ b. ―I put a list of emergency numbers next to the telephone.‖ c. ―Last week we made a first aid kit together.‖ d. ―There is a neighbor available in case of an emergency.‖ ANS: A

Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to be home alone in an unsupervised environment is an unsafe situation.

DIF: Cognitive Level: Application REF: pp. 450-451 OBJ: 4 TOP: Latchkey Children KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A mother is concerned because her 9-year-old boy has developed the habit of twitching his

eyes and flipping his hair while communicating with anyone. What is the best nursing response to this parent? a. ―This may indicate that he needs eyeglasses.‖ b. ―Children sometimes do these things for attention.‖ c. ―This behavior suggests low self-esteem.‖ d. ―Tics appear when a child is under stress.‖ ANS: D

The child cannot help such actions and should not be scolded for them because they are mainly a result of tension.

DIF: Cognitive Level: Application REF: p. 452 OBJ: 3 TOP: Nine-Year-Old KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. A seventh-grade girl tells the school nurse that her art teacher, a woman, is her hero. What is

the most appropriate interpretation of the girl‘s comment? a. The student may be exploring her career options. b. The comment is cause for concern about sexual abuse. c. The child may have difficulty interacting with her peers. d. Hero worship is a normal phenomenon.

ANS: D

School-age children tend to admire their teachers and adult companions. For the 11- to 12-year-old, hero worship is a normal phenomenon.

DIF: Cognitive Level: Comprehension REF: p. 452| Table 19.3 OBJ: 3 TOP: Social Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. Which stage of cognitive development is a 9-year-old child in according to Piaget? a. Formal operations b. Preoperational c. Concrete operations d. Sensorimotor ANS: C

School-age children are in the concrete operations stage of cognitive development.

DIF: Cognitive Level: Knowledge REF: p. 445 OBJ: 3 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. What statement by an 11-year-old child leads the nurse to determine he has moved from the

mind-set of egocentrism? a. ―I am a member of the best Cub Scout group in the world.‖ b. ―I must do my homework before I can play.‖ c. ―My dad can do anything!‖ d. ―I‘m sorry. I bet that hurt your feelings.‖ ANS: D

The ability to see another‘s point of view indicates moving away from egocentrism into a more altruistic mind-set.

DIF: Cognitive Level: Analysis REF: p. 445| Table 19.3 OBJ: 3 TOP: Increasing Understanding KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. A school-age child becomes frustrated with a school assignment and says, ―I can‘t do this!‖

What is the most developmentally supportive response from the parent? a. Ask, ―What is it that is so difficult?‖

b. Allow the child to quit the effort. c. Call in older siblings to help. d. Finish the project for them.

ANS: A

Helping the child focus on the problem that is keeping him from mastery can limit frustration.

Quitting or having someone else finish is detrimental to the development of industry.

DIF: Cognitive Level: Analysis REF: p. 448 | Table 19.2 OBJ: 3 TOP: Industry KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. What is best for the nurse to suggest to the parents of an overweight 9-year-old child to help

prevent obesity? a. Use whole milk as a between-meal snack because it is more filling than skim milk. b. Feed the child before family meal times to monitor intake more closely. c. Encourage the child to engage in physical activity for at least an hour a day. d. Remove all sweets and junk food from the house.

ANS: C

Regular physical activity reduces weight.

DIF: Cognitive Level: Comprehension REF: p. 458 | Nursing Tip OBJ: 7 TOP: Prevention of Obesity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. A parent confides in the school nurse that her 8-year-old twins argue and bicker constantly.

What is the best response by the nurse? a. Express alarm at the constant aggression. b. Voice concern and investigate referral for counseling. c. Inquire about what punitive action the parents have taken to stop it. d. Offer reassurance that such behavior is normal for 8-year-olds.

ANS: D

Argumentative and competitive behavior is normal in 8-year-olds.

DIF: Cognitive Level: Application REF: p. 452 | Table 19.3 OBJ: 3 TOP: Argumentative Behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. The school nurse is planning sex education classes for school-age children. What should the

nurse be sure to do? a. Use simple terms. b. Avoid slang or ―street‖ words and concepts. c. Keep topics on biological aspects of sexual development. d. Limit questions to keep content clear.

ANS: A

Using simple terms is essential but slang and street terms need to be clarified. Apply age-specific information across broad aspects of biological, social, and current attitudes.

DIF: Cognitive Level: Application REF: p. 447 OBJ: 7 TOP: Sex Education KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. Parents ask the pediatric nurse how school life might influence their growing child. What area

of development will the nurse indicate that school affects the least? a. Moral development b. Social development c. Physical development d. Cognitive development ANS: C

Physical development is the least affected by school life. Moral development occurs as they have experience with, and understand, rules and fairness in the school setting. Schools have a profound influence on the socialization of children, who bring to school what they have learned and experienced in the home. Success in school requires an integration of cognitive, receptive, and expressive (language) skills.

DIF: Cognitive Level: Application REF: p. 448 OBJ: 5 TOP: Impact of School Life KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. What basic ―feeling‖ words should the nurse use in attempting to help a 7-year-old girl

express her feelings about being in a new school? (Select all that apply.) a. Mad b. Glad c. Sad d. Scared e. Jealous ANS: A, B, C, D

The words ―mad,‖ ―glad,‖ ―sad,‖ and ―scared‖ are basic feeling words that can prompt a young child to better express his or her feelings.

DIF: Cognitive Level: Application REF: p. 458 | Nursing Tip OBJ: 3 TOP: Expression of Feelings KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The school nurse is preparing an educational program for new teachers regarding school-age

children. What information is accurate for the nurse to include? (Select all that apply.) a. Participation in group activity increases. b. Egocentricity prevails. c. Thinking is logical. d. Preference is toward family interaction. e. Understand cause and effect.

ANS: A, C, E

Piaget refers to the thought processes of the school-age period as concrete operations.

Concrete operations involve logical thinking and an understanding of cause and effect. The egocentric view of the preschool child is replaced by the ability to understand the point of view of another person. Between 6 and 12 years of age, children prefer friends of their own sex and usually prefer the company of their friends to that of their brothers and sisters.

DIF: Cognitive Level: Comprehension REF: p. 445 OBJ: 2 TOP: Personality Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. The pediatric nurse is presenting school-age children with information on safety issues to

follow when going home alone. What guidelines should they be educated to follow? (Select all that apply.) a. Ask for identification before letting someone in the house. b. Never accept rides with strangers. c. Keep doors locked. d. Do not enter house if door is ajar. e. Walk to and from school with friends.

ANS: B, C, D, E

Strangers should never be allowed in the house. Children should be instructed never to accept rides with strangers, to keep doors locked, not to enter the house if the door is ajar, and to walk to and from school with friends.

DIF: Cognitive Level: Comprehension REF: p. 450 | Health Promotion | p. 455 | Table 19.3 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. A 10-year-old child with disabilities is begging her parents for a dog. When at the pediatric

clinic, the parents inquire about possible benefits pet ownership may provide to their child.

What benefits of pet ownership should the nurse indicate? (Select all that apply.) a. Decrease the need for physical therapy b. Lower blood pressure c. Improve communication d. Foster trust e. Ease path to socialization ANS: B, C, D, E

Studies have documented the positive influence of pet ownership on improving the medical and psychological outcome after illness or surgery. Disabled children especially benefit from interacting with pets. The interaction with animals can lower blood pressure and heart rate, reduce loneliness and feelings of isolation, improve communication, foster trust, and motivate participation in physical therapy. Pets allow the ill child who feels separated from other people to feel companionship and acceptance. Shy children often find pet ownership eases the path to socialization with others who initiate contact because of the pet.

DIF: Cognitive Level: Comprehension REF: pp. 458-460 OBJ: 8 TOP: Pet Ownership KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION

1. The nurse advises the parents of a 6-year-old child to try and ensure at least ______ hours of

sleep daily for the child.

ANS:

11 The 6-year-old school-age child needs at least 11 hours of sleep.

DIF: Cognitive Level: Comprehension REF: p. 451 OBJ: 3 TOP: Sleep Needs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. The nurse is aware that by the age of _____, the first permanent teeth erupt.

ANS:

6 At the age of 6, the first permanent teeth erupt: the 6-year molars.

DIF: Cognitive Level: Knowledge REF: p. 446 OBJ: 3 TOP: Eruption of Permanent Teeth KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

Chapter 20: The Adolescent Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is assessing a 13-year-old boy. Which physical change indicates that male puberty

has begun? a. Development of axillary and facial hair b. Enlargement of penis c. Enlargement of testicles d. Pigmentation of the scrotum ANS: C

In boys, pubertal changes begin with enlargement of the testicles and internal structures.

DIF: Cognitive Level: Knowledge REF: p. 465 OBJ: 4 TOP: Physical Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A 13-year-old boy states, ―The girls in my class tower over me.‖ What would be the nurse‘s

most informative response? a. ―It may seem that way because girls have a growth spurt 2 years earlier than boys.‖ b. ―Perhaps your parents are not exceptionally tall.‖ c. ―Boys usually experience a growth spurt 1 year earlier than girls.‖ d. ―You may feel short, but you are actually average height for your age.‖ ANS: A

Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlier for girls than for boys.

DIF: Cognitive Level: Application REF: p. 465 OBJ: 4 TOP: Physical Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. A parent comments that her adolescent daughter seems to be daydreaming a lot. What does

the nurse understand this behavior to indicate regarding their daughter? a. She is bored. b. She is not getting enough rest. c. She is trying to block out stress and anxiety. d. She is mentally preparing for real situations.

ANS: D

Daydreaming allows adolescents to act out in their imaginations what will be said or done in certain situations. This helps them to prepare for and cope with interactions with others.

DIF: Cognitive Level: Comprehension REF: pp. 471-472 OBJ: 5 TOP: Development—Daydreams KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The nurse is planning a safety program for high school students. Which is the top cause of

accidental deaths during adolescence? a. Firearms b. Automobiles c. Drowning d. Diving injuries ANS: B

The chief safety hazard for the adolescent is automobiles.

DIF: Cognitive Level: Knowledge REF: p. 477 OBJ: 11 | 14 TOP: Safety KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A 16-year-old boy excitedly tells his parents that he was offered a part-time job. Which

response represents an effective problem-solving approach for his parents? a. ―Your studies are too important for you to have a part-time job.‖ b. ―When we went to high school, academics were the adolescent‘s priority.‖ c. ―We want you to put your earnings in a savings account.‖ d. ―How do you think you will manage your school work and a job?‖ ANS: D

An effective approach to help adolescents learn to solve problems is for parents to guide them in exploring alternatives.

DIF: Cognitive Level: Application REF: p. 475 | Health Promotion Box OBJ: 5 TOP: Parenting KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

6. The nurse is planning care of an adolescent. What psychosocial task does the nurse understand

is important for the adolescent to develop? a. A sense of initiative b. A sense of industry c. A sense of identity d. A sense of involvement ANS: C

Psychosocial milestones that must be accomplished during adolescence include the five Is—image of self, identity, independence, interpersonal relationships, and intellectual maturity.

DIF: Cognitive Level: Knowledge REF: p. 462 OBJ: 5 TOP: Psychosocial Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. A 13-year-old girl tells the school nurse that she is getting fat, especially in her hips and legs.

What understanding by the nurse would best guide the response? a. Many adolescents are unaware of proper nutrition. b. Adolescents of this age become less active and should eat fewer calories. c. Puberty is often preceded by fat deposits in these areas. d. As soon as menarche occurs, she will lose this excess weight.

ANS: C

Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips, thighs, and breasts, causing them to enlarge.

DIF: Cognitive Level: Application REF: p. 467 OBJ: 4 TOP: Physical Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. The school nurse is planning a program for girls about the physical changes of puberty. What

is the target age the nurse should choose for this program? a. 10 years b. 12 years c. 14 years d. 16 years ANS: A

Because puberty can occur in girls as early as age 10 years, instruction must be given by that age.

DIF: Cognitive Level: Comprehension REF: p. 465 OBJ: 4 TOP: Physical Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. What statement made by a parent indicates an understanding about helping a 13-year-old adult

manage his allowance? a. ―I set amounts he can earn for particular chores.‖ b. ―I give him a certain amount of money for each day.‖ c. ―I put money into his bank account each month.‖ d. ―I told him to ask me when he needs money.‖

ANS: A

If money is simply handed out as requested, it is difficult to develop responsibility for finances and money management. The older adolescent is able to get a job. The younger adolescent can earn money by doing particular chores.

DIF: Cognitive Level: Comprehension REF: p. 471 OBJ: 14 TOP: Development—Responsibility KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. What can the nurse suggests as a good dietary source of zinc for an adolescent who is a

vegetarian? a. Green, leafy vegetables b. Citrus fruits c. Nuts d. Enriched breads ANS: C

Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources include nuts, legumes, and wheat germ.

DIF: Cognitive Level: Comprehension REF: p. 476 OBJ: 12 TOP: Nutrition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. An adolescent‘s parent comments, ―My son seems so preoccupied with his appearance these

days. Is this normal?‖ What is the nurse‘s best response? a. ―It is his attempt to express his individualism.‖ b. ―His preoccupation with his looks is quite normal.‖ c. ―He is probably troubled with his physical changes.‖ d. ―This shows that he has a positive self-image.‖ ANS: B

Preoccupation with self-image is normal and accounts for the constant primping of adolescents.

DIF: Cognitive Level: Application REF: p. 466 | Table 20.1 OBJ: 13 | 4 TOP: Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. What foods would be a healthy choice for an adolescent who just finished playing in a

strenuous sports game? a. A cheeseburger and soda b. A hot fudge sundae c. Two sausage and egg breakfast sandwiches and orange juice d. A bagel and skim milk ANS: D

A bagel provides a rapid supply of carbohydrates to the muscles, and skim milk provides a slow release of carbohydrates to the muscles.

DIF: Cognitive Level: Comprehension

REF: p. 476

OBJ: 12

TOP: Nutrition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. When planning to answer a 16-year-old girl‘s questions about menstruation, the nurse must

consider cognitive development. What is developed during adolescence according to Piaget? a. The ability to view a situation from multiple perspectives b. The ability to focus more on the past than present situations c. The ability to exercise concrete reasoning d. The ability to consider hypothetical situations ANS: D

According to Piaget, in the formal operations stage adolescents have the ability to think abstractly.

DIF: Cognitive Level: Comprehension REF: p. 462 |Box 20.1 OBJ: 2 TOP: Cognitive Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. A girl tells the nurse that she and her best friend belong to the popular clique. She states, ―I

love Katy Perry, and I want to be a singer.‖ The nurse recognizes the girl‘s statement as characteristic of what time period? a. Early adolescence b. Middle adolescence c. Late adolescence d. The entire adolescent period ANS: A

Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent.

DIF: Cognitive Level: Comprehension REF: p. 470 OBJ: 9 TOP: Social Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse is leading a discussion group with parents of adolescents. One parent comments,

―My son can‘t do anything without checking with his friends first. My opinion doesn‘t count anymore.‖ What knowledge in regard to this behavior would the nurse formulate as a response? a. It is unusual for adolescent boys. b. It is often more apparent in boys than girls. c. It is a normal phenomenon during adolescence. d. It is suggestive of feelings of low self-worth.

ANS: C

Parents may need help understanding that the adolescent‘s exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family.

DIF: Cognitive Level: Comprehension REF: p. 470 OBJ: 9 TOP: Peer Relationships KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

16. What does an adolescent‘s peer group serve as related to development? a. Social outlet b. Association to blur personal identity c. Platform for ―group think‖ d. Initial separation from family ANS: D

Being a member of a peer group and communicating with and seeking approval from this group are hallmarks of the first separation from the family.

DIF: Cognitive Level: Comprehension REF: p. 474 OBJ: 9 TOP: Peer Groups KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. At what stage is the adolescent considered to be, according to Freud‘s theory? a. Conceptual b. Genital c. Glandular d. Pubertal ANS: B

Freud describes the adolescent period as genital.

DIF: Cognitive Level: Knowledge REF: p. 463 | Box 20.1 OBJ: 2 TOP: Freud KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse using the PACE interview guide for persons at risk for substance abuse arrives at a

score of 2 for an adolescent patient. How would the nurse interpret this score? a. Nonindicative of potential substance abuse b. Normal experimentation of the adolescent c. Need to schedule another PACE interview in 3 months d. Indication for referral for counseling ANS: D

The PACE guide recommends that a score of 2 or higher would suggest the need for a referral for counseling about substance abuse.

DIF: Cognitive Level: Analysis REF: p. 479 OBJ: 14 TOP: PACE Interview KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. What does adolescent acne result from? a. Ineffective sweat glands b. Oily skin c. Inadequate hygiene d. A poor diet ANS: B

Adolescent acne is the result of overactive sweat glands and oily skin.

DIF: Cognitive Level: Comprehension

REF: p. 463

OBJ: 14

TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The nurse suggests the use of ―I‖ messages to communicate a parent‘s feeling to an

adolescent. What is the most appropriate example of an ―I‖ message? a. ―I feel frightened when you stay out past your curfew.‖ b. ―I am your mother, and I insist that you observe your curfew.‖ c. ―I am sick and tired of your staying out late.‖ d. ―I expect you to show me proper respect.‖ ANS: A

This is the only statement that associates the parent‘s feelings about the adolescent behavior that is not aggressive or accusatory.

DIF: Cognitive Level: Analysis REF: p. 475 | Health Promotion Box OBJ: 14 TOP: ―I‖ Statements KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. A 13-year-old girl tells the nurse she is concerned because she has not had her first menstrual

period. What is the best initial response from the nurse? a. ―Your hormone levels may be irregular.‖ b. ―Could you be pregnant?‖ c. ―Age of first menstrual cycle varies.‖ d. ―Do not worry about it.‖ ANS: C

Puberty is easily recognized in girls by the onset of menstruation. The first menstrual period is called the menarche. It commonly occurs about age 12 or 13 years, but this varies. It may occur as early as age 10 years or as late as age 15 years.

DIF: Cognitive Level: Application REF: p. 465 OBJ: 10 TOP: Menstrual Cycle KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. The nurse is documenting the pediatrician‘s assessment of a female patient. When assessing

Tanner‘s stages of breast development there is elevation of papilla only. What stage of development will the nurse document? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: A

According to Tanner‘s Stages of Sexual Maturity, Stage 1 (preadolescent) is elevation of papilla only.

DIF: Cognitive Level: Application REF: p. 466 | Box 20.2 OBJ: 6 TOP: Breast Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development

23. The school nurse is educating high school students about guidelines to be followed when

participating in sports. Which statement by a student alerts the nurse of the need for further information? a. ―I will eat carbohydrates before practice.‖ b. ―I drink large amounts of fluid when working out.‖ c. ―I wear protective gear every time I play sports.‖ d. ―I avoid caffeine when participating in sports.‖ ANS: B

Fluids lost by sweat must be replaced by drinking small amounts of fluid during a workout.

Thirst is one guide for intake. Caffeine and alcohol deplete body water and are to be avoided.

Carbohydrates that provide both energy and other nutrients are best for athletes. Protective gear should be worn by all team players in any contact sport.

DIF: Cognitive Level: Application REF: p. 476 OBJ: 13 TOP: Sport Guidelines KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 1. Restlessness in adolescence is most likely attributed to which changes? (Select all that apply.) a. Drive to be accepted by society as an individual b. Urge for independence c. Establishment of a personal identity d. Intense libido e. Slowing of body changes ANS: A, B, C, D

All the options listed are sources of stress to the adolescent and are stimulants to restlessness except option E body changes are rapid.

DIF: Cognitive Level: Comprehension REF: p. 462 OBJ: 7 TOP: Sources of Stress for the Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What are the best breakfast choices for the nurse to point out prior to a big exam, to provide

high levels of alertness and increased memory? (Select all that apply.) a. Pancakes and syrup b. Coffee and chocolate-covered donuts c. Bacon and fried eggs d. Whole grain cereal and yogurt e. Oatmeal and sliced apples ANS: D, E

Meals high in protein will break down into norepinephrine and increase alertness. Meals with a high sugar content result in a soothing sleepy response. Meals high in fats digest slowly and draw blood from the brain during the lengthy digestive process.

DIF: Cognitive Level: Application REF: p. 472 OBJ: 12 TOP: Nutrition KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse considers what ―rites of passage‖ valued by the adolescent in American society?

(Select all that apply.) a. Attaining legal drinking age b. Selection of a career c. Religious affiliation d. Obtaining a driver‘s license e. High school graduation ANS: A, D, E

Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, driver‘s license, and matriculation through high school are such signals. Religious affiliation and selection of a career path do not necessarily signal adulthood.

DIF: Cognitive Level: Comprehension REF: p. 478 | Nursing Tip OBJ: 9 TOP: Rites of Passage KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. A mother confides in the school nurse that she witnessed her son kissing another boy. Which

concepts should guide the nurse to base a reply? (Select all that apply.) a. Homosexual behavior in adolescents is not uncommon. b. Homosexuality is a mental disorder. c. Adolescents often desire to explore alternative lifestyles. d. Homosexual tendencies should be addressed with counseling. e. Parents should immediately seek a support group for parents of gays.

ANS: A, C

Adolescents may experiment with an alternate sexual expression as part of their self-discovery. Homosexual activities are not uncommon in adolescence.

DIF: Cognitive Level: Comprehension REF: p. 473 OBJ: 11 TOP: Homosexuality KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The school nurse is discussing challenges of the adolescent years with a group of high school

students in health class. What challenges toward adolescent development will the nurse include? (Select all that apply.) a. b. c. d. e.

Developing intimacy Maintaining dependence on parents Searching for identity Adjusting to body changes Establishing future goals

ANS: A, C, D, E

Adolescents face the challenges of developing intimacy, searching for identity, adjusting to body changes, and establishing goals for the future. Adolescents are striving for independence from parents.

DIF: Cognitive Level: Comprehension

REF: p. 462

OBJ: 3

TOP: Challenges KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 1. The nurse stresses the need for using a sunscreen with a sun protection factor (SPF) of at least

_____.

ANS:

30 A sunscreen with an SPF of at least 30 is recommended to block sun rays that cause cancer.

DIF: Cognitive Level: Knowledge REF: p. 477 OBJ: 14 TOP: Sunscreen KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 21: The Child’s Experience of Hospitalization Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. Which child would have the most difficulty in coping with separation from parents because of

hospitalization? a. 3-month-old child b. 16-month-old child c. 4-year-old child d. 7-year-old child ANS: B

Separation anxiety occurs after age 6 months and is most pronounced in the toddler.

DIF: Cognitive Level: Comprehension REF: p. 485 OBJ: 3 TOP: Separation Anxiety KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days

ago. What does this behavior suggest? a. The toddler feels abandoned by his mother. b. The child still has not adjusted to his hospitalization. c. The child is not separated from his mother often. d. There is a poor mother–child bond.

ANS: A

Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization are obvious.

DIF: Cognitive Level: Analysis REF: p. 485 OBJ: 3 TOP: Separation Anxiety KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

3. Which statement best corresponds to a preschooler‘s understanding of hospitalization? a. ―A germ made me get sick.‖ b. ―I got sick because I was mad at my brother.‖ c. ―My tonsils are sick and they have to come out.‖ d. ―I have a cast because I broke my leg.‖ ANS: B

The preschooler may feel guilty, particularly if an accident happens as a result of mischief on his or her part.

DIF: Cognitive Level: Application REF: p. 496 OBJ: 5 | 9 | 10 TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The parents of a hospitalized toddler are upset because she seems more interested in her toys

when they come to visit her. In which stage of separation anxiety is the toddler? a. Protest b. Despair c. Denial d. Attachment ANS: C

In the stage of denial or detachment, the child appears to deny the need for the parents and becomes uninterested in their visits.

DIF: Cognitive Level: Comprehension REF: p. 486 OBJ: 3 TOP: Separation Anxiety KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nurse must make a room assignment for a 16-year-old adolescent with cystic fibrosis.

Which roommate would be the most appropriate for this patient? a. A 4-year-old child who had an appendectomy b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis c. A 15-year-old adolescent with type 1 diabetes mellitus d. To assign the adolescent to a private room ANS: C

Adolescents usually do better in rooms with one or more roommates than in single rooms. The adolescent would do best with a roommate who is closest to his or her age and also lives with a chronic illness.

DIF: Cognitive Level: Application REF: p. 497 OBJ: 9 | 11 TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his

younger sibling. What understanding would assist the nurse most in formulating a response? a. Preschool children can be disruptive in the hospital environment. b. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided. c. The sibling could view the infant from the doorway but not enter the room to prevent the spread of microorganisms.

d. The preschooler needs to visit his infant sister to reassure himself that she is all

right.

ANS: D

Siblings are affected by a child‘s hospitalization. Their ability to cope is influenced by their age, experience, and intactness of the family.

DIF: Cognitive Level: Application REF: p. 491 OBJ: 8 TOP: Siblings—Parents‘ Reaction to Hospitalization KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. A hospitalized toddler was drinking from a cup at home but now refuses to drink from

anything except his favorite bottle. What is the most likely reason for this behavior? a. He is dealing with the anxiety of hospitalization by regressing. b. He is demonstrating attention-seeking behaviors because of an overabundance of attention in the hospital. c. He is attempting to refocus the attention of the adults around him to avoid further painful procedures. d. He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they have mastered them.

ANS: A

Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital.

DIF: Cognitive Level: Comprehension REF: p. 495 OBJ: 1 | 10 TOP: Regression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 8. A nurse encourages a school-age child to draw a picture after a painful procedure. What is the

best rationale for this nursing intervention? a. Attempting to re-establish rapport b. Providing a way for the child to express his feelings c. Encouraging quiet play d. Distracting the child from thinking about the pain ANS: B

After treatments, the nurse should encourage children to draw and talk about their drawings or to act out their feelings through puppet play.

DIF: Cognitive Level: Comprehension REF: p. 497 OBJ: 9 | 11 TOP: The Hospitalized School-Age Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. What is the best suggestion by the nurse when parents ask, ―When is the best time to begin to

prepare a 5-year-old child for surgery and hospitalization?‖ a. ―As soon as the surgery is scheduled‖ b. ―About 2 weeks before surgery‖ c. ―About 4 days before surgery‖

d. ―On the night before admission to the hospital‖ ANS: C

Parents should prepare children for procedures and hospitalization a few days in advance.

DIF: Cognitive Level: Application REF: p. 492 OBJ: 10 TOP: The Nurse‘s Role in Hospital Admission—Preparing the Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. The mother of a 3-year-old child tells the nurse that she will be in to visit tomorrow around

12:00 PM. The next morning, the child asks the nurse, ―When is my mommy coming?‖ What is the nurse‘s best response? a. ―Your mommy will be here around noon.‖ b. ―Your mommy will be here when you have lunch.‖ c. ―Mommy will be here very soon.‖ d. ―Your mommy is coming in 4 hours.‖ ANS: B

The toddler and preschooler do not understand time yet. They understand time relationships through activities in their experience, such as naptime and mealtimes.

DIF: Cognitive Level: Application REF: p. 496 OBJ: 10 TOP: The Hospitalized Toddler/Preschooler KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. A 13-year-old girl has been hospitalized for the past week. When discussing the girl‘s feelings

about her illness, what would the nurse expect the girl to express as her biggest concern? a. Invasive procedures b. Loss of control c. Appearance d. Separation from her boyfriend ANS: C

Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image.

DIF: Cognitive Level: Comprehension REF: p. 497 OBJ: 11 TOP: The Hospitalized Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. The nurse notices that the mother of a child with cerebral palsy corrects and redoes many of

the things the nurse does for her child. What is the nurse‘s most appropriate response to this mother? a. ―Would you like to do all of your child‘s care?‖ b. ―I‘m doing the very best job that I can with your child.‖ c. ―Why don‘t you go have a cup of coffee? You are going to be exhausted if you don‘t take a break.‖ d. ―I‘d love for you to share with me some of the special things you do for your child.‖ ANS: D

The person who cares daily for the child with a chronic illness can provide information that will best guarantee continuity of care between the home and the hospital.

DIF: Cognitive Level: Application REF: p. 498 OBJ: 4 TOP: The Parents‘ ReactionKEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The mother of a hospitalized toddler states, ―He cries when I visit. Maybe I should just stay

away.‖ What is the nurse‘s best response? a. ―Perhaps you are right. He only gets upset when you have to leave.‖ b. ―It is important that you are here. This is a common reaction in children when they are separated from their parents.‖ c. ―It might be easier for your child if you would stay with him, but this decision is up to you.‖ d. ―We take good care of him and he seems fine when you are not here.‖ ANS: B

During the second stage of separation anxiety (despair), the child is quiet, is not crying, and is sad and depressed. The child will revert to protest when the parent arrives for a visit.

DIF: Cognitive Level: Application REF: p. 486 OBJ: 3 TOP: Separation Anxiety KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. What should the nurse, preparing to collect an admission history from parents who have

recently emigrated from Russia, keep in mind? a. Eye-to-eye contact is considered disrespectful. b. Touching the child‘s head means the nurse is superior. c. Smiling is inappropriate in a serious situation. d. Staring is a sign of the nurse‘s rudeness.

ANS: C

In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.

DIF: Cognitive Level: Comprehension REF: p. 490 OBJ: 4 TOP: Fostering Intercultural Communication KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 15. Which nursing action would facilitate rapport with a child and the child‘s parents during the

admission process? a. Direct the parents to undress the child. b. Answer questions in a calm and matter-of-fact way. c. Perform assessments and ask questions as quickly as possible. d. Express concern about the seriousness of the child‘s condition.

ANS: B

The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless of the child‘s condition.

DIF: Cognitive Level: Application REF: p. 492 TOP: Nurse‘s Role in Hospital Admission

OBJ: 4

KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 16. When a 2-year-old child returns to her hospital room following a diagnostic procedure, her

parents are not available, and the child is crying loudly. Which technique is most appropriate to alleviate the child‘s distress? a. Rock the child gently to sleep. b. Play with the child using pop-up toys. c. Role-play with the child to act out her feelings. d. Ask the child to draw a picture about her feelings.

ANS: B

Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help reduce anxiety and pain.

DIF: Cognitive Level: Application REF: p. 495 OBJ: 5 TOP: The Hospitalized Toddler KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 17. A 4-year-old child begins to cry when his mother tells him it is time for his operation. The

nurse understands this is an expected reaction. On which particular fear of the preschooler does the nurse base this understanding? a. Loss of control b. Restricted mobility c. Unfamiliar routines d. Invasive procedures ANS: D

The preschool child is afraid of bodily harm, particularly invasive procedures.

DIF: Cognitive Level: Comprehension REF: p. 496 OBJ: 5 TOP: The Hospitalized Preschooler KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 18. What statement by the parent of a hospitalized toddler leads the nurse to determine the parent

understands a hospitalized toddler‘s need for transitional objects? a. ―This stuffed animal makes him feel secure.‖ b. ―He insisted on bringing this dirty old blanket with him.‖ c. ―I‘m going to buy him a big stuffed animal from the gift shop.‖ d. ―I‘d like to get him some toys from the playroom.‖ ANS: A

The use of a transitional object such as a blanket or a favorite toy promotes security.

DIF: Cognitive Level: Application REF: p. 494 OBJ: 5 TOP: The Hospitalized Toddler KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 19. An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a

fractured femur. What does the nurse realize immobilization in this age group can generate feelings of in planning care of this child? a. Loss of control

b. Altered body image c. Shame and guilt d. Fear of bodily harm ANS: A

Forced dependency in the hospital, such as immobilization, can result in a feeling of loss of control and loss of security.

DIF: Cognitive Level: Application REF: p. 496 OBJ: 10 TOP: The Hospitalized School-Age Child KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. The nurse explains to the parents of a hospitalized child that their child will receive fentanyl

for an upcoming procedure. What advantage of fentanyl will the nurse explain? a. It is specifically designed for children. b. It has a rapid onset. c. It is nonaddicting. d. It has a long duration.

ANS: B

Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.

DIF: Cognitive Level: Knowledge REF: p. 488 OBJ: 6 TOP: Fentanyl KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. The nurse shares the information and timelines recorded on the interdisciplinary outline of

care for a child. What is this document? a. Clinical pathway b. Comprehensive nursing care plan c. Holistic care approach d. Incorporated cost analysis ANS: A

This document is the clinical pathway, which is a broad outline of interdisciplinary plan of care with specific timelines.

DIF: Cognitive Level: Comprehension REF: p. 493 OBJ: 9 TOP: Clinical Pathway KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 22. The anxious parent asks if there is a danger of her 2-year-old child becoming addicted to the

opioid pain reliever. What is the nurse‘s most helpful response? a. ―Although this drug is addictive, the doctor monitors the dose very carefully.‖ b. ―Don‘t worry. Addicted children are very easy to wean off the drug.‖ c. ―Addiction is rare in children when opiates are given for pain.‖ d. ―Addictive behaviors are easy to assess. The drug will be stopped if that happens.‖ ANS: C

Addiction is rare in children.

DIF: Cognitive Level: Comprehension

REF: p. 488

OBJ: 6

TOP: Pain Relief KEY: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What

intervention is appropriate for the nurse to implement? a. Involve the parents. b. Provide a simple explanation to the child. c. Let the child examine the equipment. d. Suggest coping techniques.

ANS: A

It is appropriate to involve the parents when performing a procedure on an infant. Providing a simple explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate interventions for an infant.

DIF: Cognitive Level: Application REF: p. 484 OBJ: 4 TOP: Age-Appropriate Interventions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. The pediatric nurse is caring for a child that weighs 15 kg and calls the physician for an order

for acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates ordering? a. 100 mg b. 150 mg c. 225 mg d. 250 mg ANS: C

Acetaminophen is commonly used for the relief of mild to moderate pain in infants and children. The maximum dose is 15 mg/kg/dose for infants and children, with a maximum of 5 doses in 24 hours.

DIF: Cognitive Level: Analysis REF: p. 488 OBJ: 6 TOP: Age-Appropriate Interventions KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 1. What will the nurse include when documenting the discharge of a pediatric patient? (Select all

that apply.) a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation e. Instructions that were given to physician ANS: A, B, C, D

Information that should be included in the discharge note include time of discharge, adults accompanying the child and relationship to the child, condition of the child, and method of transportation. It should also be documented that instructions were given to parents.

DIF: Cognitive Level: Application REF: p. 498 | Legal and Ethical Considerations Box OBJ: 12 TOP: Discharge Documentation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 2. The nurse suggests to parents that they use the outpatient surgical center for their child‘s

upcoming surgery. What advantage(s) does this type of facility have to offer? (Select all that apply.) a. Lower cost b. Less incidence of health care–associated infections c. Reduction of parent–child separation d. Ample time for recuperation at the facility e. Decreased emotional impact of illness ANS: A, B, C, E

All options listed are advantages of outpatient services with the exception of recuperating at the facility.

DIF: Cognitive Level: Comprehension REF: pp. 483-484 OBJ: 2 TOP: Outpatient Facilities KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. What are the basic fears of a young child being hospitalized? (Select all that apply.) a. Separation b. Permanent scarring c. Pain d. Cost e. Body intrusion ANS: A, C, E

Small children all share the same basic fears relative to hospitalization, which are separation from family, pain, and body intrusion or mutilation.

DIF: Cognitive Level: Comprehension REF: p. 485 OBJ: 5 TOP: Basic Fear KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. What information will the nurse include when taking a developmental history? (Select all that

apply.) a. Previous experience with hospitalization b. Cultural needs c. History of illness d. Allergies e. Child‘s nickname ANS: A, B, E

The developmental history has information about the child and the child‘s developmental and cultural needs and personal preferences. The information relative to history of illness or allergies would be covered in the medical history.

DIF: Cognitive Level: Application TOP: Developmental History

REF: p. 492 OBJ: N/A KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are

appropriate for the nurse to implement? (Select all that apply.) a. Model desired behavior. b. Instruct patient not to yell. c. Use distractions. d. Explain the procedure in detail. e. Encourage the child to ask questions.

ANS: A, C

Whenever possible the parent should be involved in the preparation for and initiation of a treatment or procedure, and the child should be prepared according to his or her developmental level. For a toddler, model the behavior desired (i.e., opening the mouth), tell the child it is okay to yell if the treatment or procedure is uncomfortable, and use distractions.

Explaining the procedure in detail and encouraging questions are appropriate interventions for an older child.

DIF: Cognitive Level: Application REF: p. 484 OBJ: N/A TOP: Promoting a Positive Experience KEY: Nursing Process Step: Intervention MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. Parents are preparing their child for admission to the pediatric unit for minor surgery. What

should they expect to see when visiting the pediatric unit? (Select all that apply.) a. Nurses wearing all white b. Formal atmosphere c. Availability of a playroom d. Dim lighting e. Colored bedding ANS: C, E

The children‘s hospital unit differs in many respects from adult divisions. The pediatric unit or hospital is designed to meet the needs of children and their parents. A cheerful, casual atmosphere helps to bridge the gap between home and hospital and is in keeping with the child‘s emotional, developmental, and physical needs. Nurses wear colorful uniforms, and colored bedspreads and wagons or strollers for transportation provide a more homelike atmosphere. The physical structure of the unit includes furniture of the proper height for the child, soundproof ceilings, and color schemes with eye appeal. Most pediatric departments include a playroom.

DIF: Cognitive Level: Knowledge REF: pp. 484-485 OBJ: 2 TOP: Health Care Delivery Settings/Pediatric Unit KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

Chapter 22: Health Care Adaptations for the Child and Family Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE

1. What is the best pulse location for the nurse to use when assessing the pulse rate on a

12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral ANS: B

Apical pulses are advised for children under age 5 years.

DIF: Cognitive Level: Knowledge REF: p. 505 OBJ: 10 TOP: Physical Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID

bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the child‘s name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet.

ANS: C

After confirmation of the child‘s identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

DIF: Cognitive Level: Application REF: pp. 500-501 OBJ: 2 TOP: ID Bracelets KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen.

What statement made by the adolescent led the nurse to determine she understood the instructions? a. ―I should wash my perineum with soap and water, then begin to urinate.‖ b. ―I clean the perineum from front to back with an antiseptic wipe before I urinate.‖ c. ―I‘ll collect the first stream of urine in a sterile container.‖ d. ―I will discard the first void and collect a freshly voided specimen 30 minutes later.‖ ANS: B

To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

DIF: Cognitive Level: Analysis REF: p. 511 OBJ: 7 TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. Which strategy might the nurse use when administering oral medications to a young child

who is reluctant? a. Mix the medication with chocolate milk. b. Tell the child that the medication is candy. c. Give the medication quickly if the child is crying.

d. Offer the child fruit juice after the medication is swallowed.

ANS: D

The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk because the child may develop distaste for it.

DIF: Cognitive Level: Application REF: p. 516 | Skill 22.6 OBJ: 9 TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. A parent tells the nurse, ―I‘m not sure how to give this medicine to my infant.‖ How would

the nurse teach the parent to best administer an oral suspension? a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and placing the medication in the side of the infant‘s mouth. d. Administer the medication with a dropper onto the back of the infant‘s tongue.

ANS: C

An oral syringe is a useful device for measuring small quantities of medications for infants.

The syringe is placed midway back, at the side of the mouth.

DIF: Cognitive Level: Application REF: p. 515 OBJ: 9 TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the

auricle when administering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out ANS: A

For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

DIF: Cognitive Level: Application REF: p. 517 | Skill 22.8 OBJ: 9 TOP: Administering Ear Drops KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. Why is a tympanic thermometer considered more accurate than other types of thermometers? a. The thermometer probe is blunt and wide. b. It takes a brief time to register. c. The tympanic membrane shares circulation with the hypothalamus. d. The tympanic membrane and the brain have the same temperature.

ANS: C

The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the hypothalamus share the same circulation.

DIF: Cognitive Level: Knowledge REF: p. 508 OBJ: 10 TOP: Tympanic Thermometer KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? a. Discard the residual and increase the volume of feeding by the amount of residual. b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding. c. Refill the syringe with formula after it has completely emptied. d. Position the child on the right side after a feeding.

ANS: D

To prevent regurgitation and aspiration, the child is placed in the Fowler‘s position or on the right side to promote gastric emptying after a gastrostomy tube feeding.

DIF: Cognitive Level: Application REF: p. 529 | Skill 22.10 OBJ: 14 TOP: Enteral Feedings KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 9. Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of

an infant? a. Mummy b. Clove hitch c. Jacket d. Elbow ANS: A

A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.

DIF: Cognitive Level: Comprehension REF: p. 502 OBJ: 12 TOP: Restraining the Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. How often should a child who has a continuous intravenous infusion should be assessed? a. Hourly b. Every 2 hours c. Every 3 hours d. Every 4 hours ANS: A

The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

DIF: Cognitive Level: Knowledge REF: p. 519 TOP: Administering Parenteral Medications KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: 12

11. The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug

is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide?

a. b. c. d.

1.25 1.4 1.6 1.8

ANS: B

This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an infant.

DIF: Cognitive Level: Analysis REF: p. 517 | Medication Safety Alert| p. 525 OBJ: 11 TOP: Administering Injections KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. Which intervention will the nurse implement when suctioning a tracheostomy? a. Suction for two to three breaths. b. Clear the catheter with water after suctioning for reuse. c. Apply suction for no more than 15 seconds. d. Establish a regular schedule for suctioning.

ANS: C

Suctioning should be limited to 15 seconds.

DIF: Cognitive Level: Application REF: p. 530 OBJ: 16 TOP: Respiration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. What emergency action should be implemented for airway obstruction in the infant? a. Six to 10 midsternal thrusts b. Five back blows followed by five chest thrusts c. Five chest thrusts followed by five back blows d. Abdominal thrusts until the object is expelled ANS: B

Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the infant.

DIF: Cognitive Level: Knowledge REF: p. 534 TOP: Management of Airway Obstruction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: 2

14. A 4-year-old child asks tearfully if the IM injection will hurt. What is the nurse‘s most

effective response? a. ―No. It is over before you know it.‖ b. ―Yes. It will sting a little.‖ c. ―No. Would you like to see the syringe?‖ d. ―Yes. Your mom and I are going to hold you to help you be still.‖ ANS: B

Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

DIF: Cognitive Level: Application REF: p. 518 OBJ: 11 TOP: Preparation for an IM Injection KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. Where is the best site for giving an IM injection to a 15-month-old child? a. Ventrogluteal muscle b. Dorsogluteal muscle c. Deltoid muscle d. Vastus lateralis muscle ANS: D

The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

DIF: Cognitive Level: Application REF: p. 517 OBJ: 11 TOP: Administering Injections KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 16. What factor does the nurse explain affects the infant‘s physiological response to medications? a. Faster metabolism in the liver b. Slower intestinal transit c. Immature kidney function d. Increased secretion of hydrochloric acid ANS: C

Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of age.

DIF: Cognitive Level: Comprehension REF: p. 514 TOP: Physiological Responses to Medication KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

OBJ: 4

17. What intervention should the nurse implement after topical administration of hydrocortisone

cream to the buttocks and abdomen of an infant? a. Diaper the infant snugly with a disposable diaper. b. Cover the area with a transparent dressing. c. Apply a cloth diaper. d. Place the infant on a plastic pad, undiapered.

ANS: C

Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left undiapered on a cloth pad.

DIF: Cognitive Level: Application REF: p. 514 OBJ: 2 TOP: Rapid Absorption of Drug KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. Which observation on entering the hospital room lets the nurse know that there is a need for

the parents to receive safety education to prevent unintentional injury?

a. b. c. d.

The blanket is not tucked into the mattress.

Diapers and wipes are stacked at the foot of the crib.

The crib side is locked in the up position.

Pillows are stacked on the bedside table.

ANS: B

Disposable diapers and supplies must be kept out of the infant‘s reach to prevent accidental suffocation.

DIF: Cognitive Level: Analysis REF: p. 501 OBJ: 2 TOP: Essential Safety Measures KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 19. A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the

child will assume for this procedure? a. ―On your stomach with your head turned to the side.‖ b. ―On your side, keeping the legs bent and the head arched back.‖ c. ―On your back with your legs extended straight out.‖ d. ―On your side with the knees bent and the head close to the knees.‖ ANS: D

The child is positioned on his or her side with the knees flexed, and the head is brought down close to the flexed knees.

DIF: Cognitive Level: Application REF: p. 513 OBJ: 8 TOP: Collecting Specimens—Lumbar Puncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. The nurse is caring for a 4-year-old child. What will the nurse expect the child‘s daily urinary

output to be? a. 400 to 500 mL b. 500 to 600 mL c. 600 to 720 mL d. 700 to 1000 mL ANS: C

The average daily excretion of urine for a 4-year-old child is 600 to 720 mL. DIF: Cognitive Level: Knowledge REF: p. 512 | Table 22.1 OBJ: 7 TOP: Collecting Specimens—Urine Output KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 21. An infant‘s dry diaper weighs 2.5 g. The wet diaper weighs 47 g. How would the nurse record

the infant‘s urine output? a. 47 mL b. 44.5 mL c. 43.5 mL d. 40.5 mL ANS: B

Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one milliliter of output. 47 – 2.5 = 44.5 g = 44.5 mL of urine.

DIF: Cognitive Level: Analysis REF: p. 528 | Nursing Tip OBJ: 7 TOP: Collecting Specimens—Urine Output KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 22. The nurse instructs the mother of a 2-year-old child who is taking iron supplements for

anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse? a. Red meat b. Green, leafy vegetables c. Acidic fruit juices d. Egg yolks ANS: D

Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement.

DIF: Cognitive Level: Application REF: p. 528 | Table 22.5 OBJ: 2 TOP: Food/Drug Interactions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. The pediatric nurse completes an assessment on all patients assigned during evening shift at

the hospital. Which patient assessment requires immediate intervention? a. Toddler with an axillary temperature of 99°F b. School-age child with widening pulse pressure c. Infant pulse rate of 100 beats/minute d. Adolescent with a respiratory rate of 28 breaths/minute ANS: B

A widening pulse pressure can indicate increased ICP; therefore, it is the priority. An axillary temperature of 99°F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments.

DIF: Cognitive Level: Application REF: p. 504 OBJ: 5 TOP: Vital Signs KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial

position will the nurse maintain for this patient? a. Left side-lying b. Supine c. Prone d. Semi-Fowler‘s ANS: B

The adolescent may avoid post–lumbar puncture headache by lying flat for some time.

DIF: Cognitive Level: Application REF: p. 514 OBJ: 8 TOP: Lumbar Puncture KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 1. Informed consent for a minor guarantees that the parent or legal guardian understands what

aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be brought for damages d. That the document must be signed and witnessed e. That information was given ANS: A, B, D, E

The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed.

DIF: Cognitive Level: Comprehension REF: p. 500 OBJ: 4 TOP: Informed Consent KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 2. Which specific drug(s) should be checked with a second licensed nurse prior to

administration? (Select all that apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts e. Anticoagulants ANS: A, B, D, E

Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a licensed nurse prior to administration.

DIF: Cognitive Level: Comprehension REF: p. 521 | Medication Safety Alert OBJ: 2 TOP: Drug Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. A 3-year-old patient is admitted to the pediatric unit with a fever of 103°F. Which actions will

the nurse implement? (Select all that apply.) a. Assess rectal temperature every 4 hours. b. Administer acetaminophen as ordered. c. Assess skin turgor. d. Restrict fluids. e. Assess level of consciousness.

ANS: B, C, E

When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants and children, skin turgor should be assessed.

Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.

DIF: Cognitive Level: Application REF: p. 508 OBJ: 6 TOP: Fever KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. What should the nurse assess to determine the method of transportation for a pediatric patient?

(Select all that apply.) a. Age b. Race c. Vital signs d. Distance to travel e. Level of consciousness ANS: A, D, E

The means by which the child is transported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel.

DIF: Cognitive Level: Comprehension REF: p. 502 OBJ: 3 TOP: Modes of Transportation KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION 1. The order reads, ―Give ampicillin oral suspension 400 mg PO every day.‖ The vial reads,

―Ampicillin 125 mg/5 mL.‖ The nurse will give a dose of ______ mL. ANS:

16 Per the safe drug dose calculation, 16 mL is the correct dose to give.

DIF: Cognitive Level: Analysis REF: p. 525 OBJ: 13 TOP: Pediatric Dose Calculation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. After instilling nose drops, the nurse will keep the infant in the head down position for at least

_________ seconds.

ANS:

30 The retained position for 30 seconds to 1 minute allows the nose drops to enter deeply into the nostril.

DIF: Cognitive Level: Comprehension REF: p. 515 | Skill 22.7 OBJ: N/A TOP: Nose Drops KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

Chapter 23: The Child with a Sensory or Neurological Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A parent comments that her infant has had several ear infections in the past few months. Why

are infants more susceptible to otitis media? a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure. c. They have increased susceptibility to upper respiratory tract infections. d. The Eustachian tube is short, straight, and wide.

ANS: D

An infant‘s Eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.

DIF: Cognitive Level: Knowledge REF: p. 539 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What statement by a patient‘s mother leads the nurse to determine she understands

instructions about administering an oral antibiotic for otitis media? a. ―I will continue using the medication until symptoms are relieved.‖ b. ―I will share the medicine with siblings if their symptoms are the same.‖ c. ―I will give the medication with a glass of milk.‖ d. ―I will administer prescribed doses until all the medication is used.‖ ANS: D

Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.

DIF: Cognitive Level: Application REF: p. 542 | Nursing Tip OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. Which situation would cause the nurse to suspect a hearing impairment? a. 3-month-old infant with a positive Moro (startle reaction) reflex b. 15-month-old toddler who is babbling c. 18-month-old toddler who is speaking one-syllable words d. 24-month-old toddler who communicates by pointing ANS: D

The child who is not making verbal attempts by 24 months should undergo a complete physical examination.

DIF: Cognitive Level: Analysis REF: pp. 540-541 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

4. What is the best way for the nurse to communicate with a 10-year-old child who has a hearing

impairment? a. Use gestures and signs as much as possible. b. Let the child‘s parents communicate for her. c. Face the child and speak clearly in short sentences. d. Recognize that the child‘s ability to communicate will be on a 6-year-old child‘s level.

ANS: C

The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.

DIF: Cognitive Level: Application TOP: Hearing Impairment MSC: NCLEX: Physiological Integrity

REF: p. 543 OBJ: 3 KEY: Nursing Process Step: Implementation

5. What would the nurse include when planning postoperative teaching for a child who has had a

tympanostomy with insertion of tubes? a. Keeping the infant flat after feeding b. Giving over-the-counter decongestants c. Avoiding getting water in the ears d. Cleaning the ear canal with cotton-tipped applicators ANS: C

After a tympanostomy, care should be taken to avoid getting water in the ears.

DIF: Cognitive Level: Comprehension REF: p. 542 TOP: Postoperative Care of Tympanostomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: 2

6. What assessment made by the school nurse would lead to the suspicion of strabismus? a. Reddened sclera in one eye b. Child covers one eye to read the chalkboard c. Child complains of a headache d. Copious tears while watching TV ANS: B

Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder.

DIF: Cognitive Level: Analysis REF: p. 545 OBJ: 5 TOP: Strabismus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. What might the nurse explain as a common treatment for amblyopia? a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractory muscles to rest c. Using glasses that will slightly blur the image for the good eye d. Using corticosteroids to treat inflammation of the optic nerve

ANS: A

Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.

DIF: Cognitive Level: Knowledge REF: p. 545 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. What assessment does the school nurse recognize as the cardinal sign of a hyphema? a. Opacity of the lens b. A yellow-white reflex on the pupil c. A dark-red spot in front of the iris d. Inflamed mucous membranes of the eyelids ANS: C

A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.

DIF: Cognitive Level: Knowledge REF: p. 547 OBJ: N/A TOP: Hyphema KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse is planning to teach parents about prevention of Reye‘s syndrome. What

information would the nurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parents to have their children immunized against Reye‘s syndrome. c. Avoid giving salicylate-containing medications to a child who has viral symptoms. d. Get the child tested for Reye‘s syndrome if the child exhibits fever, vomiting, and lethargy.

ANS: C

Prevention of Reye‘s syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms.

DIF: Cognitive Level: Application REF: p. 550 OBJ: 10 TOP: Reye‘s Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. What symptom leads the nurse caring for a 5-month-old child with viral influenza to suspect

the development of Reye‘s syndrome? a. Respirations drop from 18 to 14 breaths/minute b. Falling asleep after feeding c. Sudden vomiting without effort d. Development of a macular rash ANS: C

A child with a viral infection is at risk for Reye‘s syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal.

DIF: Cognitive Level: Application TOP: Reye‘s Syndrome

REF: p. 550 OBJ: 10 KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. What does the nurse explain to parents of a child with febrile seizures? a. They occur when the body temperature exceeds 38.3C (101F). b. They can be prevented by anticonvulsant medication. c. They usually lead to the development of epilepsy. d. They occur when the temperature rises quickly.

ANS: D

Febrile seizures occur in response to a rapid rise in temperature, often above 38.8C (102F).

DIF: Cognitive Level: Comprehension REF: p. 553 OBJ: 13 TOP: Febrile Seizures KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A parent reports that her child has begun to do poorly at school and experiences episodes

where he appears to be staring into space. Of which type of seizure is this behavior a characteristic? a. Absence b. Akinetic c. Myoclonic d. Complex partial ANS: A

Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.

DIF: Cognitive Level: Comprehension REF: p. 555 | Table 23.2 OBJ: 13 TOP: Epilepsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. An adolescent has just had a generalized seizure and collapsed in the school nurse‘s office.

When should the nurse should call 911? a. The seizure lasts more than 5 minutes. b. The child is sleepy and lethargic after the seizure. c. The child vomited at the onset of the seizure. d. The child is confused and has slurred speech after the seizure.

ANS: A

If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.

DIF: Cognitive Level: Application REF: p. 555 | Table 23.2 OBJ: 13 TOP: Epilepsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic

seizure? a. Assist the child to bed and then go for help. b. Move objects out of the child‘s immediate area. c. Stick a padded tongue blade between the child‘s teeth. d. Manually restrain the child.

ANS: B

During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

DIF: Cognitive Level: Application REF: p. 555 | Table 23.2 OBJ: 13 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds.

What would the nurse expect to assess after a generalized tonic-clonic seizure? a. Restlessness b. Sleepiness c. Nausea d. Anxiety ANS: B

Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.

DIF: Cognitive Level: Comprehension REF: p. 555 | Table 23.2 OBJ: 13 | 15 TOP: Epilepsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What would the nurse include when creating a teaching plan that includes the long-term

administration of phenytoin (Dilantin)? a. The medication should be given on an empty stomach. b. Insomnia can be a significant side effect. c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored.

ANS: C

Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day.

DIF: Cognitive Level: Comprehension REF: p. 557 | Table 23.3 | Figure 23.10 OBJ: 13 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the

child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed ANS: C

Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

DIF: Cognitive Level: Comprehension TOP: Cerebral Palsy

REF: p. 559 OBJ: 14 KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. Which assessment finding in a child with meningitis should be reported immediately? a. Irregular respirations b. Tachycardia c. Slight drop in blood pressure d. Elevated temperature ANS: A

Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately, because they could indicate increased intracranial pressure.

DIF: Cognitive Level: Application REF: p. 552 OBJ: 11 TOP: Meningitis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity 19. The nurse observes a child‘s position is supine with his arms and legs rigidly extended and the

hands pronated. How does the nurse identify this posture? a. Correct anatomical position b. Decorticate c. Decerebrate d. Opisthotonos ANS: C

In decerebrate posturing, arms are extended along the side of the body and hands are pronated.

This posture indicates brainstem function only.

DIF: Cognitive Level: Application REF: p. 565 | Figure 23.13 OBJ: 17 TOP: Posturing KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. What will the nurse teach parents when giving instructions for acute conjunctivitis? a. Apply cool compresses to the affected eye several times a day. b. Instill topical steroid eyedrops for 1 week. c. Clear drainage from the inner to the outer aspect of the eye. d. Keep the eye patched until the inflammation resolves.

ANS: C

Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).

DIF: Cognitive Level: Application REF: p. 547 OBJ: N/A TOP: Conjunctivitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. A child is brought to the emergency department after he fell and hit his head on the ground.

Which nursing assessment suggests the child has a concussion? a. Sleepy but easily arousable b. Complaining of a stiff neck c. Cannot remember what happened to him d. Pupils react sluggishly to light

ANS: C

A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

DIF: Cognitive Level: Analysis REF: p. 564 OBJ: 15 TOP: Head Injury KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A child is admitted to the hospital because she had a seizure. Her parents report that for the

past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect? a. Meningitis b. Reye‘s syndrome c. Brain tumor d. Encephalitis ANS: C

The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

DIF: Cognitive Level: Analysis REF: p. 552 OBJ: N/A TOP: Brain Tumor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse urges the mother of a 6-month-old child to get her child inoculated with

Haemophilus influenzae type B. What does this immunization protect against? a. Encephalitis b. Influenza c. Bacterial meningitis d. Otitis media ANS: C

H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.

DIF: Cognitive Level: Knowledge REF: p. 551 OBJ: 11 TOP: Prevention of Meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. The nurse is caring for a 3-year-old child with a head injury. Which assessment would lead

the nurse to report the probability of increasing intracranial pressure (ICP)? a. Temperature increase from 37.2C (99F) to 37.7C (100F) b. Increase in blood pressure with an attendant decrease in pulse c. Increase in respirations d. Equilateral pupils ANS: B

Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.

DIF: Cognitive Level: Comprehension REF: p. 553|Figure 23.9 OBJ: 12 TOP: ICP KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 25. A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be

corrected? a. Patching the unaffected eye b. Corrective lenses c. Laser treatment d. Surgery ANS: B

In nonparalytic strabismus, the refractory error is usually corrected with eyeglasses.

DIF: Cognitive Level: Comprehension REF: p. 546 OBJ: 5 TOP: Strabismus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 26. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple

approaches they implement in dealing with various challenges. Which statement by the parents alerts the nurse they need further instruction? a. ―We dress our son every morning for school.‖ b. ―Our son participates in the Special Olympics every year.‖ c. ―Our son attends play therapy at a center close to home.‖ d. ―We attend a support group once a week.‖ ANS: A

The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not ―take over‖ projects because of their own need to assist or speed up the process.

DIF: Cognitive Level: Application REF: p. 563 |Nursing Tip OBJ: 16 TOP: Cognitive Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment 27. What would the nurse include in teaching when preparing to teach parents about air travel

instructions to prevent barotrauma in infants? a. Using ear plugs during takeoff b. Omitting the meal just before takeoff c. Letting the infant nurse during descent d. Applying ear drops before takeoff ANS: C

Encouraging an infant to swallow reduces the pressure in the ears during descent.

DIF: Cognitive Level: Comprehension REF: p. 543 OBJ: 1 TOP: Barotrauma KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE

1. Which assessments would cause the pediatric nurse to suspect the probability of an ear

infection in a 6-month-old child? (Select all that apply.) a. Hypersensitivity to noise b. Irritability c. Ecchymotic ear canal d. Rolls head from side to side e. Temperature of 39.4C (103F) ANS: B, D, E

Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.

DIF: Cognitive Level: Comprehension REF: p. 541 | Nursing Tip OBJ: 2 TOP: Indications of Ear Infection KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. Which aspect(s) of a child‘s development does the nurse caution parents that hearing

impairment can affect? (Select all that apply.) a. Speech clarity b. Language development c. Immunity to disease d. Personality development e. Academic achievement ANS: A, B, D, E

All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.

DIF: Cognitive Level: Comprehension REF: p. 542 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What intervention(s) would the nurse caring for a child with infectious meningitis include?

(Select all that apply.) a. Isolation precautions b. Provision of brightly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions ANS: A, C, D, E

All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive care of a child with meningitis.

DIF: Cognitive Level: Application REF: pp. 551-552 OBJ: 11 TOP: Nursing Care of Child with Meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. What will the nurse include when documenting a grand mal seizure? (Select all that apply.) a. Presence of incontinence

b. c. d. e.

Current dose of antispasmodic medication Activity level prior to and following seizure Level of consciousness following seizure Length of seizure

ANS: A, C, D, E

Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.

DIF: Cognitive Level: Application REF: p. 554 OBJ: 13 TOP: Documentation of Seizure KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What

information will the nurse include? (Select all that apply.) a. Encourage books with large type. b. Words in books should be closely spaced. c. Provide adequate lighting without glare. d. Be sure desks and chairs are adequate height. e. Instruct child to squint when reading.

ANS: A, C, D

Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height.

DIF: Cognitive Level: Comprehension REF: p. 546 OBJ: 6 TOP: Eyestrain KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 6. An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be

implemented? (Select all that apply.) a. Parental education regarding prevention b. Respiratory support c. Cardiovascular support d. Controlled rewarming e. Adequate cerebral oxygenation ANS: B, C, D, E

Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up.

DIF: Cognitive Level: Comprehension REF: p. 568 OBJ: 15 TOP: Near-drowning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 24: The Child with a Musculoskeletal Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition

MULTIPLE CHOICE 1. What would the nurse include in planning teaching to parents of a child with

Legg-Calvé-Perthes disease about the long-term effects of this disease? a. There are no long-term effects. b. The disease is self-limited and requires no long-term treatment. c. Degenerative arthritis may develop later in life. d. There is risk of osteogenic sarcoma in adulthood.

ANS: C

Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life.

DIF: Cognitive Level: Comprehension REF: p. 584 OBJ: 11 TOP: Legg-Calvé-Perthes Disease KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. What intervention will the nurse caring for a child in Buck skin traction implement? a. Position in high Fowler‘s position. b. Assist the child to be pulled up in bed. c. Keep child‘s heel on the bed surface. d. Maintain child‘s feet against the foot of the bed.

ANS: B

Buck traction is a type of skin traction that relies on the child‘s weight as counterbalance. The child must be kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.

DIF: Cognitive Level: Application REF: p. 577 OBJ: 6 TOP: Buck‘s Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What will the nurse include when caring for a child in Buck‘s extension? a. Positioning the child with hips flexed 90 degrees at all times b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule ANS: C

The skin exposed to frequent friction may break down.

DIF: Cognitive Level: Application REF: p. 579 | Nursing Tip OBJ: 6 TOP: Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse is reviewing the characteristics of Ewing‘s sarcoma. Which statement if made by

the nurse indicates correct understanding of this disease? a. ―Amputation is the accepted treatment.‖ b. ―The disease is sensitive to radiation and chemotherapy.‖ c. ―Metastasis is rare.‖ d. ―The disease is more prevalent among toddlers and preschoolers.‖

ANS: B

Ewing‘s sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize.

DIF: Cognitive Level: Comprehension REF: p. 585 OBJ: N/A TOP: Ewing‘s Sarcoma KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 5. What characteristic manifestation does the nurse caring for a child with Duchenne‘s muscular

dystrophy document? a. Ambulates by holding onto furniture. b. Exhibits atrophy of the calf muscles. c. Falls frequently and is clumsy. d. Has delayed fine-motor development.

ANS: C

Frequent falling and clumsiness are clinical manifestations of Duchenne‘s muscular dystrophy.

DIF: Cognitive Level: Knowledge REF: p. 584 OBJ: 10 TOP: Duchenne‘s Muscular Dystrophy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse assessing a child with juvenile rheumatoid arthritis notes the child‘s right knee and

ankle are swollen, warm, and tender. The child has a temperature of 38.8C (102F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest? a. Psoriatic b. Enthesitis c. Systemic d. Acute febrile ANS: C

The systemic form of juvenile rheumatoid arthritis is associated with an elevated temperature, erythrocyte sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash.

DIF: Cognitive Level: Application REF: pp. 588-586 OBJ: 12 TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse is providing instructions about how to treat a sprained ankle. What statement by the

mother does the nurse recognize as indicative of a need for additional teaching? a. ―Apply warm compresses to the ankle for the first 24 hours.‖ b. ―Put an ice pack on the ankle, alternating 30 minutes on with 30 minutes off.‖ c. ―Wrap the ankle in an Ace bandage for support.‖ d. ―Keep the leg elevated when sitting.‖ ANS: A

Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation.

DIF: Cognitive Level: Application REF: p. 575 | Memory Jogger OBJ: 4 TOP: Soft Tissue Injury KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. How does Russell traction provide adequate skin traction? a. Subluxates the tibia. b. Does not interfere with range of motion. c. Prevents the knee from flexing. d. Supplies continuous pull in two directions.

ANS: D

Russell traction is skin traction, similar to Buck, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions.

DIF: Cognitive Level: Comprehension REF: p. 576 OBJ: 6 TOP: Russell Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is checking for capillary refill on a child in Bryant‘s traction. How long does it take

for the toe to regain color if adequate perfusion is assessed? a. 3 seconds b. 4 seconds c. 5 seconds d. 6 seconds ANS: A

Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.

DIF: Cognitive Level: Comprehension REF: p. 579 | Skill 24.1 OBJ: 8 TOP: Fracture KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The parent of a child with osteomyelitis asks why his child is in so much pain. What will the

nurse respond causes the pain experienced with osteomyelitis? a. ―Pressure of inelastic bone‖ b. ―Purulent drainage in the bone marrow‖ c. ―The cast applied on the extremity‖ d. ―Circulatory congestion of the skin‖ ANS: B

Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.

DIF: Cognitive Level: Comprehension REF: p. 583 OBJ: N/A TOP: Osteomyelitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and

wants to know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will probably last? a. 2 weeks b. 6 weeks c. 2 months d. 3 months ANS: B

Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.

DIF: Cognitive Level: Application REF: p. 583 OBJ: 1 TOP: Osteomyelitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. What finding would the nurse assessing the neurovascular status of a child in Russell traction

report immediately? a. Skin that‘s warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish coloration of skin ANS: D

Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.

DIF: Cognitive Level: Application REF: p. 578 OBJ: 7 | 8 TOP: Neurovascular Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. A 13-year-old girl is diagnosed with functional scoliosis. What does the nurse explain as the

cause of this spinal curvature defect? a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele ANS: B

Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.

DIF: Cognitive Level: Comprehension REF: p. 586 OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis? a. Ask the child to bend forward at the waist and observe the child‘s back for

asymmetry. b. Observe the gait while the child is walking forward heel to toe. c. Have the child flex the knees and look for uneven knee height. d. Look at the child‘s shoulders and hips while fully clothed.

ANS: A

The nurse looks at the back as the child bends forward for general body alignment and asymmetry.

DIF: Cognitive Level: Application REF: p. 588 OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. What nursing action will significantly decrease the risk of serious complications for a child in

Bryant‘s traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child is restrained from rolling over. d. The child‘s buttocks are resting on the bed.

ANS: A

The nurse caring for a child in traction must be alert for Volkmann‘s ischemia, which occurs when circulation is obstructed.

DIF: Cognitive Level: Application REF: p. 578 OBJ: 7 | 8 TOP: Traction: Volkmann‘s Ischemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. Which intervention would be helpful in relieving morning discomfort associated with juvenile

rheumatoid arthritis? a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillows under the head ANS: B

Application of moist heat, with a compress or by tub bath upon awakening in the morning, will help to lessen stiffness.

DIF: Cognitive Level: Application REF: p. 586 OBJ: 12 TOP: Juvenile Rheumatoid Arthritis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. What instruction would the nurse provide to an adolescent who has been fitted with a

Milwaukee brace? a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt 23 hours a day. d. Remove the brace before sleeping.

ANS: C

A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protects the skin.

DIF: Cognitive Level: Application REF: p. 587 OBJ: 13 TOP: Scoliosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. Which observation is most likely to cause the nurse to consider the possibility of child abuse

when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruises on his body. b. Bruises are dispersed on his head, arms, and legs. c. A broken arm last year, and the child being described as accident-prone. d. The mother is very anxious for her son to get medical attention.

ANS: A

As bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretaker‘s explanation of what happened.

DIF: Cognitive Level: Analysis REF: p. 592 | Safety Alert OBJ: 15 TOP: Child Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She

screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child? a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction ANS: A

Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.

DIF: Cognitive Level: Analysis REF: p. 582 | NCP 24.1 OBJ: 7 | 8 TOP: The Child with a Fracture in Traction KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. What would the nurse consider an abnormal finding on a musculoskeletal assessment of a

4-year-old child? a. Has inward-turned knees while standing. b. Walks on the toes. c. Appears to have flat feet. d. Swings his arms when walking.

ANS: B

Toe walking after 3 years of age may indicate a muscle problem.

DIF: Cognitive Level: Analysis REF: p. 573 OBJ: 3 TOP: Assessment of the Musculoskeletal System KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. Why does a child‘s fracture heal more rapidly than the adult‘s? a. A child‘s bones are less porous than adult bone. b. A child‘s bones are covered by a thicker periosteum. c. A child‘s bones are not affected by bone overgrowth.

d. A child‘s bones have faster callus formation.

ANS: D

Callus forms more rapidly in the child than the adult.

DIF: Cognitive Level: Knowledge REF: p. 573 OBJ: 2 TOP: Differences Between the Child and Adult KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. On entering the room of a child in Buck traction, the nurse makes all of the following

observations. Which observation requires a nursing intervention? a. Child‘s heels are placed firmly against the foot of the bed. b. Head of bed is elevated 20 degrees. c. Weights are hanging freely. d. Ropes are on pulleys.

ANS: A

Buck traction is dependent on the child as a counterweight. The heels should be elevated above the level of the foot of the bed.

DIF: Cognitive Level: Application REF: p. 576 OBJ: 7 | 8 TOP: Buck‘s Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 23. Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old

to be? a. 2 days b. 4 days c. 6 days d. 8 days ANS: C

Bruises heal in various stages that are indicated according to color; after 5 to 7 days bruise are green.

DIF: Cognitive Level: Comprehension REF: p. 592 | Safety Alert OBJ: 15 TOP: Child Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 24. A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What

type of fracture would be the most likely to alert the nurse to the possibility of physical abuse? a. Stress fracture b. Compound fracture c. Spiral fracture d. Greenstick fracture ANS: C

A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity.

DIF: Cognitive Level: Comprehension

REF: p. 575 | Safety Alert

OBJ: 5 TOP: Fractures/Child Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. A child is sent to the school nurse for assessment because she comes to school every day

disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate? a. Sexual abuse b. Physical abuse c. Physical neglect d. Emotional abuse ANS: C

Physical neglect is the failure to provide for the basic physical needs of the child, including food, clothing, shelter, and basic cleanliness.

DIF: Cognitive Level: Comprehension REF: p. 590 OBJ: 14 TOP: Child Abuse Triggers KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 26. Which assessment performed by a nursing student performing a neurovascular check alerts

the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils ANS: D

Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement. Pupils are assessed with a neurological check.

DIF: Cognitive Level: Comprehension REF: p. 579 | Skill 24.1 | Safety Alert OBJ: 7 TOP: Neurovascular Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. What factor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care ANS: A, C, D, E

All options except high self-esteem are possible triggers for a parent to become abusive.

DIF: Cognitive Level: Comprehension REF: p. 590 | Health Promotion Box OBJ: 15 TOP: Child Abuse Triggers KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

2. The nurse demonstrates which similarities among all traction devices? (Select all that apply.) a. Pull the limb into extension. b. Decrease muscle spasm. c. Reduce pain. d. Align two bone fragments. e. Immobilize the limb.

ANS: A, B, D, E

Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some traction devices may relieve pain, many may actually cause pain.

DIF: Cognitive Level: Comprehension REF: pp. 575-579 OBJ: 7 TOP: Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse performing a neurovascular check on a limb in traction would report and document

which finding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend.

ANS: C, D

The limb should be warm, and capillary refill should be less than 3 seconds.

DIF: Cognitive Level: Comprehension REF: p. 579 | Skill 24.1 OBJ: 7 TOP: Neurovascular Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. How does the pediatric skeletal system differ from that of the adult? (Select all that apply.) a. Lower mineral content b. More ossification c. Open epiphyses d. Less porosity e. Greater strength ANS: A, C, E

The child‘s skeletal system has lower mineral content, greater porosity, open epiphyses, greater bone strength, and a thicker periosteum.

DIF: Cognitive Level: Comprehension REF: pp. 572-573 OBJ: 2 TOP: Skeletal Differences KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse explains that Bryant‘s traction is reserved for children who weigh less than _____

pounds.

ANS:

30 Bryant‘s traction is a skin traction used in the treatment of orthopedic disorders of young children who weigh less than 30 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues.

DIF: Cognitive Level: Knowledge REF: p. 575 OBJ: 8 TOP: Bryant‘s Traction KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

Chapter 25: The Child with a Respiratory Disorder Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What will the nurse tell parents of a child with a positive throat culture for group A hemolytic

streptococcus that the treatment is most likely to be? a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until his sore throat is gone d. Streptococcus immunization ANS: B

When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.

DIF: Cognitive Level: Comprehension REF: pp. 598-599 OBJ: N/A TOP: Acute Pharyngitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. Which initial intervention will the nurse suggest to the parents of a child experiencing

laryngeal spasm? a. Take the child outside in the cool air. b. Bring the child directly to the emergency department. c. Take the child to the bathroom and turn on a hot shower. d. Have the child drink plenty of fluids.

ANS: C

The child experiencing laryngeal spasm should be placed in a high-humidity environment, such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.

DIF: Cognitive Level: Application REF: p. 600 OBJ: 6 TOP: Croup Syndromes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse would observe a child for frequent swallowing after a tonsillectomy and

adenoidectomy (T&A). What might this indicate? a. Bleeding from the surgical site

b. Pain at the incision area c. Sore throat from postnasal drip d. Potential vomiting ANS: A

Hemorrhage is the most common postoperative complication. Blood trickling down the back of the child‘s throat could cause frequent swallowing.

DIF: Cognitive Level: Comprehension REF: p. 606 OBJ: 9 TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 4. What is the best choice for fluid replacement that the nurse can offer a child who has just had

a tonsillectomy? a. A popsicle b. Chocolate milk c. Orange juice d. Cola drink ANS: A

Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated.

DIF: Cognitive Level: Application REF: p. 606 OBJ: 9 TOP: Tonsillitis and Adenoiditis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. When auscultating breath sounds of an infant with respiratory syncytial virus, which

assessment would the nurse immediately report? a. Respiration rate decreases from 40 to 32 breaths/minute b. Heart rate decreases from 110 to 100 beats/minute c. ―Quiet chest‖ from previous assessment of wheezing d. Oxygen saturation of 90% ANS: C

A ―quiet chest‖ after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.

DIF: Cognitive Level: Analysis REF: p. 602 OBJ: 4 | 6 TOP: Respiratory Syncytial Virus (RSV) KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for

an acute asthma attack, expect to find? a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases ANS: C

The child experiencing an acute asthma attack wheezes as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced.

DIF: Cognitive Level: Knowledge REF: p. 609 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What is the best intervention for the nurse caring for a child experiencing an acute asthma

attack? a. Offer plenty of fluids, particularly carbonated beverages. b. Place the child in a humidified cool mist tent with oxygen. c. Administer sedatives as ordered to decrease anxiety. d. Position the child with arms resting on the overbed table.

ANS: D

This position is comfortable and allows maximum use of the accessory muscles for breathing.

Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea.

DIF: Cognitive Level: Comprehension REF: p. 612 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. What should the nurse explain to the parent of a child with exercise-induced asthma about

when to inhale Cromolyn? a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as 4 times a day ANS: A

Anti-inflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the attack in progress. They are meant to be used as prophylactic therapies.

DIF: Cognitive Level: Application REF: p. 612 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got

this disease, because no one in either of their families has CF. What is the nurse‘s best response based on the understanding of CF? a. Only one parent carries the CF gene. b. Both parents are carriers of the CF gene. c. The inheritance pattern is multifactorial. d. The result is probably a genetic mutation.

ANS: B

Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease.

DIF: Cognitive Level: Comprehension TOP: Cystic Fibrosis

REF: p. 615 OBJ: 14 KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. Which statement indicates that the child‘s parents understand how to perform respiratory

therapy? a. ―We do her postural drainage before the aerosol therapy.‖ b. ―We give her respiratory treatments when she is coughing a lot.‖ c. ―We give the aerosol followed by postural drainage before meals.‖ d. ―She needs respiratory therapy every day when she has an infection.‖ ANS: C

Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting.

DIF: Cognitive Level: Analysis REF: p. 615 OBJ: 14 TOP: Cystic Fibrosis KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. What will the nurse teach the child with cystic fibrosis to take in order to facilitate digestion

and absorption of nutrients? a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Salt supplements ANS: A

An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the child‘s body cannot produce.

DIF: Cognitive Level: Knowledge REF: p. 618 OBJ: 14 TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. How would the nurse advise a mother to clear the nostrils when her infant has a cold? a. Clear the nasal passages after the infant has a feeding. b. Use over-the-counter nose drops to clear passages. c. Remove nasal secretions with a bulb syringe. d. Instill saline nose drops after clearing away secretions.

ANS: C

The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe.

DIF: Cognitive Level: Application TOP: Nasopharyngitis MSC: NCLEX: Physiological Integrity

REF: p. 598 OBJ: 2 KEY: Nursing Process Step: Implementation

13. The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid

loss through dyspnea. Which fluids are most appropriate? a. Room temperature water b. Carbonated beverages c. Iced fruit juice d. Cold milk

ANS: A

Room temperature fluids are the best. Carbonated and iced beverages increase spasm. Milk stimulates mucus production.

DIF: Cognitive Level: Application REF: p. 612 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. The asthmatic child who has been taking theophylline complains of stomachache and

tachycardia and is sweating profusely. What does the nurse recognize as the cause of these symptoms? a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Drug toxicity ANS: D

The symptoms described are the signs of theophylline toxicity.

DIF: Cognitive Level: Analysis REF: p. 611 | Table 25.3 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS).

What significant information would the nurse include? a. Wrapping the infant snugly for rest periods b. Positioning the infant prone for sleep c. Sitting the infant up in an infant seat d. Placing infants on their backs or sides for sleep ANS: D

The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS. DIF: Cognitive Level: Comprehension REF: p. 622 | Safety Alert OBJ: 16 TOP: Sudden Infant Death Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity 16. The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment

finding would indicate the child is experiencing increased respiratory obstruction? a. Restlessness b. Tachycardia c. Brassy cough d. Expiratory wheezing ANS: A

Restlessness is a primary sign of increased respiratory obstruction.

DIF: Cognitive Level: Analysis REF: p. 600 OBJ: 6 TOP: Acute Croup KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The teaching plan for the use of a dry powder inhaler for the treatment of asthma should

include the warning to rinse the mouth after inhaling the powder. What does this prevent? a. Discoloration of tooth enamel b. Halitosis c. Irritation of oral membranes d. Candidiasis ANS: D

Inhalant powders can cause candidiasis (yeast) infection of the mouth.

DIF: Cognitive Level: Comprehension REF: p. 614 OBJ: 13 TOP: Candidiasis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. The nurse is caring for a 3-year-old child who suffered a smoke inhalation injury. How long is

this patient at the highest risk for pulmonary edema after exposure? a. 2 hours b. 4 hours c. 18 hours d. 72 hours ANS: D

Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after exposure.

DIF: Cognitive Level: Comprehension REF: p. 605 OBJ: 8 TOP: Smoke Inhalation KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. Which is the most appropriate nursing action when planning care for a child with cystic

fibrosis? a. Provide chest physiotherapy before meals every day. b. Assess weight monthly. c. Administer pancreas with protein food at mealtime. d. Ensure high-protein, high-calorie diet.

ANS: D

The maintenance of adequate nutrition is essential. The diet is high in protein and calories.

Chest physiotherapy should be done between meals. Pancreatic enzyme powder should be given with applesauce or other nonstarch, nonfat, nonprotein food. Children with cystic fibrosis should be weighed daily.

DIF: Cognitive Level: Application REF: p. 621 OBJ: 14 TOP: Cystic Fibrosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask

how to prevent this from happening with the child they are currently expecting. What will the nurse explain as the best way to prevent BPD? a. Maternal intake of folic acid b. Exercise c. Prevention of preterm birth

d. Provision of oxygen therapy to the newborn ANS: C

Bronchopulmonary dysplasia (BPD) is a fibrosis, or thickening, of the alveolar walls and the bronchiolar epithelium. It occurs in premature infants (less than 32 weeks) who have abnormal or arrested lung development and receive ventilation and oxygen for more than 28 days to survive. Respiratory distress in the newborn is the major reason why oxygen and ventilators are used for prolonged periods. The main cause of respiratory distress in the newborn is prematurity. Therefore, the prevention of preterm birth is the best way to prevent BPD. DIF: Cognitive Level: Knowledge REF: p. 622 OBJ: 15 TOP: Bronchopulmonary Dysplasia KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention MULTIPLE RESPONSE 1. The nurse describes the ―allergic salute‖ as a cluster of what signs related to chronic allergy?

(Select all that apply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva ANS: A, B, C, E

The allergic salute does not include a productive cough.

DIF: Cognitive Level: Comprehension REF: p. 607 | Figure 25.4 OBJ: 10 TOP: Allergic Salute KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse would suggest the parents of an asthmatic child to encourage participation in which

sport(s)? (Select all that apply.) a. Swimming b. Gymnastics c. Baseball d. Cross-country skiing e. Distance running ANS: A, B, C

Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion.

DIF: Cognitive Level: Comprehension REF: pp. 610-612 OBJ: 12 TOP: Sports Activities Suitable for Asthmatics KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all

that apply.)

a. b. c. d. e.

Abdominal distention Vomiting Hiccoughing Jaundice Absence of stool

ANS: A, B, E

Distended abdomen, vomiting, and absence of stool are the signs indicating meconium ileus in the newborn.

DIF: Cognitive Level: Comprehension REF: p. 616 OBJ: 1 TOP: Meconium Ileus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. What would the nurse teaching an asthmatic child the technique of pursed-lip breathing

include? (Select all that apply.) a. Inhale deeply through nose with mouth closed. b. Make exhalation twice as long as inhalation. c. Use medicated inhaler prior to perform breathing exercise. d. Exhale through mouth as if whistling. e. Exhale forcefully.

ANS: A, B, D

The technique requires that breath be inhaled through the nose and exhaled through pursed lips in a nonforceful manner. The exhalation should be twice as long as the inhalation.

DIF: Cognitive Level: Comprehension REF: p. 618 OBJ: 13 TOP: Pursed-Lip Breathing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse

implement? (Select all that apply.) a. Maintain strict bed rest. b. Consider age. c. Assess developmental level. d. Implement light play activities. e. Provide hypnotic medication as ordered.

ANS: B, C, D

Confinement to bed for a child does not always result in physical rest. In pediatrics, ―bed rest‖ means providing play therapy that promotes minimal activity. The nurse should consider the age and developmental level of the child and the activity level involved in the play when designing appropriate activities and guiding parents in the home care of their child.

DIF: Cognitive Level: Application REF: p. 598 OBJ: 3 TOP: Bed Rest KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 6. The school nurse suspects a first-grade student has sinusitis. Which symptoms might lead the

nurse to this suspicion? (Select all that apply.) a. Child reports tooth pain. b. Severe wheezing is auscultated on inspiration.

c. Child reports, ―I have had a cold for 2 weeks.‖ d. Nurse observes periorbital swelling. e. Halitosis is present.

ANS: A, C, D, E

The proximity of the sinus to the tooth roots often results in tooth pain when the sinus is infected. The maxillary and ethmoid sinuses are most often involved in childhood sinusitis.

Therefore, the signs and symptoms of sinusitis in children are different from those in adults, depending on the age of the child and which sinus is fully developed. An acute sinusitis is suspected when an upper respiratory infection lasts longer than 10 days, with a daytime cough. Halitosis is often present. Untreated sinusitis can lead to periorbital cellulitis. Severe wheezing is not indicative of sinusitis.

DIF: Cognitive Level: Comprehension REF: p. 599 OBJ: 5 TOP: Sinusitis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs

and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.) a. Harsh cough b. Restlessness c. Edematous epiglottis d. Child insists on lying down e. Drooling ANS: B, C, E

H. influenzae type B and most often occurs in children 3 to 6 years of age. It can occur in any season. The course is rapid and progressive. The onset of epiglottitis is abrupt, and the child presents with classic symptoms. The child insists on sitting up, leans forward with the mouth open, and drools saliva because of the difficulty in swallowing. The child appears wide-eyed, anxious, and restless, and he or she may emit a froglike croaking sound on inspiration. Cough is absent. Inspection of the throat shows an enlarged, reddened edematous epiglottis much like a ―beefy-red thumb.‖ However, the examining tongue blade may trigger a laryngospasm and result in sudden respiratory arrest.

DIF: Cognitive Level: Comprehension REF: p. 601 OBJ: 7 TOP: Epiglottitis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. What will the nurse discourage when providing education to parents of a child with asthma?

(Select all that apply.) a. Stuffed toys b. Pet ownership c. Gymnastics d. Basketball e. Cotton blankets ANS: A, D

Use of stuffed toys is discouraged due to potential allergens. Basketball might not be well tolerated because of the constant physical exertion. Certain pets are encouraged, gymnastics is usually well tolerated, and cotton blankets are recommended for children with asthma.

DIF: Cognitive Level: Comprehension REF: p. 609 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention COMPLETION 1. After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral

medications, the nurse explains that routine immunizations will need to be delayed for _______ months.

ANS:

9 After a protocol of antiviral medications, the routine immunizations should be delayed because the antiviral medications affect the integrity of the immunizations.

DIF: Cognitive Level: Knowledge REF: p. 602 OBJ: 6 TOP: Respiratory Syncytial Virus (RSV) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 26: The Child with a Cardiovascular Disorder Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. What does the nurse explain that a ventricular septal defect will allow? a. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis b. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis c. No shunting because of high pressure in the left ventricle d. Increased pressure in the left atrium, impeding circulation of oxygenated blood in

the circulating volume ANS: A

Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.

DIF: Cognitive Level: Comprehension REF: p. 627 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Which assessment would lead the nurse to suspect that a newborn infant has a ventricular

septal defect? a. A loud, harsh murmur with a systolic thrill b. Cyanosis when crying c. Blood pressure higher in the arms than in the legs

d. A machinery-like murmur ANS: A

A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.

DIF: Cognitive Level: Comprehension REF: p. 628 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What finding would the nurse expect when measuring blood pressure on all four extremities

of a child with coarctation of the aorta? a. Blood pressure higher on the right side b. Blood pressure higher on the left side c. Blood pressure lower in the arms than in the legs d. Blood pressure lower in the legs than in the arms ANS: D

The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.

DIF: Cognitive Level: Comprehension REF: p. 629 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What

is the nurse‘s best response? a. Squatting increases the return of venous blood back to the heart. b. Squatting decreases arterial blood flow away from the heart. c. Squatting is a common resting position when a child is tachycardic. d. Squatting increases the workload of the heart.

ANS: A

The squatting position allows the child to breathe more easily because systemic venous return is increased.

DIF: Cognitive Level: Comprehension REF: p. 629 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). What does the

nurse understand regarding why dyspnea occurs? a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion. b. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia. c. Blood is shunted past cardiac arteries, causing myocardial hypoxia. d. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.

ANS: A

When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.

DIF: Cognitive Level: Comprehension REF: p. 629 OBJ: 4 TOP: Congenital Heart Disease KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. Which is the most appropriate nursing action related to the administration of digoxin

(Lanoxin) to an infant? a. Counting the apical rate for 30 seconds before administering the medication b. Withholding a dose if the apical heart rate is less than 100 beats/minute c. Repeating a dose if the child vomits within 30 minutes of the previous dose d. Checking respiratory rate and blood pressure before each dose ANS: B

As a rule, if the pulse rate of an infant is less than 100 beats/minute, the medication is withheld and the physician is notified.

DIF: Cognitive Level: Application REF: p. 632 OBJ: 5 TOP: Congestive Heart Failure KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. A child develops carditis from rheumatic fever. Which areas of the heart are affected by

carditis? a. Coronary arteries b. Heart muscle and the mitral valve c. Aortic and pulmonic valves d. Contractility of the ventricles ANS: B

The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved.

DIF: Cognitive Level: Knowledge REF: p. 634 OBJ: 6 TOP: Rheumatic Fever KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. Which comment made by a parent of a 1-month-old infant would alert the nurse about the

presence of a congenital heart defect? a. ―He is always hungry.‖ b. ―He tires out during feedings.‖ c. ―He is fussy for several hours every day.‖ d. ―He sleeps all the time.‖ ANS: B

Fatigue during feeding or activity is common to most infants with congenital cardiac problems.

DIF: Cognitive Level: Application REF: p. 626 OBJ: 3 TOP: Congenital Heart Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. The nurse is caring for a child with a diagnosis of Kawasaki disease. The child‘s parent asks

the nurse, ―How does Kawasaki disease affect my child‘s heart and blood vessels?‖ On what understanding is the nurse‘s response based? a. Inflammation weakens blood vessels, leading to aneurysm. b. Increased lipid levels lead to the development of atherosclerosis. c. Untreated disease causes mitral valve stenosis. d. Altered blood flow increases cardiac workload with resulting heart failure.

ANS: A

Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.

DIF: Cognitive Level: Comprehension REF: p. 638 OBJ: 12 TOP: Kawasaki Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly

becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions? a. ―If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.‖ b. ―If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.‖ c. ―If the baby turns blue, I will immediately put the baby upright in an infant seat.‖ d. ―If the baby turns blue, I will put the baby in supine position with his head elevated.‖ ANS: A

In the event of a paroxysmal hypercyanotic or ―tet‖ spell, the infant should be placed in a knee-chest position.

DIF: Cognitive Level: Application REF: p. 630 OBJ: 4 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, ―Why do my child‘s

fingertips look like that?‖ On what understanding does the nurse base a response? a. Clubbing occurs as a result of untreated congestive heart failure. b. Clubbing occurs as a result of a left-to-right shunting of blood. c. Clubbing occurs as a result of decreased cardiac output. d. Clubbing occurs as a result of chronic hypoxia.

ANS: D

Clubbing of the fingers develops in response to chronic hypoxia.

DIF: Cognitive Level: Comprehension REF: p. 632 OBJ: 4 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in

conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints, and carditis

c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate ANS: B

The presence of two major Jones criteria would indicate a high probability of rheumatic fever.

DIF: Cognitive Level: Application REF: p. 634| Box 26.1 OBJ: 6 TOP: Rheumatic Fever KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. An infant with congestive heart failure is receiving digoxin (Lanoxin). What does the nurse

recognize as a sign of digoxin toxicity? a. Restlessness b. Decreased respiratory rate c. Increased urinary output d. Vomiting ANS: D

Symptoms of digoxin toxicity include nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

DIF: Cognitive Level: Comprehension REF: p. 632 OBJ: 5 TOP: Heart Failure KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 14. Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated

blood? a. The patent ductus arteriosus b. A ventricular septal defect c. The closure of the foramen ovale d. An atrial septal defect ANS: D

Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.

DIF: Cognitive Level: Knowledge REF: p. 630 OBJ: 3 TOP: Hypoplastic Left Heart Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What

does the nurse recognize that this indicates? a. Seizure activity b. Hypoxia c. Sydenham‘s chorea d. Decreasing level of consciousness ANS: C

As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham‘s chorea, manifested by involuntary, purposeless movements of the limbs.

DIF: Cognitive Level: Knowledge REF: p. 634 OBJ: 6 TOP: Sydenham‘s Chorea KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. How long should a 4-year-old child recovering from rheumatic fever need to receive monthly

injections of penicillin G? a. 1 year b. 2 years c. 5 years d. 10 years ANS: C

Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections (about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 years to prevent further bouts of rheumatic fever.

DIF: Cognitive Level: Knowledge REF: p. 635 OBJ: 7 TOP: Prophylaxis for Rheumatic Fever KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. What is accurate about the characteristics of high-density lipoproteins (HDLs)? a. They have high amounts of triglycerides. b. They have only small amounts of protein. c. They have little cholesterol. d. They aid in steroid production.

ANS: C

HDLs have low amounts of triglycerides, large amounts of proteins, and low amount of cholesterol, and are excreted via the liver. They have no role in the production of steroids.

DIF: Cognitive Level: Knowledge REF: p. 637 OBJ: 11 TOP: High-Density Lipoproteins KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. The nurse is planning a hypertension-prevention program. What should be the main focus of

the nurse when presenting information? a. Pharmacological treatment b. Surgical interventions available c. Patient education d. Reduction of aerobic exercise ANS: C

The main focus of a hypertension-prevention program is patient education.

DIF: Cognitive Level: Knowledge REF: p. 636 OBJ: 10 TOP: Hypertension Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. A pediatric patient is scheduled for a noninvasive procedure to determine if his heart is

structurally normal and to localize a murmur. What diagnostic test does the nurse anticipate? a. Barium swallow

b. Chest x-ray c. Electrocardiogram d. Echocardiogram ANS: D

Echocardiography is a noninvasive procedure that localizes murmurs and determines if the heart is structurally normal.

DIF: Cognitive Level: Knowledge REF: p. 627 | Table 26.1 OBJ: N/A TOP: Diagnostic Tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding

techniques to adapt for the child‘s weakness and fatigue? (Select all that apply.) a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula ANS: A, B, C, E

Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft, large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held.

DIF: Cognitive Level: Application REF: p. 631 OBJ: 5 TOP: Feeding Infant with CHF KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select all

that apply.) a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventral septal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta ANS: A, B, D, E

The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus, stenosis of pulmonary artery, and dextroposition of the aorta.

DIF: Cognitive Level: Knowledge REF: p. 627 OBJ: 4 TOP: Tetralogy of Fallot KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing

a paroxysmal hypercyanotic episode? (Select all that apply.) a. Spontaneous cyanosis

b. c. d. e.

Dyspnea Weakness Dry cough Syncope

ANS: A, B, C, E

Indicators of a paroxysmal hypercyanotic episode or a ―tet‖ episode are spontaneous cyanosis, dyspnea, weakness, and syncope.

DIF: Cognitive Level: Comprehension REF: p. 630 OBJ: 3 TOP: ―Tet‖ Spells KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 4. Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that

apply.) a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Dextroposition of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs) ANS: A, D, E

The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus.

DIF: Cognitive Level: Comprehension REF: p. 627 OBJ: 3 TOP: Congenital Heart Defects KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A 16-year-old patient is diagnosed with primary hypertension. What risk factors does the

nurse mention when providing education on this diagnosis to the patient and his family?

(Select all that apply.) a. Heredity b. Stress c. Congenital defect d. Obesity e. Poor diet ANS: A, B, D, E

Primary, or essential, hypertension implies that no known underlying disease is present.

Nevertheless, heredity, obesity, stress, and a poor diet and exercise pattern can contribute to any type of hypertension.

DIF: Cognitive Level: Comprehension REF: p. 636 OBJ: 9 | 10 TOP: Primary Hypertension KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 27: The Child with a Condition of the Blood, Blood-Forming Organs, or Lymphatic System Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE

1. The nurse is teaching the parents of a young child with iron deficiency anemia about nutrition.

What food would the nurse emphasize as being a rich source of iron? a. An egg white b. Cream of Wheat c. A banana d. A carrot ANS: B

Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried fruits, beans, nuts, and whole-grain breads.

DIF: Cognitive Level: Comprehension REF: p. 642 OBJ: 6 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. Which statement by a mother may indicate a cause for her 9-month-old‘s iron deficiency

anemia? a. ―Formula is so expensive. We switched to regular milk right away.‖ b. ―She almost never drinks water.‖ c. ―She doesn‘t really like peaches or pears, so we stick to bananas for fruit.‖ d. ―I give her a piece of bread now and then. She likes to chew on it.‖ ANS: A

Because cow‘s milk contains very little iron, infants should drink iron-fortified formula for the first year of life.

DIF: Cognitive Level: Application REF: p. 642 OBJ: 4 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What will the nurse administer with ferrous sulfate drops when providing them to a child on

the pediatric unit? a. With milk b. With orange juice c. With water d. On a full stomach ANS: B

Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.

DIF: Cognitive Level: Application REF: p. 642 OBJ: 4 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. What is the result of a deficiency of factor IX? a. Thalassemia b. Idiopathic thrombocytopenic purpura c. Hemophilia A d. Christmas disease

ANS: D

Christmas disease, or hemophilia B, is caused by the deficiency of factor IX. DIF: Cognitive Level: Knowledge REF: p. 647 OBJ: 11 TOP: Christmas Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse

include in a teaching plan about home care? a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b. Children‘s aspirin in lowered doses may be given for joint discomfort. c. A firm, dry toothbrush should be used to clean teeth at least twice a day. d. Do not permit interactive play with other children.

ANS: A

When bleeding occurs, the traditional approach is to follow RICE—rest, ice, compression, and elevation.

DIF: Cognitive Level: Application REF: p. 648 OBJ: 12 TOP: Hemophilia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. What will the nurse teach the parents of a child with a low platelet count to avoid? a. Benadryl b. Aspirin c. Caffeine d. Prednisone ANS: B

Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding.

DIF: Cognitive Level: Application REF: p. 648 OBJ: 15 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. What should the nurse closely assess in a child receiving a transfusion? a. Fever b. Lethargy c. Jaundice d. Bradycardia ANS: A

The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain.

DIF: Cognitive Level: Comprehension REF: p. 652 OBJ: 16 TOP: Blood Transfusion KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 8. On admission, a child with leukemia has widespread purpura and a platelet count of

19,000/mm3. What is the priority nursing intervention?

a. b. c. d.

Assessing neurological status Inserting an intravenous line Monitoring vital signs during platelet transfusions Providing family education about how to prevent bleeding

ANS: A

When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are therefore a priority of care.

DIF: Cognitive Level: Application REF: p. 649 OBJ: 15 TOP: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. An adolescent is diagnosed with Hodgkin‘s disease. Lymph nodes on both sides of her

diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this? a. I b. II c. III d. IV ANS: C

Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage-III Hodgkin‘s disease.

DIF: Cognitive Level: Application REF: p. 653 | Table 27.2 OBJ: N/A TOP: Hodgkin‘s Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with

severe abdominal pain. Which type of crisis is the child most likely experiencing? a. Aplastic b. Hyperhemolytic c. Vaso-occlusive d. Splenic sequestration ANS: C

Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm.

DIF: Cognitive Level: Application REF: p. 645 | Table 27.1 OBJ: 8 TOP: Sickle Cell Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Which statement made by a parent indicates an understanding of health maintenance of a child

with sickle cell disease? a. ―I should give my child a daily iron supplement.‖ b. ―It is important for my child to drink plenty of fluids.‖ c. ―He needs to wear protective equipment if he plays contact sports.‖ d. ―He shouldn‘t receive any immunizations until he is older.‖

ANS: B

Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with sickle cell disease.

DIF: Cognitive Level: Application REF: p. 645 OBJ: 9 TOP: Sickle Cell Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. A newly married couple is seeking genetic counseling because they are both carriers of the

sickle cell trait. How can the nurse best explain the children‘s risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b. All of their children will be carriers, just as they are. c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier. d. The risk levels of their children cannot be determined by this information.

ANS: C

The sickle cell gene is inherited from both parents; therefore, each offspring has a one in four chance of inheriting the disease.

DIF: Cognitive Level: Analysis REF: p. 643 | Figure 27.4 OBJ: 7 TOP: Sickle Cell Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. A child with thalassemia major receives blood transfusions frequently. What is a complication

of repeated blood transfusions? a. Hemarthrosis b. Hematuria c. Hemoptysis d. Hemosiderosis ANS: D

As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues.

DIF: Cognitive Level: Comprehension REF: p. 645 OBJ: 16 TOP: Thalassemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an

overproduction of immature white blood cells in the bone marrow? a. Decreased T-cell production b. Decreased hemoglobin c. Increased blood clotting d. Increased susceptibility to infection ANS: D

An overproduction of immature white blood cells increases the child‘s susceptibility to infection.

DIF: Cognitive Level: Comprehension

REF: p. 650

OBJ: 14 | 15

TOP: Leukemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The child receiving a transfusion complains of back pain and itching. What is the best initial

action by the nurse? a. Notify the charge nurse. b. Disconnect intravenous lines immediately. c. Give diphenhydramine (Benadryl). d. Clamp off blood and keep line open with normal saline.

ANS: D

If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse.

DIF: Cognitive Level: Application TOP: Blood Transfusion MSC: NCLEX: Physiological Integrity

REF: p. 652 OBJ: 16 KEY: Nursing Process Step: Implementation

16. What would the nurse include in a teaching plan about mouth care of a child receiving

chemotherapy? a. Use commercial mouthwash. b. Clean teeth with a soft toothbrush. c. Avoid use of a Water-Pik. d. Inspect the mouth weekly for ulcerations.

ANS: B

A soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection.

Water-Pik is useful for toughening gums.

DIF: Cognitive Level: Application REF: p. 652 OBJ: 15 TOP: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. A 6-year-old child with leukemia asks, ―Who will take care of me in heaven?‖ What is the

best response by the nurse? a. ―Who do you think will take care of you?‖ b. ―Your grandparents and God will take care of you.‖ c. ―Your mom will know more about that than I do.‖ d. ―Why are you asking me that?‖ ANS: A

This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed responses shut off communication. The asking of a ―why‖ question is not therapeutic as it calls for justification.

DIF: Cognitive Level: Application REF: p. 652 OBJ: 18 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. The nurse is dealing with a preschool child with a life-threatening illness. What should the

nurse remember the child‘s concept of death is at this age?

a. b. c. d.

That it is final Only a fear of separation from her parents That a person becomes alive again soon after death An understanding based on simple logic

ANS: C

The preschooler views death as reversible and temporary.

DIF: Cognitive Level: Comprehension REF: p. 655 OBJ: 19 TOP: Nursing Care of the Dying Child KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 19. The nurse notes that a 4-year-old child‘s gums bleed easily and he has bruising and petechiae

on his extremities. Which lab value is consistent with these symptoms? a. Platelet count of 25,000/mm3 b. Hemoglobin level of 8 g/dL c. Hematocrit level of 36% d. Leukocyte count of 14,000/mm3 ANS: A

The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential.

DIF: Cognitive Level: Analysis REF: p. 649 OBJ: 14 TOP: Idiopathic Thrombocytopenic Purpura KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse, caring for a child receiving chemotherapy, notes that the child‘s abdomen is firm

and slightly distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest? a. Peripheral neuropathy b. Stomatitis c. Myelosuppression d. Hemorrhage ANS: A

Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel.

DIF: Cognitive Level: Analysis REF: p. 651 OBJ: 14 | 15 TOP: Leukemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. The nurse finds an adolescent with Hodgkin‘s disease crying. The adolescent says, ―I am so

scared.‖ What is the most appropriate nursing response to this comment? a. ―I understand how you must feel.‖ b. ―You shouldn‘t feel that way.‖ c. ―Is this the strongest feeling you‘ve had today?‖ d. ―Tell me what‘s got you scared.‖ ANS: D

The nurse should encourage the adolescent to express her feelings and concerns.

DIF: Cognitive Level: Application REF: p. 655 TOP: Adolescent with Cancer—Fear of Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

OBJ: 18

22. The most recent blood count for a child who received chemotherapy last week shows

neutropenia. What is the priority nursing diagnosis for this child? a. Risk for infection b. Risk for hemorrhage c. Altered skin integrity d. Disturbance in body image ANS: A

The child with neutropenia is at risk for infection.

DIF: Cognitive Level: Application REF: p. 651 |Nursing Tip OBJ: 15 TOP: Chemotherapy: Neutropenia KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 23. What important focus of nursing care for the dying child and the family should the nurse

implement? a. Nursing care should be organized to minimize contact with the child. b. Adequate oral intake is crucial to the dying child. c. Families should be made aware that hearing is the last sense to stop functioning before death. d. It is best for the family if the nursing staff provides all of the child‘s care.

ANS: C

Hearing is intact even when there is a loss of consciousness.

DIF: Cognitive Level: Analysis REF: p. 658 OBJ: 18 TOP: Dying Child KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. The nurse is presenting information on the congenital disorder of hemophilia A. What fact

will the nurse include? a. It is seen in males and females equally. b. It is transmitted by symptom-free females. c. It is a sex-linked dominant trait. d. It is a defective gene located on the Y chromosome.

ANS: B

Hemophilia A affects mostly males who received the sex-linked recessive trait from a symptom-free female. The defective gene is on the X chromosome.

DIF: Cognitive Level: Comprehension REF: p. 647 OBJ: 11 TOP: Hemophilia A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

25. A child is diagnosed with iron deficiency anemia. What will the nurse explain can occur if this

disorder goes untreated? a. Hemorrhage b. Heart failure c. Infection d. Pulmonary embolism ANS: B

Untreated iron deficiency anemias progress slowly, and in severe cases the heart muscle becomes too weak to function. If this happens, heart failure follows.

DIF: Cognitive Level: Comprehension REF: p. 642 OBJ: 5 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse is caring for a child with a low platelet count. What skin assessments would alert

the nurse to bleeding? (Select all that apply.) a. Petechiae b. Purpura c. Ecchymosis d. Hematoma e. Lymphadenopathy ANS: A, B, C, D

The reduction or destruction of platelets in the body interferes with the clotting mechanism.

Skin lesions that are common to these disorders include petechiae, a bluish, nonblanching, pinpoint-sized lesion; purpura, groups of adjoining petechiae; ecchymosis, an isolated bluish lesion larger than a petechia; and hematoma, a raised ecchymosis. Lymphadenopathy is an enlargement of lymph nodes that is indicative of infection or disease.

DIF: Cognitive Level: Comprehension REF: pp. 648-649 OBJ: 13 TOP: Manifestations of Bleeding KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old

sister in care? (Select all that apply.) a. She will feel less neglected by the parents. b. She can make amends for past hostilities to her brother. c. She will feel increased helplessness. d. She can express her feelings through care. e. She can experience being supportive of her parents and brother.

ANS: A, B, D, E

All options are potential benefits to including the sibling in the care of a dying child except increased helplessness. She would feel less helpless.

DIF: Cognitive Level: Comprehension REF: p. 658 OBJ: 20 TOP: Siblings KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

3. What should be included in the nursing care of a 12-year-old child receiving radiation therapy

for Hodgkin‘s disease? (Select all that apply.) a. Application of sunblock b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger e. Preparation for premature sexual development ANS: A, B, C, D

Sun block should be applied to skin after radiation to prevent burning. Low energy levels produce anorexia and anger in many young patients. Radiation delays the development of secondary sex characteristics and menses.

DIF: Cognitive Level: Application REF: p. 653 OBJ: N/A TOP: Effects of Radiation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. What are the classic symptoms of thalassemia major (Cooley‘s anemia)? (Select all that

apply.) a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Renal failure ANS: A, B, C, D

All of the options are classic signs of thalassemia major except renal failure.

DIF: Cognitive Level: Comprehension REF: p. 646 OBJ: 10 TOP: Thalassemia Major KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. How has synthetic recombinant antihemophilic factor improved the management of

hemophilia? (Select all that apply.) a. Eliminates the need for frequent transfusions. b. Can be administered by family at home. c. Prevents hemorrhage. d. Reduces cost of care of the hemophiliac. e. Reduces risk of HIV and hepatitis A and B transmission.

ANS: A, B, D, E

The drug can be given at home by the family. Because it supplies the missing factor, transfusions are not necessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatly reduced because hospitalizations and transfusions are not as frequently required. The drug does not prevent hemorrhage; it makes hemorrhage manageable.

DIF: Cognitive Level: Comprehension REF: p. 648 OBJ: 11 TOP: Hemophilia A KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

6. The family of a child receiving chemotherapy for leukemia should be taught to focus on

which aspect(s) of the child‘s care? (Select all that apply.) a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration d. Continuing with scheduled immunizations e. Reporting exposure to infectious diseases ANS: A, B, C, E

Support groups are helpful for emotional support and realistic tips on care. The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the drugs. Because the drugs suppress the bone marrow, children are at risk for infection, and the suppression will not allow the antibody response needed for immunization.

DIF: Cognitive Level: Analysis REF: p. 651 OBJ: 15 TOP: Chemotherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 7. The nurse explains that the COPP medical regimen for the treatment of Hodgkin‘s disease

uses a combination of which drugs? (Select all that apply.) a. Vincristine b. Cyclophosphamide c. Methotrexate d. Prednisone e. Procarbazine hydrochloride ANS: A, B, D, E

The COPP medical regimen includes the combination of cyclophosphamide, vincristine (Oncovin), prednisone, and procarbazine hydrochloride.

DIF: Cognitive Level: Knowledge REF: p. 653 OBJ: N/A TOP: COPP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. A school-aged child is living with a chronic disease process. How would the nurse anticipate

chronic illness will effect growth and development? (Select all that apply.) a. Delayed bonding with parents b. Delayed toilet training c. Impaired sense of belonging d. Decreased feelings of independence e. Impaired speech development ANS: C, D

A school-age child is in the stage of industry versus inferiority. A chronic illness might experience loss of grade level in school because of illness and inability to participate or compete can lead to sense of inferiority. Sense of independence and accomplishment can be lost. Being different from peers may impede child‘s sense of belonging.

DIF: Cognitive Level: Comprehension REF: p. 654 |Table 27.3 OBJ: 17 TOP: Chronic Illness/Growth and Development KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Psychosocial Integrity: Grief and Loss

Chapter 28: The Child with a Gastrointestinal Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. Which finding in a newborn is suggestive of tracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen ANS: B

After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first feeding is introduced.

DIF: Cognitive Level: Comprehension REF: p. 663 OBJ: 2 TOP: Esophageal Atresia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A child is brought to the pediatric clinic because he has been vomiting for the past 2 days.

What acid-base imbalance would the nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis ANS: D

Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting.

This results in alkalosis.

DIF: Cognitive Level: Comprehension REF: p. 670 OBJ: 9 TOP: Acid-Base Balance KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. On the second day of hospitalization for a 3-month-old brought in for treatment for

gastroenteritis, the nurse makes all of the assessments listed below. Which assessment finding indicates ineffectiveness of treatment? a. Weight loss of 4 ounces b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle ANS: A

Weight loss is the most significant indicator of dehydration because an infant‘s weight comprises 77% water.

DIF: Cognitive Level: Application REF: p. 674 |Figure 28.10 |Table 28.2 OBJ: 9 TOP: Dehydration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. Why are rapid respirations a possible cause of dehydration? a. They prevent the child from drinking. b. They increase circulation, thus increasing urine production. c. They cause evaporation of fluid on the mucous membranes. d. They often lead to vomiting.

ANS: C

Rapid respirations cause increased insensible fluid loss.

DIF: Cognitive Level: Comprehension REF: p. 676 OBJ: 9 TOP: Dehydration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal

reflux? a. Position the infant in the crib on his or her abdomen, with the head elevated. b. Administer medication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infant in an infant seat after feedings.

ANS: A

After feedings, the infant is placed in a prone position to avoid increased intraabdominal pressure.

DIF: Cognitive Level: Application REF: p. 670 OBJ: 7 TOP: Gastroesophageal Reflux KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse is interviewing parents of an infant with pyloric stenosis. What would the nurse

expect the parents to report? a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation ANS: B

Vomiting is the outstanding symptom of pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting.

DIF: Cognitive Level: Comprehension REF: p. 664 OBJ: 3 TOP: Pyloric Stenosis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. A mother reports that her child has been scratching the anal area and complaining of itching.

What does the nurse suspect based on this information? a. Pinworms b. Giardiasis c. Ringworm d. Roundworm ANS: A

With pinworms, the nurse or parent may notice that the child scratches the anal area and complains of itchiness. The other choices do not cause this reaction.

DIF: Cognitive Level: Application REF: pp. 681-682 OBJ: 12 TOP: Worms KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse is teaching a parent about pyrvinium (Povan). What would be included in regard to

potential side effects? a. Diarrhea b. Skin rash c. Red stool d. Metallic taste ANS: C

The nurse should advise parents that pyrvinium stains clothing and turns stools red.

DIF: Cognitive Level: Knowledge REF: p. 682 OBJ: 12 TOP: Worms KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. What instruction will the nurse give to parents about preventing the spread and reinfection of

pinworms? a. Keep children‘s nails short. b. Dress child in loose-fitting underwear. c. Clean the bathroom with bleach solution. d. Wash bed linens in cold water.

ANS: A

One intervention to prevent the further spread of pinworms is to keep the child‘s fingernails short. Pinworms are not spread from person to person.

DIF: Cognitive Level: Comprehension REF: p. 682 OBJ: 12 TOP: Worms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. A mother reports that her 2-year-old child experiences constipation frequently. Which food

would the nurse recommend to include in the child‘s diet? a. Cooked vegetables b. Pretzels c. Whole-grain cereal d. Yogurt ANS: C

Dietary modifications for constipation include eating more high-roughage foods such as whole-grain breads and cereals.

DIF: Cognitive Level: Comprehension REF: p. 674 OBJ: N/A TOP: Constipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. What description of a child‘s stool characteristic leads the nurse to suspect intussusception?

a. b. c. d.

Currant jelly Black and tarry Green liquid Greasy and foul-smelling

ANS: A

Bowel movements of blood and mucus that contain no feces (―currant jelly‖ stools) are common about 12 hours after the onset of the obstruction.

DIF: Cognitive Level: Comprehension REF: p. 668 OBJ: 6 TOP: Intussusception KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. What is the treatment of choice for a child with intussusception? a. A barium enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage ANS: A

A barium enema is the treatment of choice for intussusception because the passage of the barium frequently ―un-telescopes‖ the bowel. Surgery is scheduled only if reduction is not achieved.

DIF: Cognitive Level: Knowledge TOP: Intussusception MSC: NCLEX: Physiological Integrity

REF: p. 668 OBJ: 6 KEY: Nursing Process Step: Implementation

13. Parents ask the nurse how their infant developed a Meckel‘s diverticulum. What condition,

will the nurse explain, is present causing this diagnosis? a. The yolk sac remains connected to the intestine. b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear. d. There is a weakness in the abdominal wall.

ANS: C

If the vitelline duct fails to disappear completely after birth, a blind pouch may form.

DIF: Cognitive Level: Knowledge REF: p. 668 OBJ: 2 TOP: Meckel‘s Diverticulum KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. An infant is admitted to the hospital with severe isotonic dehydration. For what is this child at

the highest risk? a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock ANS: D

Shock is the greatest threat to life in isotonic dehydration.

DIF: Cognitive Level: Comprehension REF: p. 677 OBJ: 9 TOP: Dehydration KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A child is brought to the emergency department because he ingested an unknown quantity of

acetaminophen (Tylenol). What does the nurse expect this child to receive following gastric lavage? a. Activated charcoal b. N-Acetylcysteine c. Vitamin K d. Syrup of ipecac ANS: B

Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen.

DIF: Cognitive Level: Comprehension REF: p. 684 | Table 28.8 OBJ: 14 TOP: Acetaminophen Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 16. The nurse is planning a parent education program about lead poisoning prevention. What will

be included regarding primary sources of lead in the community? a. Increased lead content of air b. Use of aluminum cookware c. Deteriorating paint in older buildings d. Inhaling smog ANS: C

The primary source of lead is paint from old, deteriorating buildings.

DIF: Cognitive Level: Knowledge TOP: Lead Poisoning MSC: NCLEX: Physiological Integrity

REF: p. 685 OBJ: 15 KEY: Nursing Process Step: Planning

17. A frightened mother calls the pediatrician‘s office because her child swallowed dishwashing

detergent. What is the most appropriate action? a. Induce vomiting by giving the child syrup of ipecac. b. Take the child to the local emergency department. c. Give the child activated charcoal mixed with juice. d. Give the child milk to soothe affected mucous membranes.

ANS: B

Inducing vomiting is no longer recommended because it may pose additional problems. The child should be taken immediately to the nearest emergency department along with the packaging of the ingested substance.

DIF: Cognitive Level: Application REF: p. 682 OBJ: 13 TOP: Poisoning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. A child has been diagnosed with ascariasis (roundworm). Which statement made by her

mother that may suggest a cause for her condition?

a. b. c. d.

―I‘ve been airing out the house on these nice breezy days.‖ ―My child often goes out to the garden and pulls up a carrot to eat.‖ ―She runs barefoot so much I have to wash her feet at least twice a day.‖ ―We just remodeled our bathroom at home.‖

ANS: B

The child can ingest roundworm eggs from contaminated soil.

DIF: Cognitive Level: Comprehension REF: p. 682 OBJ: 12 TOP: Worms KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. What does the nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling ANS: C

Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption.

DIF: Cognitive Level: Comprehension REF: p. 667 OBJ: 4 TOP: Celiac Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which

grain will the nurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice ANS: D

Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. These children will have a lifelong restriction of wheat, oats, barley, and rye.

DIF: Cognitive Level: Knowledge REF: p. 667 OBJ: 4 TOP: Celiac Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis.

What will be the nurse‘s priority goal of the infant‘s care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

ANS: A

The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance.

DIF: Cognitive Level: Application TOP: Gastroenteritis

REF: p. 670 OBJ: N/A KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. The nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary

modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium ANS: C

An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel movements.

DIF: Cognitive Level: Application REF: pp. 671-672 OBJ: 9 TOP: Diarrhea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. What would the nurse expect to find in a child admitted to the hospital for nonorganic failure

to thrive? a. Cry to be picked up b. Be limp like a rag doll c. Be responsive to cuddling d. Weigh in the 10th percentile for age ANS: B

Some children with failure to thrive have rag-doll limpness (hypotonia) and appear wary of their caregivers.

DIF: Cognitive Level: Comprehension REF: p. 679 OBJ: 10 TOP: Failure to Thrive KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. Which nursing interventions will be implemented for the mother of a 10-month-old infant

with nonorganic failure to thrive? a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative characteristics of the infant with the mother c. Having the nurse provide as much of the infant‘s care as possible d. Teaching the mother about the developmental milestones to expect in the next few months ANS: D

The nurse can increase parent‘s knowledge of growth and development by providing anticipatory guidance about normal developmental milestones.

DIF: Cognitive Level: Application REF: p. 679 OBJ: 10 TOP: Failure to Thrive KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 25. Which statement by a mother may indicate a cause of her son‘s vitamin C deficiency? a. ―We get our fruits from homemade preserves.‖ b. ―We use milk from our own goats.‖ c. ―We grow all our own vegetables.‖

d. ―We‘re not big meat eaters.‖ ANS: A

Vitamin C is destroyed by heat.

DIF: Cognitive Level: Comprehension REF: p. 680 OBJ: 10 TOP: Scurvy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 26. The nurse is instructing a mother how to administer oral nystatin suspension prescribed to

treat thrush. What will the nurse include? a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa.

ANS: D

An appropriate way to administer nystatin is to moisten a sterile applicator with the medication and then swab it on the inside of the mouth.

DIF: Cognitive Level: Application REF: p. 681 OBJ: 11 TOP: Thrush KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 27. Why are infants more vulnerable to fluid and electrolyte imbalances than adults? a. They have a smaller surface area than adults in proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water.

ANS: C

A greater percentage of body water is contained in the extracellular compartment of children under 2 years of age.

DIF: Cognitive Level: Knowledge REF: p. 674 OBJ: 8 TOP: Dehydration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. An infant is admitted to the hospital with severe dehydration. Laboratory results show pH

7.32, PaCO2 40, HCO3– 21. How does the nurse interpret these values? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis ANS: A

A pH lower than 7.35 indicates acidosis. If the child‘s pH falls in the same line as the HCO3–, the problem is metabolic (see Table 27-4).

DIF: Cognitive Level: Analysis REF: p. 678 | Table 28.5 OBJ: 9 TOP: Fluid and Electrolyte Imbalance KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

29. Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying.

What is the most appropriate nursing action? a. Delay feeding the child for 6 hours. b. Offer regular formula thinned with water. c. Give small amounts of regular formula thickened with cereal. d. Allow 1 ounce of glucose water at frequent intervals.

ANS: D

Small oral feedings of glucose water are given after recovery from anesthesia. Feedings are gradually increased to larger amounts of regular formula or breastmilk.

DIF: Cognitive Level: Application REF: p. 665 OBJ: 9 TOP: Postoperative Pyloric Stenosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. The nurse is caring for an 18-pound child who has had one stool of diarrhea. The nurse knows

that the child needs to consume how many milliliters of oral fluid to make up for the fluid loss? a. 18 b. 36 c. 64 d. 81 ANS: D

The formula for oral fluid replacement is 10 mL/kg. 18 pounds = 8.1 kg  10 = 81 mL. DIF: Cognitive Level: Analysis REF: p. 675 OBJ: 9 TOP: Oral Fluid Replacement KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 31. Which statement made by a parent alerts the nurse to the need for additional education about

poison prevention? a. ―I keep the poison control center phone number easily accessible.‖ b. ―All medication is kept out of reach in a locked cabinet.‖ c. ―I keep a bottle of syrup of ipecac handy.‖ d. ―Our garden is free from marigolds.‖ ANS: C

Traditionally, syrup of ipecac was the treatment of choice to remove some types of poisons from a child‘s system and parents were advised to keep a supply on hand in the home.

However, the American Academy of Pediatrics (AAP) revised this policy in 2003. Parents are now advised to call the poison control center and bring the container of the substance ingested to the hospital emergency department as quickly as possible because stomach lavage is rarely effective 1 hour or more after ingestion. Ipecac syrup should not be kept in the home.

Uncontrolled vomiting can cause serious complications.

DIF: Cognitive Level: Comprehension REF: p. 682 OBJ: 13 TOP: Poison Control KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 32. Which assessment would the nurse report to the physician immediately?

a. b. c. d.

2-month-old with a urine output of 150 mL in 24 hours 3-year-old with a urine output of 650 mL in 24 hours 8-year-old with a urine output of over 1000 mL in 24 hours 14-year-old with a urine output of 800 mL in 24 hours

ANS: A

The urine output of a 2-month-old infant should be between 400 and 500 mL/24 hours.

DIF: Cognitive Level: Application REF: p. 677 |Table 28.3 OBJ: 9 TOP: Dehydration KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Adaptation: Physiological Integrity MULTIPLE RESPONSE 1. What interventions will the nurse perform when feeding a child with pyloric stenosis? (Select

all that apply.) a. Give a formula thinned with water. b. Burp the infant before and during feeding. c. Give the feeding slowly. d. Refeed if the infant vomits. e. Position infant on left side after feeding.

ANS: B, C, D

Children with pyloric stenosis are given formula or breastmilk thickened with cereal; the infant is burped before and during feeding to get rid of any gas in the stomach; the infant is fed slowly and refed if vomiting occurs. The infant is positioned on the right side to allow the weight of the feeding to stay in the stomach against the pyloric valve.

DIF: Cognitive Level: Application REF: p. 665 OBJ: 3 TOP: Pyloric Stenosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. What assessment(s) would lead a nurse to suspect Hirschsprung‘s disease in a 1-month-old

infant? (Select all that apply.) a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis ANS: A, B, C, D, E

All options are significant indicators of Hirschsprung‘s disease.

DIF: Cognitive Level: Comprehension REF: pp. 667-668 OBJ: 5 TOP: Hirschsprung‘s Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What sign(s) indicate(s) moderate dehydration? (Select all that apply.) a. 10% weight loss b. Dry mucous membranes c. Normal anterior fontanel

d. Increased urinary output e. Lethargy ANS: A, B, C

The child that is moderately dehydrated will have lost 10% of his body weight, will have dry mucous membranes, normal (nonsunken) anterior fontanelle, decreased urine output, and will be irritable.

DIF: Cognitive Level: Comprehension REF: p. 676 | Table 28.2 OBJ: 9 TOP: Moderate Dehydration KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. A child is brought into the ED with suspected appendicitis. What signs and symptoms does

the nurse expect to assess? (Select all that apply.) a. Left lower quadrant pain b. Guarding c. Rebound tenderness d. Decreased C-reactive protein e. Pain on lifting thigh when supine ANS: B, C, E

With appendicitis on examination, characteristic tenderness in the right lower quadrant known as McBurney‘s point will occur. Other diagnostic signs include guarding (tightening of the abdominal muscles or rigidity of the abdomen on palpation); rebound tenderness (pressing the RLQ with rapid release of pressure causes severe pain); pain on lifting the thigh while in the supine position is caused by muscle irritation. C-reactive protein levels will be increased after 12 hours if any infection is present.

DIF: Cognitive Level: Comprehension REF: pp. 680-681 OBJ: 1 TOP: Appendicitis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. Parents have adopted a child with the diagnosis of kwashiorkor. What is most likely to be

observed when assessing this child? (Select all that apply.) a. Hyperactivity b. White streak in hair c. Edematous abdomen d. Slowed growth e. Thick, oily hair ANS: B, C, D

Kwashiorkor means, in native dialect, ―the disease of the deposed baby when the next one is born,‖ indicating that the child no longer breastfeeds because a sibling is born and takes over the breast of the mother. Oral intake then is deficient in protein. The child fails to grow normally. The muscles become weak and wasted. There is edema of the abdomen that may become generalized. Diarrhea, skin infections, irritability, anorexia, and vomiting may be present. The hair becomes thin and dry. Because protein is the basis of melanin, a substance that provides color to hair, melanin becomes deficient. This is the reason the earliest sign of this protein malnutrition is a white streak in the hair of the child (depigmentation). The child looks apathetic and weak.

DIF: Cognitive Level: Comprehension REF: p. 680 OBJ: 10 TOP: Nutritional Deficiencies KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse explains the medically accepted definition of constipation is fewer than _____

bowel movements in a 2-week period.

ANS:

seven The medically accepted definition of constipation is fewer than seven bowel movements in a 2-week period.

DIF: Cognitive Level: Knowledge REF: p. 674 OBJ: N/A TOP: Constipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 29: The Child with a Genitourinary Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse discussed strategies with a parent to prevent a recurrence of urinary tract infection

in the child. Which statement made by the parent indicates a need for further teaching? a. ―My daughter should wash and wipe the perineal area from front to back.‖ b. ―I am only going to have my daughter wear cotton underwear.‖ c. ―It is acceptable to take frequent bubble baths.‖ d. ―She needs to drink lots of fluids and void frequently.‖ ANS: C

Oils in bubble bath and similar products are known to irritate the urethra.

DIF: Cognitive Level: Comprehension REF: p. 694 | Nursing Tip OBJ: 6 TOP: Acute Urinary Tract Infection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. When asked about correcting the hypospadias of a newborn, what does the nurse explain

about this condition? a. No intervention is necessary as the defect will correct itself over time. b. Surgical repair of the hypospadias is done before 18 months of age. c. Corrective surgery is usually delayed until the preschool age. d. Repairing the defect will increase the risk of testicular cancer.

ANS: B

Treatment of hypospadias consists of surgical repair and is usually performed before 18 months of age.

DIF: Cognitive Level: Comprehension

REF: p. 693

OBJ: 5

TOP: Hypospadias KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. What is an initial sign of nephrosis that the nurse might note in a child? a. Raspberry-like rash b. Periorbital edema c. Temperature elevation d. Abdominal pain ANS: B

The edema of nephrotic syndrome is generalized and not readily noticed, even by the parents, but an early sign that can be assessed is periorbital edema.

DIF: Cognitive Level: Knowledge REF: p. 699 | Table 29.3 OBJ: 9 TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. What is it important to assess in a child receiving prednisone to treat nephrotic syndrome? a. Infection b. Urinary retention c. Easy bruising d. Hypoglycemia ANS: A

Prednisone depresses the immune response and increases susceptibility to infection. Because steroids mask signs of infection, the child must be assessed for more subtle symptoms of illness.

DIF: Cognitive Level: Comprehension TOP: Nephrotic Syndrome MSC: NCLEX: Physiological Integrity

REF: p. 697 OBJ: 6 KEY: Nursing Process Step: Data Collection

5. During a physical assessment of a hospitalized 5-year-old child, the nurse notes that the

foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. What action should the nurse implement? a. Forcibly push the foreskin down over the head of the penis. b. Place a warm compress on the penis. c. Notify the charge nurse. d. Wait a few hours and try again.

ANS: C

Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the penis; this should be remedied immediately.

DIF: Cognitive Level: Application REF: p. 692 OBJ: 1 TOP: Paraphimosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. A 7-year-old child with acute glomerulonephritis has gross hematuria and has been confined

to bed. What is the most appropriate nursing intervention for this child? a. Providing activities for the child on restricted activity

b. Feeding the child a protein-restricted diet c. Carefully handling edematous extremities d. Observing the child for evidence of hypotension ANS: A

Although children may feel well, activity is limited until hematuria resolves.

DIF: Cognitive Level: Application REF: p. 699 OBJ: 9 TOP: Acute Glomerulonephritis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 7. Which urinary diversion procedure is the least damaging to the body image of the adolescent? a. Urostomy b. Ileal conduit c. Nephrostomy d. Suprapubic placement ANS: B

The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no external appliance, as is needed with the other diversion methods.

DIF: Cognitive Level: Comprehension REF: p. 694 | Table 29.2 OBJ: 12 TOP: Obstructive Uropathy—Urinary Diversions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The mother of a 5-year-old child taking prednisone for nephrotic syndrome tells the nurse he

needs to get immunizations to enter kindergarten. What does the nurse clarify about receiving immunizations while on prednisone? a. Can interfere with the treatment for nephrosis. b. Require that the child have antibiotic coverage. c. Can be given in smaller, divided doses. d. Should be delayed.

ANS: D

No vaccinations or immunizations should be administered while the disease is active and during immunosuppressive therapy.

DIF: Cognitive Level: Comprehension REF: p. 698 OBJ: 6 TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 9. Diuresis has not occurred on a child with nephrotic syndrome after a month on corticosteroids.

What protocol can the nurse encourage to bring about diuresis? a. Ibuprofen, an anti-inflammatory agent b. Furosemide (Lasix), a diuretic c. Ciprofloxacin (Cipro), an antibiotic d. Cyclophosphamide (Cytoxan), an antisuppressant ANS: D

A potent antisuppressant such as Cytoxan can bring about diuresis when corticosteroids have proven ineffective.

DIF: Cognitive Level: Application REF: p. 694 OBJ: 9 TOP: Nephrotic Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. What foods does the nurse recommend the child with acute glomerulonephritis avoid to

prevent hyperkalemia? a. Dairy products b. Whole-grain cereals c. Organ meats d. Bananas ANS: D

Bananas are very high in potassium and should be avoided.

DIF: Cognitive Level: Comprehension REF: p. 699 OBJ: 9 TOP: AGN KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. Which physical assessment technique will the nurse omit when caring for a 2-year-old child

diagnosed with Wilms‘ tumor? a. Performing range-of-motion exercises on lower extremities b. Palpating the abdomen c. Assessing for bowel sounds d. Percussing ankle and knee reflexes ANS: B

Palpation of the abdomen could disturb the tumor and cause the malignancy to spread.

DIF: Cognitive Level: Application REF: p. 699 | Safety Alert OBJ: 10 TOP: Wilms‘ Tumor KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. Parents are speaking with the urologist about their son‘s undescended testicle. Which

statement by the child‘s father causes the nurse to determine he understands the information presented? a. ―An undescended testicle can reduce fertility.‖ b. ―The testicle usually descends spontaneously during the first month of life.‖ c. ―Surgical correction reduces the risk for testicular tumors.‖ d. ―The optimal time to surgically correct the condition is at diagnosis.‖ ANS: A

Although orchiopexy improves the condition, the fertility rate among patients may be reduced even when only one testis is undescended.

DIF: Cognitive Level: Application REF: p. 700 OBJ: 1 | 5 TOP: Cryptorchidism KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A parent tells the nurse that her child is scheduled for an x-ray of the bladder and urethra that

is done while the child is urinating. What is this test known as?

a. b. c. d.

Cystometrogram Cystoscopy Voiding cystourethrogram Intravenous pyelogram

ANS: C

An x-ray examination of the bladder and urethra before and during micturition is called a voiding cystourethrogram.

DIF: Cognitive Level: Comprehension TOP: Diagnostic Procedures MSC: NCLEX: Physiological Integrity

REF: p. 695 OBJ: 1 KEY: Nursing Process Step: Planning

14. A 6-year-old child with daytime enuresis complains of dysuria and urgency. What does the

nurse recognize these signs and symptoms indicate? a. Urinary tract infection b. Nephrotic syndrome c. Acute glomerulonephritis d. Vesicoureteral reflux ANS: A

Urinary frequency and pain during micturition are symptoms of acute urinary tract infection.

DIF: Cognitive Level: Comprehension REF: p. 691 OBJ: 6 TOP: Acute Urinary Tract Infection KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. What is an appropriate intervention for the edematous child with reduced mobility related to

nephrotic syndrome? a. Reach the child to minimize body movements. b. Change the child‘s position frequently. c. Keep the head of the child‘s bed flat. d. Keep edematous areas moist and covered.

ANS: B

The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate skin.

DIF: Cognitive Level: Application REF: p. 697 OBJ: 9 TOP: Nephrotic Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. Which statement made by a parent of a child with nephrotic syndrome indicates an

understanding of discharge teaching? a. ―I will make sure he gets his measles vaccine as soon as he gets home.‖ b. ―He can stop taking his medication next week.‖ c. ―I should check his urine for protein when he goes to the bathroom.‖ d. ―He should eat a low-protein diet for the next few weeks.‖ ANS: C

The parents should be instructed to keep a daily record of the child‘s urinary proteins.

DIF: Cognitive Level: Application REF: p. 697 OBJ: 9 TOP: Nephrotic Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the

child‘s history, what does the nurse recognize as the probable cause? a. Recovery from German measles 2 months ago b. Dysuria since the previous night c. A history of allergy d. A sore throat 2 weeks ago ANS: D

Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which causes an allergic-type response that alters the effectiveness of the glomeruli.

DIF: Cognitive Level: Comprehension REF: p. 698 OBJ: 9 TOP: Acute Glomerulonephritis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection.

Which is the best beverage for the nurse to recommend to keep urine acidic? a. Milk b. Grape juice c. Apple juice d. Orange juice ANS: C

Juices such as apple or cranberry help maintain acidity of urine.

DIF: Cognitive Level: Comprehension REF: p. 696 | NCP 29.1 OBJ: 6 TOP: Acute Urinary Tract Infection KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 19. The 6-year-old child scheduled for an orchiopexy shyly asks the nurse, ―What are they going

to do to me ‗down there‘?‖ What is the nurse‘s best response? a. ―They are going to fix you up ‗down there‘.‖ b. ―They will move your testicle from your abdomen to your scrotum.‖ c. ―What do you think your doctor is going to do?‖ d. ―You shouldn‘t worry. Your doctor knows exactly what to do.‖ ANS: C

Encourage the patient to talk about what he knows and what feelings he has about the surgery.

School-age children have a fear of bodily harm.

DIF: Cognitive Level: Application REF: p. 700 OBJ: 11 | 12 TOP: Orchiopexy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. What will the nurse caution the parents of a child who has had a nephrectomy that he will

have to avoid? a. Contact sports

b. Horseback riding c. Alcohol d. Diuretic medications ANS: A

Children who have only one kidney should avoid contact sports to prevent injury to that remaining organ.

DIF: Cognitive Level: Comprehension REF: p. 699 OBJ: 12 TOP: Postnephrectomy Instruction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 21. The parents of a newborn are concerned that their son‘s scrotum is enlarged and swollen on

one side. What is the nurse‘s best response? a. ―It is very common in the newborn that one gonad is larger than the other.‖ b. ―Birth trauma caused bruising to the scrotum. It will reduce in size in a few days.‖ c. ―It is a collection of fluid that will most likely correct itself in a year.‖ d. ―The doctor will drain this collection of blood before your baby is discharged.‖ ANS: C

These signs are indicative of a hydrocele, a collection of fluid in the scrotum that usually corrects itself in a year.

DIF: Cognitive Level: Comprehension REF: p. 700 OBJ: 5 TOP: Hydrocele KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. The nurse is providing information to parents of a child born with bilateral cryptorchidism.

What information is accurate to include? a. This is the most common form. b. Fertility will be unaffected. c. Surgical intervention is not recommended. d. An inguinal hernia may be present.

ANS: D

When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism.

The unilateral form is more common. Because the testes are warmer in the abdomen than in the scrotum, the sperm cells begin to deteriorate. If both testes are affected, sterility results.

Inguinal hernia often accompanies this condition. Occasionally, a testis or the testes spontaneously descend during the first year of life. An operation called an orchiopexy may be performed.

DIF: Cognitive Level: Comprehension REF: p. 700 OBJ: 5 TOP: Cryptorchidism KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. An adolescent male is admitted to the ED with severe acute scrotal pain. When documenting

medical history the nurse notes cryptorchidism at birth. What diagnosis does the nurse expect? a. Urinary tract infection b. Nephrosis c. Torsion d. Phimosis

ANS: C

When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism.

Acute scrotal pain may indicate a testicular torsion (twisting), which necessitates immediate surgery to preserve testicular function.

DIF: Cognitive Level: Comprehension REF: p. 700 OBJ: 1 | 5 TOP: Torsion KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. A 7-year-old child has a BUN of 25 mg/dL. What is the nurse aware this lab value might

indicate? (Select all that apply.) a. Dehydration b. Renal disease c. Need for steroid therapy d. Diabetes e. Pituitary malfunction ANS: A, B, C

Increased BUN can indicate dehydration, renal disease, and/or need for steroid therapy.

DIF: Cognitive Level: Analysis REF: p. 692 | Table 29.1 OBJ: 4 TOP: Diagnostic Tests KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 2. What will the nurse caring for a newborn with exstrophy of the bladder include in the care?

(Select all that apply.) a. Diaper infant tightly. b. Protect skin around bladder. c. Position infant on back. d. Prepare for surgical closure. e. Cover exposed bladder with shield.

ANS: B, C, D, E

The infant is kept on his back or side with special attention to the skin around the exposed bladder, which is constantly bathed with urine. These infants are diapered loosely, if at all.

Surgical closure is done as quickly as possible.

DIF: Cognitive Level: Application REF: p. 693 OBJ: 5 TOP: Exstrophy of the Bladder KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 3. The nurse caring for a child with nephrotic syndrome is alert to which classic symptoms of

this disorder? (Select all that apply.) a. Proteinuria b. Grossly bloody urine c. Hyperalbuminemia d. Fatigue e. Generalized edema

ANS: A, B, D, E

All options listed are those of nephrotic syndrome with the exception of hyperalbuminemia.

The nephrotic child has hypoalbuminemia, as most of the protein has been spilled in the urine.

DIF: Cognitive Level: Knowledge REF: pp. 695-697 OBJ: 9 TOP: Nephrotic Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse is aware that genitourinary surgery is especially stressful for preschool children.

What factor(s) lend to this stress? (Select all that apply.) a. They may perceive the treatment as punishment. b. They are especially prone to separation anxiety. c. They are sexually curious and developmentally fixated on their genitals. d. They have a fear of castration. e. They fear death.

ANS: A, B, C, D

All options, except fear of death, are especially stressful for preschool children undergoing genitourinary surgery. Children in this age group do not have an understanding of the concept of death.

DIF: Cognitive Level: Comprehension REF: p. 700 OBJ: 12 TOP: Impact of Surgery on Preschoolers KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. What special considerations are related to long-term prednisone therapy in preschoolers?

(Select all that apply.) a. Delayed immunization b. Hypertension c. Enlargement of the sex organs d. Alteration in nutrition e. Increased risk for infection ANS: A, E

Delayed immunization and greater risk for infection are concerns relative to long-term prednisone therapy.

DIF: Cognitive Level: Comprehension REF: p. 698 OBJ: 9 TOP: Long-Term Prednisone Therapy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies COMPLETION 1. The nurse is measuring output on an infant on the pediatric unit. When weighing the diaper

and subtracting the weight of the dry diaper, the nurse records 30 g and documents this as _________ mL. ANS:

30 Diapers may be weighed on a gram scale before application and after removal (1 g = 1 mL).

DIF: Cognitive Level: Analysis REF: p. 698 OBJ: 3 TOP: Urinary Output KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques

Chapter 30: The Child with a Skin Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. The nurse is careful to apply only the prescribed amount of ointment to the skin of a

2-month-old infant. How is infant skin different from adult skin? a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption ANS: D

The child‘s skin has a dramatically greater ability to absorb than does that of the adult.

DIF: Cognitive Level: Comprehension REF: p. 703 | Figure 30.1 OBJ: 2 TOP: Skin Comparison KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. What risk is increased with children who have been diagnosed with infantile eczema? a. Pneumonia b. Acne c. Sun sensitivity d. Asthma ANS: D

Some children with eczema also develop asthma and hay fever–type allergies.

DIF: Cognitive Level: Knowledge REF: p. 709 OBJ: 6 TOP: Infantile Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What is the appropriate technique for the application of a topical treatment for a child with

eczema? a. Apply skin lotions in a circular motion. b. Apply prescribed ointments with a gloved hand. c. Apply as much and as frequently as relieves the symptoms. d. Choose lanolin-based ointments.

ANS: B

The prescribed amount of ointment is usually applied to the skin by a gloved hand in long, smooth strokes. Lanolin-based preparations should be avoided because of a possible allergy to wool.

DIF: Cognitive Level: Knowledge TOP: Infantile Eczema

REF: p. 709 OBJ: 7 | 8 KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity 4. A 2-day-old infant is noted to have small pustules on her skin. What is the best nursing

action? a. Report it immediately because it may be a staphylococcus infection. b. Keep the affected area dry and clean. c. Teach the parents how to care for seborrheic dermatitis. d. Chart the finding because it may be the beginning of a strawberry nevus.

ANS: A

A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn must be reported immediately.

DIF: Cognitive Level: Application TOP: Staphylococcal Infection MSC: NCLEX: Physiological Integrity

REF: p. 711 OBJ: 3 KEY: Nursing Process Step: Implementation

5. The home health nurse discovers a family infected with pediculosis. What information can the

nurse provide to the mother to start eradication of the lice? a. Cover the hair with Vaseline. b. Apply a soda–vinegar solution to the hair. c. Comb through the hair with a vinegar–water solution. d. Shampoo the hair with dish detergent.

ANS: C

Combing a vinegar–water solution through the hair with a fine-tooth comb and then shampooing is an initial step toward eradication.

DIF: Cognitive Level: Application REF: p. 713 OBJ: 9 TOP: Tinea Capitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. A group of football players is taking oral griseofulvin for tinea pedis. What should the school

nurse caution them to avoid? a. Citrus fruit and juice b. Eating shellfish c. Alcohol consumption d. Taking corticosteroids ANS: C

Consumption of alcohol while taking griseofulvin will cause severe tachycardia.

DIF: Cognitive Level: Comprehension REF: p. 712 OBJ: 9 TOP: Tinea Pedis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. What should the nurse suggest before a 17-year-old girl starts a protocol of isotretinoin

(Accutane) for her acne? a. Get a prescription for oral contraceptives. b. Increase the dose of the present medication. c. Limit intake of chocolate, cola, and peanuts. d. Increase exposure to sunlight.

ANS: A

Oral contraceptives are often prescribed for adolescents with acne. Accutane can cause birth defects, so pregnancy should be prevented.

DIF: Cognitive Level: Application REF: p. 709 OBJ: 5 TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. A child had a burn, evidenced by pink skin and blistering. The child complains of pain and is

crying. How does the nurse classify this burn when documenting? a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree ANS: B

A second-degree superficial burn appears blistered, moist, and pink or red. The pain associated with this burn indicates tissue viability.

DIF: Cognitive Level: Analysis REF: p. 716 | Table 30.2 OBJ: 10 TOP: Burns KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. A child has sustained a second-degree deep thermal burn to the hand. What is the best first

action to take? a. Immerse the burned area in cold water. b. Apply ice to the burned area. c. Break any blisters that are present. d. Apply petroleum jelly to the burned skin.

ANS: A

First aid treatment of a second-degree deep thermal burn is immersion of the burned area in water to halt the burning process.

DIF: Cognitive Level: Application REF: p. 716 | Table 30.2 OBJ: 10 | 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 10. Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical

agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations d. Sulfa ANS: D

The use of Silvadene cream on burns is contraindicated if the patient has a sulfa allergy.

DIF: Cognitive Level: Knowledge OBJ: 10 TOP: Burns MSC: NCLEX: Physiological Integrity

REF: p. 720 | Box 30.2 KEY: Nursing Process Step: Data Collection

11. What would help the child with a serious burn meet nutritional needs during the subacute

phase of recovery? a. Decrease calories because the child will be on bed rest and will not need as many. b. Increase calories and protein to compensate for the healing process. c. Increase fat to replace the layer of fat next to the burned skin. d. Decrease carbohydrates and starches because the pancreas is strained by the healing process.

ANS: B

Frequent meals and snacks high in calories, protein, and iron are needed to meet the increased metabolic needs of the child with burns.

DIF: Cognitive Level: Comprehension REF: p. 721 OBJ: 13 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. Which statement made by a parent indicates an understanding of the topical application of

medications for a skin condition? a. ―I apply the medication after I give my child a bath.‖ b. ―I rub the ointment in a circular motion over the rash.‖ c. ―I increased the amount of cream because the rash was not improving.‖ d. ―I use powder and cornstarch to keep the skin dry.‖ ANS: A

Absorption of topical medications is best when preparations are applied after a warm bath.

DIF: Cognitive Level: Comprehension REF: p. 711 OBJ: 7 TOP: Topical Medications KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13. On the first day following a severe burn, the body‘s fluid reserves have left the circulating

volume and entered the interstitial space, causing massive edema. What should the nurse monitor for very closely in the burn victim? a. Increasing intracranial pressure b. Reduced urine output c. Eschar formation d. Fluid overload ANS: B

With the fluid shift associated with severe burns, the nurse must be observant for the reduction of urine, an indication of altered renal function.

DIF: Cognitive Level: Application REF: p. 718 OBJ: 11 TOP: Burns KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 14. At a 2-month well-child visit, parents ask the nurse about the red area on the infant‘s neck.

They tell the nurse that the mark appeared a few weeks after birth. What does the nurse recognize this skin lesion as? a. A port wine nevus b. A strawberry nevus c. Exanthem

d. Intertrigo ANS: B

The strawberry nevus is a common hemangioma consisting of dilated capillaries in the dermal space, which may not become apparent for a few weeks after birth.

DIF: Cognitive Level: Comprehension REF: p. 705 | Figure 30.3 OBJ: 3 TOP: Congenital Lesions KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. A mother is concerned about what might have caused a heat rash on her infant. The nurse

observes tiny pinhead-sized reddened papules on the infant‘s neck and axilla. What does the nurse explain as the most likely cause of this rash? a. Sun exposure b. Allergic reaction c. Infection d. Heat and moisture ANS: D

Miliaria, or prickly heat rash, is caused by excess body heat and moisture.

DIF: Cognitive Level: Comprehension REF: p. 706 | Figure 30.5 OBJ: 3 TOP: Skin Infections KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What is the correct nursing response to a mother who asks, ―How can I get rid of the baby‘s

cradle cap?‖ a. ―Rub baby oil on the infant‘s head at night and shampoo the hair the next morning.‖ b. ―Use a brush with firm bristles to loosen the scales on the baby‘s head several times a day.‖ c. ―Wash the baby‘s head every night with a dandruff-control shampoo.‖ d. ―Lubricate the baby‘s head every morning with a small amount of olive oil.‖ ANS: A

Scales may be softened by applying baby oil to the head the evening before, and shampooing the hair in the morning.

DIF: Cognitive Level: Application REF: p. 707 | Figure 30.7 OBJ: 7 TOP: Seborrheic Dermatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. Which statement made by a parent indicates the need for further teaching about strategies to

control itching for the infant with eczema? a. ―Wool is the best fabric for the infant‘s clothing.‖ b. ―I should avoid laundry detergents with fragrances.‖ c. ―I put cotton gloves on the infant‘s hands.‖ d. ―The infant‘s fingernails are kept short.‖ ANS: A

Clothing should be made of cotton. Wool is avoided because of its allergy potential.

DIF: Cognitive Level: Comprehension REF: p. 711 OBJ: 2 TOP: Infantile Eczema KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 18. What will the nurse include when teaching about general skin care measures that could help

prevent acne? a. Eliminating chocolate, peanuts, and cola from the diet b. Washing the face with a cleansing product frequently c. Planning indoor activities to avoid sun exposure d. Eating a balanced diet and getting sufficient rest ANS: D

General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help prevent exacerbations.

DIF: Cognitive Level: Comprehension REF: p. 708 OBJ: 4 TOP: Acne Vulgaris KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. The nurse caring for a patient with severe frostbite observes a purple flush on the hands and

feet. What is the most appropriate nursing action? a. Report this sign immediately. b. Place a warm towel over the extremities. c. Gently sponge with cool water. d. Medicate for pain.

ANS: D

A purple flush indicates the return of sensation and causes extreme pain.

DIF: Cognitive Level: Application REF: p. 722 OBJ: 14 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. A child is brought to the emergency department with burns on the face and chest. What is the

nurse‘s first priority? a. Assess respiratory status. b. Administer pain medication. c. Remove clothing. d. Insert a Foley catheter.

ANS: A

Airway assessment and establishing an airway are the initial priorities.

DIF: Cognitive Level: Application REF: p. 717 OBJ: 10 | 12 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. An adolescent girl with acne is being treated with an antibiotic in addition to topical

applications. What side effect does the nurse caution the girl to expect? a. Lessened effectiveness of oral contraceptives

b. Urinary burning and frequency c. Breast engorgement d. Vaginitis ANS: D

Antibiotic therapy can cause a monilial vaginitis.

DIF: Cognitive Level: Comprehension REF: p. 709 OBJ: 5 | 7 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 22. The nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2

weeks. Which complication does the nurse anticipate? a. Diverticulitis b. Stress diarrhea c. Curling‘s ulcer d. Perforated bowel ANS: C

Curling‘s ulcer is a complication of burn victims resulting from the stress of their trauma.

DIF: Cognitive Level: Application REF: p. 718 OBJ: 13 TOP: Burns KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 23. A child is brought to the emergency department with severe frostbite. Which body parts

should be warmed first? a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso ANS: D

In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the extremities.

DIF: Cognitive Level: Application REF: p. 722 OBJ: 14 TOP: Frostbite KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. An adolescent is at the pediatrician‘s office because he has been experiencing intense itching,

particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. With what is this symptom associated? a. Scabies b. Pediculosis capitis c. Tinea corporis d. Eczema ANS: A

Intense itching, especially at night, is characteristic of scabies.

DIF: Cognitive Level: Comprehension REF: p. 714 OBJ: 9 TOP: Scabies KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 25. What should the nurse stress to the mother of a child with impetigo? a. The condition is caused by the herpes simplex virus type I. b. The crusts on the lesions should be left in place. c. The lesions may spread, but the disease is not contagious. d. Small cuts and bites should be treated promptly.

ANS: D

Small cuts and bites should be treated promptly to prevent the invasions of the bacteria that cause impetigo. The crusts from the lesions should be gently removed. The disease is contagious.

DIF: Cognitive Level: Comprehension REF: pp. 711-712 OBJ: 3 | 4 TOP: Impetigo KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 26. The nurse is caring for a 3-year-old child with severe burns. What is the nurse aware is the

minimum adequate hourly urine output? a. 5 mL/hr b. 10 mL/hr c. 15 mL/hr d. 20 mL/hr ANS: D

The minimum acceptable hourly urine output for children over the age of 2 years is 20 to 30 mL/hr.

DIF: Cognitive Level: Comprehension REF: p. 718 OBJ: 13 TOP: Urine Output After Burn KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. An adolescent patient at a pediatric clinic presents with a butterfly rash. What diagnosis does

the nurse suspect? a. Tuberous sclerosis b. Eczema c. Psoriasis d. Systemic lupus erythematosus ANS: D

Butterfly rash over the nose and cheeks can be associated with photosensitivity and may be associated with systemic lupus erythematosus (SLE).

DIF: Cognitive Level: Comprehension REF: p. 706 OBJ: N/A TOP: Skin Manifestations of Illness KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 28. The nurse is documenting a description of a skin assessment. What term can be used for an

elevated, fluid-filled blister? a. Pustule b. Papule c. Wheal

d. Vesicle ANS: D

A vesicle is an elevated, fluid-filled blister (cold sore, chicken pox).

DIF: Cognitive Level: Comprehension REF: p. 705| Box 30.1 OBJ: 1 TOP: Skin Conditions KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. What should the nurse keep in mind when providing care to the school-age child hospitalized

with a burn injury? a. Hospitalization will be brief. b. Analgesics should be given immediately after dressing changes. c. Contact with peers should be maintained. d. Parents usually handle injury worse than the child.

ANS: C

A burn injury is taxing to the child and parents. It requires long periods of hospitalization and frequent readmissions. The accident itself is terrifying for the child but is made even worse if caused by disobedience. Nurses encourage children to express their feelings. Analgesics are administered before painful procedures. The long-term patient requires diversions of various types. School tutors are requested, and contact is maintained with peers through cards or e-mail.

DIF: Cognitive Level: Comprehension REF: p. 721 OBJ: 11 | 13 TOP: Burns KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity MULTIPLE RESPONSE 1. Parents of a child show the nurse that their child has a flat strawberry nevus. What

information can the nurse provide in educating the parents regarding strawberry nevus?

(Select all that apply.) a. It is a rare skin variation. b. It is harmless. c. It gradually becomes raised. d. Laser treatment is available. e. Sometimes it can disappear spontaneously.

ANS: B, C, D

The strawberry nevus is a common hemangioma (consists of dilated capillaries in the dermal space) that may not become apparent for a few weeks after birth. Although it is harmless and usually disappears without treatment, it is disturbing to parents, especially when it appears on the head or face. At first it is flat, but it gradually becomes raised. The lesions gradually blanch, with 60% disappearing spontaneously by 5 years of age and 90% disappearing by 9 years of age. Laser treatment or excision may be considered if the area becomes ulcerated.

DIF: Cognitive Level: Knowledge REF: pp. 705-706 OBJ: 3 TOP: Strawberry Nevus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. What would the nurse teach parents to do in order to avoid diaper rash? (Select all that apply.) a. Use ointments. b. Keep perineum covered at all times. c. Use disposable diapers. d. Avoid plastic bloomers or pants. e. Change diaper frequently.

ANS: A, C, D, E

Keeping the skin dry and protected with emollients, leaving the area exposed to light and air periodically, changing the diaper frequently, and avoiding plastic pants will prevent diaper rash.

DIF: Cognitive Level: Comprehension REF: pp. 707-708 OBJ: N/A TOP: Avoiding Diaper Rash KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse speaking to a group of junior high school students informs them that acne can be

exacerbated by which drug(s)? (Select all that apply.) a. Steroids b. Phenytoin c. Phenobarbital d. Aspirin e. Oral contraceptives ANS: A, B, C

Long-term use of steroids, phenytoin, phenobarbital, lithium, and vitamin B12 can cause acne.

DIF: Cognitive Level: Knowledge REF: p. 709 OBJ: 5 TOP: Acne KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. What intervention(s) would the nurse preparing a teaching plan for the care of a child with

infantile eczema include? (Select all that apply.) a. Bathe the child using products with a light fragrance. b. Use oatmeal and baking soda as bath additives. c. Add bath oil to bath water after the child has soaked. d. Apply lanolin-based lotions after the bath. e. Bathe child several times a day.

ANS: B, C

Use of oatmeal, baking soda, and baking powder is soothing. Adding oil to the bath water after the child has soaked for a while makes the oil application more effective. Items with any fragrance should be avoided as well as lanolin-based products. Many dermatologists advise minimal bathing.

DIF: Cognitive Level: Comprehension REF: p. 710 OBJ: 6 TOP: Infantile Eczema KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. Which factor(s) activate the herpes simplex virus type I? (Select all that apply.) a. Stress

b. c. d. e.

Sun Menses Fever Food allergies

ANS: A, B, C, D

The herpes simplex virus type I can be activated to cause a cold sore by exposure to stress, sun, initiation of menses, and fever. Food allergies do not activate the virus as a rule.

DIF: Cognitive Level: Comprehension REF: p. 709 OBJ: 4 TOP: Herpes Simplex Type I KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. A 5-year-old boy is brought to the emergency department with a second-degree burn of his

entire right arm and hand, anterior trunk and genital area, and front of right thigh. The nurse assesses the total body surface area (TBSA) percentage burn as ______%.

ANS:

26 Using the Burn Size Estimation Table on page 695, the nurse can determine that for a 5-year-old child, the upper and lower arm = 5.5%, the hand = 2.5%, anterior trunk = 13%, genital area = 1%, and half of the thigh = 4%. Together this totals to 26% BSA burn.

DIF: Cognitive Level: Analysis REF: p. 714 | Figure 30.15 OBJ: 10 | 11 | 13 TOP: BSA Burn Estimation KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse assesses a major burn as a full-thickness burn involving _____% or more of the

body surface.

ANS:

10 A full-thickness burn involving 10% or more of the body surface is considered a major burn.

DIF: Cognitive Level: Knowledge REF: p. 711 OBJ: 10 TOP: Burns KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 31: The Child with a Metabolic Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A nurse is planning to teach a family about Tay-Sachs disease. What will the nurse relay

about the pattern of inheritance for inborn errors of metabolism? a. They are usually autosomal recessive.

b. They are usually autosomal dominant. c. They are usually X-linked recessive. d. They are usually multifactorial.

ANS: A

The pattern of inheritance is generally autosomal recessive.

DIF: Cognitive Level: Knowledge REF: p. 725 OBJ: 2 TOP: Tay-Sachs KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. What occurs as a result of an inadequate secretion of insulin? a. Protein synthesis is increased. b. Increased fat breakdown leads to ketonemia. c. Serum glucose levels are markedly decreased. d. More rapid conversion and storage of carbohydrates to glucose occurs.

ANS: B

When insulin is deficient, the body cannot metabolize carbohydrates for energy. The body is also unable to store and use fat properly. Incomplete fat metabolism produces ketone bodies that accumulate in the blood.

DIF: Cognitive Level: Comprehension REF: p. 727 OBJ: 7 TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. On what understanding does the nurse plan the care of a child with a new diagnosis of type 1

diabetes mellitus? a. There is an absolute deficiency of insulin. b. Insufficient quantities of insulin are produced by the pancreas. c. Oral hypoglycemic agents can control it. d. Insulin deficiency is caused by another disease affecting the pancreas.

ANS: A

Type 1 insulin-dependent diabetes mellitus is characterized by an absolute or complete deficiency of insulin.

DIF: Cognitive Level: Comprehension REF: p. 728 | Table 31.2 OBJ: 5 TOP: Diabetes Mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A child receives a combination of regular and NPH insulin at 8:00 AM. At 8:45 AM the

breakfast trays have not yet arrived from the kitchen. What is the best action by the nurse? a. Notify the charge nurse. b. Give the patient a snack of graham crackers and milk. c. Ambulate the patient in the hall for a short time. d. Give the patient more insulin according to the sliding scale.

ANS: B

A child who receives regular insulin before meals may have an insulin reaction if food is not eaten within 20 minutes. A snack of graham crackers and milk will prevent an episode of hypoglycemia.

DIF: Cognitive Level: Application REF: p. 737 | Table 31.6 OBJ: 8 | 9 TOP: Prevention of Hypoglycemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 5. Although the child with type 1 diabetes had her prescribed insulin at 7:30 AM, the child is

complaining of hunger and thirst and is drowsy at 10:30 AM. What should the nurse do first? a. Walk the patient in the hall for 10 minutes. b. Allow the patient a short nap. c. Give her a cup of orange juice. d. Test her blood with a glucometer and give insulin according to the sliding scale.

ANS: C

The immediate remedy is to give orange juice to raise the blood glucose. Giving more sugar will increase the blood glucose in a hyperglycemic child. Walking exercise will use up even more glucose. The treatment for hyperglycemia is to give the patient more insulin.

DIF: Cognitive Level: Application REF: p. 736 OBJ: 7 | 8 TOP: Hypoglycemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. Which comment made by a school-age child indicates that he needs more teaching about

diabetes mellitus and exercise? a. ―I carry a piece of hard candy with me in case I start to feel shaky.‖ b. ―I make sure I have emergency money when I have soccer practice or a game.‖ c. ―Sometimes I skip my breakfast when I have a game in the morning.‖ d. ―I play in soccer games that are scheduled after dinner.‖ ANS: C

Blood glucose is high after meals. The child with type 1 diabetes mellitus who skips a meal before exercise is at risk for hypoglycemia.

DIF: Cognitive Level: Comprehension REF: p. 738 OBJ: 8 TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. Which statement made by a 7-year-old child with type 1 diabetes mellitus indicates a need for

more teaching? a. ―My pancreas is sick and needs insulin until it is well.‖ b. ―I will need to take my insulin every day.‖ c. ―I need to keep a piece of candy in my pocket in case I start to feel shaky.‖ d. ―My mom has to give me insulin shots twice a day.‖ ANS: A

The child with type 1 diabetes mellitus has an insulin deficiency and will require lifelong management of this disease. Insulin does not cure the pancreas.

DIF: Cognitive Level: Comprehension

REF: p. 728 | Table 31.2

OBJ: 5 TOP: Diabetes Mellitus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. Which general dietary measure should the nurse include in a teaching plan for the child with

type 1 diabetes mellitus? a. Control intake of carbohydrates and consume fewer calories. b. Focus on complex carbohydrates and eat foods high in fiber. c. Obtain most calories from proteins and fats. d. Eat a diet low in fat and low in complex carbohydrates.

ANS: B

The nutritional needs of a child with diabetes mellitus are essentially the same as those of the nondiabetic child, with the exception of the elimination of concentrated carbohydrates such as sugar. Fiber has been shown to reduce blood glucose levels.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: 8 TOP: Diet KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A child with diabetes is brought to the emergency department. He is flushed and drowsy, and

his skin is dry. His father states that the child has been feeling progressively worse since the morning. What is this child most likely experiencing? a. Somogyi phenomenon b. Dawn syndrome c. Ketoacidosis d. Water intoxication ANS: C

In ketoacidosis, the child‘s skin is dry, and the face is flushed. Patients appear dehydrated.

They may perspire and be restless. The breath has a fruity odor, and there is no rest period between inspiration and expiration.

DIF: Cognitive Level: Analysis REF: p. 730 | Table 31.4 OBJ: 6 TOP: Ketoacidosis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. A mother reports that her 4-month-old infant is lethargic, sleeps 18 hours a day, and snores.

The nurse recognizes these signs are characteristic of what? a. Hypothyroidism b. Hyperthyroidism c. Type 1 diabetes mellitus d. Tay-Sachs disease ANS: A

The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing noisy respiration.

DIF: Cognitive Level: Analysis REF: p. 726 OBJ: 3 TOP: Hypothyroidism KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

11. What is an important consideration for the school-age child taking DDAVP for diabetes

insipidus? a. Observe for signs of water deprivation. b. Restrict his physical education program. c. Arrange for the child to use the bathroom when needed. d. Limit fluid intake other than during the lunch period.

ANS: C

The child with diabetes insipidus needs liberal access to bathrooms and water fountains.

Arrangements may have to be made with the school to allow access.

DIF: Cognitive Level: Application REF: pp. 726-727 OBJ: 4 TOP: Diabetes Insipidus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. What condition does the nurse suspect when a child with type 1 diabetes mellitus has

hyperglycemia, diaphoresis, and headaches in the morning? a. Dawn phenomenon b. Somogyi phenomenon c. Honeymoon effect d. Ketoacidosis ANS: B

The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level is lowered to the point at which the body‘s counter-regulatory hormones are released, producing the symptoms described.

DIF: Cognitive Level: Analysis TOP: Somogyi Phenomenon MSC: NCLEX: Physiological Integrity

REF: p. 736 OBJ: 11 KEY: Nursing Process Step: Data Collection

13. What would be the most appropriate nursing response to a woman who says, ―My sister had a

child with Tay-Sachs disease, and I want to know if I could have a child with this condition‖? a. ―The disease is rare. It is unlikely that you would have a child with Tay-Sachs disease.‖ b. ―A screening test can be done to determine if you are a carrier of the gene.‖ c. ―The gene for Tay-Sachs disease is transmitted by the father.‖ d. ―The cause of Tay-Sachs disease is thought to be an autoimmune response to a virus.‖ ANS: B

Carriers can be identified by screening tests. Tay-Sachs disease has an autosomal recessive pattern of transmission.

DIF: Cognitive Level: Comprehension REF: p. 725 OBJ: 2 TOP: Tay-Sachs Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. What statement by a parent leads the nurse to determine a parent is administering

levothyroxine (Synthroid) correctly? a. ―I stopped giving the medication because my daughter was losing her hair.‖

b. ―I am using a different brand now because it costs less money.‖ c. ―I don‘t give the medication on the weekends.‖ d. ―I give the medication at 8:00 AM every day.‖ ANS: D

Synthroid should be given at the same time each day, preferably in the morning.

DIF: Cognitive Level: Comprehension REF: p. 726 OBJ: 3 TOP: Levothyroxine (Synthroid) KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. After a closed head injury, the unconscious 10-year-old child begins to excrete copious

amounts of pale urine with an attendant drop in blood pressure (BP). Based on these symptoms, what does the nurse suspect has developed? a. Diabetes insipidus b. Diabetes mellitus c. Hypothyroidism d. Hyperthyroidism ANS: A

Diabetes insipidus can be acquired as the result of a head injury or tumor, and suppression of the posterior pituitary causes copious urine output with an attendant drop in BP. The child can become dehydrated very quickly if some remedy is not applied.

DIF: Cognitive Level: Analysis REF: p. 726 OBJ: 4 TOP: Diabetes Insipidus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. The nurse is teaching the parents of a child with diabetes insipidus about water intoxication.

The nurse would tell the parents to be alert for what symptom? a. Polyuria b. Cough c. Weight loss d. Lethargy ANS: D

Signs of water intoxication include edema, lethargy, nausea, and central nervous system signs.

DIF: Cognitive Level: Comprehension REF: p. 726 OBJ: 4 TOP: Diabetes Insipidus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 17. The parents of a child newly diagnosed with diabetes mellitus tell the nurse, ―Our son‘s body

is resistant to insulin.‖ With what does the nurse recognize this description is consistent? a. Type 1, insulin-dependent diabetes mellitus b. Type 2, non–insulin-dependent diabetes mellitus c. Maturity-onset diabetes of youth d. Drug-induced diabetes ANS: B

Type 2, non–insulin-dependent diabetes mellitus is caused by insulin resistance or failure of the body to use the insulin.

DIF: Cognitive Level: Comprehension REF: p. 728 OBJ: 5 TOP: Insulin Resistance KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. What does the nurse instruct a 12-year-old to do when teaching how to administer insulin? a. Make sure injection sites are 6 inches apart. b. Select an injection site that was recently exercised. c. Inject the needle at a 90-degree angle. d. Give the injection deep into the muscle.

ANS: C

Children often find it easier to learn to inject the needle at a 90-degree angle.

DIF: Cognitive Level: Application REF: p. 733 OBJ: 9 TOP: Diabetes Mellitus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 19. The nurse discussed treatment of hypoglycemia with an adolescent. Which statement by the

adolescent leads the nurse to determine the patient understood the instructions? a. ―When my blood glucose is low or if I begin to feel hungry and weak, I will eat six LifeSavers.‖ b. ―When my blood glucose is low or if I begin to feel hungry and weak, I will give myself Lispro insulin.‖ c. ―When my blood glucose is low or if I begin to feel hungry and weak, I will have a slice of cheese.‖ d. ―When my blood glucose is low or if I begin to feel hungry and weak, I will drink a diet soda.‖ ANS: A

The immediate treatment of hypoglycemia consists of administering sugar in some form such as orange juice, hard candy, or a commercial product. Cheese will eventually raise the blood glucose, but not as quickly as candy.

DIF: Cognitive Level: Application REF: p. 736 OBJ: 7 TOP: Diabetes Mellitus KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. Why does the nurse instruct an 11-year-old diabetic child to use the side of the finger for

blood testing? a. It has fewer capillaries. b. It is easier to puncture. c. It is less likely to become infected. d. It has fewer nerve endings.

ANS: D

The sides of the finger have fewer nerve endings and more capillaries but are not easier to puncture than the fingertip. The risk for infection is remote for either site.

DIF: Cognitive Level: Comprehension REF: p. 732 OBJ: 8 TOP: Finger Stick KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

21. What is the function of an insulin pump? a. Releases insulin as blood glucose rises. b. Provides continuous infusion of insulin. c. Decreases need for painful glucose monitoring. d. Delivers a prescribed amount of insulin twice a day.

ANS: B

The insulin pump that is attached to a subcutaneous tube releases a continuous infusion of insulin.

DIF: Cognitive Level: Knowledge REF: p. 732 OBJ: 8 TOP: Insulin Pump KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 22. The nurse is preparing to administer a long-acting insulin. Which insulin is considered long

acting? a. Lispro b. Aspart c. Glargine d. Regular ANS: C

Insulin glargine is a long-acting insulin. Regular is short acting. Lispro and Aspart are rapid acting.

DIF: Cognitive Level: Knowledge REF: p. 734 OBJ: 9 TOP: Insulin KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 1. When discussing possible causes of diabetes in children, the nurse mentions chromosomal

defects. Which chromosomes are associated with diabetes? (Select all that apply.) a. 6 b. 7 c. 12 d. 20 e. 21 ANS: A, B, C, D

Defects in chromosomes 6, 7, 12, and 20 and other genetic disorders are associated with diabetes mellitus syndrome.

DIF: Cognitive Level: Knowledge REF: p. 725 OBJ: 5 TOP: Diabetes Mellitus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Which food sources are high in soluble fiber? (Select all that apply.) a. Raw fruits b. Cooked vegetables

c. Beans d. Lean meat e. Bran cereal ANS: A, C, E

Foods high in soluble fiber include raw fruits, beans, and bran cereal.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: 8 TOP: Dietary Fiber Sources KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What does the nurse remind the adolescent with diabetes that soluble fiber in the diet can

reduce? (Select all that apply.) a. Blood glucose b. Serum cholesterol c. Incidence of infections d. Absorption of sugar e. Insulin requirements ANS: A, B, D, E

Soluble fiber can reduce blood glucose, serum cholesterol, absorption of sugar, and insulin requirements. It has no effect on infections.

DIF: Cognitive Level: Comprehension REF: p. 737 OBJ: 8 TOP: Fiber in Diet KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which process(es) does the nurse explain the endocrine system is primarily responsible for

controlling? (Select all that apply.) a. Maturation b. Reproduction c. Stress response d. Sexual identity e. Growth ANS: A, B, C, E

The endocrine system governs maturation, reproduction, stress response, and sexual maturity.

Sexual identity is a psychosocial response.

DIF: Cognitive Level: Comprehension REF: p. 724 OBJ: 3 TOP: Endocrine System KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The home health nurse is monitoring an 8-month-old child with hypothyroidism taking

levothyroxine (Synthroid). Which symptoms does the nurse recognize as signs of overdose?

(Select all that apply.) a. Tachycardia b. Irritability c. Vomiting d. Weight gain e. Diaphoresis

ANS: A, B, E

All the options with the exception of weight gain and vomiting are indications of overdose of Synthroid. Weight loss is a symptom of overdose, however.

DIF: Cognitive Level: Comprehension REF: p. 726 OBJ: 3 TOP: Levothyroxine (Synthroid) Overdose KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. What makes keeping diabetes in control in an adolescent difficult? (Select all that apply.) a. Hormonal changes b. Developmental conflicts c. Preference for fast food d. Growth spurts e. Knowledge of disease ANS: A, B, C, D

The adolescent who is in a growth spurt and filled with raging hormones resents and denies the need to be dependent on a medication. Medication schedules and diet restrictions do not correlate well with the adolescent‘s lifestyle of eating fast foods. Denial of disease is prevalent in the adolescent.

DIF: Cognitive Level: Comprehension REF: p. 730 | Table 31.7 OBJ: 8 TOP: Diabetic Adolescent KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. A child with diabetes mellitus is observed to have cold symptoms. What signs and symptoms

will alert parents of the possibility of ketoacidosis? (Select all that apply.) a. Chest congestion b. Ear pain c. Fruity breath d. Hyperactivity e. Nausea ANS: C, E

Symptoms of ketoacidosis are compared with those of hypoglycemia. Signs and symptoms include a fruity odor to the breath, nausea, decreased level of consciousness and dehydration.

Lab values include ketonuria, decreased serum bicarbonate concentration (decreased CO2 levels) and low pH, and hypertonic dehydration.

DIF: Cognitive Level: Comprehension REF: p. 730 OBJ: 6 TOP: Ketoacidosis KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse is discussing insulin shock with parents of a child recently diagnosed with diabetes

mellitus. What will the nurse respond when the parents ask why children are more prone to insulin reactions? (Select all that apply.) a. ―The condition is more unstable in children.‖ b. ―Parents are often noncompliant.‖ c. ―The activities are irregular.‖ d. ―They are still growing.‖

e. ―Sleep patterns are not established.‖ ANS: A, C, D

Children are more prone to insulin reactions than adults because of the following: the condition itself is more unstable in young people; they are growing; their activities are more irregular.

DIF: Cognitive Level: Comprehension REF: p. 736 OBJ: 10 TOP: Insulin Shock KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 1. The nurse reminds the parents of a diabetic with an insulin pump that the tubing of the pump

should be changed aseptically every ______ hours.

ANS:

48 The tubing of the insulin pump should be changed every 48 hours.

DIF: Cognitive Level: Knowledge REF: p. 733 OBJ: 8 TOP: Insulin Pump KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. The nurse explains that the diagnosis of diabetes is made when the fasting blood glucose level

is _______ mg/dL on two separate occasions, and the history is positive for indication of the disease.

ANS:

126 An elevated blood glucose level of 126 mg/dL on two separate occasions is grounds for the diagnosis of diabetes mellitus when the history is positive for the disease.

DIF: Cognitive Level: Comprehension REF: p. 728 OBJ: 8 TOP: Diagnosis of DM KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can

evaluate average glucose levels over a period of _____ to _____ months.

ANS:

3; 4 3, 4 3 to 4 three, four three; four three to four

Glucose attaches to the red cells over the life span of the cell and can be read as percentages.

An HbA1c reading of 6% to 9% is normal; a reading of 12% or higher is indicative of DM. DIF: Cognitive Level: Knowledge REF: pp. 729-730 OBJ: 8 TOP: Glycosylated Hemoglobin KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 32: Childhood Communicable Diseases, Bioterrorism, Natural Disasters, and the Maternal–Child Patient Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. Which classification of medication would make a child most susceptible to an opportunistic

infection? a. Anticonvulsant b. Beta-adrenergic agent c. Antibiotic d. Corticosteroid ANS: D

Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic infections.

DIF: Cognitive Level: Knowledge REF: p. 749 OBJ: 3 TOP: Effect of Steroids KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. An 8-year-old child asks the nurse how she got the antibodies that kept her from getting

whooping cough. What is the nurse‘s best explanation? a. ―You received borrowed antibodies from another person who had whooping cough.‖ b. ―You were given a tiny case of whooping cough and then you made your own antibodies.‖ c. ―An immunization strengthened antibodies you were born with.‖ d. ―You received only temporary borrowed antibodies and you need to have another shot every 5 years.‖ ANS: B

Vaccines contain live weakened or dead organisms not strong enough to cause disease but they stimulate the body to develop an immune reaction and antibodies. This is active acquired immunity.

DIF: Cognitive Level: Comprehension REF: p. 749 OBJ: 7 TOP: Vaccines KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. How would the nurse document a rash that has erythematous, circular raised lesions? a. Macular b. Papular c. Vesicular

d. Pustular ANS: B

A papule is a circular, reddened elevated area on the skin.

DIF: Cognitive Level: Knowledge REF: p. 754 OBJ: 2 TOP: Rashes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which finding would lead the nurse to delay the administration of DTaP for an infant? a. Diarrhea b. Temperature of 40.5C (105F) from the previous inoculation c. Teething d. Traveling to Europe in a week ANS: B

A contraindication to giving the DTaP vaccine is a 40.5C (105F) temperature following the previous vaccination.

DIF: Cognitive Level: Application REF: p. 757 OBJ: 5 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. What type of precautions are necessary when caring for a toddler with varicella? a. Contact b. Protective c. Airborne d. Droplet ANS: C

Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubella. Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room.

DIF: Cognitive Level: Application REF: p. 750 OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. Which statement assures the nurse that parents understand how long a child who has varicella

is contagious? a. ―My child should stay home from school for 6 days after the pox appear.‖ b. ―My child can return to school when the rash fades.‖ c. ―My child must stay away from other children until all of the lesions have healed.‖ d. ―My child is contagious as long as he has a fever.‖ ANS: A

The child with varicella is contagious for 6 days after the appearance of the rash.

DIF: Cognitive Level: Comprehension REF: p. 744| Health Promotion Box OBJ: 2 TOP: Common Varicella KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

7. Which statement made by a sexually active adolescent girl indicates an understanding of the

prevention of sexually transmitted diseases? a. ―I always douche after intercourse.‖ b. ―I think you can get a vaccination for STDs now.‖ c. ―I insist that my partner wear a condom.‖ d. ―I am protected because I take the pill.‖ ANS: C

The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual intercourse.

DIF: Cognitive Level: Comprehension REF: p. 761 | Nursing Tip OBJ: 10 TOP: Sexually Transmitted Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. What is the priority nursing diagnosis for a hospitalized infant who is HIV positive? a. Risk for injury b. Altered nutrition c. Impaired skin integrity d. Risk for infection ANS: D

The infant who is HIV positive has impaired immunologic functioning and is at high risk for infection.

DIF: Cognitive Level: Application REF: p. 749 OBJ: 10 TOP: Human Immunodeficiency Virus KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. The mother of a newborn asked the nurse, ―When will my baby get the hepatitis B vaccine?‖

When will the nurse explain the first dose of Comvax should be given to infants born to a hepatitis B-positive mother? a. Within 12 hours after birth b. Within 2 weeks after birth c. Within 1 month after birth d. Within 2 months after birth ANS: A

The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free hepatitis B vaccine, should be used for infants born to HBsAg-positive mothers within 12 hours of birth.

DIF: Cognitive Level: Knowledge REF: p. 751 | Figure 32.6 OBJ: 5 TOP: Immunization Schedule KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A 10-year-old child is diagnosed with hepatitis A. What is the most likely way the child

contracted this disease? a. Came in contact with infected blood.

b. Came in contact with droplets in the air. c. Was bitten by a mosquito or a tick. d. Ate shrimp while in Mexico.

ANS: D

Hepatitis A results from ingestion of contaminated water or shellfish.

DIF: Cognitive Level: Comprehension REF: p. 746 | Health Promotion Box OBJ: 3 TOP: Hepatitis A KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 11. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse

use when caring for the infant? a. Large-droplet infection precautions b. Airborne-infection precautions c. Contact precautions d. Protective precautions ANS: C

Contact precautions are used when the condition transmits organisms via skin-to-skin contact or indirect touch of a contaminated fomite.

DIF: Cognitive Level: Application REF: p. 743 OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the

most appropriate response for the nurse to make when the child asks, ―Why do you have to wear a gown and mask when you are in my room?‖ a. ―Nurses and doctors wear gowns and masks because you have a condition that could be spread to others.‖ b. ―The gown and mask are to protect you because you could get an infection very easily.‖ c. ―I‘m wearing this because there are a lot of bacteria in the hospital.‖ d. ―I might look scary but you won‘t need this after you have had medication for 24 hours.‖ ANS: B

Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly susceptible to infection.

DIF: Cognitive Level: Application REF: p. 753 OBJ: 3 | 4 TOP: Protective Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. The nurse is planning to administer immunizations at a well-child visit when a parent reports

the 18-month-old child is allergic to eggs. Which vaccine would be contraindicated? a. Influenza b. Inactivated polio vaccine c. Diphtheria, tetanus, acellular pertussis d. Hepatitis B

ANS: A

The influenza vaccine should not be given to children who are allergic to eggs.

DIF: Cognitive Level: Knowledge REF: p. 756 OBJ: 7 TOP: Nurse‘s Role in Immunizations—Allergy KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. The nurse is preparing to administer immunizations at a well-child clinic. Which method of

administration will the nurse implement? a. DTaP subcutaneously b. Hib vaccine prepared in a separate syringe c. Varicella intramuscularly d. Varicella 1 week after the MMR vaccine ANS: B

Hib vaccine must be given in a separate syringe from other vaccines administered at the same time.

DIF: Cognitive Level: Knowledge REF: p. 757 OBJ: 7 TOP: Hib KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. A child was sent to the school nurse because of a rash. The nurse noted the rash was present

on the trunk, extremities, and face. The child‘s cheeks were bright red. With what is the nurse aware this type of rash is consistent? a. Measles b. Roseola c. Varicella d. Fifth disease ANS: D

In fifth disease, the child has a generalized rash and the cheeks have a slapped-cheek appearance.

DIF: Cognitive Level: Comprehension REF: p. 745 | Health Promotion Box OBJ: 2 TOP: Fifth Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. What statement leads the nurse to determine that a child‘s parent understands information

related to tick bites? a. ―I‘ll have my son wear dark clothing on his hike.‖ b. ―We should all get the Lyme disease vaccine before our trip.‖ c. ―I‘ll get a prescription for amoxicillin to take with us.‖ d. ―We will wear long pants and long-sleeved shirts in the woods.‖ ANS: D

People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites.

DIF: Cognitive Level: Application

REF: p. 747 | Health Promotion

OBJ: 4 TOP: Prevention of Tick Bites KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 17. An adolescent is taking tetracycline for a sexually transmitted disease. What would the nurse

stress when providing instruction about this medication? a. Finish all of the medication. b. Get plenty of fresh air and sunlight. c. Take the medication with food. d. Take an antacid if the medication causes an upset stomach.

ANS: A

The nurse would teach the adolescent to take all of the prescribed medication to avoid making the microorganism resistant to tetracyclines.

DIF: Cognitive Level: Comprehension REF: p. 761 | Table 32.4 OBJ: 10 TOP: Sexually Transmitted Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. The nurse explains to the parents that their child is in the prodromal stage of varicella. What

does this mean? a. The child is now immune to varicella. b. The child has varicella but has not yet broken out. c. The child is infected with varicella but is not contagious. d. The child does not have varicella but has been exposed to it.

ANS: B

The prodromal stage is the initial stage of the communicable disease in which the child is infected and contagious but does not yet have outward signs of the disease.

DIF: Cognitive Level: Comprehension REF: p. 748 OBJ: 1 | 2 TOP: Prodromal Period KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 19. Which is an example of an opportunistic infection? a. Measles b. Pneumocystis jiroveci c. Clostridium difficile d. Smallpox ANS: B

Pneumocystis jiroveci is the most common of opportunistic diseases.

DIF: Cognitive Level: Knowledge REF: p. 749 OBJ: 1 TOP: Opportunistic Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 20. A child is admitted to the pediatric unit with a diagnosis of cellulitis on the right upper thigh.

Patient history reveals the child had a 2-cm laceration on the right thigh prior to infection.

When explaining the chain of infection, how does the nurse identify this laceration? a. Reservoir

b. Portal of entry c. Portal of exit d. Vector ANS: B

The chain of infection refers to the way in which organisms spread and infect the individual.

A portal of entry is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit is the route by which the organisms exit the body (e.g., feces or urine). A reservoir for infection is a place that supports the growth of organisms (e.g., standing, stagnant water). A vector is an insect or animal that carries and spreads a disease.

DIF: Cognitive Level: Comprehension REF: p. 749 OBJ: 1 TOP: Chain of Infection KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. What are the most likely reasons a female adolescent with STDs resist reporting the

condition? (Select all that apply.) a. She is reluctant to name contacts. b. She is embarrassed. c. She doubts confidentiality. d. She doesn‘t want to take the medication. e. She dreads the pelvic examination.

ANS: A, B, C, E

Adolescents are uncomfortable about the pelvic examination and require a lot of support.

Adolescents doubt the confidentiality of the agency and are reluctant to name contacts.

DIF: Cognitive Level: Comprehension REF: pp. 761-762 | Table 32.4 OBJ: 10 TOP: Reporting STDs KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. What sources are examples of acquired immunity? (Select all that apply.) a. Gamma globulin b. The disease c. Maternal antibodies d. The vaccine e. Immune globulin ANS: B, D

Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination. Gamma globulin is simply a support to the immune system. Immune globulin is receiving the antibodies from some other source, giving the person an immediate immunity but one that does not last.

DIF: Cognitive Level: Knowledge REF: p. 749 OBJ: 1 TOP: Acquired Immunity KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. The well-child clinic nurse is preparing to give which immunizations to a healthy 2-month-old

infant? (Select all that apply.) a. DTaP b. Hib c. IPV d. MMR e. PCV ANS: A, B, C, E

All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps, measles, and rubella are not expected until the child is 1-year old.

DIF: Cognitive Level: Knowledge REF: p. 757 OBJ: 5 TOP: Inoculations for a 2-Month-Old KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 4. The nurse is explaining to a family about disaster preparedness. What will the nurse instruct

the family to prepare in a disaster kit in case of emergency? (Select all that apply.) a. Small television b. Vital documents c. Nonperishable food d. Pet food e. Blankets ANS: B, C, D, E

The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or man-made disasters, such as bioterrorist attacks or bombings. The American Medical Association (AMA) office guidelines for preparing a family and community disaster plan state that the family should keep several days‘ supply of food, water, pet food, warm clothing, blankets, copies of vital documents, and toiletries on hand. A battery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential.

DIF: Cognitive Level: Knowledge REF: p. 760 OBJ: 9 TOP: Disaster Preparedness KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. The nurse is assisting with an admission assessment of a child with scarlet fever. Which

actions will the nurse expect to implement? (Select all that apply.) a. Obtain a throat culture. b. Encourage ambulation. c. Assess for desquamation. d. Initiate droplet precautions. e. Administer isoniazid.

ANS: A, C

A diagnosis of scarlet fever would indicate throat culture and assessment for desquamation.

Bed rest with quiet activity is indicated. Droplet precautions would not be implemented for scarlet fever. Isoniazid is administered for tuberculosis.

DIF: Cognitive Level: Application REF: p. 748 | Health Promotion OBJ: 2 TOP: Scarlet Fever KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION 1. A parent is concerned because her son was exposed to varicella at preschool. The nurse would

tell this parent that the incubation period for varicella is 14 to _____ days.

ANS:

21 The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days.

DIF: Cognitive Level: Knowledge REF: p. 744 | Health Promotion Box OBJ: 2 TOP: Varicella KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. The nurse demonstrates proper hand hygiene pointing out that the process should take a

minimum of ____ seconds.

ANS:

15 Hand hygiene should take a minimum of 15 seconds to complete.

DIF: Cognitive Level: Knowledge REF: p. 753 | Nursing Tip OBJ: 4 TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

Chapter 33: The Child with an Emotional or Behavioral Condition Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition MULTIPLE CHOICE 1. A parent asks the nurse to describe what is meant by a ―learning disability.‖ Which is the

nurse‘s most helpful response? a. ―A child may have difficulty with perception, language, comprehension, or memory.‖ b. ―It is characterized by inattention, impulsiveness, and hyperactivity.‖ c. ―The child‘s intellectual ability limits his learning.‖ d. ―The child has difficulty learning because of brain damage.‖ ANS: A

Learning disability is an educational term. Children with learning disabilities may have average to above-average intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization.

DIF: Cognitive Level: Comprehension REF: p. 767 OBJ: N/A TOP: Learning Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

2. What would be the appropriate response to an adolescent who states, ―This has been the worst

day of my life?‖ a. ―You should focus your mind on positive thoughts.‖ b. ―Everybody has a bad day now and then.‖ c. ―You‘re young. What could be so terrible?‖ d. ―Tell me about the worst day of your life.‖ ANS: D

The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and giving the adolescent full attention.

DIF: Cognitive Level: Application REF: p. 775 | Nursing Tip OBJ: 10 TOP: Suicide KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse asks, ―Do your parents drink every day?‖ The adolescent suddenly shouts, ―I‘m not

going to talk about that! It‘s none of your business, anyway! Leave me alone!‖ How does the nurse interpret the adolescent‘s behavior? a. The adolescent is acting out and needs to be brought under control so the conference can continue. b. The adolescent is trying to shift the focus of the conference away from himself, and the nurse needs to refocus. c. The adolescent is demonstrating that this problem requires the assistance of a psychiatrist. d. The adolescent is responding to the discrediting of his parents, which causes anxiety.

ANS: D

Discrediting parents threatens the child‘s security and creates anxiety.

DIF: Cognitive Level: Analysis REF: pp. 776-777 OBJ: 13 TOP: Children of Alcoholics KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. The nurse is answering phone calls at a local suicide prevention hotline. Which statement

would be recognized as the greatest risk of suicide? a. ―I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself.‖ b. ―My parents aren‘t home and won‘t be back for 4 hours. That should be enough time for the pills to work. I‘ve got a hundred of them.‖ c. ―My dad will be home first, so he‘ll find me. So I think I‘ll use his gun. I hope he didn‘t lock the cabinet.‖ d. ―My girlfriend is here with me. She told me to call because I was talking crazy about killing myself.‖ ANS: B

The risk of death increases when there is a definite plan of action, the means are readily available, and the person has few resources for help and support.

DIF: Cognitive Level: Analysis REF: p. 772 | NCP 33.1 OBJ: 9 | 10 TOP: Suicide KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. A 15-year-old boy was previously active in a band and saved money to buy a special guitar.

What would a nurse assess as an early sign of depression in this boy? a. He gives up the band to spend time with his girlfriend. b. He spends all of his time at the library studying to qualify for the honor society. c. He gives his guitar away and spends his time listening to music in his room. d. He withdraws all of his money out of the bank to buy an expensive leather jacket.

ANS: C

A major depression is characterized by a prolonged behavioral change from baseline that interferes with school, family life, and age-specific activities, frequently signaled by giving prized possessions away.

DIF: Cognitive Level: Analysis REF: p. 768 OBJ: 5 | 9 | 10 TOP: Depression KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. A mother is concerned because her adolescent son is always in trouble for fighting at school

and always seems to be angry. She mentions that her husband drinks a bit. Which understanding will guide the nurse‘s response? a. The boy is displaying antisocial behavior and should be evaluated for mental illness. b. The boy is displaying one of the typical defense patterns of children of alcoholics and should receive immediate treatment. c. The mother is displaying her own anger with her husband‘s drinking, and she needs immediate intervention. d. The boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention.

ANS: D

Early recognition of and intervention for children of alcoholics are paramount. This adolescent is using the coping pattern of acting-out behaviors to deal with the family situation.

DIF: Cognitive Level: Comprehension REF: pp. 776-777 OBJ: 13 TOP: Children of Alcoholics KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. What is the most appropriate classroom intervention for a child with attention-deficit

hyperactivity disorder (ADHD) for the school nurse to suggest? a. Seat the child in the back of the room to prevent distractions for other children. b. Pair the child with a student buddy to offer reminders to pay attention. c. Divide work assignments into shorter periods with breaks in between. d. Separate the child from others to increase his focus on schoolwork.

ANS: C

The child with ADHD needs breaks between periods of work and study.

DIF: Cognitive Level: Application REF: p. 770 | Health Promotion Box OBJ: 7 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care

8. How does the nurse describe a person who is bulimic? a. Severely underweight b. Alternates binge eating with purging c. Introverted perfectionist d. Has extremely close family relationships ANS: B

Bulimia is characterized by alternating binge eating and purge behavior.

DIF: Cognitive Level: Comprehension REF: p. 771 OBJ: 8 TOP: Bulimia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 9. A 14-year-old girl with obsessive-compulsive disorder (OCD) tells the nurse other adolescents

tease her because she washes her hands many times during the school day. For what does this disorder put the adolescent at greater risk? a. Anorexia nervosa b. Depression c. ADHD d. A learning disability ANS: B

OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for adolescents with OCD. DIF: Cognitive Level: Comprehension REF: p. 768 OBJ: 5 TOP: Obsessive-Compulsive Disorder KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. Which statement made by a parent of an adolescent with anorexia nervosa indicates an

understanding of this condition? a. ―There really isn‘t anything to worry about. Don‘t they say you can never be too thin?‖ b. ―My daughter just doesn‘t have much of an appetite.‖ c. ―She is just trying to punish me for divorcing her father.‖ d. ―She seems to see herself as fat, even though her weight is below normal.‖ ANS: D

Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes.

DIF: Cognitive Level: Comprehension REF: p. 770 | Figure 33.3 OBJ: 8 TOP: Anorexia Nervosa KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 11. What is an appropriate nursing intervention for a hospitalized child who is autistic? a. Place the child in a location where she can watch all of the activity on the unit. b. Use the child‘s chronological age as a guide for communication. c. Keep the child‘s room free of toys or objects that she might want to take home

with her. d. Organize care to provide as few disruptions to the routine as possible.

ANS: D

During hospitalization, the nurse should provide a highly structured environment with few distractions for a child who is autistic.

DIF: Cognitive Level: Application REF: p. 768 OBJ: 4 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 12. A nurse is planning to speak with a parent support group about childhood autism. What will

the nurse include? a. Significant signs of the disorder manifest by 1 year of age. b. The earliest signs of autism are impulsivity and overactivity. c. Autism is usually diagnosed when the child goes to elementary school. d. Medications can cure childhood autism.

ANS: A

Failure to use eye contact and look at others, poor attention span, and poor orienting to one‘s name are significant signs of dysfunction by 1 year of age.

DIF: Cognitive Level: Comprehension REF: p. 768 OBJ: 4 TOP: Autism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. An adolescent is brought to the emergency department after an automobile accident. When the

nurse approaches the adolescent, he becomes combative. The nurse notes his speech is slurred and his gait is ataxic. What does the nurse suspect the adolescent has used? a. Alcohol b. Cocaine c. Amphetamines d. PCP ANS: A

Behavioral signs of alcohol ingestion include slurred speech, short attention span, drowsiness, combativeness, and violence.

DIF: Cognitive Level: Analysis REF: pp. 775-776 OBJ: 11 TOP: Substance Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 14. When the nurse is collecting a nursing history, an adolescent states that she has tried speed.

For what does the nurse recognize this as the street name? a. Barbiturates b. Cocaine c. Methamphetamine d. Marijuana ANS: C

―Speed‖ is the street name for methamphetamine.

DIF: Cognitive Level: Knowledge REF: p. 775 | Table 33.2 OBJ: 11 TOP: Substance Abuse KEY: Nursing Process Step: Data Collection

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. How would the nurse identify a member of the child guidance team who is a medical doctor

with special training in psychoanalytic theory? a. Psychiatrist b. Psychoanalyst c. Psychologist d. Counselor ANS: A

The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a psychologist. The psychologist is not a medical doctor, and neither is the counselor.

DIF: Cognitive Level: Knowledge REF: p. 767 OBJ: 2 TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. A young child on the pediatric unit cannot express himself well. What therapeutic intervention

might the nurse implement that allows children to act out their feelings? a. Art therapy b. Play therapy c. Music therapy d. Bibliotherapy ANS: B

Play therapy allows a young child to act out with dolls or figures concerns that the child may be unable to adequately express verbally.

DIF: Cognitive Level: Comprehension REF: p. 767 OBJ: 2 TOP: Play Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic child.

What is a negative aspect of stimulants? a. Sedating the child b. Impairing cognition c. Causing hypotension d. Creating fluid retention ANS: B

Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the potential of self-injuring behavior.

DIF: Cognitive Level: Comprehension REF: p. 768 OBJ: 4 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. A 9-year-old child has been admitted to the hospital after ―huffing‖ lighter fluid and is in a

high euphoric state. For what should the nurse assess? a. Depressed respirations b. Severe vomiting c. Frightening hallucinations

d. Elevation of temperature ANS: A

Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and general sensorium.

DIF: Cognitive Level: Application REF: p. 775 OBJ: 11 TOP: Substance Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. The pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate. What action

by 9-year-old child leads the nurse to question possible dyslexia? a. Becomes hyperactive and ceases to read. b. Reads the word dog as God. c. Makes up a story rather than reading the text. d. Stutters as he reads.

ANS: B

Dyslexics often transpose a word as they read; for example, the word is dog, but it appears to the dyslexic child as the word God. DIF: Cognitive Level: Comprehension REF: pp. 767-768 OBJ: N/A TOP: Dyslexia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. How is a gateway substance defined? a. Recreational drug used occasionally b. Nonaddictive drug used daily c. Drug used to wean from stronger drugs d. Substance that can lead to use of stronger drugs ANS: D

A gateway drug is a substance that creates a high that can lead to the use of stronger drugs.

DIF: Cognitive Level: Knowledge REF: p. 776 OBJ: 11 TOP: Gateway Drugs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. Which substance puts a person at the greatest risk for HIV and hepatitis B? a. Alcohol b. Opiates c. Cocaine d. Marijuana ANS: B

The use of opiates coupled with sharing needles put the user at risk for HIV and hepatitis B. DIF: Cognitive Level: Comprehension REF: p. 776 OBJ: 11 TOP: Opiate Use KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. What role has the child of an alcoholic assumed if he tries to do everything perfectly? a. Perfect child

b. Super coper c. Flight d. Helper ANS: B

Of the four roles for the child of the alcoholic, the super coper is one who tries to do everything perfectly and feels overly responsible. The perfect child is the child who tries to earn love by never causing any trouble.

DIF: Cognitive Level: Comprehension REF: pp. 776-777 OBJ: 3 TOP: Child of an Alcoholic KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation MULTIPLE RESPONSE 1. The nurse working with children from dysfunctional families must be prepared to address

what associated problem(s)? (Select all that apply.) a. Lack of trust b. Acting out c. Exaggerated self-confidence d. Blaming others for problems e. Depression ANS: A, B, E

Children from dysfunctional families exhibit lack of trust, act out, and show signs of depression.

DIF: Cognitive Level: Comprehension REF: p. 767 OBJ: 3 TOP: Dysfunctional Families KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 2. The nurse counsels parents that the early school years create nervous tension in the child

manifested by which abnormal behavior(s)? (Select all that apply.) a. Masturbation b. Food fads c. Stuttering d. Aggressive behavior e. Nonnutritive sucking ANS: C, D, E

Stuttering, aggressive behavior, and finger or thumb sucking that appear suddenly with no previous history are a clue to increased nervous tension in the young school-age child.

Masturbation and food fads are normal behavioral phenomena for the early school-age child.

DIF: Cognitive Level: Comprehension REF: p. 767 OBJ: 3 TOP: Nervous Tension KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 3. The nurse states that the members of a mental health team for child guidance include which

member(s)? (Select all that apply.) a. Psychiatrist

b. c. d. e.

Pediatrician Psychologist Dietitian Social worker

ANS: A, B, C, E

The traditional members of the child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team.

DIF: Cognitive Level: Knowledge REF: p. 767 OBJ: 2 TOP: Members of the Child Guidance Team KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 4. The school nurse cautions a group of parents about the prevalence of children who get high by

inhaling hydrocarbons and fluorocarbons. Which products contain these substances? (Select all that apply.) a. Glue b. Chlorine c. Cleaning fluid d. Copy machine toner e. Aerosol sprays ANS: A, C, E

Although there are many products that could be inhaled, the most frequently used products are glue, cleaning fluid, aerosol sprays, Freon, shoe polish, and gasoline products.

DIF: Cognitive Level: Knowledge REF: p. 776 OBJ: 11 TOP: Inhaling Hydrocarbons KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. The nurse is planning the care of an adolescent with anorexia nervosa. What characteristic(s)

cause this disorder? (Select all that apply.) a. Discomfort relative to emerging sexuality b. Fear of intimacy c. Pervasive high self-esteem d. Egocentricity e. Inability to meet developmental needs ANS: A, B, D, E

All options except pervasive high self-esteem are considered to be a cause of anorexia nervosa. Pervasive low self-esteem also is considered a cause of anorexia nervosa.

DIF: Cognitive Level: Comprehension REF: p. 770 OBJ: 8 TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 6. The nurse is assessing a 16-year-old female for characteristics of anorexia nervosa. Which

assessment finding(s) would lead the nurse to suspect the possibility of this diagnosis? (Select all that apply.) a. Amenorrhea b. Severe weight loss

c. Oily skin d. Hypertension e. Lanugo on back ANS: A, B, E

The primary symptom of anorexia nervosa is severe weight loss. Adolescents who wish to be fashion models or actresses or who participate in sports, dance, or gymnastics activities may be at risk for developing an eating disorder. On physical examination, some of the following conditions may be evident: dry skin, amenorrhea, lanugo hair over the back and extremities, cold intolerance, low blood pressure, abdominal pain, and constipation.

DIF: Cognitive Level: Comprehension REF: p. 770 | Figure 33.1 OBJ: 8 TOP: Anorexia Nervosa KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. A nurse is hired to work in a psychiatric facility on a unit specializing in

obsessive-compulsive disorders (OCD). Which diagnoses might the nurse expect to encounter? (Select all that apply.) a. Trichotillomania b. Hoarding disorder c. Excoriation disorder d. Body dysmorphic disorder e. Oppositional defiant disorder ANS: A, B, C, D

Oppositional defiant disorder is described as an ongoing pattern of anger-guided disobedience, a hostile or defiant response to authority and is not considered a form of OCD. DIF: Cognitive Level: Knowledge REF: pp. 768-769 OBJ: 5 TOP: Obsessive Compulsive Disorder KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. A child is diagnosed with attention-deficit hyperactivity disorder (ADHD). Which

characteristics would the nurse assess in this child? (Select all that apply.) a. Social anxiety b. Impulsivity c. Hyperactivity d. Distractibility e. Inattention ANS: B, C, D, E

ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility.

DIF: Cognitive Level: Knowledge REF: p. 769 OBJ: 6 | 7 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 34: Complementary and Alternative Therapies in Maternity and Pediatric Nursing Leifer: Introduction to Maternity and Pediatric Nursing, 9th Edition

MULTIPLE CHOICE 1. A pregnant woman tells the nurse that she got relief from nausea when she had a therapy that

involves pressure and massage on meridian sites. What type of therapy does this describe? a. Acupuncture b. Acupressure c. Aromatherapy d. Ayurveda ANS: B

Acupressure uses finger pressure and massage on the meridian sites. It can be used during pregnancy to control nausea, backache, and pain. It has been useful for minor postpartum problems such as constipation.

DIF: Cognitive Level: Knowledge REF: p. 784 OBJ: 2 TOP: Acupressure KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Which child should not receive massage therapy? a. 15-year-old with a fractured femur b. 12-year-old with diabetes mellitus c. 8-year-old with Down syndrome d. 17-year-old with an eating disorder ANS: C

Children with Down syndrome are prone particularly to cervical spine anomalies and may be injured by massage therapy.

DIF: Cognitive Level: Comprehension REF: p. 783 OBJ: 3 TOP: Massage KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. A 12-year-old with rheumatoid arthritis finds aromatherapy helpful for relieving her joint

discomfort. Which essential oil is useful for children with chronic pain? a. Lavender b. Ephedra c. Ginseng d. Kava-kava ANS: A

Lavender, chamomile, and sandalwood essential oils are useful in aromatherapy for children with chronic pain.

DIF: Cognitive Level: Knowledge REF: p. 785 | Nursing Tip OBJ: 2 TOP: Alternative Health Practices—Aromatherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. A pregnant woman wishes to use aromatherapy during her labor and delivery. What is the

most appropriate essential oil for the nurse to recommend? a. Juniper

b. Wintergreen c. Thyme d. Citrus ANS: D

Citrus is one essential oil that has been shown to be useful during labor and delivery.

DIF: Cognitive Level: Comprehension REF: p. 785 OBJ: 10 TOP: Aromatherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A parent asks the nurse, ―What is guided imagery?‖ Which statement is the most accurate

response? a. ―It is a technique where the patient focuses on an image to relieve stress.‖ b. ―It involves using water to promote relaxation.‖ c. ―The patient enters a hypnotic state of sleep to promote relaxation.‖ d. ―It helps the patient recognize tension in the muscles with responses on an electronic machine.‖ ANS: A

In guided imagery, by focusing on a specific image, stress reduction and improved performance can result.

DIF: Cognitive Level: Knowledge REF: pp. 785-786 OBJ: 9 TOP: Guided Imagery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. A woman taking St. John‘s wort and ginseng daily is scheduled to have a hysterectomy in 3

weeks. What instruction should the nurse provide? a. The herbs are not likely to cause any problems during the surgery. b. The St. John‘s wort must be stopped prior to surgery, but she can continue the ginseng. c. The ginseng should be stopped 1 week before surgery. d. She should discontinue taking both herbs 2 weeks before surgery.

ANS: D

Both St. John‘s wort and ginseng can cause problems during surgery, and their use should be discontinued 2 weeks before surgery.

DIF: Cognitive Level: Application REF: p. 782 | Table 34.1 OBJ: 6 TOP: Herbal Remedies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 7. Which herb can the nurse suggest to be used for discomforts associated with menopause, such

as hot flashes? a. Evening primrose oil b. Echinacea c. Milk thistle d. Black cohosh ANS: D

Black cohosh diminishes hot flashes by reducing luteinizing hormone. It also reduces joint pain and other menopausal discomforts.

DIF: Cognitive Level: Knowledge REF: p. 790 | Table 34.4 OBJ: 12 TOP: Herbal Remedies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. A young mother asks, ―Is there an alternative medicine for children with asthma?‖ Which

form of alternative medicine would be the most helpful for the nurse to suggest? a. Reflexology b. Rolfing c. Guided imagery d. Acupressure ANS: C

The use of guided imagery has helped relieve some of the symptoms of asthma.

DIF: Cognitive Level: Comprehension REF: pp. 780-781 OBJ: 3 | 9 TOP: Guided Imagery KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. What is the difference between complementary therapy and alternative therapy? a. Complementary therapy must be administered by a medical doctor. b. Complementary therapy is administered with conventional therapy. c. Complementary therapy replaces conventional therapy. d. Complementary therapy is administered to a group of patients at the same time.

ANS: B

Complementary therapy is administered with conventional therapy, such as massage with muscle relaxants for low back pain.

DIF: Cognitive Level: Comprehension REF: p. 780 OBJ: 2 TOP: CAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse uses a diagram to show the location of meridians. How will the nurse explain the

definition of meridians? a. They are lymph nodes. b. They are invisible pathways for energy. c. They are lines that divide the body into 10 zones. d. They are areas of skin that are specifically innervated.

ANS: B

Meridians are invisible pathways through which energy travels to effect acupuncture treatment.

DIF: Cognitive Level: Knowledge REF: p. 784 | Figure 34.4 OBJ: 8 TOP: Herbal Remedies: CAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

11. Which herbal remedy used by a patient taking warfarin should the nurse report to the

physician? a. Angelica (dong quai) b. Chamomile c. Ginseng d. Kava-kava ANS: A

Angelica prolongs prothrombin time and will synergize the effect of the warfarin.

DIF: Cognitive Level: Application REF: p. 787 | Table 34.2 OBJ: 4 TOP: Herbal Remedies KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. What should the nurse remind a parent who is considering homeopathic remedies for

treatment of her child‘s asthma? a. Should be drunk with large amounts of fluid. b. Can be taken with traditional Western medications. c. Can be enhanced by drinking hot tea. d. May contain mercury, alcohol, or arsenic.

ANS: D

Homeopathic remedies often contain mercury, alcohol, or arsenic and are taken sublingually.

All Western medications should be stopped when the homeopathic therapy is begun. Caffeine drinks are to be avoided during homeopathic treatment.

DIF: Cognitive Level: Application REF: p. 786 OBJ: 9 TOP: Homeopathic Remedies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. The focus of acupressure is to restore the balance of what? a. Chi b. Shiatsu c. Yin and yang d. Ayurveda ANS: A

Acupressure is focused on the return of the balance of Chi to control disease processes.

DIF: Cognitive Level: Comprehension REF: p. 784 OBJ: 9 TOP: Acupressure KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. A breastfeeding mother tells the nurse she is taking large doses of vitamin C to keep up her

energy. What should the nurse warn that large doses of vitamin C can cause in an infant? a. Diarrhea b. Jaundice c. Colic d. Retinal damage ANS: C

Vitamin C can be passed on to a breastfeeding child through breast milk and can cause colic.

DIF: Cognitive Level: Comprehension REF: p. 788 OBJ: 5 TOP: Vitamin C KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 15. The pregnant patient with a stasis ulcer asks if she might be a candidate for hyperbaric oxygen

therapy (HBOT). What is the nurse‘s best response? a. ―Yes. Hyperbaric oxygen therapy should have no harmful effect on your baby.‖ b. ―No. High amounts of oxygen in your system will cause changes in your baby‘s heart.‖ c. ―Yes. Hyperbaric oxygen therapy is a much better option than using antibiotics.‖ d. ―No. Hyperbaric oxygen therapy may cause the placenta to separate from the uterine wall.‖ ANS: B

High concentrations of oxygen in the mother‘s blood can cause closure of the ductus arteriosus and cause fetal death.

DIF: Cognitive Level: Application REF: p. 790 OBJ: 2 TOP: HBOT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 16. A patient is providing history information to the admitting nurse about treatment used for

chronic pain. The patient reports she participates in a type of relaxation therapy that enables her to recognize tension in the muscles via responses on an electronic machine and visual electromyography responses. What type of therapy does the nurse record on admission record? a. Guided imagery b. Biofeedback c. Hypnotherapy d. Chiropractic care ANS: B

Biofeedback is a type of relaxation therapy that enables the patient to recognize tension in the muscles via responses on an electronic machine and visual electromyography responses. The process is also used by traditional health care providers for drug addiction and chronic pain control.

DIF: Cognitive Level: Comprehension REF: p. 786 OBJ: 9 TOP: CAM Therapies KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk MULTIPLE RESPONSE 1. What conditions would a nurse expect to see treated with hyperbaric oxygen therapy

(HBOT)? (Select all that apply.) a. Wounds b. Carbon monoxide poisoning c. Hyperemesis gravidarum d. Decompression illness

e. Pneumonia ANS: A, B, D

Hyperbaric oxygen therapy (HBOT) uses an airtight enclosure to provide compressed air or oxygen under increased pressure. HBOT is used to revive children with carbon monoxide poisoning, to aid wound healing, and to treat the diving syndrome known as decompression illness. HBOT is contraindicated during pregnancy, because the increased oxygen saturation can cause the ductus arteriosus to close, resulting in fetal death.

DIF: Cognitive Level: Knowledge REF: p. 790 OBJ: 13 TOP: HBOT KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. The mother of a pediatric patient asks the nurse about safety concerns with using herbal

supplements with children. Which herbal products would the nurse educate this mother are safe to use in most of the pediatric population? (Select all that apply.) a. Ephedra b. Ginger c. Fish oil d. Chamomile e. Aloe vera ANS: B, C, D, E

Ginger, fish oil, chamomile, and aloe vera are safe herbal products for children. However, some herbs, such as ephedra, can be fatal to children.

DIF: Cognitive Level: Knowledge REF: p. 786 OBJ: 11 TOP: Herbal Therapies KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse points out that light therapy is used in the treatment of patients with which

disorder(s)? (Select all that apply.) a. Digestive disorders b. Seasonal affective disorder c. Inflammatory diseases d. Stress disorders e. Jaundice ANS: B, E

Light therapy has proven effective in the treatment of persons with seasonal affective disorders. Light therapy is also used in the treatment of jaundiced babies.

DIF: Cognitive Level: Comprehension REF: p. 784 OBJ: 9 TOP: Light Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. What advantage(s) of alternative health care should the nurse outline when providing

information to patients? (Select all that apply.) a. Offering more patient control of health care b. Offering a variety of health care advisors c. Keeping patients from having to make decisions d. Using natural products rather than chemical ones

e. Incorporating cultural beliefs and practices ANS: A, B, D, E

Alternative health care actually promotes the patient‘s decision making in care.

DIF: Cognitive Level: Comprehension REF: p. 780 OBJ: 5 TOP: CAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. Which approaches to care are combined with osteopathy? (Select all that apply.) a. Manipulation therapy b. Aroma therapy c. Herbal application d. Pressure point therapy e. Traditional medicine ANS: A, D, E

Osteopaths combine manipulative therapy including pressure point therapy with traditional (allopathic) medicine.

DIF: Cognitive Level: Knowledge REF: p. 783 OBJ: 9 TOP: Osteopathy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort