Introductory Maternity & Pediatric Nursing Fifth, North American Edition by Nancy Hatfield (Author),

Chapter 1 1. The opening up of hospital visiting policies for children and families likely resulted from the work of which individual?

A. Joseph Brennaman B. John Bowlby C. Marshal Klaus D. John Kennell Answer: B Rationale: In 1951, John Bowlby received worldwide attention with his study that revealed the negative results of the separation of child and mother because of hospitalization. His work led to a re-evaluation and liberalization of hospital visiting policies for children. Joseph Brennaman suggested that a lack of stimulation for infants contributed to high infant mortality rates at the time. In the 1970s and 1980s, physicians Marshall Klaus and John Kennell carried out important studies on the effect of the separation of newborns and parents. They established that early separation may have long-term effects on family relationships and that offering the new family an opportunity to be together at birth and for a significant period after birth may provide benefits that last well into early childhood.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 4 2. An expectant mother states that she read that more black mothers die in childbirth than do white mothers. When responding to her questions about the reasons for this, the nurse accurately states that which is the major reason for the high maternal mortality rate?

A. having formal education.

B. being unmarried.

C. income.

D. lack of prenatal care.

Answer: D Rationale: Research shows that maternal mortality rate is directly related to lack of prenatal care secondary to lack of access to services or insurance. Income as well as educational level may play a role in the availability of health care, but they are not directly responsible. Being unmarried has no bearing on infant mortality.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Understand

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 9 3. Which statement correctly defines the term "infant death rate"?

A. number of deaths in utero of fetuses 500 g or more per 1,000 live births B. number of deaths occurring in the first 28 days of life per 1,000 live births C. number of deaths occurring at birth or in the first 12 months of life per 1,000 live births D. death of a live-born child before his or her first birthday.

Answer: D Rationale: The term infant death refers to the death of a live-born child before he or she reaches age 1 year. It also includes neonatal mortality rate. Neonatal mortality rate is the number of infant deaths during the first 28 days of life for every 1,000 live births. Infant mortality rate is the number of deaths during the first 12 months of life per 1,000 live births.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 9 4. The nursing instructor is preparing to teach a group of students about the history of maternity care. What major development will the instructor emphasize as greatly influencing the practice of maternity care in the United States over the past century?

A. technologic advances and the use of forceps by primary care providers B. development of anesthesia and acceptance of the germ theory C. advent of birthing centers and the development of family-centered care D. development of pediatric specialty and replacement of midwives as primary birth attendants Answer: B Rationale: The emphasis should be placed on anesthesia and the germ theory. The development of anesthesia allowed women a choice for pain management in birth; the germ theory advanced the progress of general health care and decreased infections in laboring women. Pediatrics as a specialty is an important step forward but is not the greatest development, and midwives are still in practice. Maternity care continues to evolve, and birthing centers are still under development. Forceps are not considered an advance in maternity care.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 3 5. When preparing a client for surgery, the nurse explains that the use of an antiseptic during the surgery has greatly improved client survival rates and was started by which physician?

A. Louis Pasteur B. Ignaz Philip Semmelweis C. Joseph Lister D. Alexander Gordon Answer: C Rationale: Joseph Lister was a British surgeon who embraced Louis Pasteur's theory of microorganisms as the cause of infection. Lister used carbolic acid as an antiseptic during surgery and improved the survival rates of his patients. Alexander Gordon proposed the theory of infection. Oliver Wendell Holmes and Ignaz Philip Semmelweis confirmed his theory.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 4 6. A young couple are very excited to learn they are expecting their first child and question the nurse about which test they need to discover its gender. Which procedure will best provide this information to the couple?

A. Ultrasound B. Amniocentesis C. Chorionic villus sampling D. HGP Answer: A Rationale: Ultrasound is a visual method for assessing the fetus in the uterus and will provide information about the gender. Amniocentesis and chorionic villus sampling provide the entire genetic code of the fetus. HGP refers to the Human Genome Project, which can provide information regarding gene mutations and variations.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 6

7. A family is seeking sources for payment of health care costs. When talking with the family, the nurse determines that the family makes too much money to qualify for the federal program. Which source would the nurse likely recommend?

A. Medicaid B. Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) C. Centers for Disease Control D. State Child Health Insurance Program Answer: D Rationale: The State Child Health Insurance Program, first known by its acronym "SCHIP" now referred to as "CHIP," was enacted in 1997. CHIP provides health insurance to newborns and children in low-income families who do not otherwise qualify for Medicaid and are uninsured. Based on the information given, the family does not qualify for Medicaid, a federal program that supplies grants to states to provide health care for individuals who have low incomes and meet other eligibility criteria. The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional servides to low-income, nutritionally at-risk pregnant, breast-feeding, and postpartum women and their children (as old as 5 years). The Centers for Disease Control does not provide funding for health care services.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 8 8. After discussing the various options with a pregnant client and partner, they have chosen to stay with their newborn and receive care from one nurse at the time of birth. This is referred to as which type of care?

A. Regionalized care B. Maternal-child care C. Centralized care D. Couplet care Answer: D Rationale: Couplet care is care in which the mother and child remain in the same room after labor/delivery through the postpartum period. This has become the standard of care. Regionalized or centralized care places the treatment centers in centralized locations and transfers the patient to the facility. Maternal child care allows the mother to be the primary provider of care.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring

Reference: p. 5 9. A group of nursing students are examining the data of the local hospitals to determine the potential maternal needs of the community. Which factor will be the best statistical indicator of the adequacy of prenatal care?

A. Number of prenatal visits B. Maternal mortality rate C. Infant mortality rate D. Infant measurements at birth Answer: B Rationale: Maternal mortality rate is the best indicator of a country's level of prenatal care. Increases in prenatal care result in a decrease in maternal mortality.

Infant mortality is a reflection of postnatal care. Infant mortality includes all infant deaths from birth to 12 months and can be the result of congenital anomalies, genetic anomalies, or other problems. The number of prenatal visits and measurements of the infant at birth are not the best indicators as they do not accurately reflect the health of the mother.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 9 10. The nurse is teaching a client about lifestyle changes that could help the client reach a higher level of wellness. The nurse is engaged in which aspect of care?

A. Infection prevention B. Cost containment C. Health promotion D. Illness treatment Answer: C Rationale: By encouraging healthy lifestyle changes, the nurse is engaging in health promotion activities. Health promotion involves helping people make lifestyle changes to move them to higher levels of wellness. Health promotion includes all aspects of health: physical, mental, emotional, social, and spiritual. Although health promotion can help to contain costs over a longer span, this is not what the nurse is doing. Healthy lifestyle changes are not part of infection prevention or illness treatment.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 7

11. A young female client is pregnant for the first time and is uncertain who to seek prenatal care from. The nurse should point out which health care provider as the likely choice?

A. Perinatologist B. Neonatologist C. Family practitioner D. Obstetrician Answer: D Rationale: The obstetrician is the common choice for prenatal care through labor and delivery. Perinatologists may care for women who have a high-risk pregnancy, and neonatologists provide care to infants. Family practitioner physicians may provide care but are less likely to attend in labor and delivery.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 3 12. While preparing to teach a group of nursing students the history of maternity care, which factor will the instructor include to explain as the etiology of most infections in females after birthing in the 1700s?

A. Reproductive tract infection B. Breast infection C. Kidney infection D. Urinary tract infection Answer: A Rationale: Prior to the germ theory, women most often died of puerperal fever, an illness marked by high fever caused by infection of the reproductive tract after delivering infants. Women who delivered in hospitals were more likely to develop this infection than women who delivered at home. Breast infections occurred during breast feeding but were not usually fatal. There was no greater incidence of kidney or urinary tract infections.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 3-4 13. A group of nursing students are comparing the various changes in maternity care over the course of history and discover that the development of what medical

treatment was most influential in moving birth from the home into the hospital setting?

A. Infection control and germ theory B. Planned cesarean birth C. Instruments to assist in birth of infants D. Anesthesia and analgesic therapy Answer: D Rationale: Movement from the home to the hospital for the birth of infants began with the use of medications to control pain during labor. This trend started with the wealthy and followed to include more of society. Cesarean births are a more recent development than the advent of anesthesia. Infection control could be maintained at home, so it was not a driving force. The use of instruments developed along with cesarean technology.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 3 14. The nursing instructor is teaching a group of students about the history of maternity and family care. The instructor determines the session is successful when the students correctly choose which major change resulting from research by Klaus and Kennell?

A. Limited family visits for children in the hospital B. Family-centered care of today C. Rooming-in for maternity patients D. Isolation of children with infections Answer: B Rationale: Klaus and Kennell conducted studies and determined the optimal outcomes for children occurred when parents had more contact and interaction with the child in the hospital. Limiting visits has detrimental effects on infant development. Rooming-in was not as well received, as patients were not comfortable with the loss of privacy. Isolation of children with infections is still a proper precaution.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 4 15. A client with a history of type 1 diabetes mellitus is confirmed to be pregnant.

The nurse determines this client will be best cared for under which practice model?

A. Case management B. The nursing process C. A clinical pathway D. A health maintenance organization Answer: A Rationale: Case management is a system that integrates management and coordination of care with financing in an attempt to improve cost-effectiveness, use, quality, and outcomes. The nursing process involves the practice of nursing; it is not a means of cost saving for the client. The clinical pathway is a treatment regimen. HMOs are insurance organizations.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 7 16. A nursing student is preparing a presentation illustrating the Human Genome Project. Which function will the student point out as being the primary focus?

A. Genetic testing in adults B. Detection of genetic mutations in children C. Identification of human genes and functions D. Treatment of gene mutations Answer: C Rationale: The Human Genome Project was founded in 1990 and its primary purpose was to identify and label all human genes and their functions. Information from the HGP may eventually be used in genetic testing, the detection of mutations or variations in children, and gene therapy.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 6 17. A healthy client without a primary care provider is exploring the options available for a health care provider to assist with her pregnancy. Which health care provider can the nurse point out as a best option?

A. Women's health nurse practitioner (NP) B. Certified nurse midwife C. Lay midwife D. Clinical nurse specialist (CNS) Answer: B

Rationale: A certified nurse midwife is a nurse with advanced practice training in the care of women, specific to pregnancy and birth. A women's health NP would not be able to deliver the infant. A CNS is an advanced practice role but not specific to the care of pregnancy women. The lay midwife has no formal education.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 3-4 18. The nursing instructor is teaching a session comparing the various steps of the nursing process. The instructor determines the session is successful when the students correctly choose which step as the first one?

A. Nursing diagnosis B. Planning C. Assessment D. Evaluation Answer: C Rationale: Assessment is the first step in the nursing process. The nurse must complete the assessment and gather information to advance the nursing process.

Nursing diagnosis is based on actual or potential health problems that fall within the range of nursing practice. Evaluation measures the success or failure of the nursing plan of care. Planning is a stage of execution.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 13 19. After completing an assessment, the nurse examines the information to develop a wellness diagnosis for the client to identify which potential goal?

A. Acute health problems B. Potential problems C. The potential for improvement in health D. Chronic health problems Answer: C Rationale: Wellness diagnosis identifies the potential for a client to move from one level of wellness to a higher level. The identification of potential, acute, and chronic health problems is part of the diagnostic process.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment

Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 14 20. The nurse is organizing health information to teach a client basic principles that will help maintain wellness in the family. Which actions should the nurse prioritize in this teaching?

A. encouraging yearly checkups for all clients.

B. teaching insulin injection techniques C. medication administration D. assisting in understanding a treatment Answer: A Rationale: The current movement in health care is to focus on health promotion and thereby prevent future illness and diseases. Encouraging yearly checkups would assist with finding problems before they become serious. Prevention, treatment, and rehabilitation are all processes of care. Teaching a client how to give injections, administer medication, or understand a treatment would occur after a specific health issue but not prevent these issues from occurring.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 14 21. Which nursing intervention would best demonstrate evidence-based practice in maternal–child health care?

A. Family-centered pediatric care B. Minimizing parental interaction with preterm infants C. Placing adults and children with similar diseases on the same unit D. Decentralizing care to allow clients to be closer to home Answer: A Rationale: Evidence-based practice has become the standard that nurses are to strive for in caring for their clients. By involving the family in caring for ill children, the child and the family are better served and have improved outcomes. Parental interaction is encouraged for preterm infants to foster bonding. Children and adults need to be separated on inpatient units to ensure that the caregivers have a clear understanding of each client's needs, since children are not small adults.

Centralized care has proved to be most beneficial to client outcomes by providing resources and specialists in one location.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 5 22. What societal issues greatly influence delivery of maternal and pediatric health care? Select all that apply.

A. Cost of health care B. Increase in surrogacy and adoption C. Low income of families D. Increased cultural and ethnic diversity of clients E. Increased number of children born in the U.S. Answer: A, C, D Rationale: Demographic trends such as a decreased number children being born, combined with an increase in a multicultural society seeking health care, are affecting the delivery of maternal–child health care. Poverty and the cost of health care also play a major role in influencing health care delivery for both women and children.

Question format: Multiple Select Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 7 23. The United States lags behind other industrialized countries regarding infant mortality. The main factor that contributes to this is: A. lack of available facilities for caring for the infants.

B. older mothers having babies.

C. the large number of preterm births in the U.S. D. more congenital anomalies in children born in the U.S. Answer: C Rationale: Two factors that contribute to the fact that the United States lags behind other industrialized countries are the large number of preterm births and the differences in reporting live births in various countries.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 9 24. The nurse reviews the client's plan of care (above). Which nursing action(s) does the nurse identify as independent? Select all that apply.

A. assisting out of bed

B. administering ibuprofen C. giving IV normal saline D. reinforcing breathing exercises E. offering oral fluids Answer: A, E Rationale: Independent nursing actions are actions that may be performed based on the nurse's own clinical judgment, for example, getting the client out of bed and offering oral fluids. Dependent nursing actions, such as administering medications or IV fluids, are actions that the nurse performs as a result of a health care provider's prescription. Interdependent nursing actions are actions that the nurse must accomplish in conjunction with other health team members, such as reinforcing breathing exercises with the respiratory therapist.

Question format: Multiple Select Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 14 25. A nurse manager is orienting a group of new nurses to the maternity unit.

During the orientation, the nurse manager emphasizes the need for accurate and complete documentation based on which reason?

A. The facility could lose its standing in the community.

B. The facility might not keep its accreditation.

C. The records could be used in a legal action in the future.

D. The records act as the main source of communication among team members.

Answer: C Rationale: One of the most important parts of nursing care is recording information about the client on the permanent record. This record, the client's chart, is a legal document and must be accurate and complete. In maternity and pediatric settings, documentation is extremely important because records can be used in legal situations many years after the fact. Although documentation is a form of communication among team members, it is not the main source for doing so.

Incomplete or inaccurate documentation can affect a facility's accreditation and or status in the community, but this is not the main reason for accurate and thorough documentation.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 14

26. A community-based nurse is part of an agency sponsoring a booth at a local health fair. An acute care nurse comes up to the booth and asks the communitybased nurse, "How is your practice different from practice in a hospital?" Which response(s) by the community-based nurse would be appropriate? Select all that apply.

A. "In the community, we rely on other disciplines for decision-making."

B. "We are more autonomous when providing client care."

C. "We tend to address the client's needs more holistically."

D. "Our major focus is on illness and treatment."

E. "We care for clients over a longer span of time."

Answer: B, C, E Rationale: Unlike the hospital setting, community-based nursing practice is autonomous and the nurse is often called on to be self-reliant. Community practice tends to be more holistic and focuses on wellness rather than illness. In addition, the nurse in a community-based setting sees the client over time.

Question format: Multiple Select Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 28-29 27. A nurse is developing a program for families to promote spending more time together. Which cause(s) of decreased family togetherness will the nurse incorporate into the program? Select all that apply.

A. increase in families with one working parent B. rise in children participating in extracurricular activities C. increase in television use over discussion among family members D. rise in time spent sitting down to meals as a family E. greater focus on material things rather than relationships Answer: B, C, E Rationale: There is a trend for families to spend less time together. Many factors contribute to this trend which may include two working parents, rather than just one; the children participating in many extracurricular activities; family members watching television, rather than talking together at mealtime, or eating fast food or individual meals without sitting down together as a family; or an emphasis on the acquisition of material goods, rather than the development of relationships.

Question format: Multiple Select Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 22

28. A nurse will conduct an information session for a group of parents who have children in elementary school. The session will focus on child growth and development. Which information about the parents would be important for the nurse to obtain before planning the session to promote the success of the session?

Select all that apply.

A. ages B. educational levels C. primary language(s) spoken D. cultural attitudes E. financial background Answer: A, B, C, D Rationale: A successful group experience relies on the nurse being prepared before the session in addition to providing factual, unbiased information. It is important to know the needs of the target population to provide information to a group successfully. Important information about the group includes age, educational level, ethnic and gender mix, language barriers, cultural attitudes regarding receiving and acknowledging information, and any previous education the group has already had on the subject.

Question format: Multiple Select Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 28 29. A community-based nurse caring for a family gives the family information about free transportation services to medical appointments. Which skill is the nurse is using?

A. nursing process B. data collection C. education D. client advocacy Answer: D Rationale: Client advocacy is speaking or acting on behalf of clients. This helps them gain greater independence and to make the health care delivery system more responsive and relevant to their needs. Giving the family information about free transportation is an example. The nursing process is a proven form of problemsolving based on the scientific method and involves data collection. Education is a fundamental part of community-based care and involves the relaying of information to improve outcomes.

Question format: Multiple Choice Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care

Integrated Process: Caring Reference: p. 28 30. A nurse working at a child health clinic is involved in primary and secondary prevention activities. Which activity(ies) reflects secondary prevention? Select all that apply.

A. vision screening at all well-child visits B. safety education for bicycles and skateboards C. administration of immunizations D. instructions for treatment of head lice E. drug education program Answer: A, D Rationale: Secondary prevention involves health screening activities that aid in early diagnosis and encourage prompt treatment before long-term negative effects arise. Therefore, vision screening and instructions for head lice treatment would be appropriate. Safety education, immunizations, and drug education are examples of primary prevention activities, which are health-promoting activities to prevent the development of illness or injury.

Question format: Multiple Select Chapter 1: The Nurse's Role in a Changing Maternal-Child Health Care Environment Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 23

Chapter 2 1. A young couple are asking the nurse for suggestions on the best way to help their newborn develop properly. Which is the best response by the nurse?

A. Provide nutritional supplements.

B. Start reading to the child on first birthday.

C. Minimize distractions in the nursery.

D. Provide a variety of brightly colored toys.

Answer: D Rationale: Children, from an early age, need stimulation and interaction to develop the five senses optimally. Many parents buy brightly colored toys to facilitate stimulation. You should encourage proper nutrition through diet rather than supplementation. Reading should begin immediately, not on first birthday.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 19 2. Which situation may occur in immediate families at a greater level than in some other types of families?

A. financial difficulties B. problems with allocation of resources C. formation of a poor parent–child relationship D. lack of support people in a crisis Answer: D Rationale: People in an immediate family may all be so involved in a crisis that there is no objective support person. Financial difficulties, resource allocation problems, and poor relationships may be formed in any family situation.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 21-22 3. Which of the following may be a strength of the single-parent type of family?

A. financial security B. readily available support in a crisis C. development of a special parent-child relationship D. child wishing for no other siblings

Answer: C Rationale: Because there is no competition for time from a spouse, single-parent families can promote special parent-child relationships. Financial security, support in a crisis, and the desire for no siblings can occur in any family situation.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 21-22 4. The nurse is preparing to teach a drug education class at a local elementary school. The nurse is focused on providing which type of care to the community?

A. Primary prevention B. Secondary prevention C. Tertiary prevention D. Preventive care Answer: A Rationale: Primary prevention is promotion of healthy activities and includes education concerning safety, diet, rest, exercise, and disease prevention.

Secondary prevention focuses on health screening activities that aid in early diagnosis and encourage prompt treatment. Tertiary prevention focuses on rehabilitation and instruction on ways to prevent further injury or illness.

"Preventive care" is not considered a specific category but is a general function that encompasses all three levels.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 23 5. The primary health care provider has recommended a client consult a nutritionist for specialized care. The nurse, by providing a list of referrals to the client, is providing which service?

A. Client advocacy B. Community-based nursing C. Primary care D. Secondary prevention Answer: A Rationale: Client advocacy is speaking or acting on behalf of clients to help them gain greater independence and to make the health care delivery system more

responsive and relevant to their needs. Community-based nursing focuses on prevention and is directed toward persons and families within a community.

Primary care is the direct action of the primary care provider. Secondary prevention involves health screening activities that aid in early diagnosis and encourage prompt treatment before long-term negative effects occur.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 28 6. A community-based nurse is assessing the needs of a family of four, which includes a physically challenged 9-year-old. Which activity would the nurse prioritize to be an advocate for this family?

A. Ensure case history is complete for all family members.

B. Establish eligibility for assistive devices for child.

C. Ensure the client follows physical therapy recommendations.

D. Train the school nurse on the needs of the child.

Answer: B Rationale: Client advocacy is acting on behalf of the client. Making calls to arrange for special equipment is one role of a nurse who is acting on behalf of the client. A case history would be taken at the initial visit to the treatment center by the attending nurse. The client's progress in physical therapy is to be noted by the therapist or PT assistant. The community-based nurse should not have to train the school nurse but would share the needs of the child so that the school nurse is prepared to provide appropriate care.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 28 7. The nurse is preparing a prenatal seminar for young mothers. Which type of information should the nurse gather to ensure success of the program?

A. Who will be accompanying the mother B. Approximate education level of the participants C. Names of each of the participants D. Incomes of each of the participants Answer: B Rationale: When teaching a group of clients, the nurse should seek demographic information, such as the education level of the participants, to help develop an

appropriate teaching plan for the group. This is an impersonal group, so learning who is accompanying the mothers, their names, or their incomes is not appropriate.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 27-28 8. A nursing student is exploring community-based nursing as a career focus. The nurse is prepared to prioritize which activity as a primary focus?

A. Wellness B. Cost containment C. Rehabilitation D. Emergency care Answer: A Rationale: The community-based nurse is in a unique position of health promotion for the community. Wellness is health promotion and aligns with the holistic practice of the community-based nurse. Cost containment, rehabilitation, and emergency care are the responsibility of direct care facilities.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 23-24 9. The community health nurse is assessing a new client who reports having recently moved to the area and living with an aunt and her parents. The nurse determines this client resides in which type of family structure?

A. extended B. immediate C. communal D. blended Answer: A Rationale: The extended family is an immediate family with other family members in the same house. The immediate family is composed of an individual's smallest family unit (commonly parents and their children), all of whom share a common household. Members of a communal family share responsibility for homemaking and child rearing; all children are the collective responsibility of adult members. In a blended family, both partners in the marriage bring children from a previous marriage into the household.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing

Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 20 10. The nurse at a family planning clinic is meeting with a young couple who have decided not to have any children after they marry since they are both bringing children into the relationship. The nurse will document this as which type of family structure?

A. Blended family B. Immediate family C. Extended family D. Communal family Answer: A Rationale: The blended family consists of each parent bringing their own children into the family when they marry. It may also consist of additional children if the couple decide to have more. The immediate family is composed of a man, a woman, and their children (either biological or adopted), who share a common household. Members of a communal family share responsibility for homemaking and child rearing; all children are the collective responsibility of adult members. An extended family consists of one or more nuclear families plus other relatives, often crossing generations to include grandparents, aunts, uncles, and cousins.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 21 11. The nurse is assessing a child of a different cultural background. Which nursing action should the nurse prioritize when providing nursing care?

A. Use personal cultural experiences with the family.

B. Use a standard nursing care plan for the family.

C. Expect the family to adopt the cultural beliefs of that facility.

D. Ask the family for input into their care based on their cultural beliefs.

Answer: D Rationale: Cultural beliefs vary; care should be based on the individual beliefs of each family. The imposition of personal or institutional beliefs, as well as the beliefs of others, should never be placed on a client.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process

Reference: p. 22 12. The nurse is explaining the differences of language development in children.

Which example would be appropriate for the nurse to include in the explanation?

A. Firstborn children are slower to develop language skills than their siblings.

B. Second-born children are quicker to develop language skills than their siblings.

C. Boys raised with older sisters are slower to develop language skills than their siblings.

D. Girls raised with older brothers are quicker to develop language skills than their siblings.

Answer: C Rationale: Birth order has an impact on the development of children. Firstborn children command a great deal of attention and tend to be higher achievers than siblings; thus language skills develop sooner in the firstborn child. With second and subsequent children, parents tend to be more relaxed and permissive. These children are likely to be more relaxed and are slower to develop language skills.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 21 13. A nursing instructor is teaching the class about community-based nursing. The instructor determines the session is successful when the students correctly choose which activity as an example of tertiary prevention?

A. Caring for new mothers and infants in a maternity clinic B. Identifying a child with pediculosis in an elementary school C. Ensuring the client attends physical therapy after orthopedic surgery D. Reviewing dietary habits with parents of a slightly anemic child Answer: C Rationale: Tertiary prevention focuses on rehabilitation activities and would be the focus of a nurse in an orthopedic clinic, aligning with the needs of the clients in that clinic. Orthopedic clients are typically recovering from injury or surgery and are in need of rehabilitation such as physical therapy. Secondary prevention includes health screening activities that aid in early diagnosis and encourage prompt treatment, such as screening for head lice in schools and reviewing dietary habits in individuals who are experiencing anemia. Primary prevention includes health promoting activities to prevent the development of illness or injury, such as new mothers bringing their infants to the clinic for follow-up well-child appointments.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 23 14. The nurse is preparing to discuss birthing options with a 25-year-old female who is in a low-risk pregnancy with one older child. Which option will be best for the nurse to recommend for this client?

A. Home setting B. Birthing center C. Hospital D. Any birthing settings Answer: D Rationale: When a woman is low-risk and has no known medical needs, birth location is the choice of the mother. Home births attended with certified nurse midwives are less likely to have complications and require interventions. Birthing centers are an option for an alternative birth setting, and hospitals are required birth locations for women with potential needs or complications. The nurse should present the advantages and disadvantages of each option and allow the client to make the decision.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 24 15. Which action by the nurse in a community clinic would best meet a family's need of physical sustenance?

A. Enrolling the pregnant mother in a WIC program B. Offering parenting classes to teenage mothers C. Holding monthly educational sessions on nutrition D. Providing weekly exercise classes for the neighborhood families Answer: A Rationale: Physical sustenance deals with meeting the basic needs of food, clothing, shelter and protection from harm of each family member. By enrolling the pregnant mother in WIC, her physical needs of nutrition are addressed. Parenting classes, nutrition classes, and exercise classes are all good ideas but do not directly address physical sustenance.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 19

16. A mother voices her concerns to the nurse that her daughter is an "only child" and she is worried that having no siblings may be detrimental to the child. The nurse can reassure the mother that an "only child" tends to excel in what area(s)?

Select all that apply.

A. Being more relaxed around others B. Advanced language development C. Intellectual achievement D. Less dependence upon the parent E. Closer identification with peers instead of parents Answer: B, C Rationale: It is shown that "only children" tend to have more advanced language skills and intellectual achievement than children from larger families. This is thought to be from the fact that the parents have more one-on-one time with the only child. "Only children" more closely identify with their parents, are more dependent upon the parents and are not necessarily more relaxed around others.

Question format: Multiple Select Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 21 17. The nurse is providing tertiary care to a young, uninsured family who has a child with frequent seizures. Which action by the nurse would demonstrate tertiary care?

A. Performing a well-child checkup, noting weight gain B. Educating the parents regarding appropriate play activities for the child C. Finding a company to provide a helmet for the child to wear daily.

D. Nutritional guidance for healthy meals for the family.

Answer: C Rationale: Tertiary care involves health promotion focused on rehabilitation and prevention of further injury or illness, and it optimizes function. By providing a safety helmet to the child with a history of seizures, the nurse is preventing further injury to the child. Nutritional guidance is an example of primary prevention, focusing on good nutrition to prevent risk factors that may cause impairment.

Performing the well-child checkup and educating about appropriate play activities address secondary prevention, which reflects health screening and prompt treatment of problems.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 23

18. A 7-year-old child who has recently immigrated with the family is brought to the school nurse because the child refuses to eat lunch. Which response should the nurse prioritize?

A. Eat lunch with the child.

B. Discuss the situation with the child.

C. Investigate for potential cultural issues.

D. Refer the family to a nutritionist.

Answer: C Rationale: Culture influences the family's health beliefs. A newly immigrated family may have attitudes toward food that are culturally founded. The nurse should seek to clarify the cultural food influences of the family and the needs of this child.

Discussing the issue with the parents may be an option if the nurse is unable to detect a possible cultural connection by talking with the child. Referring the family to a nutritionist would be inappropriate.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 22 19. The nurse is assessing an infant girl at her first well-baby visit. The nurse also observes the actions of the 6-year-old brother and parents who share that she was the best anniversary present they received this year. Which type of family will the nurse conclude these individuals represent?

A. Cohabitation B. Adoptive C. Immediate D. Extended Answer: C Rationale: An immediate family is defined as consisting of parents and children. An extended family consists of one or more nuclear families plus other relatives, often crossing generations to include grandparents, aunts, uncles, and cousins. In the cohabitation family, couples live together but are not married. The children in this family may be children of earlier unions, or they may be a result of this union. The adoptive family is created when parents take in children who are not biologically theirs but raise them as if they were.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 20

20. A nursing instructor is teaching a group of nursing students about the various options available to provide nursing care in a community. The instructor determines the session is successful when the students correctly choose which action as the primary focus of home care nursing?

A. Provide care based on insurance coverage.

B. Teach and supervise caregivers.

C. Provide direct client care.

D. Act as a liaison between health care provider and family.

Answer: C Rationale: The primary focus of home care nursing is to provide direct care.

Teaching and supervising caregivers and acting as a liaison between the health care provider and family are additional functions of the home care nurse that support the direct care. The nurse should be aware of potential insurance restrictions so that other options may be explored if insurance will not cover specific treatments or medications that the health care provider has determined essential to the client. In these instances, the nurse can then act as the advocate to help find the necessary resources the client may need.

Question format: Multiple Choice Chapter 2: Family-Centered and Community-Based Maternal and Pediatric Nursing Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 24

Chapter 3 1. A client who is trying not to get pregnant calls the nurse on Saturday at 11 a.m. reporting that she had unprotected sex on Thursday at 10 p.m. She believes she has just ovulated and wants to verify that she has no risk of pregnancy. What can the nurse tell her?

A. Because she did not ovulate before the unprotected sex, she will not get pregnant.

B. If she ovulated on Saturday around 11 a.m., the egg could be fertilized any time before about 11 a.m. on Sunday.

C. If she ovulated on Saturday around 11 a.m., the egg could be fertilized any time before about 10 p.m. on Sunday.

D. If she ovulated on Saturday around 11 a.m., the egg could be fertilized any time before about 11 a.m. on Monday.

Answer: B Rationale: A single ovum is released from the ovary 14 days before the next menstrual period. It lives approximately 24 hours. The client's fertile period would be from Saturday at 11 a.m. to Monday at 11 a.m. During any other time frame, it would be unlikely that she would become pregnant.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 43 2. Male and female reproductive systems are complementary; for example, male testes and female ovaries; male scrotum and female labia majora; and male glans penis and female clitoris. What part of the female system is homologous to the spermatic cord in the male?

A. cardinal ligaments B. round ligaments C. uterosacral ligaments D. broad ligament Answer: B Rationale: Round ligaments and spermatic cord are both fibromuscular bands that assist in holding specific reproductive structures in place in the male and female.

Cardinal ligaments anchor the walls of the cervix and vagina to the lateral pelvic walls. The uterosacral ligaments anchor the lower posterior portion of the uterus to the sacrum. The broad ligament is a sheet of peritoneum that attaches the lower sides of the uterus to the sidewalls of the pelvis.

Question format: Multiple Choice

Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 39 3. When reviewing normal menstruation with an early adolescent, the nurse would teach that during the second half of a typical menstrual cycle, the endometrium of the uterus becomes: A. thin and transparent, due to progesterone stimulation.

B. thin and transparent, due to follicle-stimulating hormone.

C. thick and purple-hued, due to estrogen stimulation.

D. thick and purple-hued, due to progesterone stimulation.

Answer: D Rationale: Progesterone is released following ovulation and thus is the dominating hormone of the second half of the menstrual cycle; its effect is to increase endometrium growth. Progesterone stimulates a growth of tissue, not a thinning of it. FSH and estrogen are found in the earlier stages of menstruation, not in the second half.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44 4. A woman tells the nurse that both she and her husband like to continue sexual relations during her menstrual period. They have a monogamous relationship. She asks if this will harm her. Which would be the best response?

A. "Avoid sexual relations because orgasm may be painful during your menses."

B. "The risk of infection is too great for sexual relations during this time."

C. "You will not be able to achieve orgasm during your menses."

D. "If this is satisfying for you and your partner, then there is no harm in it."

Answer: D Rationale: Sexual relations may be continued through a menstrual flow if this is satisfying for both partners. There is no danger to either party, and it is possible to achieve orgasm.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 42

5. A client asks the nurse questions about female hygiene and wants to know if she should douche to clean her vagina. Which response by the nurse would be most appropriate?

A. "Only douche if the vagina has an odor."

B. "You do not need to douche; the vagina is self-cleaning."

C. "Only douche if you have itching and burning."

D. "If you want, douching is ok."

Answer: B Rationale: The vagina has an acidic environment, and this should not be disturbed.

It does not need to be cleaned with douching. Douching can change the environment and lead to vaginal infection or irritation. Douching will only cover odor for a short time and may make other issues worse. Itching and burning could be signs of an infection, and the client should contact a health care provider.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 39 6. A nurse is preparing a presentation on the menstrual cycle for a health fair.

Which phase will the nurse illustrate as producing progesterone?

A. menstrual B. proliferative C. secretory D. ischemic Answer: C Rationale: The corpus luteum begins to produce progesterone during the secretory phase of the menstrual cycle. The follicle develops during the menstrual phase and begins to secrete estrogen. The proliferative phase continues secreting estrogen and progesterone. There are no hormones secreted during the ischemic phase, which will result in the endometrium sloughing off and leaving the uterus.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44 7. The nurse is preparing to assess a new client who has arrived for her initial visit with a gynecologist specializing in menopause issues. The nurse anticipates the client will be in which age group?

A. 45 to 50 B. 47 to 55

C. 53 to 58 D. 49 to 56 Answer: B Rationale: Menopause refers to the time in a women's life when reproductive capability ends. The average age at which menopause occurs is between 47 and 55 years. Although it is possible to start menopause earlier or later, 47 to 55 is the typical age.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 44 8. The nurse is preparing to teach a birthing class and intends to alert the couples to potential difficulties, ensuring they have as much accurate information as possible. Which area of the uterus will the nurse explain has the highest risk of rupture during labor?

A. cervix B. corpus C. uterine isthmus D. fundus Answer: C Rationale: The uterine isthmus is the lower uterine segment and is the thinnest portion of the uterus; it does not participate in the muscular contractions of labor.

The cervix is the tubular structure that connects the vagina and the uterus. The corpus is the main body of the uterus. The fundus is the top portion of the uterus.

The cervix, corpus, and fundus will all stretch and contract due to the muscular action.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 39 9. The nurse is teaching a group of college students about the four phases of the sexual response. Which phase will the nurse point out as producing an elevation in heart rate, blood pressure, and respirations?

A. excitement B. plateau C. orgasm D. resolution

Answer: A Rationale: During the excitement phase, the physiologic response of both male and females results in an increase in heart rate, blood pressure, and respirations.

During the plateau phase, the physiologic changes that occurred during excitement are maintained. In the female, the clitoris retracts and the uterus is fully elevated.

In the male, the penis engorges further and the testes remain elevated. Orgasm is marked by muscular contractions. During resolution, the muscles relax and blood pressure, heart rate, and breathing return to normal.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44-45 10. The nurse is answering questions from a newborn's parents concerning a circumcision. Which structure will the nurse point out is removed during the procedure?

A. tunica albuginea B. corpus spongiosum C. rugae D. prepuce Answer: D Rationale: The foreskin or prepuce is a fold of skin which covers the glans of the penis. This fold of skin is removed in a circumcision. The tunica albuginea is connective tissue found inside the penile shaft. The corpus spongiosum is erectile tissue that runs the full length of the penis. Rugae are folds that allow for stretching during an erection.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 35 11. The nurse at a health fair is teaching about the various changes of puberty.

Which sequence of events will be best for the nurse to present when illustrating pubertal changes in females?

A. menarche, breast budding, appearance of pubic hair B. Appearance of pubic hair, menarche, breast budding C. breast budding, appearance of pubic hair, menarche D. appearance of pubic hair, breast budding, menarche Answer: C

Rationale: Secondary sexual characteristics develop in an orderly sequence with variance in the timing for individuals. Breast budding in the female is usually the first physical sign noted, and occurs between the ages of 10 and 12 years on average. Appearance of pubic hair usually occurs just before menarche, the first menstrual period. From the onset to the start of menarche is typically 2 years.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 42 12. The nurse is assessing a 16-year-old female on a routine well-child visit. Which assessment finding will the nurse predict this healthy female will report concerning her menstrual cycles?

A. Flow usually lasts 4 to 6 days.

B. The usual cycle is 36 days.

C. There's abundant clear mucus at the beginning D. Menstruation began at age 15.

Answer: A Rationale: The average menstrual flow is 4 to 6 days in length. The cycle usually lasts 28 days. There should be no mucus during the menstrual cycle, with clear mucus being noted at the time of ovulation or approximately day 14. Menstruation usually begins at the age of 12 to 14 years.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 42 13. The nurse is teaching a family planning class at a health fair. Which physiologic change during the plateau stage of sexual response will the nurse point out?

A. lengthening of the vagina B. labia minor lightens in color C. retraction of the clitoris D. scrotal elevation Answer: C Rationale: Retraction of the clitoris occurs during the plateau stage prior to orgasm.

Lengthening of the vagina and scrotal elevation occur during excitement. The labia minora deepens in color.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44-45 14. The nursing instructor is teaching a group of nursing students about the menstrual cycle. The instructor determines the session is successful when the students correctly choose which action as responsible for the increased thickness of the endometrium?

A. the level of the FSH B. the decreasing level of the progesterone C. the dropping level of LH D. the increasing level of estrogen Answer: D Rationale: Estrogen levels increase after menstruation. These levels promote a thickening of the endometrial tissue. FSH and LH are responsible for ovarian changes. Progesterone will be increasing not decreasing, and works with estrogen in influencing the menstrual cycle.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44 15. The nurse is teaching a couple trying to conceive about the changes in the cervical mucus near the time of ovulation. The nurse determines the session is successful when the couple correctly choose mucus in which form as indicating ovulation has occurred?

A. Thin and copious B. Thick and tacky C. Scant amount D. Mucus is not visible at ovulation Answer: A Rationale: During ovulation, the mucus will be distensible and stretchable. After ovulation, the mucus will be scant, thick and opaque in nature. During the proliferative phase before ovulation, it is tacky, crumbly, and yellow or white in color. During the menses, there will be no mucus noted.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44

16. A group of nursing students are preparing a presentation for a health fair illustrating what happens to the body during pregnancy. Which structure will the students point out is influenced the most by hormones to prepare for conception?

A. myometrium B. endometrium C. perimetrium D. fundus Answer: B Rationale: The endometrium is the inner layer of the uterus; it builds with hormones during the month in potential preparation for pregnancy. The myometrium is the muscular layer. The perimetrium is a protective layer, and the fundus is the upper area of the uterus.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 40 17. The school nurse is preparing to illustrate the menstrual cycle to a group of high school students. Which change in the hormones will the nurse point out as being responsible for the onset of menstruation?

A. Decrease in progesterone B. Increase in estrogen C. Increase in luteinizing hormone D. Decrease in follicle-stimulating hormone Answer: A Rationale: A decrease in progesterone and estrogen during the menstrual phase is responsible for the shedding of the uterine lining, resulting in menstruation.

Increases in estrogen and progesterone result in the growth of the endometrium in preparation for implantation of the fertilized ovum. An increase in luteinizing hormone will result in ovulation. An increase in follicle-stimulating hormone will result in the formation of a follicle, which results in a mature ovum being released at ovulation.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 44 18. A group of nursing students are comparing male and female reproductive organs. The instructor determines the class is successful when the students correctly deduce the male glans penis is complementary to which female structure?

A. vulva B. vagina C. labia majora D. clitoris Answer: D Rationale: The female clitoris is complementary (equitable) to the glans; both of these are composed of erectile tissue and are the primary organs responsible for orgasm. Other comparable structures include the testes and ovaries, and scrotum and labia majora. The vagina does not have a comparable male structure.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Reference: p. 34 19. A young male asks the nurse at the clinic about what he can do to maintain his sperm production. The nurse would instruct him to take which action?

A. Wear snug fitting pants to support the scrotum.

B. Buy only cotton underwear for use.

C. Take long, hot baths to encourage sperm production.

D. It is recommended that men wear boxer-style underwear.

Answer: D Rationale: It is recommended that men wear loose fitting pants and underwear in order to keep the testes cooler than body temperature to best support sperm production. Tight pants and hot baths are counterproductive to sperm production; wearing cotton underwear does not affect it.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 37 20. The alkaline fluids secreted by the prostate and Cowper glands serve what functions related to sperm? Select all that apply.

A. Provide nourishment of the sperm B. Protect the sperm from the acidic vaginal environment C. Help mature the sperm D. Enhance sperm motility E. Cool the sperm prior to ejaculation Answer: A, B, D

Rationale: Alkaline seminal fluids serve several purposes, including nourishing the sperm by providing fructose, protecting the sperm from acidic vaginal fluids, and enhancing motility. The alkaline fluids do not help in sperm maturation or cooling the sperm, which would be ill advised.

Question format: Multiple Select Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 38 21. The nurse is assessing a female client who is having difficulty experiencing an orgasm. Which action should the nurse point out as often being necessary for an orgasm in females?

A. penile penetration B. clitoral stimulation C. uterine stimulation D. sensory deprivation Answer: B Rationale: The clitoris is highly sensitive and allows the woman to experience pleasure during sexual stimulation. It is thought to be the main stimulus for initiating orgasm in women. Penetration may be pleasurable, but alone it is not enough to stimulate orgasm. Uterine stimulation does not affect orgasm. Sensory arousal also plays a major role in attaining female orgasm.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 39 22. The school nurse is preparing a teaching session for a group of adolescent girls explaining the menstrual cycle. The nurse determines the session is successful when the young students correctly choose which fact?

A. The average menstrual flow lasts 4 to 6 days.

B. The average age for menarche is 11 to 13 years.

C. Menarche is the start of puberty.

D. Total blood loss each month averages 45 to 80 ml of blood.

Answer: A Rationale: The average flow lasts 4 to 6 days and is caused by casting away of blood, tissue, and debris from the uterus. The average age for menarche is from 12 to 14 years. Menarche is the end of puberty, which follows breast budding and the appearance of pubic hair. The total blood loss each month is 25 to 60 ml.

Question format: Multiple Choice

Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 42 23. The nurse is teaching an adolescent client about fertility and the various phases of the menstrual cycle. The client has a 28-day menstrual cycle. Which statement is a priority for the nurse to include in the teaching?

A. "Days 1 through 5 are the days you will typically experience menstrual flow."

B. "Day 10 is part of the proliferative phase of your menstrual cycle."

C. "Day 14 of your menstrual cycle is normally when you will ovulate."

D. "Days 27 and 28 are when you have declining hormonal secretions."

Answer: C Rationale: It is a priority for the nurse to teach the client when ovulation will occur to assist in pregnancy prevention at this age. While the other statements are all true, not knowing the specific information for those days does not hold the same consideration or life-altering potential as when pregnancy can occur. The menstrual cycle is based on an average of 28 days and divided into four phases based on the hormones secreted and their actions. Days 1 through 5 are the menstruation phase. Days 6 through 14 are the proliferative phase, ending with ovulation on the 14th day. Days 15 through 26 are the secretory phase. Days 27 and 28 are the ischemic phase when hormonal secretions decline.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 43 24. A nurse is conducting a sexual health education class about the structures of the female reproductive system. Which structure will the class identify as responsible for contractions during labor if the teaching has been successful?

A. endometrium B. myometrium C. broad ligament D. corpus Answer: B Rationale: The corpus is the main body of the uterus, and the fundus is the topmost section resembling a dome. The walls of the corpus and fundus have three layers. The perimetrium is the tough outer layer of connective tissue that supports the uterus. The middle layer is the myometrium, a muscular layer that is responsible for the contractions of labor. The muscle fibers of the myometrium wrap around the uterus in three directions: obliquely, laterally, and longitudinally.

This muscle configuration allows for the strong contractions and expulsion of the fetus during labor and birth. The endometrium is the vascular mucosal inner layer.

This layer changes under hormonal influence every month in preparation for possible conception and pregnancy. Four ligaments provide support and hold the uterus in position. These ligaments anchor the uterus at the base (cervical region), leaving the upper portion (corpus) free in the pelvic cavity. The broad ligament attaches the lower sides of the uterus to the sidewalls of the pelvis.

Question format: Multiple Choice Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 40 25. A nurse is conducting a sexual health education class about the structures and events of semen production. Which component will the students identify as responsible for semen production if the teaching has been successful?

A. accessory gland alkaline fluids B. sperm C. testes D. vas deferens E. seminiferous tubules Answer: A, B Rationale: The alkaline fluids from the accessory glands and sperm combine to form a thick, whitish secretion termed semen or seminal fluid. The testes and seminiferous tubules within the testes are where sperm are produced. The vas deferens is the muscular tube in which sperm begin their journey out of the man's body. It connects the epididymis with the ejaculatory duct.

Question format: Multiple Select Chapter 3: Structure and Function of the Reproductive System Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference:

Chapter 4 1. A nurse is counseling women on birth control choices. Which woman is the best candidate for an IUD? A. a woman who has multiple sex partners B. a woman who has a history of PID C. a woman who is in her early twenties and wants children later in life D. a woman who has one partner and three children Answer: D Rationale: A women who is in a stable monogamous relationship and has already had one successful pregnancy is the best candidate for an IUD. An IUD is not without risk to a woman. IUDs do not protect against STIs. PID may be caused by IUDs. A woman in her twenties has several better, lower risk options.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 69 2. A married couple, both age 27, is in the reproductive clinic and have been trying for a year to become pregnant. In a year, what percentage of couples usually do conceive?

A. 40 percent B. 60 percent C. 90 percent D. 100 percent Answer: C Rationale: Ninety percent of couples who engage in intercourse regularly will conceive within a year.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 73-74 3. A 20-year-old college student presents to the health clinic reporting fatigue, nausea, vomiting, severe abdominal cramping radiating to the lower back, and headaches. She reports these symptoms have started accompanying her menstrual cycle, which started 2 days ago. The nurse anticipates the health care provider will attempt to rule out which disorder first?

A. premenstrual syndrome B. toxic shock syndrome C. secondary dysmenorrhea D. primary dysmenorrhea Answer: C Rationale: Dysmenorrhea is painful or difficult menses. Primary refers to painful menstrual periods not associated with a disease process; secondary dysmenorrhea is related to a pelvic pathology and should be ruled out first to ensure a serious problem is not neglected but corrected as quickly as possible. PMS is a normal change in mood and physical discomfort that occurs with menstruation. Toxic shock syndrome is caused by bacterial infections.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 53 4. The nurse is preparing to teach a 22-year-old college student with PID how to prevent a repeat episode in the future. Which suggestion should the nurse prioritize?

A. Avoid sexual intercourse.

B. Use latex condoms.

C. Douche following intercourse.

D. Use diaphragms.

Answer: A Rationale: PID is an inflammation of any portion of a woman's reproductive tract often secondary to an infection, especially STIs. The patient should be encouraged to avoid sexual intercourse until she is in a monogamous relationship. If the client does not desire to do that, then a barrier such as a condom or diaphragm would be the next suggestion. It will still be possible, however, to contract an infection and develop PID again. Douching is never recommended due to its potential to push any bacteria which may be present up into the uterus, increasing the chances of an infection.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 55-56 5. The school nurse is preparing a health education session on the topic of birth control for a college group. Which method should the nurse emphasize for this group?

A. barrier B. hormonal C. rhythm D. transdermal Answer: A Rationale: The nurse should emphasize a barrier method of birth control such as a condom. The condom will help not only with birth control but with the spread of STIs, which is common in this age group. The other methods, such as hormonal, rhythm, and transdermal, will only prevent pregnancy and are more commonly utilized in long-term monogamous relationships.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 64-65 6. The nurse is preparing a teaching session for a client considering tubal ligation.

Which factor should the nurse prioritize in this session?

A. Wait several months after birth, and schedule the surgery as an outpatient.

B. The procedure is easy to perform and will be painless.

C. This is a permanent and irreversible procedure for birth control.

D. She must have signed consent from her partner.

Answer: C Rationale: The procedure is considered permanent and irreversible. This is a procedure not for routine birth control but for permanent birth control. If the women elects for this procedure, it can be done immediately following the birth of the child, lessening the inconvenience or hospitalization of the client. The procedure is not painless, nor easy. A consent form from the partner is not always required.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 70 7. The nurse is conducting a well-visit physical assessment on a 29-year-old female. The nurse determines the client is probably ovulating based on which condition of the cervical mucus?

A. Thin, slippery, and stretchy B. Cloudy, thick, and watery C. Clear and of large quantity D. Thin and red-tinged

Answer: A Rationale: The mucus at the time of ovulation is thin, slippery, and stretchy to allow for the passage of sperm into the uterus. This is called spinnbarkeit fiber. If the mucus is too thick, it will inhibit fertilization. Before ovulation, the mucus is thick and does not stretch easily.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 62 8. A community health nurse is preparing a presentation for a health fair on the topics of planning for a pregnancy. Which major goal has the nurse determined should be accomplished with this presentation?

A. Ensure women are using the correct contraceptive method.

B. Ensure couples understand genetic risks.

C. Provide one-on-one counseling.

D. Decrease the number of unwanted pregnancies.

Answer: D Rationale: Preconception counseling with general health care is a health promotion activity to help prevent unwanted pregnancies. The nurse will be responsible for presenting the basic information to everyone. In this environment it would not be appropriate for the nurse to provide one-on-one counseling due to privacy concerns. The nurse could present various risks but it would be beyond the scope of this event to ensure every participant understands each point.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 58-59 9. A young couple are disappointed that they are not yet pregnant and are seeking assistance at the health clinic. After assessing their medical history, the nurse discovers the female has a history of several episodes of PID. The nurse predicts this may be a source of the infertility related to which factor?

A. It causes anovulation due to interference with secretion of pituitary hormones.

B. It causes changes in cervical mucus that make it less receptive to penetration by sperm.

C. It causes sperm-agglutinating antibodies to be produced in the vagina.

D. It interferes with the transport of ova due to tubal scarring.

Answer: D

Rationale: Pelvic inflammatory disease results in scarring and adhesions of the tubes, leading to poor transport of ova. PID does not affect hormone metabolism, nor does it affect the production of cervical mucus. Antibodies are present only in a few cases and are unrelated to PID. Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 55-56 10. The nurse is preparing to meet with a couple who have requested counseling concerning family planning. The nurse will prioritize which topics for discussion?

A. Ensuring the couple is legally married B. Ensuring the correct time frame is followed C. Possible genetic abnormalities D. Preventing STIs Answer: C Rationale: Family planning consists of two complementary components: planning pregnancy and preventing pregnancy. The nurse may be involved with teaching the families how to avoid unwanted pregnancies, bring about wanted births, and control the intervals between births. Discussing potential genetic anomalies would be involved as the family prepares for children. It would not be proper for the nurse to ignore this couple based on their marriage status. The time frame would be determined by the couple and is flexible. Preventing STIs would also not be a focus of this session.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 58-60 11. A client is requesting information on the various available contraceptives. When explaining a vaginal spermicide, which information should the nurse prioritize?

A. Wash with clean water and soap after intercourse.

B. Insert the product by applicator in the vagina prior to intercourse.

C. Apply the spermicide directly to the glans penis to kill the sperm when they exit the penis.

D. Leave the product in place for 24 hours after intercourse.

Answer: B Rationale: Vaginal spermicides provide a physical barrier that prevents sperm penetration and a chemical barrier that kills sperm. It is designed to be inserted vaginally immediately before or within a few hours before sexual intercourse.

Hygiene is always important and is unrelated to the use of spermicides. Applying the spermicide to the penis would be ineffective as it would rub off. The product is immediately effective and can be removed right after intercourse.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 63 12. A 30-year-old woman reports that she has not had a menstrual period for the last 4 or 5 months. Pregnancy is ruled out and she is experiencing no endocrine symptoms. What factors could be contributing to her amenorrhea? Select all that apply.

A. ovarian dysfunction B. working out at the gym 3 hours per day C. hypothyroidism D. endometrial adhesions E. history of chemotherapy Answer: B, C, D Rationale: Amenorrhea without endocrine symptoms often is caused by disorders that interfere with hypothalamic function, such as excessive exercise, malnutrition, and endocrine disorders of the thyroid gland. It may also be caused by outflow tract problems such as adhesions of the endometrium, an imperforate hymen, or female circumcision. The other two factors are associated with amenorrhea due to endocrine problems.

Question format: Multiple Select Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 52 13. The nurse is teaching a young couple who desire to start their family the various methods for determining fertility. After discovering the woman regularly travels internationally for work, deals with a lot of job anxiety, and frequently uses an electric blanket at home, the nurse will discourage the use of which method?

A. calendar method B. basal body temperature method C. cervical mucus method D. symptothermal method Answer: B Rationale: BBT is a method where the body temperature should be checked and recorded first thing in the morning, immediately after waking and before getting out

of bed. It is important for the patient to maintain a normal bedtime routine. Use of an electric blanket, stress, and anxiety can cause a false elevation in the BBT. The calendar method would depend upon her schedule. Cervical mucus and symptothermal methods would be viable options.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 62 14. The nurse is meeting with a 36-year-old client who wishes to begin using contraceptives. The client reports being in a long-term, monogamous relationship, runs 2 miles per day, and smokes a pack of cigarettes each day. Which method will the nurse be least likely to suggest to the client?

A. oral contraceptive pills (OCPs) B. condoms C. coitus interruptus D. spermicides Answer: A Rationale: Oral contraceptive pills (OCPs) are contraindicated for women who smoke; these women would be at a higher risk for blood clots. Condoms, coitus interruptus, and spermicides can be used at no risk.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 68 15. A client is desiring to start birth control and is questioning the nurse concerning the best options. Which option should the nurse point out is the most reliable?

A. diaphragms B. condoms C. oral contraceptive pills (OCPs) D. hormonal implant Answer: D Rationale: Hormonal implant is a small, flexible, plastic rod implanted into the arm of the client. This method requires replacement only every 3 years and has a high success rate for pregnancy prevention. The client does not have to remember to do anything. Oral contraceptive pills, although highly effective, depend on the individual remembering to take the pill every day at the same time without fail.

Diaphragms and condoms can have structural failures (a hole) and would be less reliable.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 61 16. A client prescribed a combined oral contraceptive (COC) has presented for a routine visit. Which finding if reported by the client upon assessment should the nurse prioritize?

A. abdominal pain B. small amount of breakthrough bleeding C. light menstrual flow D. cramping during menses Answer: A Rationale: The warning signs to report for a client on combined oral contraceptives are severe abdominal or chest pain, dyspnea, headache, weakness, numbness, blurred or double vision, speech disturbances, or severe leg pain and edema. Light bleeding, light flow, and cramping are all normal.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 68 17. The nurse has assessed several clients who have arrived for routine appointments. The nurse predicts the health care provider will prioritize a bone density scan for which client?

A. a 40-year-old black client, 5 ft 4 in (1.62 m) tall, 172 lbs (78 kg), inactive lifestyle B. a 25-year-old Asian client, 5 ft 7 in (1.7 m) tall, 129 lbs (58.5 kg), with two children C. a 55-year-old white client who smokes and has family history of osteoporosis D. a 45-year-old Hispanic client with a vitamin D deficiency Answer: C Rationale: Risk factors for osteoporosis include female gender, white or Asian ethnicity, slender build, advanced age, estrogen deficiency because of menopause, low bone mass density, family history of osteoporosis, personal history of fracture as an adult, smoking, excessive alcohol intake, low dietary intake of calcium, vitamin D deficiency, inactive lifestyle, and use of glucocorticoids and anticonvulsants. The more of these risk factors an individual has, the higher the risk for osteoporosis. The 55-year-old white smoker with a family history of

osteoporosis should be referred for bone scan or density testing. The other individuals have fewer overall risk factors.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 78 18. The nurse is assessing a young couple who desire to get pregnant. The 38year-old husband and 29-year-old wife report they had used oral contraceptive pills (OCPs); however, they have now been trying unsuccessfully to conceive over the past 4 months. What is the best response for the nurse to make?

A. Return in 9 months for further assessment if not pregnant.

B. Should seek fertility counseling from a specialist.

C. Increase intercourse frequency to four times a week around the time of ovulation.

D. Should undergo comprehensive diagnostic testing.

Answer: C Rationale: The most fertile time is the ovulation period of the woman's ovarian cycle. Increasing the frequency of intercourse around ovulation will increase the chance of conception. Individuals are not considered infertile until they have tried for at least 1 year to get pregnant. If this couple is still not pregnant after 8 months, then they can be referred for a fertility workup.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 74-75 19. The nurse is assessing a 52-year-old perimenopausal female who is concerned about the changes occurring in her body. When questioned about the most serious changes, which effect should the nurse point out?

A. pelvic support muscles lose tone B. dense breast tissue is replaced with adipose tissue C. the uterus and ovaries decrease in size D. bone mineral density decreases Answer: D Rationale: As women age, the decrease in hormone levels place women at increased risk for osteoporosis. This is a potential concern that can impact life, and bone mineral density should be monitored. There is no evidence of atrophy in the pelvic muscles, nor in the uterus or ovaries as related to menopause. Breast tissue changes at the same rate that all other tissue changes.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 78 20. The nurse is preparing to teach a client how to conduct the basal body temperature method to determine her fertile window. Which instruction should the nurse prioritize?

A. It depends on the average temperature taken each morning.

B. Temperature should be taken prior to any activity every morning.

C. Avoid intercourse only on the days the temperature drops.

D. It is the best method for predicting ovulation.

Answer: B Rationale: BBT is the basal body temperature method and requires the woman to take her temperature and record it every morning. This should be the first activity of the day before exiting the bed or doing other activities. To prevent conception, avoid unprotected intercourse from the day the BBT drops through the fourth day of temperature elevation. The BBT alone is not a reliable method for predicting ovulation. Use BBT along with calendar or cervical mucus methods to increase effectiveness.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 62 21. The nurse was teaching a college student how to properly take the prescribed combination oral contraceptive (COC). The nurse determines the session is successful when the client correctly chooses which instruction to follow when taking the OCP? A. empty stomach, full glass of water B. same time of day, each day C. take with a meal D. same day of the week, once a week Answer: B Rationale: OCPs are to be taken daily at the same time of day every day.

Absorption is not affected by the stomach contents. Oral contraceptive pills must be taken every day to be effective.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Analyze

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 67 22. A young couple is having difficulty getting pregnant. The nurse is preparing the couple for the initial tests to determine their fertility. When asked by the couple why they need to start with a sperm analysis, what will be the nurse's best response?

A. Asking the male to undergo diagnostic procedures first is the best way to assess interest in treatment of infertility.

B. The man is found to be fertile in over 75 percent of couples with infertility problems.

C. Male fertility testing is time-consuming and therefore should be initiated early.

D. Sperm analysis is one of the easiest tests to complete.

Answer: D Rationale: Because sperm analysis is noninvasive, it is one of the easiest (and most cost-effective) tests to complete. There is no bias in male vs. female with regard to being the cause of infertility.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 76 23. The nurse is teaching a client about a vasectomy. The nurse determines the session is successful when the client correctly chooses which fact concerning the vasectomy?

A. Usually done as an office procedure B. Will no longer ejaculate C. May notice permanent increased scrotal swelling D. Testes will no longer produce sperm.

Answer: A Rationale: Vasectomy is an outpatient surgical procedure that is usually performed in the office. It involves ligating and cutting the vas deferens, which stops the flow of sperm from the testes to the outside of the body; however, it does not stop sperm production. There may be short-term swelling immediately after the procedure, but there should not be any permanent swelling. The client should still have normal sexual function.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning

Reference: p. 70 24. The nurse is conducting a routine well-visit on a 43-year-old client who is concerned about developing breast cancer, although no family members have experienced it. What is the best advice for this client at this time?

A. Be aware of the normal appearance and feel of your breasts.

B. Inspect your nipples every day for discharge or bleeding.

C. Ask the health care provider for recommendations based on family history.

D. Have a yearly mammogram as part of a comprehensive screening.

Answer: A Rationale: The American Cancer Society recommends that each woman know how her breasts normally look and feel, and if she finds changes, she should immediately report them to a health care provider. Discharge from the nipple is not necessarily related to cancer. For women with an average risk for breast cancer, yearly mammograms should start at age 45 and can change to every 2 years beginning at age 55. Women who are at a higher risk for breast cancer due to family history or other reasons may need to begin screening earlier and/or more often.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 49 25. A 24-year-old female client states, "About a week before my period starts, I have recently started craving certain sweets, having terrible mood swings, and feeling fatigued and irritable." Which action will the nurse take next?

A. Document the findings in the client's medical record.

B. Educate the client on treatment for premenstrual syndrome.

C. Notify the client's primary health care provider.

D. Recommend the client's hormone levels be tested.

Answer: B Rationale: The client is exhibiting symptoms of premenstrual syndrome and the nurse would provide education on treatment options for the client's specific symptoms, such as increased rest and exercise. The nurse would document the findings and education provided in the client's medical record and notify the primary health care provider; however, these are not a priority as the client is stable and in need of treatment options. The client does not have symptoms warranting hormone testing at this time. If the symptoms worsened or became intolerable, then testing may be needed.

Question format: Multiple Choice Chapter 4: Special Issues of Women's Health Care and Reproduction Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 53

Chapter 5 1. In caring for a fully immunized pregnant woman who is a nurse in a family health practice, the obstetric nurse should remind the client that she must not come in contact with clients who have symptoms that could indicate which infection?

A. measles B. Chicken pox C. smallpox D. diphtheria Answer: B Rationale: Chicken pox can be teratogenic to the fetus and exposure may have a significant impact on the fetus and may cause defects. The fetus receives passive immunity from the mother for measles, diphtheria, and smallpox.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 92 2. Assessment for surfactant level via lecithin/sphingomyelin (L/S) ratio in the amniotic fluid is a primary estimation of fetal maturity. The purpose of surfactant is to: A. prevent alveoli from collapsing on expiration.

B. increase lung resistance on inspiration.

C. encourage immunologic competence of lung tissue.

D. promote maturation of lung alveoli.

Answer: A Rationale: Surfactant is a phospholipid that reduces surface tension; it prevents alveoli from collapsing on expiration. Resistance to airflow is an effect of tissue elasticity and airway size. Immunologic competence is provided by antibodies in the mucus layer. Fully matured alveoli contain squamous cells as well as type II surfactant cells.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 90 3. A 38-year-old client presents to the clinic desiring to get pregnant. She reports she had a tubal ligation in her early 20s after two babies and a divorce. After

learning that the client recently underwent a reversal of the tubal ligation, the nurse will warn the client of which potential risk?

A. ectopic pregnancy B. Down syndrome C. twins D. exposure to teratogens Answer: A Rationale: Tubal ligation reversal is a difficult procedure and can place the woman at higher risk for ectopic pregnancy. She needs to be aware of the possibility. Down syndrome, multiple births, and exposure to teratogens are all issues that have nothing to do with reversal of tubal ligation. These are issues that any pregnant female should be made aware.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 98 4. A client and partner are excited to discover they are expecting twins. The nurse is prepared to monitor the twins for which potential situation after noting they share an amniotic sac?

A. increased teratogenic effects B. conjoined twins C. twin-to-twin transfusion syndrome D. cord entanglement Answer: D Rationale: The greatest risk for monoamniotic monochorionic twins is cord entanglement as they share the same amnio and chorion and are contained in the amniotic fluid together. Conjoined is a possibility but not the greatest risk. Twin-totwin transfusion syndrome is also a possibility but is a greater risk for diamniotic monochorionic as they share either placenta or vessels. Fraternal (dizygotic) twins with two placentas, two amnions, and two chorions are diamniotic dichorionic and would not be at risk for the cord entanglement.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 98 5. The nurse is assessing a 38-year-old Black client who has just discovered she is pregnant. On assessment, the nurse documents the client is 5 ft 10 in (1.77 m) tall

and stopped using oral contraceptives 3 months ago hoping to become pregnant.

Which situation may accompany her pregnancy?

A. hypertension B. sickle cell anemia C. twins D. ectopic pregnancy Answer: C Rationale: Women who have recently stopped using oral contraceptives, are tall or large stature, or are Black race have an increased chance for multifetal pregnancy.

She is at no higher risk of hypertension or sickle cell anemia than she would be if she had not gotten pregnant. Ectopic pregnancy is not influenced by age or race.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 98 6. At a 12-week visit, the nurse assesses a pregnant woman who is questioning what the baby may look like at this point. Based on the current stage, which structures would the nurse point out to the client?

A. Budlike structures for arms and legs B. Beating heart and differentiated fingers and toes C. Audible heartbeat and identifiable sex characteristics D. Fully shaped lungs and a defined skeletal system Answer: C Rationale: At the end of 12 weeks' gestation, most structures are fully developed but need time to grow. The heartbeat is audible by Doppler, gender is discernible by outward appearance, the placenta is complete, divisions of the brain begin to develop, the face is well formed, the eyes are widely spaced and fused, kidney secretion has begun, and spontaneous movements occur. The arms and legs are budlike structures by the end of 4 weeks. By the end of 8 weeks, the heart with a septum and valves is beating rhythmically and the fingers and toes are distinct and separated. The skeletal structure is identifiable at the end of 16 weeks. The lungs do not take on their final shape until after birth when the infant starts to oxygenate its own blood by its own lungs. By the end of 32 weeks the lungs are not yet fully developed, but the fetus usually does well if born at this time.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 91

7. The parents are questioning why their newborn was born deaf when there are no other deaf family members. The nurse could explore possible exposure to a teratogenic agent at which stage of the pregnancy?

A. 6 weeks B. at fertilization C. 12 weeks D. 18 weeks Answer: A Rationale: Teratogenic agents ingested during the embryonic stage (2 to 8 weeks) can affect the neurologic system of the fetus, including the hearing. During weeks 6 through 8, the ear is most vulnerable to teratogenic agents. From the preembryonic stage of fertilization to the beginning of week 2, there is decreased risk due to no implantation or transfer of substances from the mother to the developing blastocyte. During the fetal stage (9 weeks to birth), the fetus is fully formed and is now concentrating on increasing in size. There is a decreased risk from teratogenics during this time period.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 97 8. A group of nursing students are preparing a presentation depicting the fetal circulation. The instructor determines the presentation is successful when the students correctly illustrate which route for the ductus arteriosus?

A. The left to right heart atria B. The aorta to the pulmonary veins C. The right ventricle to the aorta D. The pulmonary artery to the aorta Answer: D Rationale: Because the fetal lungs are not inflated, blood must be diverted past them. The ductus arteriosus helps to do this by shunting blood from the pulmonary artery to the aorta. The foramen ovale diverts blood from the right atrium to the left atrium, bypassing the lungs. The ductus venosus diverts a portion of blood from the umbilicus to the inferior vena cava instead of passing through the liver first.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 94

9. The nurse is preparing a presentation for a health fair which will illustrate the development of a baby. The nurse should point out the fertilized egg is implanted in the endometrium by which day?

A. 4 B. 6 C. 8 D. 10 Answer: D Rationale: By day 10 after fertilization, the blastocyst has completely buried itself in the endometrial lining. Prior to day 10, the attachment is much looser.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 88 10. The nurse is meeting with a young couple who desire to get pregnant to teach them how to determine the best times for intercourse. During which time frame should the nurse encourage them to engage in intercourse to increase their chances of getting pregnant?

A. 2 days before to 1 day after ovulation B. 1 day before ovulation to 2 days after ovulation C. 3 days before or the day of ovulation D. 3 days before to 2 days after ovulation Answer: D Rationale: Sperm are able to live for up to 72 hours after ejaculation and the ovum remains fertile for a maximum of 48 hours after ovulation. The window of opportunity for conception is 3 days before to 2 days after ovulation.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 86 11. A group of nursing students are analyzing the fetal circulation. After the session, the students correctly point out which fetal structure contains the highest concentration of oxygen?

A. umbilical artery B. umbilical vein C. ductus arteriosus D. pulmonary vein

Answer: B Rationale: The umbilical vein carries oxygenated blood from the placenta to the fetus; the umbilical artery carries deoxygenated blood from the fetus to the placenta. The ductus arteriosus shunts blood from the right atrium to the left atrium in order to bypass the deflated lungs. The pulmonary vein drains the deflated lungs.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 94 12. The nurse is assessing a young female who just found out she is pregnant. She is now reporting vague abdominal discomfort. After noting the client has a history of PID, the nurse predicts the health care provider will give priority to ruling out which situation?

A. Ectopic pregnancy B. Repeat PID C. UTI D. Endometriosis Answer: A Rationale: An ectopic pregnancy or tubal pregnancy can result when there is blockage or scarring of the fallopian tubes due to infection (PID) or trauma (tubal ligation reversal). Ectopic pregnancy may present with vague signs and symptoms but is the leading cause of maternal death in the first trimester and should be given priority when determining the cause of abdominal complaints. The other choices would be ruled out after the ectopic pregnancy is ruled out.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 98 13. The nurse is conducting a prenatal class for a group of first-time parents in the first trimester. The nurse should point out that the mother should feel the baby move by the end of which week of gestation?

A. 16 weeks B. 18 weeks C. 20 weeks D. 22 weeks Answer: C

Rationale: On average, the first time a mother can feel the fetus move is by the end of 20 weeks' gestation.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 91 14. The nursing instructor is illustrating the circulatory flow between the mother and fetus. The instructor determines the session is successful when the class correctly chooses which structure with which route?

A. The one umbilical artery carries oxygen-rich blood to the fetus from the placenta.

B. The two umbilical arteries carry waste products from the placenta to the fetus.

C. The one umbilical vein carries oxygen-rich blood to the fetus from the placenta.

D. The two umbilical veins carry waste products from the fetus to the placenta.

Answer: C Rationale: There are two umbilical arteries and one umbilical vein. The arteries carry waste from the fetus to the placenta; the vein carries oxygenated blood to the fetus from the placenta.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 95 15. A group of nursing students are preparing a presentation for a health fair illustrating the structures found during a pregnancy. Which structures should the students point out form a protective barrier around the developing fetus?

A. ectoderm and amnion B. amnion and mesoderm C. chorion and amnion D. chorion and endoderm Answer: C Rationale: The chorion and amnion are the two fetal membranes. The ectoderm, mesoderm, and endoderm are layers in the developing blastocyst.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 90

16. A nurse is discussing the importance of good nutrition to a young pregnant client. The nurse would point out that the growing fetus is getting nutrition from the mother via which structure?

A. decidua B. placenta C. amniotic fluid D. umbilical arteries Answer: B Rationale: The placenta is a flat, round structure which forms on the decidua and attaches to the fetus by the umbilical cord. The placenta is the organ responsible for supplying nutrients and oxygenated blood to the fetus. The amniotic fluid surrounds the fetus and provides protection, temperature regulation, allows movement, and symmetric growth. It collects urine and other waste products from the fetus. The decidua is the name given to the endometrium after the pregnancy starts. The umbilical arteries carry waste products away from the fetus to the placenta, where they are filtered out into the maternal body for proper disposal.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 92 17. The nurse is teaching a prenatal class on the functions of the various structures involved with a pregnancy. The nurse determines the class is successful when the class correctly chooses which function of amniotic fluid?

A. "This is how the baby is fed."

B. "It helps cushion the baby."

C. "It prevents viruses from passing to the baby."

D. "It provides oxygen to the fetus."

Answer: B Rationale: The amniotic fluid has four functions: physical protection, temperature regulation, provision of unrestricted movement, and symmetrical growth. Feeding the baby, preventing infection, and providing oxygen are functions of the placenta.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 90 18. The nursing instructor is preparing a class presentation covering the various hormones and their functions during pregnancy. The instructor determines the class is successful when the class correctly matches which function with hCG?

A. provides rich blood supply to decidua B. maintains nutrient-rich decidua C. continues progesterone production by corpus luteum D. sustains life of placenta Answer: C Rationale: The corpus luteum is responsible for producing progesterone until this function is assumed by the placenta. hCG is a fail-safe mechanism to prolong the life of the corpus luteum and ensure progesterone production. Estrogen is responsible for providing a rich blood supply to the decidua. Progesterone helps maintain a nutrient-rich decidua.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 88 19. The nurse is assessing a young couple who desire to start a family and are questioning the nurse concerning various cautions to keep in mind. Which time period should the nurse point out that teratogenics pose the greatest risk and should be avoided?

A. weeks 3 to 8 B. week 9 to birth C. fertilization through week 2 D. the entire pregnancy Answer: A Rationale: Teratogenic agents should be avoided throughout the entire pregnancy to include 3 months prior to conception. The embryonic stage (weeks 3 through 8) produces the greatest risk of damaging effects because the cells are rapidly dividing and differentiating into specific body structures. Basic structures of all major body organs and the main external features are completed during this time period, including internal organs. Week 9 to birth is the fetal stage; fertilization through week 2 is the pre-embryonic stage, and is not as concerning since the embryo is not yet connected to the mother and the chance of receiving teratogenic agents is decreased. The CNS is vulnerable throughout the entire pregnancy since it is continuously developing, and is most vulnerable during the embryonic stage.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 95

20. A student nurse is preparing an illustration for a health fair depicting the various types of twins. Which format will the student use to depict identical twins?

A. two separate eggs and different sperm B. two separate eggs and one sperm C. one egg and two different sperm D. one egg and one sperm Answer: D Rationale: Identical twins develop from the fertilization of one egg by one sperm, and this divides into two zygotes shortly after fertilization, resulting in two babies who share identical genetic material and are termed identical twins. With two separate eggs and two separate sperm, the twins would be fraternal dizygotic. One sperm cannot fertilize two eggs, and two sperm cannot fertilize one egg.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 98 21. A client calls the nurse in a panic after a home pregnancy test indicates she is pregnant. She reports that that she consumed a lot of alcohol on the night that she thinks the pregnancy occurred. The next day she had taken several acetaminophen.

For the past 3 weeks, she has had her usual nightly glass of wine with dinner but no other alcohol. What is an appropriate response for the nurse to make when the client questions if she has caused irreversible damage to the fetus?

A. "Why did you have unprotected sex if you had been drinking? Exposure to alcohol can cause facial deformities, low birth weight, and underdeveloped brains."

B. "The fetus is not exposed to the mother's blood until after it implants about 6 days after fertilization, so the first night is not an issue. But it is best to avoid alcohol while you are pregnant."

C. "The wedding night is not an issue because the fetus is not exposed to the mother's blood at first, but I hope this last week of drinking has not caused any problems."

D. "Alcohol is very damaging to the growing fetus, so you had better be sure to stop drinking. Do you need any support for that?"

Answer: B Rationale: The fetus was not developing during the initial night of drinking. The embryo would be exposed to the mother's blood following the sixth day after implantation, at which time the alcohol will be circulating in the embryo's circulation. Alcohol use should be stopped now that the client knows she is pregnant, but the nurse should reassure her that the limited amounts she has consumed will most likely not have an adverse effect on the fetus. A practitioner should not question the client's choice of drinking and having unprotected sex.

There is no indication of alcohol use disorder, so support may not be warranted.

The nurse should maintain a professional and calm attitude and not criticize or condemn the client.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 95 22. The nursing instructor is teaching a class on the structures vital to the development of the fetus. The instructor determines the class is successful when the class correctly chooses which facts concerning amniotic fluid?

A. Produced by fetal brain B. Amniotic fluid is 90% water C. Production stops in the eighth month D. Helps the fetus regulate body temperature Answer: D Rationale: Amniotic fluid is formed by the fetal membranes, the amnion and chorion, on a constant basis until birth. It is 98% to 99% water, with the remaining 1% to 2% composed of electrolytes, creatinine, urea, glucose, hormones, fetal cells, lanugo, and vernix. It serves four main functions: physical protection, temperature regulation, provision of unrestricted movement, and symmetrical growth. The fetus is unable to regulate its own body temperature so the amniotic fluid provides this function.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 90 23. A young couple, 8 weeks' pregnant with their first child, are being assessed at their first prenatal visit. They ask about scheduling an ultrasound to find out the gender of the fetus. For when should the nurse recommend this ultrasound be scheduled?

A. for today (8 weeks' gestation) B. for 12 weeks' gestation C. for 16 weeks' gestation D. for 20 weeks' gestation Answer: C Rationale: The sex organs can be distinguished at 12 weeks' gestation but are difficult to see on routine ultrasound. The gender of the fetus can be determined at the end of 16 weeks' gestation on ultrasound.

Question format: Multiple Choice

Chapter 5: Fetal Development Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 91 24. The nurse is conducting an obstetrics assessment on a client at 20 weeks' gestation who is questioning the nurse about the development of the fetus. Which new occurring developments can the nurse point out to this client?

A. Eyelids are open.

B. Lungs are fully shaped.

C. Eyebrows and scalp hair are present.

D. A developed startle reflex is evident.

Answer: C Rationale: At 20 weeks, the fetus is still developing. All structures are present, but not in full size. The fetus will have limited amounts of eyebrows and scalp hair. At 20 weeks, the eyelids are not present; the lungs are present, but not developed.

The startle reflex will not be evident until after birth.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 91 25. The nurse is preparing a pregnant client with severe hypertension for an emergent amniocentesis for possible early delivery of the fetus. The nurse will explain to the client that the health care provider is evaluating which parameter?

A. fetal renal output B. fetal alimentary output C. maternal blood makeup D. level of fetal surfactants Answer: D Rationale: Amniocentesis is done to check the lung surfactant ratio of the fetus, which will determine if the lungs are matured enough for delivery. Amniocentesis can be used to determine fetal renal and alimentary output, but these factors are not critical to birth. Maternal blood work will reveal information about the mother and not the lung maturity of the fetus.

Question format: Multiple Choice Chapter 5: Fetal Development Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 92

Chapter 6 1. The nurse is spending time with a client who has just learned, unexpectedly, that she is pregnant. Which initial task should the nurse assist the client to focus on?

A. Accepting the pregnancy B. Accepting a coming child C. Making plans for the baby D. Sharing time with a significant other Answer: A Rationale: The first task of pregnancy is to accept the pregnancy. This task is usually met during the first trimester, although some women have difficulty fully accepting the pregnancy until they can feel the baby move. Accepting the baby or coming child usually occurs in the second trimester. It is also during the second trimester when the woman spends more time with her partner as they prepare for the coming infant. The third trimester is spent making plans for the baby, getting the nursery ready, buying necessary supplies and preparing for the child.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 111 2. A 17-year-old client arrives for an annual examination and reports no changes since the last exam; however, the nurse assesses a positive Chadwick sign, slightly enlarged uterus, and subsequent positive urine pregnancy test. Which task should the nurse prioritize to assist this client who is denying any possibility that she is pregnant?

A. Accepting the pregnancy B. Accepting the baby C. Preparing for parenthood D. Telling her partner and family Answer: A Rationale: Acceptance of pregnancy is multi-factorial, and how the woman responds to the pregnancy is certainly influenced by her age and if the pregnancy was planned. As a teenager, she may not have been trying to get pregnant and may not want to accept the role and experience. Baby and parenthood decisions should all occur later.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Psychosocial Integrity

Integrated Process: Nursing Process Reference: p. 111 3. The nurse is assessing a 37-year-old woman, pregnant with twins in her second trimester, and notes the following over the past 3 visits: blood pressure 128/88, 134/90, and 130/86. Which nutritional supplement should the nurse suggest the client take?

A. vitamin A B. iron C. calcium D. lactase Answer: C Rationale: The elevated blood pressures indicate the client is possibly developing gestational hypertension. This increases the risk of developing preeclampsia.

Current research has demonstrated that calcium supplementation during pregnancy may reduce the risk of preeclampsia. Excessive levels of vitamin A may cause birth defects. Iron supplementation is used to fortify blood cell formation and decrease anemia. Lactase supplementation aids in the digestion of dairy.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 113 4. A pregnant client in her second trimester reports feeling tired all the time. The nurse notes pale skin and low normal hemoglobin on assessment. Which recommendation should the nurse prioritize for this client?

A. An iron supplement B. A calcium supplement C. More meat in her diet D. More seafood and organ meats in her diet Answer: A Rationale: Iron is necessary for the formation of hemoglobin; therefore, it is essential to the oxygen-carrying capacity of the blood. Women who have normal hemoglobin may need increased iron to carry more oxygen. Calcium supplementation is essential for normal fetal development. The use of measured supplements would ensure a steady amount, whereas the use of meat and seafood would not allow this.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process

Reference: p. 113 5. A pregnant vegan reports eating lots of dark green leafy vegetables, legumes, citrus fruits, and berries. To ensure that her infant's nervous system will develop properly, what foods should the nurse recommend that she add to her diet?

A. Milk and cheese B. Carrots, sweet potatoes, and mangoes C. Nuts, seeds, and chocolate D. Fortified cereals Answer: D Rationale: The best source to recommend are the fortified cereals to meet the amino acid needs necessary for the development of her infant's nervous system during pregnancy. She should be encouraged to include fortified cereals to meet these needs. The carrots, sweet potatoes, mangoes, nuts, and seeds will add other nutrients to her diet. A vegan will not eat milk and cheese, as they are animal products.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 116 6. The nurse is assessing a pregnant client at her 20-week visit. Which breast assessment should the nurse anticipate documenting?

A. Slack, soft breast tissue B. Deeply fissured nipples C. Enlarged lymph nodes D. Darkened breast areolae Answer: D Rationale: As part of the pigment changes that occur with pregnancy, breast areolae become darker. The breast tissue should not be softer or slacker than before. There should not yet be any lymph enlargement, and the nipples should not have fissures.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 105 7. A client calls to cancel an appointment for the first prenatal visit after reporting a home pregnancy test is negative. Which instruction should the nurse prioritize?

A. Use a diluted urine specimen.

B. Wait until after two missed menstrual periods.

C. Keep the appointment.

D. Refrain from eating for 4 hours before testing.

Answer: C Rationale: Although home pregnancy tests are accurate 95% of the time, they may still have false positives or false negatives, and the client needs to seek prenatal care and confirmation from her health care provider. Diluting the urine, waiting to miss a second period, or eating before the test would have no effect. The tests look for hCG, which is not affected.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 104 8. A client in her first trimester reports frequent urination and asks the nurse for suggestions. The nurse should teach the client that the urination is most likely related to which cause?

A. Pressure on the bladder from the uterus B. Increased concentration of urine C. Addition of fetal urine to maternal urine D. Decreased glomerular selectivity Answer: A Rationale: Early in pregnancy, the expanding uterus presses on the bladder. During the second trimester there is some relief when the uterus lifts, but the pressure returns again as the fetus continues to grow. Urine concentration does not affect frequency. Fetal urine does not enter the mother's renal system, except through increases in circulatory volume. The glomeruli should not be affected by pregnancy.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 109 9. A pregnant client in her third trimester, lying supine on the examination table, suddenly grows very short of breath and dizzy. Concerned, she asks the nurse what is happening. Which response should the nurse prioritize?

A. Cerebral arteries are growing congested with blood.

B. The uterus requires more blood in a supine position.

C. Blood is trapped in the vena cava in a supine position.

D. Sympathetic nerve responses cause dyspnea when a woman lies supine.

Answer: C Rationale: Supine hypotension syndrome, or an interference with blood return to the heart, occurs when the weight of the fetus rests on the vena cava. Cerebral arteries should not be affected. Mean arterial pressure is high enough to maintain perfusion of the uterus in any orientation. The sympathetic nervous system will not be affected by the supine position.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 107 10. The nurse is explaining the latest laboratory results to a pregnant client who is in her third trimester. After letting the client know she is anemic, which heme ironrich foods should the nurse encourage her to add to her diet?

A. Legumes B. Dairy C. Grains D. Meats Answer: D Rationale: Meats are the best source of heme-rich iron and should be included in her diet if she is not following a vegetarian diet. Grains and legumes are non-heme iron sources. Dairy products will add various vitamins and calcium to the diet.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 113 11. The nurse is assessing a pregnant client in her third trimester who is reporting a first-time occurrence of constipation. When asked why this is happening, what is the best response from the nurse?

A. There is not enough fiber in your diet.

B. The intestines are displaced by the growing fetus.

C. This shouldn't be happening.

D. hCG is delaying peristalsis.

Answer: B Rationale: The growing fetus is displacing the intestines and interfering with peristalsis, delaying the passage of fecal matter and resulting in constipation. This is common and expected; however, the client should take measures to prevent

hemorrhoids that can occur as the result of the pressure and straining.

Progesterone, not hCG, can delay gastric emptying and decrease peristalsis.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 109 12. The nurse is assessing a client who believes she is pregnant. The nurse points out a more definitive assessment is necessary due to which sign being considered a probable sign of pregnancy?

A. Fatigue B. Amenorrhea C. Positive home pregnancy test D. Nausea and vomiting Answer: C Rationale: A urine pregnancy test is considered a probable sign of pregnancy as the hCG may be from another source other than pregnancy. Fatigue, amenorrhea, and vomiting are presumptive or possible signs of pregnancy and can also have other causes.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 104 13. The nursing instructor is teaching a class on the various hormones necessary for a successful pregnancy and birthing process. The instructor determines the session is successful when the students correctly choose which hormone as being necessary after birth to ensure growth of the newborn?

A. Oxytocin B. Estrogen C. Progesterone D. Prolactin Answer: D Rationale: Prolactin is the hormone responsible for the initiation of lactation, the production of breast milk. Oxytocin is responsible for the letdown of milk and uterine contractions enabling the infant to be born, and estrogen and progesterone are responsible for uterine and pregnancy maintenance.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 107 14. The community nurse is preparing a presentation for a health fair illustrating successful pregnancies. Which component should the nurse prioritize as the most critical to ensure a positive psychological experience with the pregnancy by the mother?

A. Early prenatal care B. Age at the time of pregnancy C. Having a planned pregnancy D. Social support Answer: D Rationale: All options are correct and play a role pregnancy, but the most critical for a positive psychological experience is for the woman to have a social support system. Early care, maternal age, and planned pregnancy all affect fetal and maternal health, but are not necessarily linked to positive psychological experiences.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 110 15. The nursing instructor is teaching a class on the nutritional needs of the pregnant client. The instructor determines the session is successful when the students correctly choose which supplement as being known to prevent up to 70% of CNS birth defects?

A. iodine B. zinc C. folic acid D. vitamin A Answer: C Rationale: Folic acid is noted to help prevent up to 70% of CNS birth defects; however, the folic acid needs to be in the body prior to the pregnancy to be most effective. Iodine affects thyroid development. Zinc is required for enzyme formation and gene expression. Vitamin A helps develop vision.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 114

16. A client in her third trimester reports sleeping poorly: sleeping on her back results in lightheadedness and dizziness and lying on her side results in no sleep.

Which suggestion for sleeping should the nurse prioritize for this client?

A. without a pillow B. with a pillow under her shoulders C. with a pillow under her right hip D. with a pillow under both hips Answer: C Rationale: Pregnancy places strain on the cardiovascular system with increased fluid in the lungs and heart. The use of one pillow under the right hip will help displace the uterus and fetus off the major blood vessels, allowing the circulation to flow appropriately and provide relief to the client. When the woman lies flat on her back the uterus and contents can compress the vena cava and aorta and reduce blood flow, resulting in the light-headedness and dizzy spells. Removal of the pillow would not alter the effects on the vena cava. A pillow under the shoulders would hurt the neck, and a pillow under both hips would exacerbate the light-headedness.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 107 17. A client at 39 weeks' gestation calls the OB triage and questions the nurse concerning a bloody mucus discharge noted in the toilet after an OB office visit several hours earlier. What is the best response from the triage nurse?

A. "It might be nothing. If it happens again call your provider who is on-call."

B. "If the provider did an exam, it might be just normal vaginal secretions, so don't worry about it."

C. "A one time discharge of bloody mucus in the toilet might have been your mucus plug."

D. "Bloody mucus is a sign you are in labor. Please come to the hospital."

Answer: C Rationale: Bloody mucus can either be a mucus plug or bloody show. The one-time occurrence would be more likely to be the mucus plug. A bloody show would continue if her cervix was changing, but this usually does not occur until after contractions start. It is a sign that something is happening and should be reported to the health care provider. The bloody mucus is not a sign of labor, but it can be an early sign that labor is coming soon.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 106 18. The nurse is assessing a pregnant client at 20 weeks' gestation and obtains a hemoglobin level. Which result would be a cause for concern?

A. 12.8 g/dL B. 11.9 g/dL C. 11.2 g/dL D. 10.6 g/dL Answer: D Rationale: The average hemoglobin level at term is 12.5 g/dl. The hemoglobin level is considered normal until it falls below 11 g/dl.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 107 19. A client at 40 weeks' gestation informs the nurse that she is tired of being pregnant. What is the best response from the nurse?

A. "Do you need to speak with someone about your feelings?"

B. "That is a very normal feeling, especially at this point in pregnancy."

C. "Most woman would have asked to be induced by this point. Is that what you want?"

D. "Are you getting enough rest? If you don't take time for rest, that is why you might be tired."

Answer: B Rationale: During the third trimester, the client is preparing for parenthood and is often tired and ready for a break. The woman may feel large and unable to do any normal activities, and may feel ready to have the baby in her arms rather than in her uterus. This is not an abnormal statement, and the provider should not overreact. Deciding to induce labor is something that should be done in consultation with the health care provider and only when it is necessary for the health/safety of the mother or baby.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 112

20. The nurse is teaching a pregnant teenager the importance of proper nutrition and adequate weight gain throughout the pregnancy. What is the best response when the client refuses to eat due to fear of possible weight gain?

A. The infant will be small and could have problems.

B. There may be little impact on the infant, but the mother can suffer complications.

C. It will just make the baby smaller, but there are no other problems associated.

D. The infant will be smaller but should quickly gain weight.

Answer: A Rationale: Women who gain less than 16 pounds (7257 g) are at risk of giving birth to small infants, which is associated with poor neonatal outcomes. The infant may not quickly gain weight but continue to slowly put on weight.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 112 21. The nurse cares for a pregnant client at the first prenatal visit and reviews expected changes that will occur during pregnancy. Which information will the nurse include in the education?

A. During pregnancy blood volume can increase by at least 40%.

B. Pregnancy typically causes a decrease in respiratory rate.

C. Hemoglobin levels rise significantly during pregnancy.

D. Blood pressure decreases in the third trimester.

Answer: A Rationale: The pregnant woman can experience a blood volume increase by approximately 40% to 50% above prepregnancy levels by the end of the third trimester. Pregnancy results in an increased respiratory rate to provide oxygen to both the mother and fetus. Hemoglobin levels are usually low during pregnancy because of hemodilution of red blood cells, which is termed physiologic anemia of pregnancy. Blood pressure usually reaches a low point mid-pregnancy and, thereafter, increases to prepregnancy levels by the third trimester.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 105 22. The nurse is conducting an annual examination on a young female who reports her last menses was 2 months ago. The client insists she is not pregnant due to a

negative home pregnancy test. Which assessment should the nurse use to assess confirm the pregnancy?

A. Chadwick sign B. fetal heartbeat C. positive urine human chorionic gonadotropin (hCG) D. uterine size and shape changes Answer: B Rationale: The only positive sign of pregnancy is a sign or symptom that could only be attributable to the fetus; thus, fetal heartbeat can have no other origin.

Chadwick sign is a color change in the cervix, vagina, and perineum; these could all be the result of other causes. A positive urine hCG is a probable sign as it can be related to causes other than pregnancy. A change in the size and shape of the uterus can occur due to other causes.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 104 23. The nurse is assessing a pregnant client at 12 weeks' gestation and the client reports some new bumps on the dark part of her nipples. What is the best response from the nurse when questioned by the client as to what they are?

A. Normal bumps of pregnancy; they do nothing B. Might be sign of cancer; need to speak with health care provider C. Montgomery glands (Montgomery tubercles); secrete lubricant for the nipples D. Striae, stretching of the breast tissue Answer: C Rationale: All women have Montgomery glands (Montgomery tubercles). They become more prominent during pregnancy and help to prepare the nipples for breastfeeding. The bumps are not specific to pregnancy and are not a sign of cancer. They are not the result of stretching.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 106 24. A client arrives to the clinic very excited and reporting a positive home pregnancy test. The nurse cautions that the home pregnancy test is considered a probable sign and will assess the client for which sign to confirm pregnancy?

A. Positive office pregnancy test B. Fetal movement felt by examiner

C. Hegar sign D. Chadwick sign Answer: B Rationale: The positive signs of pregnancy are fetal image on a sonogram, hearing a fetal heart rate, and examiner feeling fetal movement. A pregnancy test has 95% accuracy; however, it may come back as a false positive. Hegar sign is a softening of the uterine isthmus. Chadwick sign may have other causes besides pregnancy.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 104 25. A client in her first trimester is concerned about how weight gain will affect her appearance and questions the nurse concerning dietary restrictions. How much weight gain should the nurse point out will be safe for this client with a low BMI? A. 25 to 35 pounds (11 to 16 kilograms) B. 28 to 40 pounds (13 to 18 kilograms) C. 15 to 25 pounds (7 to 11 kilograms) D. 16 to 30 pounds (7.25 to 14 kilograms) Answer: B Rationale: The recommendation for average weight gain is 25 to 35 lbs (11 to 16 kilograms). The woman who is underweight with a low BMI should gain 28 to 40 pounds (13 to 18 kilograms). Less than 28 pounds (13 kilograms) may hinder fetal development, and weight gain over 40 pounds (18 kilograms) may be dangerous to the mother. Individuals with a high BMI should gain 15 to 25 pounds (7 to 11 kilograms). A weight gain of less than 16 pounds (7.25 kilograms) may result in a low-birth-weight infant and gains over 30 pounds (14 kilograms) may necessitate a cesarean section.

Question format: Multiple Choice Chapter 6: Maternal Adaptation during Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 113

Chapter 7 1. Charlene McCoy, who has several children already, reports for a first prenatal visit. She seems preoccupied and withdrawn, and she makes consistently negative remarks about the pregnancy. Reviewing her records, you note that she is receiving a serotonin reuptake inhibitor. What should you do?

A. Reassure her that ambivalence is normal.

B. Refer her for drug and alcohol counseling.

C. Give her printed material to read at home.

D. Alert the RN or health care provider.

Answer: D Rationale: A client on an SSRI or SRI (serotonin reuptake inhibitor) might be in current treatment for a psychiatric disorder. The medication may also be one that is not safe during pregnancy. The RN and the health care provider need to be alerted to seek more information from the client. Reassurance is good practice, but not enough in this case. You do not have enough information to refer her for drug and alcohol counseling. She is under the care of another provider for her mental disorder, so do not confuse her with more material to read.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 122 2. As part of the first prenatal visit, the nurse is assessing a pregnant woman's obstetrical history, which includes an 18-month-old daughter, born 2 days after her estimated date of birth; a 3-year-old son born at 35 weeks' gestation; and two lost pregnancies, one at 12 weeks and one at 21 weeks. How should the nurse document this history?

A. G5 T1 P2 A1 L2 B. G4 T1 P1 A2 L2 C. G5 T2 P2 A1 L1 D. G4 T1 P2 A2 L2 Answer: A Rationale: The G represents the total number of pregnancies, which is 5. The T represents term deliveries that ended at or beyond 38 weeks' gestation, which is 1.

The P refers to preterm deliveries (ended after 20 weeks and before end of 37 weeks), which is 2. The A refers to abortions or the number of pregnancies that ended before 20 weeks' gestation, which is 1. The L refers to living children, which is 2. Thus the nurse will document G5 T1 P2 A1 L2 for this client.

Question format: Multiple Choice

Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 122 3. A client who is uncertain when her LMP occurred is given an EDD of April 23 after the first ultrasound. Based on this information, the nurse determines the client's LMP was probably which day?

A. July 13 B. July 16 C. July 19 D. July 21 Answer: B Rationale: According to Naegele rule, the last menstrual period was July 16th. Take the LMP and add 7 days and subtract 3 months; if finding the LMP from the EDD, subtract 7 days and add 3 months.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 123 4. The nurse has just received the results of a pregnant client's MSAFP screening and notes the levels are elevated. The nurse should prioritize which discussion with the client?

A. risk for Down syndrome B. risk for neural tube defects C. test needs to be repeated D. further testing is required Answer: D Rationale: The maternal serum alpha-fetoprotein (MSAFP) measures the levels of alpha-fetoprotein, which is a protein manufactured by the fetus. The woman's blood contains small amounts of this protein during pregnancy. The blood test is run between 16 and 20 weeks' gestation; an abnormal level indicates a need for further testing to determine the risks her fetus may face. Higher levels can indicate multiple fetuses, death of the fetus, the presence of neural tube defects, and possibly Down syndrome; however, further testing such as ultrasound or amniocentesis is required to determine the exact cause of the elevation.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Nursing Process Reference: p. 127 5. A 38-year-old client and partner are carriers of the Tay-Sachs gene, have one child with Tay-Sachs, and are concerned to learn she is pregnant again. The nurse predicts the health care provider will order which test if the couple wants to know if this baby will also be born with Tay-Sachs?

A. a multiple marker screening test B. amniocentesis C. chorionic villus sampling D. percutaneous umbilical blood sampling Answer: C Rationale: Chorionic villus sampling (CVS) is a procedure that can provide information on fetal chromosomal studies similar to an amniocentesis, but earlier in pregnancy. The CVS is typically performed between 8 and 12 weeks gestation.

Multiple marker screen tests are done later in the pregnancy, as is amniocentesis.

Percutaneous umbilical blood sampling examines the blood and is not the best source for chromosomal studies.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 128 6. The nurse is assessing a 24-year-old pregnant client who reports excessive vaginal discharge that is messy and unpleasant but without a strong odor, itching, or irritation present. Which response should the nurse prioritize?

A. Douche frequently with mild soap and water.

B. See her primary care provider.

C. Use sanitary pads.

D. Decrease her fluid intake.

Answer: C Rationale: Vaginal discharge increases during pregnancy and is a concern for many women. Encourage the client to keep clean and wear sanitary pads as needed.

Douching may be dangerous for the mother. STIs are not indicated simply by discharge. Pregnant women should not decrease fluid intake.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 133

7. A client at 27 weeks' gestation still walks daily but reports "terrible" heartburn at night. Which action should the nurse point out will best address this situation?

A. Stop or severely curtail her exercise.

B. Take sodium bicarbonate.

C. Seek emergency medical care.

D. Elevate the head of the bed.

Answer: D Rationale: Heartburn is a common problem worsening as the pregnancy progresses.

The pregnancy hormones relax the lower esophageal sphincter, resulting in increased heartburn. Elevation of the head of the bed will help prevent the acid from refluxing. Exercise does not negatively impact heartburn and should be continued. The pregnant mother should not take any medication that is not prescribed by her primary care provider. Heartburn is not a medical emergency.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 131 8. The health care provider has prescribed an over-the-counter antacid for a pregnant client in her first trimester who is having ongoing nausea, vomiting, and heartburn. Which instruction concerning the antacid should the nurse prioritize after noting the client is also prescribed a multivitamin supplement?

A. Avoid caffeinated beverages.

B. Take only at bedtime.

C. Take antacid 1 hour after the multivitamin.

D. Take with dairy products.

Answer: C Rationale: Antacids interfere with the uptake of the vitamin contents so the client should take the antacid 1 hour after taking the multivitamin. Caffeine should be avoided due to increases in blood pressure and diuretic effects. Antacids can be taken more often than solely at bedtime, and some clients need them after each meal. Antacids do not have to be taken with dairy products. The priority is to avoid allowing the antacid to cancel out the multivitamin.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 131

9. The nurse advises a pregnant client to keep a small high-carbohydrate, low-fat snack at the bedside. The nurse should point out this will assist with which condition?

A. heartburn B. faintness C. slowed GI transit time D. nausea and vomiting Answer: D Rationale: Women will commonly experience nausea and vomiting upon awakening first thing in the morning. Clients who experience this should be encouraged to have small snacks at their bedside for eating prior to moving from the bed.

Heartburn is a result of pressure and hormone action. Faintness is due to pressure on the vena cava, not blood sugar. GI transit time is not affected.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 131 10. The nurse is teaching a pregnant client some nonpharmacologic ways to handle common situations encountered during pregnancy. The nurse determines the session is successful when the client correctly chooses which condition that can be minimized if she avoids drinking fluids with her meals?

A. nosebleeds B. heartburn C. blood clots D. constipation Answer: B Rationale: Filling the stomach with heavy food and fluid can cause overfill and place pressure on the stomach, increasing gastric reflux. Avoid excess fluids with meals and eat small frequent meals to avoid heartburn. Nosebleeds result from increased estrogen. Blood clots can result from sitting still for too long. Constipation can result from increased progesterone.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 131 11. The nurse is meeting with a client at 28 weeks' gestation. To prepare her for the final trimester, which factor should the nurse prioritize in the teaching session?

A. preventing anemia B. decreasing shortness of breath C. decreasing bleeding gums D. preventing varicosities Answer: B Rationale: As the fetus grows inside the mother, there is more pressure on the diaphragm, more difficulty breathing, and episodes of dyspnea may occur. This tends to decrease with "lightening," when the fetus drops. Preventing anemia, decreasing bleeding gums, and preventing varicosities are situations that should be addressed throughout the entire pregnancy.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 131 12. A pregnant client reports difficulty sleeping well. Which suggestion for sleeping should the nurse prioritize to assist this client?

A. on her stomach with a pillow under her breasts B. on her side with the weight of the uterus on the bed C. on her back with a pillow under her knees and hips D. on her back with a pillow under her head Answer: B Rationale: Resting on the side prevents pressure from the uterus against the vena cava and therefore allows blood to return to the uterus. Other positions may be more uncomfortable or may exacerbate the problems associated with pressure on the vena cava.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 131 13. A pregnant client is planning a vacation to a different state and questions the nurse concerning precautions. Which suggestion should the nurse prioritize for this client who will be traveling by automobile?

A. Travel no more than 120 miles daily.

B. Sit in the back seat with feet elevated.

C. Stop and walk every 2 hours.

D. Limit trips away from home, greater than 200 miles.

Answer: C

Rationale: Walking increases venous return and reduces the possibility of thrombophlebitis, a risk for pregnant women who sit for extended periods of time.

Limiting mileage, sitting in the back with the feet elevated, and limiting trips may help, but they are not enough to prevent phlebitis.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 137 14. The nurse is assessing a client at 30 weeks' gestation who reports increased constipation. Which suggestion should the nurse prioritize for this client?

A. taking mineral oil B. increasing fluid intake C. reducing iron supplement D. increasing intake of meat Answer: B Rationale: Increasing fluid content by drinking at least 8 glasses of noncaffeinated beverages helps relieve constipation in both pregnant and nonpregnant women.

Reducing an iron supplement could lead to anemia; mineral oil can reduce absorption of fat-soluble vitamins. The client should add foods rich in fiber, which would include grains, vegetables, and fruits (instead of meat).

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 132 15. The nurse is assessing a client at 12 weeks' gestation who reports enjoying her usual slow, long daily walk. The nurse should point out which recommendation to this client?

A. Reduce walking to half a block daily.

B. Continue this as long as she enjoys it.

C. Stop and rest every block.

D. Engage in aerobics for greater benefits.

Answer: B Rationale: Walking is an excellent exercise during pregnancy because it is low impact and increases venous circulation. Exercise should be maintained as long as it is comfortable, but intensity should not increase over what is normally performed.

Question format: Multiple Choice Chapter 7: Prenatal Care

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 135 16. The nurse is assessing a client at her first prenatal visit and notes that she is exposed to various chemicals at her place of employment. Which statement by the client would indicate she needs additional health education to protect her and her fetus?

A. "I only work four hours a day so I don't get exposed too much."

B. "The gloves they provide irritate my hands, so I don't use them."

C. "There hasn't been a chemical spill in three years."

D. "I have an assistant helping me now to handle the chemicals."

Answer: B Rationale: There are various chemicals which are recognized for their teratogenic effects and must be avoided during pregnancy. The nurse should find out which chemicals the client is exposed to and determine the risk factor. The greatest danger is the client handling chemicals without a barrier protection such as gloves.

The other issues may also be dangers depending on the chemicals and the environment in which the client is working and should also be evaluated.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 136 17. The nurse is assisting a pregnant client who underwent a nonstress test that was ruled reactive. Which factor will the nurse point out when questioned by the client about the results?

A. There is no evidence of congenital anomalies or deformities.

B. The fetal heart rate increases with activity and indicates fetal well-being.

C. The fetus is developing at a fast rate but doing fine.

D. The results indicate a stress test is needed for further evaluation.

Answer: B Rationale: A nonstress test is a noninvasive way to monitor fetal well-being. A reactive NST is a positive sign the fetus is tolerating pregnancy well by demonstrating heart rate increase with activity, and this indicates fetal well-being.

This test is not used to determine congenital anomalies or deformities. It does not determine the speed by which fetus is developing. Further evaluation would be necessary if the results were nonreactive.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Analyze

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 129 18. A 31-year-old client at 28 weeks' gestation reports frequent low back pain and ankle edema by the end of the day. Which suggestion should the nurse prioritize for this client?

A. Soak feet every night and perform pelvic rocks.

B. Lie on right side with feet elevated and a heating pad on the back.

C. Take breaks at work and sit in a semi-Fowler position with feet below.

D. Rest when possible with feet elevated at or above the heart.

Answer: D Rationale: Resting in the recumbent position helps alleviate stress on the back, and elevating the legs will help relieve the edema. Soaking the feet or lying on the right side will not alleviate the edema. Sitting semi-Fowler is not enough to alleviate the edema.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 131-132 19. A 25-year-old client at 27 weeks' gestation reports waking up with leg cramps.

Which suggestion should the nurse point out to the client to help relieve this discomfort?

A. Use plantar flexion exercises three times every day.

B. Dorsiflex the foot while extending her leg during the cramp.

C. Encourage her to drink more fluids, 10 glasses a day.

D. Avoid any supplementation of vitamins or minerals.

Answer: B Rationale: Plantar flexion can make cramps worse, so dorsiflexion while extending the leg can relieve the cramp; excess fluid and lack of supplementation with vitamins or minerals may worsen cramps. Performing plantar flexion exercise does not prevent the cramp. Increasing fluids may help, but has never proven to eliminate cramping.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 131-132

20. The nurse is preparing to administer a prescribed medication to the pregnant client. Which order should the nurse question?

A. penicillin B. rubella C. acetaminophen D. folic acid Answer: B Rationale: Most vaccines are contraindicated during pregnancy and are considered teratogenic, such as rubella. Penicillin and acetaminophen may be taken under provider supervision. Folic acid supplementation should be encouraged.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 123 21. The nurse is assessing a client at her first prenatal visit and reports her LMP started December 1. Which date will the nurse predict for the EDD? A. October 7 B. September 8 C. July 7 D. August 8 Answer: B Rationale: According to Naegele rule, the estimated date of birth is September 8.

Add 7 days and subtract 3 months to the LMP to determine the estimated date of birth.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 123 22. A young couple are very excited to discover they are pregnant and ask the nurse when to expect the baby. Based on a July 20 LMP, which day will the nurse predict for delivery?

A. April 27 B. March 13 C. April 13 D. May 20 Answer: A

Rationale: Naegele rule is to subtract 3 months and add 7 days from the first day of the last menstrual period to determine an expected due date, making the client's due date April 27.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 123 23. The nurse will be assisting a client during an amniocentesis. Which nursing intervention should the nurse prioritize?

A. Caution about the opioid premedication.

B. Be certain she is aware of potential complications.

C. Ensure she understands the need for 2 days of bed rest.

D. Expect test results within 1 week.

Answer: B Rationale: The client should be aware of the potential complications and risks, and should sign an informed consent. Opioids are contraindicated for pregnant woman due to side effects. She should maintain bed rest for the remainder of the day, with light housework the following day and a return to normal activities on the third day.

It may take 2 or 3 weeks before the test results come back from the laboratory.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 128 24. The nurse is assessing a client at her first prenatal visit and notes the fundal height is palpable at the level of the umbilicus. The nurse predicts the client is at which gestational age?

A. 18 weeks B. 20 weeks C. 24 weeks D. 22 weeks Answer: B Rationale: Some clients will not seek early prenatal care, especially if it is not their first pregnancy. The uterus expands to reach the height of the umbilicus by week 20. Before week 20 it is too low to be palpated, and after week 20 it may be beyond the umbilicus.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 121 25. A pregnant client arrives for her first prenatal appointment. She reports her previous pregnancy ended at 19 weeks, and she has 3-year-old twins born at 30 weeks' gestation. How will the nurse document this in her records?

A. G2 T2 P1 A0 L2 B. G2 T1 P1 A1 L1 C. G3 T0 P1 A1 L2 D. G3 T2 P2 A0 L1 Answer: C Rationale: G indicates the total number of pregnancies (2 prior, now pregnant = 3); T indicates term deliveries at or beyond 38 weeks' gestation (none = 0); P is for preterm deliveries (at 20 to 37 weeks = 1; multiple fetus delivery are scored as 1); A is for abortions or pregnancies ending before 20 weeks' gestation (1); and L refers to living children which is 2. Thus, G3 T0 P1 A1 L2 is what the nurse should note in the client's record.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 122 26. The nurse takes a call from a worried client who was seen several hours earlier for her 35-weeks' gestation visit, which included a pelvic examination. Which instruction should the nurse prioritize if the client is reporting a small amount of vaginal spotting?

A. Return right away.

B. Watch it and report if heavy increase in bleeding.

C. The bleeding, called Chadwick sign, is a normal part of pregnancy.

D. The cervical mucus plug may have been expelled.

Answer: B Rationale: During the third trimester, if the provider completes a vaginal exam it can be normal to have a small amount of spotting. If the bleeding becomes active or increases, the client needs to be seen immediately. Chadwick sign is a change of color in the vaginal area. The loss of the mucus plug would lead to a much greater amount of blood.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning

Reference: p. 125 27. The nurse discovers a new prescription for Rho(D) immune globulin for a client who is about to undergo a diagnostic procedure. The nurse will administer the Rho(D) immune globulin after which procedure?

A. contraction stress test B. amniocentesis C. nonstress test D. biophysical profile Answer: B Rationale: Amniocentesis is an invasive procedure whereby a needle is inserted into the amniotic sac to obtain a small amount of fluid. This places the pregnancy at risk for a woman with Rh(D)-negative blood, since the puncture can allow the seepage of blood and amniotic fluid into the woman's system. She should receive Rho(D) immune globulin after the procedure to protect her and future babies. The CST, NST, and a biophysical profile are noninvasive tests.

Question format: Multiple Choice Chapter 7: Prenatal Care Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 128

Chapter 8 1. A 28-year-old primigravida client presents to the unit in early labor. The record reveals the client is 5 ft (1.5 m) tall, 95 lb (43 kg), and has gained 25 lb (11.3 kg) over a normal, uneventful pregnancy. The nurse predicts this client will have which type of pelvis upon assessment?

A. gynecoid B. platypelloid C. android D. cannot be determined Answer: D Rationale: Pelvis shape cannot be determined by the information included in the statement. The gynecoid is the most common; however, there is no way to predict it. Early in the pregnancy, particularly if a woman has never given birth to a baby vaginally, the practitioner may take pelvic measurements to estimate the size of the true pelvis. This helps to determine if the size is adequate for vaginal birth.

However, these measurements do not consistently predict which women will have difficulty giving birth vaginally, so most practitioners allow the woman to labor and attempt a vaginal birth.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 151 2. The nursing instructor is teaching a session on the birth process. During which stage does the woman's cardiac output increase 80% above the pre-labor level?

A. first stage B. pushing C. immediately after birth D. transition stage Answer: C Rationale: Due to an increased demand for oxygen the cardiac output increases up to 80% immediately after birth. During the first stage of labor there is a moderate increase in the demand for oxygen. While pushing, cardiac output can increase by 40% to 50%. During transition, changes are more psychological than physiologic.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process

Reference: p. 161-162 3. The 29-year-old client presents at 5:30 a.m. with labor pains. Her history reveals G4, three previous vaginal births, and gynecoid pelvis. At 9 a.m. her assessment reveals 80% effaced and dilated at 3 cm. What nourishment can the nurse provide if the client mentions she hasn't eaten since 5 p.m. yesterday and is hungry?

A. solid food and fluids B. nothing except for intravenous fluids C. clear liquids but no solid food D. cannot assess with the information given Answer: C Rationale: The nurse should offer clear liquids but no solid foods. She is moving closer to active labor nearing the end of the latent phase. It would not be advisable to offer her solid foods, but she needs to continue her nourishment with fluids to her thirst. Solid foods may lead to nausea and vomiting. Intravenous fluids are too extreme as long as she is able to drink.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 161-162 4. The nurse is preparing to teach a group of soon-to-be new parents about the labor process. When detailing the differences between the various presentations, which one should the nurse point out seldom happens?

A. Breech B. Shoulder C. Oblique lie D. Transverse lie Answer: B Rationale: Shoulder presentations are the least likely to occur. They occur in less than 0.3% of all births. Approximately 97% of fetuses are in a cephalic presentation at the end of pregnancy. A longitudinal lie, in which the long axis of the fetus is parallel to the long axis of the mother, is the most common. When the fetus is in a transverse lie, the long axis of the fetus is perpendicular to the long axis of the woman. An oblique lie is in between the two.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 153

5. A 33-year-old client has been progressing slowly through an unusually long labor. The nurse assesses the fetal scalp pH and determines it is 7.26. How should the nurse explain this result to the client when asked what it means?

A. Reassuring; it is associated with normal acid-base balance.

B. Worrisome; it may be associated with metabolic acidosis.

C. Critical; it represents metabolic acidosis.

D. Damaging; it is frequently associated with fetal neurological damage.

Answer: A Rationale: The fetal pH slowly decreases during labor as a result of the normal stress of labor. Although 7.26 is low for an adult, it is not problematic during labor for an emerging fetus.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 162 6. A 24-year-old primigravida client at 39 weeks' gestation presents to the OB unit concerned she is in labor. Which assessment findings will lead the nurse to determine the client is in true labor?

A. The contraction pains are 2 minutes apart and 1 minute in duration.

B. The client reports back pain, and the cervix is effacing and dilating.

C. The contraction pains have been present for 5 hours, and the patterns are regular.

D. After walking for an hour, the contractions have not fully subsided.

Answer: B Rationale: True labor is indicated when the cervix is changing. Contractions occur for weeks before true labor, and may occur close together. Contractions may also occur for a long time before true labor begins.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 158 7. The nurse is monitoring a client who is in active labor. The nurse will carefully monitor which phase of the involuntary uterine contraction to ensure the fetus is progressing adequately?

A. Increment B. Acme C. Decrement D. Relaxation

Answer: D Rationale: The relaxation phase of uterine contractions is the time in which the fetus has a break. This time needs to be observed, and it is beneficial for the fetus to have a break. The three phases of a uterine contraction are the increment (building up in intensity), acme (peak intensity), and decrement (decreasing intensity). These phases are followed by a relaxation phase.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 162 8. A primigravida client at 39 weeks' gestation calls the OB unit questioning the nurse about being in labor. Which response should the nurse prioritize?

A. Tell the woman to stay home until her membranes rupture.

B. Emphasize that food and fluid should stop or be light.

C. Ask the woman to describe why she believes that she is in labor.

D. Arrange for the woman to come to the hospital for labor evaluation.

Answer: C Rationale: The nurse needs further information to assist in determining if the woman is in true or false labor. The nurse will need to ask the client questions to seek further assessment and triage information. Having the client wait until membranes rupture may be dangerous, as she may give birth before reaching the hospital. The client should continue fluid intake until it is determined whether or not she is in labor. The client may be in false labor, and more information should be obtained before she is brought to the hospital.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 157 9. A pregnant client arrives to the clinic for a prenatal visit appearing uncomfortable. During the assessment, the nurse determines the client is experiencing fairly strong contractions at 12:05 p.m., 12:10 p.m., 12:15 p.m., and 12:20 p.m. What can the nurse conclude from these findings?

A. The client is in active labor.

B. The duration of the contractions is every 5 minutes.

C. The frequency of the contractions is every 5 minutes.

D. The client can be sent home.

Answer: C

Rationale: Based on the information, the nurse knows the contractions are regular and every 5 minutes apart. This is the only data gathered based on the information given, but it is very useful to the provider. A change in the cervix is necessary for active labor. This client will need further assessment to determine whether the client can go home or should be prepared for active labor. There is no information providing the duration of the contractions.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 161 10. The nurse is teaching a prenatal class on the difference between true and false labor contractions. The nurse determines the session is successful when the class correctly chooses which factor as an indication of true labor contraction?

A. increase even if relaxing and taking a shower B. remain irregular with the same intensity C. subside when walking around and use the lateral position D. cause discomfort over the top of uterus Answer: A Rationale: True labor contractions do not stop; they continue and strengthen, as well as increase in frequency. If the contractions subside while taking a shower or relaxing, then they are not labor contractions. The discomfort over the top of the uterus is normal for full term pregnancy.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 158 11. The client in active labor overhears the nurse state the fetus is ROA. The nurse should explain this refers to which component when the client becomes concerned?

A. Fetal station B. Fetal attitude C. Fetal position D. Fetal size Answer: C Rationale: When documenting the ROA, this is the right occiput anterior or the relationship of the fetal position to the mother using the maternal pelvis as the point of reference. Fetal station refers to the relationship of the presenting part of the fetus to the ischial spines of the pelvis. Fetal attitude refers to the relationship

of the fetal parts to one another. Fetal size refers the actual size of the developing fetus.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 155 12. A primigravida client at 38 weeks' gestation calls the clinic and reports, "My baby is lower and it is more difficult to walk." Which response should the nurse prioritize?

A. "The baby has dropped into the pelvis; your body and baby are getting ready for labor in the next few weeks."

B. "This is not normal unless you are in active labor; come to the hospital and be checked."

C. "That is something we expect with a second or third baby, but because it is your first, you need to be checked."

D. "The baby moved down into the pelvis; this means you will be in labor within 24 hours, so wait for contractions then come to the hospital."

Answer: A Rationale: The baby can drop into the pelvis, an event termed lightening, and can happen for up to 2 weeks before the woman goes into labor. This is normal and does not require intervention.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 156-157 13. The new parents are spending time with their newborn. However, they are concerned with the edema and ecchymosis on the baby's scalp. How should the nurse explain this to the parents after noting the baby was ROA in labor?

A. The infant needs to be assessed by the health care provider.

B. Ecchymosis indicates a blood disorder and the infant will need testing.

C. Ecchymosis with edema on the scalp is where the infant was pushed out of the canal.

D. Edema is swelling and caused by unusual trauma; the provider must have used forceps.

Answer: C Rationale: Ecchymosis and edema are normal findings when located on the part that was presenting in labor. The infant was ROA, so the head was the presenting part and has normal bruising and swelling. The effects of birth are normal, and are

not of concern. Communicate to the parents that it is similar to a bruise or a blister.

This sign is not indicative of the use of forceps.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 162 14. The nurse determines a client is 7 cm dilated. What is the best response when asked by the client's partner how long will she be in labor?

A. "She is in active labor; she is progressing at this point and we will keep you posted."

B. "She is in the transition phase of labor, and it will be within 2 to 3 hours, though it might be sooner."

C. "She is still in early latent labor and has much too long to go to tell when she will give birth."

D. "She is doing well and is in the second stage; it could be anytime now."

Answer: A Rationale: At 7 cm dilated, she is considered in the active phase of labor. There is no science that can predict the length of labor. She is progressing in labor, and it is best not to give the family a specific time frame.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 161 15. When documenting the fetus is at "zero station", the nurse knows this is where in relation to the pelvic structure?

A. Pelvic inlet B. Pelvic outlet C. Ischial spines D. Pelvic crest Answer: C Rationale: Zero station is the engagement of the fetus at the level of the ischial spines of the pelvis. The ischial spines are a landmark that is used mark the passage of the fetus. The pelvic crest is a landmark location on the pelvis for documenting fetal station. The pelvic inlet must be shaped accordingly to allow for passage of the fetus. The pelvic outlet is associated with internal rotation of the fetal head.

Question format: Multiple Choice Chapter 8: The Labor Process

Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 154 16. A 37-year-old primigravida client at 40 weeks' gestation is seen in the clinic for a scheduled prenatal visit. What report by the client would lead the nurse to predict the woman is close to labor?

A. Nesting B. Dilation C. Effacement D. Ripening of the cervix Answer: A Rationale: Nesting is the activity or burst of energy women often experience prior to the onset of labor. The client could express feeling energetic or through a report of her activities at home. Dilation, effacement, and cervical ripening are all observed by the provider during assessment.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 156-157 17. The community health nurse is conducting a presentation on labor and delivery.

When illustrating the birth process, the nurse should point out "0 station" refers to which sign?

A. "This is just a way of determining your progress in labor."

B. "This indicates that you start labor within the next 24 hours."

C. "This means +1 and the baby is entering the true pelvis."

D. "The presenting part is at the true pelvis and is engaged."

Answer: D Rationale: 0 station is when the fetus is engaged in the pelvis, or has dropped. This is an encouraging sign for the client. This sign is indicative that labor may be beginning, but there is no set time frame regarding when it will start. Labor has not started yet, and the fetus has not begun to move out of the uterus.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 154

18. The nurse has been monitoring a multipara client for several hours. She cries out that her contractions are getting harder and that she cannot do this. The nurse notes the client is very irritable, nauseated, annoyed, and doesn't want to be left alone. Based on the assessment the nurse predicts the cervix to be dilated how many centimeters?

A. 0 to 2 B. 5 to 7 C. 3 to 4 D. 8 to 10 Answer: D Rationale: The reaction of the client is indicative of entering or being in the transition phase of labor, stage 1. The dilation (dilatation) would be 8 cm to 10 cm.

Before that, when dilation is 0 to 7 cm, the client has an easier time using positive coping skills.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 160 19. A group of nursing students are preparing a presentation that will illustrate various components of the birthing process. When discussing the pelvis, the students should point out that the pelvis is often referred to as which term?

A. passenger B. passageway C. powers D. psyche Answer: B Rationale: The passageway is one of the 4 Ps and involves the pelvis, both bony pelvis and the soft tissues, cervix, and vagina. The passenger refers to the fetus.

The primary powers are the involuntary contractions of the uterus, whereas the secondary powers come from the maternal abdominal muscles. The psyche refers to the mother's mental state.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 151 20. A nulliparous client at 37 weeks' gestation calls the labor and delivery unit stating she thinks she is in labor. The nurse predicts she is in true labor based on which answer to her assessment questions?

A. contractions, irregular, lasting 15 to 20 seconds B. bloody mucus in the toilet once earlier in the day C. contraction, regular and lasting longer and stronger D. scant amount of thick, white vaginal discharge, no odor Answer: C Rationale: True labor contraction will progressively get worse and last longer. The pain will come to a point where the woman will not be able to walk or talk through the contractions. Irregular contractions, bloody show, and white vaginal discharge are normal for pregnancy but do not indicate true labor.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 158 21. The nurse is assessing a pregnant client at 37 weeks' gestation and notes the fetus is at 0 station. When questioned by the client as to what has happened, the nurse should point out which event has occurred?

A. flexion B. engagement C. extension D. expulsion Answer: B Rationale: The movement of the fetus into the pelvis from the upper uterus is engagement. This is the first cardinal movement of the fetus in preparation for the spontaneous vaginal delivery. Flexion occurs as the fetus encounters resistance from the soft tissues and muscles of the pelvic floor. Extension is the state in which the fetal head is well flexed with the chin on the chest as the fetus travels through the birth canal. Expulsion occurs after emergence of the anterior and posterior shoulders.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 157-158 22. The nurse is monitoring a client who is in labor and notes the client is happy, cheerful, and "ready to see the baby." The nurse interprets this to mean the client is in which stage or phase of labor?

A. transition phase B. stage two C. latent phase

D. stage three Answer: C Rationale: The woman in labor undergoes numerous psychological adaptations during labor. During the latent phase, she is often talkative and happy, and yet anxious. During transition, the client may show fear and anger. During stage 2 she may remain positive, but the work of labor is very intense.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 158 23. The nurse is appraising the post-birth laboratory results of a client and discovers the WBC is 22,000 cells/μL (22 x 109/L). Which action should be prioritized in response?

A. none, a normal variation due to labor B. an abnormal finding, needs antibiotics C. occurs in clients after a cesarean birth D. further testing is required to determine source.

Answer: A Rationale: An elevation of WBC up to 30,000 cells/μL (30 x 109/L) can be a normal variation for any woman after birth. This is related to the stress on her body from labor and birth. Antibiotics are not indicated as this is a normal response to intense stress. The increase in WBC is not related to cesarean birth. Further testing would be wasteful as it is known that this is a normal response to any stress.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 162 24. The nurse cares for a pregnant client in labor and determines the fetus is in the right occiput anterior (ROA) position. Which action by the nurse is best?

A. Continue to monitor the progress of labor.

B. Auscultate fetal heart rate (FHR) in the left upper quadrant.

C. Prepare the client for cesarean birth of the fetus.

D. Educate the client this fetal position may result in a longer labor.

Answer: A Rationale: ROA (right occiput anterior) means the occiput of the fetal head points toward the mother's right anterior pelvis; the head is the presenting part. This is a

common and favorable position for vaginal birth. Based on the ROA location, the nurse will auscultate FHR at the right lower quadrant of the client's abdomen (FHR will be loudest where the fetus' back is located). Occiput posterior (not anterior) positions are associated with longer, more difficult births.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 153 25. The nurse is monitoring a client and notes: contractions causing urge to push, strong intensity, cervix 10 cm, 100% effaced, fetal head crowns when client pushes. The nurse determines the client is currently in which stage or phase of labor?

A. transition B. second C. third D. active Answer: B Rationale: The second stage of labor is between full dilation (dilatation) and birth of the infant. This woman has completed transition and is in the second stage of labor.

The third stage begins with the birth of the baby and ends with delivery of the placenta. The active phase begins at 4 cm cervical dilation and ends when the cervix is dilated 8 cm. During the transition phase, contractions reach their peak of intensity, occurring every 2 to 3 minutes with a duration of 60 to 70 seconds, and a maximum cervical dilatation of 8 to 10 cm occurs. Both the active and transistion phases ocur during the first stage of labor.

Question format: Multiple Choice Chapter 8: The Labor Process Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 161

Chapter 9 1. Erin, a 19-year-old first-time mother in the second stage of labor who has been given an epidural, reports severe, unrelenting abdominal pain and rates it as 10 on a scale of 0 to 10. What should the nurse do?

A. Proceed with standard care; the nurse knows that this is typical in the second stage of labor and that younger women and those who are first-time mothers are more likely to report severe pain.

B. Call the obstetrician; severe unrelenting abdominal pain could indicate placental abruption, uterine rupture, or other undiagnosed complication.

C. Call the anesthetist, who is responsible for managing the epidural and should be monitoring Erin's pain.

D. Discuss with Erin the additional pain medication options available to her at this stage in her labor so that she can choose which option she prefers.

Answer: B Rationale: After an epidural is in place, if the woman reports unrelenting pain, the provider must assess the situation for a complication. This is not a standard reaction; pain should come in waves, and should not be unrelenting. Wait for the obstetrician to page the anesthetist. Do not leave the decision up to the mother; rather, trust the experts.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 179 2. Which nursing intervention offered in labor would probably be the most effective in applying the gate control theory for relief of labor pain?

A. Encourage the woman to rest between contractions.

B. Change the woman's position.

C. Give the prescribed medication.

D. Massage the woman's back.

Answer: D Rationale: Gate-control is based on the idea of distraction or redirection of the conduction of impulses up the neural pathways. Massage redirects the paths of sensation away from the pain to the other area. Encouragement is a form of psychological support. Position change will only distract the client. Medication should be withheld until all nonpharmacologic treatments have been exhausted.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 171 3. The nurse instructs the client about skin massage and the gate control theory of pain. Which statement would be appropriate for the nurse to include for client understanding of the nonpharmacologic pain relief methods?

A. The gating mechanism is located at the pain site.

B. Pain perception is decreased if anxiety is present.

C. The gating mechanism opens so all the stimuli pass through to the brain.

D. These methods are a technique to prevent the painful stimuli from entering the brain.

Answer: D Rationale: Gate-control diverts the pain stimuli from the pain site by replacing with a comfort stimuli in a new location. Gate control does not need to be applied directly to the site of the pain. Anxiety heightens the painful feelings. Gating blocks the flow of painful stimuli to the sensory centers in the brain.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 171 4. A client and her husband have prepared for a natural birth; however, as the client progresses to 8 cm dilation, she can no longer endure the pain and begs the nurse for an epidural. What is the nurse's best response?

A. Suggest a less extreme alternative such as a sedative.

B. Support the client's decision and call the provider.

C. Gently remind the client of her goal of a natural birth and encourage and help her.

D. Ask the husband to gently remind her of their goal of natural birth and to encourage and help her.

Answer: B Rationale: Pain is subjective and its level is only what the client experiences. The nurse should support the desire of the client. Sedatives would be counterproductive as they may slow the labor process. It would be inappropriate to negate her feelings and remind her of earlier goals; that is the job of the support person and should be left up him or her to decide what to say and when to say it.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring

Reference: p. 169 5. A primigravida client in the second stage of labor has been moaning, screaming, and generally vocal throughout her labor. Her husband is distraught seeing his wife this way and asks the nurse for more pain medication for her. What is the nurse's best response?

A. Assist the client with breathing and imagery techniques in an attempt to calm her down.

B. Reassure the first-time father that his wife will be fine, and offer to stay with her while he takes a walk.

C. Page the obstetrician to evaluate the client's pain, and administer an appropriate increase in her pain medication.

D. Ask the client to describe the intensity of her pain on a scale of 0 to 10.

Answer: D Rationale: The nurse should first assess the client's pain by asking her to describe the pain on a scale of 0 to 10, as well as evaluate the client's actions. After the assessment, further actions can then be taken, whether that be calling the obstetrician or suggesting nonpharmacologic techniques to help the client calm down. The client should be the one to request the medication, not the spouse. The nurse should not encourage the mother's support person to leave; he or she is necessary for the psychological well-being of the mother.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 178 6. The nurse has just applied a sterile pressure dressing to an epidural site after removing the epidural catheter in a client who is now recovering from a standard delivery. Which action should the nurse now prioritize?

A. Assess return of sensory and motor functions to the lower extremities.

B. Help the client get up and walk around immediately.

C. Let the client rest and recover while keeping her legs slightly elevated.

D. Make sure the client receives plenty of fluids.

Answer: A Rationale: After removal of the epidural catheter and medication is terminated, the nurse needs to assess for return of motor function to ambulate the mother. The mother will not be able to walk for some time (at least until the medication wears off). Do not elevate the legs; the goal is to maintain normal circulation. Fluids are important, but they are not related to the epidural or to the metabolism of the medication.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth

Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 175 7. A client has presented in the early phase of labor, experiencing abdominal pain and signs of growing anxiety about the pain. Which pain management technique should the nurse prioritize at this stage?

A. Immersing the client in warm water in a pool or hot tub B. Practicing effleurage on the abdomen C. Administering a sedative such as secobarbital or pentobarbital D. Administering an opioid such as meperidine or fentanyl Answer: B Rationale: In early labor, the less medication use the better; allow use of nonpharmacologic management and control the pain with effleurage. Sitting in a warm pool of water is relaxing and may lessen the pain, but it does not control the pain. Sedatives are not indicated as they may slow the birthing process. Opioids should be limited as they too may slow the progression of labor.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 170 8. The nurse is assisting a client through labor, monitoring her closely now that she has received an epidural. Which finding should the nurse prioritize to the anesthesiologist?

A. Dry, cracked lips B. Urinary retention C. Rapid progress of labor D. Inability to push Answer: D Rationale: If the client is not able to push, her epidural dose may need to be adjusted to decrease the impact on the sensory system. Dry lips indicate that she may need fluids, so the nurse should give her some ice chips or a drink of water.

Urinary retention and rapidly progressing labor should be directly reported to the obstetrician, not the anesthesiologist.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 175

9. The nurse is monitoring a client who just received IV sedation. Which instruction should the nurse prioritize with the client and her partner?

A. Ambulate only with assistance from the nurse or caregiver.

B. Ambulate within 15 minutes to prevent spinal headache.

C. Sit on the edge of the bed with her feet dangling before ambulating.

D. Remain in bed for at least 30 minutes.

Answer: A Rationale: The client may have decreased sensory ability from the medication. She needs assistance to ambulate for safety. She will be largely unable to move, so she should remain in bed unless absolutely necessary.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 175 10. The nurse is monitoring a client who is in the second stage of labor, at +2 station, and anticipating birth within the hour. The client is now reporting the epidural has stopped working and is begging for something for pain. Which action should the nurse prioritize?

A. Call the anesthetist from the nurse's station to retry the epidural.

B. Call the primary care provider, and obtain a reduced dose of meperidine.

C. Give the meperidine because she needs pain relief now.

D. Encourage her through the contractions, explaining why she cannot receive any pain medication.

Answer: D Rationale: At this point, any medication would be contraindicated as it would pass to the fetus and may cause respiratory depression. The nurse will have to work with the mother through the contractions and pushing. The client has progressed too far to retry the epidural medication. No meperidine should be given due to the risk to the fetus.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 174 11. The nurse is admitting a primigravida client who has just presented to the unit in early labor. Which response should the nurse prioritize to assist the client in remaining calm and cooperative during birth?

A. "The baby is coming. Relax and everything will turn out fine."

B. "Do you want me to call in your family?"

C. "Even though the baby is coming, the health care provider will be here soon."

D. "The baby is coming. I'll explain what's happening and guide you."

Answer: D Rationale: Continuous labor support with a trained nurse or doula has been shown to be effective in increasing coping ability of laboring woman. To keep her calm, the nurse needs to explain all procedures and discuss all events to the mother. The nurse cannot know the final outcome and should be careful of making general statements indicating everything will be OK. It is the nurse's responsibility to calm the client down and not wait for the health care provider. While calling the family may help, there is no guarantee and the nurse needs to work to calm the client down.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 168 12. The client is progressing into the second stage of labor and coping well with the natural birth method. Which instructions should the nurse prioritize at this point in the process?

A. Use a birthing ball and find a position of comfort.

B. Stay low on her back to ease the back pain.

C. Use the Valsalva maneuver for effective pushing.

D. Ask for privacy, and have just the partner present.

Answer: A Rationale: The position is very important during labor. Allowing the woman to assume the most comfortable position will facilitate natural birth. The birthing ball allows the woman to move and adjust her position so that she can remain comfortable. The Valsalva maneuver may result in dangerous increases in blood pressure, so the nurse should be sure to instruct the mother to breathe as she pushes. The nurse should not intervene with who comes in or what family members are present unless she is asked, or unless the visitation is upsetting the mother.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 171 13. The nurse is preparing a birthing care plan for a pregnant client. Which factor should the nurse prioritize to achieve adequate pain relief during the birthing process?

A. The client has the baby without any analgesic or anesthetic.

B. The health care provider decides the best pain relief for the mother and family.

C. Client priorities and preferences are incorporated into the plan.

D. The nurse suggests alternative methods of pain relief.

Answer: C Rationale: The nurse and the client should work together with the nurse seeking information on the desires of the client and work to achieve the desired level of pain control for the labor and birth experience. The nurse can suggest various options for the client to choose from, but that is not the priority. The health care provider will also work with the client and prescribe medications as necessary and/or desired. The health care professionals should respect the client's wishes for pain control and not insist the client follow any specific format.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 169 14. The nurse is preparing a client for an epidural block. Which intervention is a priority before the epidural anesthesia is started?

A. Increase oral fluids B. IV fluid bolus C. Monitor temperature D. Monitor maternal apical pulse Answer: B Rationale: The client will need to have a bolus of IV fluids prior to the epidural to prevent hypotension. The hypotensive event is transitory, and increasing oral hydration is unnecessary and may lead to nausea later. Monitor the mother's body temperature as per routine. The nurse should monitor the radial pulse not the apical pulse.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 175-176 15. The client in labor at 3 cm dilation and 25% effaced is asking the nurse for analgesia. Which explanation should the nurse provide when explaining why it is too early to administer an analgesic?

A. This would cause fetal depression in utero.

B. This may prolong labor and increase complications.

C. The effects would wear off before delivery.

D. This can lead to maternal hypertension.

Answer: B Rationale: Administration of pharmacologic agents too early in labor can stall the labor and lengthen the entire labor. The client should be offered nonpharmacologic options at this point until she is in active labor. At this point in labor, the fetus would not be affected by analgesia. The effects would wear off and the drug would need to be re-administered, which would increase the risk to the fetus. There is no link between maternal hypertension and analgesia.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 175 16. The nursing instructor is teaching a group of nursing students about the uniqueness of pain involved with the birthing process. The instructor determines the session is successful when the students correctly choose which pain factor to be related to psychosocial influences?

A. Stretching of cervix B. Descent of fetus into birth canal C. Pressure in the perineum D. Fear of pain during labor Answer: D Rationale: Fear of pain during labor is a psychosocial factor. The stretching of the cervix, descent of the fetus into the birth canal, and pressure on the perineum are physical factors.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 168 17. The nursing instructor has finished leading a general discussion with a group of nursing students exploring the labor and birthing process. The instructor determines the session is successful when the students correctly state which goal should be a priority?

A. Provide any medication the client requests.

B. Dictate the pain management during labor for the best outcome.

C. Work with the labor client to plan pain management options.

D. Monitor the client for active labor, and assess for pain as needed.

Answer: C

Rationale: The role of the nurse is to work with the client and plan with the nurse the pain management technique desired by the client to meet the level of expectation for the client. Pain is subjective, and each woman has a right to her own labor plan. As the client progresses through the labor and delivery process, the nurse should constantly monitor and assess the client's pain and provide the necessary care accordingly.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 167 18. The client and her partner have prepared for a natural birth and bring a picture of a sunset over the ocean with them. The nurse predicts they will be using which technique during labor?

A. Patterned birthing B. Water therapy C. Attention focusing D. Hypnosis Answer: C Rationale: Attention focusing is the use of an object or picture or image for the woman to reflect and focus on (internally or externally) during labor to distract her from the labor pain. Hypnosis is a psychological state. Water therapy involves the woman sitting in water to relax. Patterned breathing involves the woman controlling her breathing patterns during contractions and "breathing through" them to help control the pain. The attention focusing, patterned breathing, water therapy, and hypnosis are all variations of relaxation which may be used by the client during the birthing process.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 170 19. The client is asking the nurse about the various options for pain relief and requests more information about the intradermal water injection her sister had.

When explaining the procedure, the nurse should point out these injections are given at which location?

A. upper back B. lower back C. lumbar area D. iliac crest

Answer: B Rationale: This method of pain relief is considered nonpharmacologic in nature; it does not use medication to relieve the pain. Sterile water is injected under the skin to activate the gate theory of pain control. Injections are placed in the lower back in the sacral area.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 172 20. A client in latent labor for the past 12 hours is requesting medication to help her rest. The nurse predicts the health care provider will prescribe which medication?

A. secobarbital B. meperidine C. fentanyl D. morphine Answer: A Rationale: In the latent phase of labor, sedatives can be prescribed to assist a client to rest. The use of analgesics, such as opioids (meperidine, fentanyl, and morphine) in early labor may stop labor and are not recommended.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 175 21. The multigravida client is moving into the transition phase and asks for an opioid, stating she does not remember the pain being this bad before. Which response from the nurse will be best?

A. "I will page the provider and ask for your pain medication."

B. "You are so close to birth; do you not want to have natural birth?"

C. Pain medication can affect the baby's breathing; let's try to focus and breathe."

D. "Rather than use an opioid, let's ask for a different type of pain medication."

Answer: C Rationale: Once the woman has entered into the transition phase of labor, she is considered to be imminent for birth. Any opioid medication might pass to the fetus and is not recommended due to the effects of respiratory compromise. The nurse will need to encourage nonpharmacologic methods at this point and should not consult the provider. The nurse should also remain supportive of the mother.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 174 22. A client at 41 weeks' gestation has been in labor for 18 hours and the fetus is now showing signs of distress. Due to prior back surgery, the client is to receive general anesthesia instead of an epidural. Which medication will the nurse prepare to give the client first?

A. Pain medication B. Nonsteroidal anti-inflammatory (NSAID) C. Antacid D. Sedative Answer: C Rationale: Prior to intubation for a general surgery, the client should receive a dose of antacid to decrease the risk of aspiration of acidic stomach contents. Pain medication, NSAIDS, and sedative medications should not be given prior to a general anesthetic.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 177-178 23. The nursing instructor is preparing a presentation which will explore the various sources of pain during the labor process. Which source should the instructor emphasize as the main source of pain during the first stage?

A. perineum B. cervix C. back D. birth canal Answer: B Rationale: The first stage of labor is when the cervix is dilating. The woman in labor will have pain from the stretching and dilation (dilatation) of the cervix. Stretching of the perineum and birth canal is associated with the second stage of labor. Not all women have back pain, and typically when they do it is referred pain from the lower abdomen and can happen in both the first and second stage of labor.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 168 24. The nurse is monitoring the client's vital signs and notes: 100.2oF (37.9oC), heart rate 82, respiratory rate 17, and blood pressure 124/78. The client has recently had an epidural. What is the best response when the client's partner asks if she is getting sick?

A. "We will continue to monitor the situation."

B. "The fever may be due to the epidural."

C. "Have you been exposed to any illnesses recently?"

D. "She's dehydrated and needs something to drink."

Answer: B Rationale: A common side effect of epidural anesthesia is elevated temperature during labor. The client needs frequent assessment and to be observed for any other signs or symptoms of an infection, but it is premature to state it is related to an infection. If the mother has been exposed to any illness, it would be in the history. Oral fluids would not be advisable as they may result in nausea later.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 175-176 25. A primigravida client has just arrived in early labor and is showing signs of extreme anxiety over the birthing process. Why should the nurse prioritize helping the client relax?

A. Anxiety will increase blood pressure, increasing risk with an epidural.

B. Decreased anxiety will increase trust in the nurse.

C. Anxiety can slow down labor and decrease oxygen to the fetus.

D. Increased anxiety will increase the risk for needing anesthesia.

Answer: C Rationale: Out-of-control anxiety can decrease the oxygen of the mother by increasing her respiratory rate and increasing the demand on her body, and can have a negative impact on the fetus by decreasing the amount of oxygen reaching the fetus. Encourage control of the anxiety. Anxiety will not negatively affect the action of the epidural or the need for anesthesia. Trust in the nurse is not determined by the amount of anxiety the client experiences.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 168

26. The nurse is preparing to assist with a pudendal block. The nurse predicts the client is at which point in the labor process?

A. early-stage labor B. before dilation (dilatation) only C. just before birth D. just after birth Answer: C Rationale: Pudendal block is a local block in the perineal area and is used to numb for birth. Giving a pudendal block before labor begins or while labor is in its early stages would be counterproductive, as the client would not have proper feeling and would have a harder time pushing. After birth it is pointless; the most painful part is over.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 175 27. The client is experiencing back labor and reporting intense pain in the lower back. The nurse should point out which intervention will be effective at this point?

A. effleurage of the abdomen during the contraction B. conscious relaxation/guided imagery in low Fowler position C. counterpressure against the sacrum D. pant-blow (breaths and puffs breathing techniques) Answer: C Rationale: Counterpressure against the sacrum is a way to provide support and comfort for a women having intense back labor. Effleurage is ineffective for true back labor, as it is conscious relaxation. Breathing will not diminish the pain of back labor.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 171 28. A woman dilated to 10 cm and feeling the urge to "have a bowel movement" is refusing to push and is screaming, "It hurts down there too much to push." What option should the nurse suggest at this point for pain management to facilitate pushing?

A. epidural anesthesia B. pudendal block

C. paracervical block D. parenteral medication Answer: B Rationale: The client is too far dilated to have any parenteral medication or an epidural block. The best option is a local block or a pudendal block that will numb the vaginal wall to block the pain sensation to the pudendal nerve. The paracervical block is only used in the first stage of labor, and this client is in the second stage.

Question format: Multiple Choice Chapter 9: Pain Management during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 175

Chapter 10 1. The student nurse is preparing to assess the fetal heart rate (FHR) and has determined that the fetal back is located toward the client's left side, the small parts toward the right side, and there is a vertex (occiput) presentation. The nurse should initially begin auscultation of the fetal heart rate in the mother's: A. right upper quadrant.

B. right lower quadrant.

C. left upper quadrant.

D. left lower quadrant.

Answer: D Rationale: The best position to auscultate fetal heart tones in on the fetus back. In this position, the best place for the FHR monitor is on the left lower quadrant.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 192 2. A primigravida client admitted with signs of labor is evaluated with external electronic fetal monitoring that shows baseline FHR of 136 to 150 and two instances of FHR at 165 for 15 to 20 seconds. Which response should the nurse prioritize?

A. Immediately report to the RN that the FHR shows tachycardia.

B. Immediately report to the RN that the FHR shows no variability.

C. Before reporting to the RN, determine the short term variability (STV).

D. Before reporting to the RN, determine the uterine contraction pattern.

Answer: D Rationale: The nurse needs to assess and determine if the changes are related to accelerations secondary to contractions. Assess the contraction pattern with the fetal heart rate and provide information to the RN. If the accelerations are not due to uterine contractions, notify the RN immediately. Until then, the nurse should do the assessment before reacting.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 194 3. The client presents in the early stage of labor with mild contractions 7 to 9 minutes apart and blood pressure 130/80 mm Hg. The client changes from happy,

excited, and confident to introverted and restless. Assessment reveals heart rate 100, blood pressure 137/85 mm Hg, and hyperventilation. EFM reveals no variability for almost 20 minutes, then evident variability with no late decelerations.

Which action should the nurse prioritize?

A. Notify the RN that client's blood pressure has increased.

B. Notify the RN about the lack of FHR variability.

C. Help the client regain control of her breathing technique.

D. Assist the client into a hands-and-knees position.

Answer: C Rationale: The primary focus is to regain her breathing to a normal rhythm; focus her on breathing and relaxation and relief from the hyperventilation. If there is no improvement, notify the RN. Putting the client in the hands-and-knees position should be avoided until later in labor.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 199 4. A client has been showing a gradual increase in FHR baseline with variables; however, after 5 hours of labor and several position changes by the client, the fetus no longer shows signs of hypoxia. The client's cervix is almost completely effaced and dilated to 8 cm. Which action should the nurse prioritize if it appears the fetus has stopped descending?

A. Alert the team that internal fetal monitoring may be needed.

B. Palpate the area just above the symphysis pubis.

C. Institute effleurage and apply pressure to the client's lower back during contractions.

D. Encourage the client to push.

Answer: B Rationale: Palpate just above the symphysis pubis to determine if the infant is engaged and to determine the presenting part of the infant; it is possible for infants to rotate and change position during labor. The nurse should assess the situation and act further if necessary, but until there is more information on the fetal position, the nurse should assume all is going well.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 199

5. The nursing instructor is teaching the students the basics of the labor and delivery process. The instructor determines the session is successful when the students correctly choose which action will best help to prevent infections in their clients?

A. Clean the woman's perineum with a Betadine scrub.

B. Strictly follow universal precautions.

C. Replace soiled drapes and linen as needed.

D. Thoroughly wash the hands before and after client contact.

Answer: D Rationale: The most important infection control technique in any health care setting is thoroughly washing hands on a routine basis. Keeping the area clean is secondary but also important.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 201 6. The nurse is discussing the various positions for birth with a client and her partner. The client mentions she would like a position that speeds up the process, decreases stress to her baby, and reduces the possibility of needing an episiotomy.

Which position should the nurse point out will best meet the client's desires?

A. lithotomy B. modified dorsal recumbent C. side-lying D. hands and knees Answer: D Rationale: The hands and knees position is documented to be one of the best delivery positions for easing delivery and improving outcomes. Lithotomy (feet in stirrups), modified dorsal recumbent (feet on foot pedals), and side-lying are all potential positions, but not statistically the best. They also do not meet all the goals of the client.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 204 7. The nurse is admitting a client in early labor and notes: FHR 120 bpm, blood pressure 126/84 mm Hg, temperature 98.8°F (37.1°C), contractions every 4 to 5 minutes lasting 30 seconds, and greenish-color fluid in the vaginal vault. Which finding should the nurse prioritize?

A. Fetal heart rate B. Possible maternal infection C. Green-colored fluid in the vagina D. Irregular contractions Answer: C Rationale: Green-tinted fluid with ROM is indicative of meconium in the amniotic sac, or the infant having a bowel movement in utero. Infection would be shown by pus or cloudy fluid and possibly an elevated temperature. The FHR is within normal range. Irregular contractions are expected at this stage of labor.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 199 8. The nurse is monitoring a client who has given birth and is now bonding with her infant. Which finding should the nurse prioritize and report immediately for intervention?

A. The mother is unable to void after 4 hours.

B. Maternal tachycardia and falling blood pressure C. Placental separation 15 minutes after birth D. Dark red lochia Answer: B Rationale: Maternal tachycardia and falling blood pressure may indicate fluid volume deficit or hemorrhage and require immediate assistance. The client needs further assessment and intervention. The final stages of labor may include uterine contractions, the delivery of the placenta, and the discharge of lochia as the uterus heals. These are normal and not an emergency.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 209 9. The nurse discovers that the FHM is now recording late decelerations in a client who is in labor. The nurse predicts this is most likely related to which event?

A. Cord compression B. Maternal hypotension C. Maternal fatigue D. Uteroplacental insufficiency Answer: D

Rationale: Late decelerations are associated with uteroplacental insufficiency. They typically indicate decreased blood flow to the uterus during the contractions.

Maternal hypotension and fatigue would not be observed on the fetal heart monitor.

Cord compression would be marked by fetal tachycardia.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 193-194 10. A client in the latent phase of the first stage of labor is noted to be uncomfortable with intact membranes and mild contractions on assessment. The nurse should encourage the client to pursue which action?

A. Complete bed rest B. Ambulation ad lib C. Bathroom privileges D. Up in chair TID Answer: B Rationale: To facilitate the first stage of labor, ambulation and movement will allow better fetal descent and help to speed the labor process. Bed rest will slow or stop the labor process. The client may use the bathroom as needed, but this does not affect labor rate. The client should remain mobile.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 198 11. The nurse is monitoring a client in the first stage of labor. The nurse determines the client's uterine contractions are effective and progressing well based on which finding?

A. Engagement of fetus B. Dilation (dilatation) of cervix C. Rupture of amniotic membranes D. Bloody show Answer: B Rationale: The best determination of effective contractions is dilation (dilatation) of the cervix. Engagement, membrane rupture, and bloody show may all occur before the cervix has dilated.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 196-197 12. The nurse is admitting an obstetric client in early labor. As the nurse assists the client into the bed, which assessment should the nurse prioritize?

A. Past obstetrical history B. Fetal status C. Signs that birth is imminent D. Client's temperature Answer: C Rationale: The priority is to establish the imminence of the birth, then the fetal status. The obstetrical history can wait until after the birth of the baby, if necessary. The maternal blood pressure is a higher priority over the temperature to rule out possible preeclampsia.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 185 13. A gravida 1 client is admitted in the active phase of stage 1 labor with the fetus in the LOA position. The nurse anticipates noting which finding when the membranes rupture?

A. Bloody fluid B. Clear to straw-colored fluid C. Greenish fluid D. Cloudy white fluid Answer: B Rationale: The infant is in the correct position, and the client has been in labor.

Expectation would be for normal amniotic fluid presentation of clear to strawcolored fluid. If there is blood, then the uterus is bleeding and there is an extreme emergency. If the fluid is greenish, there is meconium in the fluid. Cloudy, white fluid may indicate an infection is present.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 187

14. The nurse is caring for a client who has been in labor for the past 8 hours. The nurse determines that the client has transitioned into the second stage of labor based on which sign?

A. Emotions are calm and happy.

B. Frequency of contractions are 5 to 6 minutes.

C. Fetus is at -1 station.

D. The urge to push occurs.

Answer: D Rationale: Second stage of labor is the pushing stage; this is typically identified by the woman's urge to push or a feeling of needing to have a bowel movement. In the second stage the cervix can be 10 cm, dilated 100% and effaced. The station is usually 0 to +2. The emotional state may be altered due to pain and pressure.

Contraction frequency is variable and not clearly indicative of a particular stage.

The fetus can be at stage -1 for any length of time.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 202-203 15. The nursing instructor is teaching a group of nursing students about the various responsibilities of the labor and delivery medical team. The instructor determines the session is successful when the students correctly choose which function as the primary role of the LPN/LVN members of the team?

A. Provide direct independent care to the client.

B. Assist the providers in the delivery room.

C. Provide care under the supervision of an RN. D. Observatory to assist the RN. Answer: C Rationale: The LPN may provide care within the appropriate scope of practice under the direct supervision of an RN. The RN is responsible for providing direct independent care of the client. Both LPN/LVNs and RNs assist health care providers in the delivery room. The LPN/LVNs provide more than just observatory functions for the RN. Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 184-185 16. A multigravida woman arrives in the emergency department panting and screaming, "The baby's coming!" Which action should the nurse prioritize?

A. Assess maternal and fetal vital signs.

B. Ask medical and obstetrical history.

C. Escort to Labor and Delivery.

D. Quickly evaluate the perineum.

Answer: D Rationale: The woman is showing signs of advanced labor, possibly in transition or stage 2. She needs to be managed as an imminent birth and a vaginal assessment performed, as there may not be time to get to Labor and Delivery. Vital signs would be assessed next. Medical/obstetrical history and her room assignment can be taken care of later in the process.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 203 17. The nurse is admitting a client who is in early labor. After determining that the birth is not imminent, which assessment should the nurse perform next?

A. Risk factors B. Maternal status C. Fetal status D. Maternal obstetrical history Answer: C Rationale: The woman may present to the birthing suite at any phase of the first stage of labor. Therefore, it is important to assess birth imminence, fetal status, risk factors, and maternal status immediately. If birth is not imminent and the fetal and maternal conditions are stable, perform additional data collection, including the full admission health history, a complete maternal physical assessment, the status of labor and any labor, birth, and cultural preferences the woman may have.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 185 18. A multigravida client at 39 weeks' gestation has been in labor for 8 hours without much change. The last vaginal exam revealed cervix 8 cm dilated and 0 station. Which is the best response if the client asks the nurse how far the fetus has advanced in the past half hour?

A. "I can arrange for a cervix check, if you want."

B. "The health care provider will have to check you. I'll call him."

C. "Once your labor signs change, we can find out."

D. "Checking your cervix will not speed up labor; let's wait."

Answer: C Rationale: The cervix must be assessed with a vaginal exam. The frequency of vaginal exams is based on the signs of changes in labor. The client has not demonstrated any changes in her labor pattern; the nurse should provide education on the reason for not checking her. Frequent exams can interfere with the labor process as well as increase the risk of infection.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 199 19. The nurse is analyzing the readout on the EFM and determines the FHR pattern is normal based on which recording?

A. Acceleration of at least 15 bpm for 15 seconds B. Increase in variability by 27 bpm C. Deceleration followed by acceleration of 15 bpm D. Decrease in variability for 15 seconds Answer: A Rationale: A normal active fetal heart rate is a change in baseline by increase of 15 bpm for 15 seconds. This is a positive and normal periodic change in fetal heart rates as a response to fetal movement. Normal variability is noted to occur within 6 to 25 bpm from the baseline FHR. There should be no decelerations.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 193 20. The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize?

A. Administer oxygen.

B. Increase her IV fluids.

C. Change the position of the client.

D. Notify the primary care provider.

Answer: C Rationale: Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If

this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 194 21. The nurse is assessing a new client who presents in early labor. The nurse determines the fetus has an acceptable heart rate if found within which range?

A. 90 to 140 bpm B. 100 to 150 bpm C. 110 to 160 bpm D. 120 to 170 bpm Answer: C Rationale: The standard acceptable fetal heart rate baseline is the range of 110 to 160 beats per minute. Sustained heart rates above or below the norm are cause for concern.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Reference: p. 193 22. The nursing instructor is preparing a class discussing the role of the nurse during the labor and birthing process. Which intervention should the instructor point out has the greatest effect on relieving anxiety for the client?

A. Massage therapy B. Continuous labor support C. Pharmacologic pain management D. Prenatal classes Answer: B Rationale: Continuous labor support by a caring nurse or doula can help decrease a woman's anxiety during labor. Anxiety causes the release of catecholamines, which slow down the labor process. The continuous support helps keep the woman focused on what is important as well as provide necessary guidance and education as needed. The massage therapy, prenatal classes, and pharmacologic pain management are all tools that the nurse can use to help the woman.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 198 23. A client has moved into the active phase of labor and is now at 6 cm dilated and +1 station. The nurse is prepared to monitor the contraction pattern how often?

A. Every 10 minutes B. Every 15 minutes C. Every 30 minutes D. Every hour Answer: C Rationale: Active labor is a phase in the first stage of labor when the cervix dilates from 4 to 8 cm. The contractions are progressing and occur every 2 to 5 minutes and last 45 to 60 seconds. The nurse needs to evaluate the labor pattern every 30 minutes. During the latent phase of the first stage, the labor pattern should be evaluated every hour. During the transition phase of the first stage, the contraction pattern should also be evaluated every 30 minutes. During the second stage of labor, the contraction pattern should be evaluated every 15 minutes.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 192 24. The nurse is assessing a client in active labor and notes a small, rounded mass above the symphysis pubis that is distended but nontender. Which action should the nurse prioritize?

A. Check the chart for the last void.

B. Notify the health care provider about the mass.

C. Ask the client if the mass has always been present.

D. Assume this is part of the uterus.

Answer: A Rationale: The most probable explanation of the mass is a full bladder. The nurse should determine the last void by the client and offer to assist the client to void or prepare to catheterize the client to empty the bladder. This can be handled by the nurse. The client would not likely know if the mass was always present or not, given its location. If it were the uterus, it would be tender to the touch.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 199

25. The nurse is admitting a client who appears to be in advanced labor with imminent birth. Which action should the nurse prioritize?

A. Obtain a comprehensive obstetric history.

B. Determine plans for labor and the newborn.

C. Take blood pressure and determine if clonus or edema are present.

D. Assess use of drugs, alcohol, and tobacco during pregnancy.

Answer: C Rationale: In advanced labor, the most important assessments must be completed first. The assessment for signs or symptoms of preeclampsia must be assessed first, which would include the assessment of her blood pressure and presence of clonus or edema. The history can be obtained after the birth of the baby or if labor slows down. Plans for the newborn can be figured out later. Blood tests can be run as soon as a sample can be taken from the mother.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 187 26. A woman required an episiotomy and it was repaired by the birth attendant.

Which instruction will the nurse give to the woman?

A. "The stitches used will absorb on their own."

B. "Try applying some warm compresses to the area for pain relief."

C. "You will need an injection of a local anesthetic periodically until it heals."

D. "You will have to keep a sterile dressing on the area for 48 hours."

Answer: A Rationale: The nurse should reassure the woman that the sutures are absorbable and do not need to be removed. The birth attendant uses local anesthesia to numb the perineum for repair, but it is not used periodically after the repair. If the woman had epidural anesthesia, she may not need additional anesthesia for repair. A sterile ice pack, not a warm compress, applied to the perineum after repair can help decrease swelling and pain. There is no need for a sterile dressing.

Question format: Multiple Choice Chapter 10: Nursing Care during Labor and Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 220

Chapter 11 1. A woman who has already had one successful vaginal birth after prior cesarean (VBAC) has elected to deliver her third child vaginally. She reports a sudden sensation of "something snapping inside," followed by chest pain. What should the nurse do?

A. Remind her that this stage of labor always seems longer than it really is.

B. Assist her into the squatting or hands-and-knees position.

C. Monitor the EFM tracing for non-reassuring patterns.

D. Prepare to assist the RN as scrub nurse.

Answer: D Rationale: With VBAC there is a chance of rupture of the uterus. The report by the client is indicative of a ruptured uterus, which is an obstetrical emergency and would require immediate surgery. Reminding the woman that this stage of labor always seems longer than it really is, or assisting her into the squatting or handsand-knees position, or monitoring the EFM tracing for nonreassuring patterns could lead to the death of both mother and fetus.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 231 2. A woman arrives at labor and delivery unit with contractions every 2–3 minutes lasting 30–45 seconds. After several hours of labor have passed and not making progress, the health care provider prepares to perform an amniotomy. The woman asks the nurse, "How will this help my labor?" Which response by the nurse would be appropriate?

A. "This procedure helps to push your baby through the birth canal."

B. "With this procedure, your body sends out hormones that make labor more effective."

C. "By doing this, the passageway for your baby isn't blocked anymore."

D. "The fluid that comes out helps flushes away any debris in the birth canal."

Answer: B Rationale: With an amniotomy, the health care provider guides the instrument through the cervix and uses the hook to create a hole in the membranes. At this point, amniotic fluid is usually expelled. This process causes the body to release prostaglandins, which enhances labor. An amniotomy does not open up the passageway, push the baby through the birth canal, or flush away debris.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 219-220 3. A client at 42 weeks' gestation presents for induction of labor. Which assessment should the nurse prioritize as the best indicator for the induction to proceed?

A. Bishop score of 7 B. L/S ratio of 1.5 C. cervical presence of fetal fibronectin D. cervical length of 28 millimeters Answer: A Rationale: Currently, the Bishop score of greater than 7 remains a reliable predictor of cervical readiness that is both cost- and time-effective. Measuring the cervical length by endovaginal ultrasound is another method that has been studied for predicting labor readiness; however, at this time it has not shown to be a reliable indicator of the cervix being ready for induction. At one time, it was considered to be an indicator if the cervix was 27 millimeters or less. Evaluating the fetal fibronectin is another test that has been conducted to determine cervical readiness.

The presence of this protein in the cervical secretions was considered a positive sign; however, drawbacks include cost of the test and time to run the test. More studies are needed to evaluate the predictive ability of the test. The L/S (lecithin/sphingomyelin) ratio is a test conducted via amniocentesis to assess lung maturity of the fetus.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 218 4. The nurse is preparing a client for treatment to ripen her cervix in anticipation of labor. When comparing the various options for the client, which one will the nurse point out possibly provides an oral option?

A. misoprostol B. prostaglandin E2 gel C. dinoprostone D. prostaglandin E2 vaginal inserts Answer: A Rationale: The synthetic prostaglandin E1 misoprostol is used off-label as a cervical ripening agent that has been successfully documented and approved by the FDA. It is administered either orally or vaginally. When given via the oral route, misoprostol causes less uterine hyperstimulation than via the vaginal route. Dinoprostone is prostaglandin E2, which can be found in a gel or vaginal inserts. The health care

provider applies the gel to the cervix during the pelvic examination; this will work to ripen the cervix. The vaginal insert is a time-release product that is inserted into the vagina and will also gradually ripen the cervix. An advantage to the vaginal insert is the ability to remove the insert should adverse reactions to the prostaglandin occur.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 219 5. The nurse is monitoring a client at 41 weeks' gestation receiving IV oxytocin.

Which action should the nurse prioritize if noticeable contractions are occurring every 2 minutes, lasting 60 to 90 seconds on the fetal monitor?

A. Administer oxygen 10L via face mask.

B. Change the client's position.

C. Stop the IV oxytocin infusion.

D. Notify the health care provider.

Answer: C Rationale: The first action is to stop the IV infusion. This contraction pattern is noted to be hyperstimulation of the uterus, and the uterine stimulant should be stopped first. Administering oxygen assists in the prevention of hypoxia to both the mother and the fetus, but it does not take priority over stopping the uterine stimulant. Changing the client's position will have no effect on the hyperstimulation of the uterus as long as the stimulant is still being infused. The nurse would notify the health care provider after stopping the stimulant.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 219-220 6. The nursing instructor is teaching a group of student nurses about the current use of episiotomies during the labor process. The instructor determines the session is successful when the students correctly choose which situation that may require the health care provider to perform an episiotomy?

A. persistent occiput anterior position B. VBAC delivery C. shoulder dystocia D. multifetal births Answer: C

Rationale: An episiotomy is appropriate in certain situations. These include shoulder dystocia (baby's shoulders are stuck in the birth canal after the head is born); the head will not rotate from an occiput posterior position (persistent occiput posterior, not anterior); the fetus is in the breech presentation; or instruments (forceps or vacuum) are being used to shorten the second stage of labor. A VBAC delivery would not necessarily require an episiotomy unless one of the above situations was present. A multifetus birth is also not an automatic indication unless one of the above situations is present.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 220 7. The LPN/LVN is caring for a client who is scheduled for a cesarean birth. The nurse points out to the client that during which stage of the process a different nurse will be the primary caregiver?

A. preoperative B. intraoperative C. immediate postoperative D. late postoperative Answer: C Rationale: In the immediate postoperative phase, the PACU RN will be the primary manager of her care. The LPN/LVN may be involved in some of the preoperative care to prepare the woman for surgery, and may also be a part of the intraoperative care by functioning in the role of scrub nurse. The LPN/LVN may assume care of the woman during the postoperative phase, after she has sufficiently recovered from anesthesia.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 226 8. The pregnant client and her partner have arrived for a scheduled cesarean birth.

Which action should the nurse prioritize?

A. Obtain laboratory specimens.

B. Give prescribed oral antacid.

C. Prep abdomen for surgery.

D. Teach turn, cough, and deep breathing.

Answer: A

Rationale: The client must have blood work drawn before any procedures can be completed. Once the blood work has been completed, the health care provider will admit the client and provide orders to the RN. The client may be given IV antacid prior to surgery if receiving general anesthesia. Shaving the abdomen and learning how to turn, cough, and deep breathe after surgery is included in preoperative teaching, which will occur after the client is admitted.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 229 9. The health care provider has ordered a cesarean birth for an exhausted client who has been in labor for many hours with the fetus now showing increasing signs of distress. As the client and partner express disappointment in not having a natural birth (and anxiety in not knowing what will now happen), which response will the nurse prioritize?

A. Compare the risks of cesarean birth with those of continuing to attempt vaginal birth.

B. Calmly and confidently describe the qualifications of the surgical team.

C. Tell them firmly that the client must be prepped for surgery and place an IV and catheter.

D. Briefly describe what will be experienced, explain each procedure, and encourage the partner to participate.

Answer: D Rationale: The client and her partner were not prepared for the possibility of an operative delivery. The nurse should explain as much as possible and provide support to them. This is not the time to compare the risks to the mother and the fetus of continuing to attempt a vaginal birth as compared to a cesarean birth. This is not the time to talk about the qualifications of the surgical team. A client always has the right to refuse a procedure. If the nurse places an IV and/or a catheter without the client's consent, he or she could be arrested for assaulting the client.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 230 10. The nurse is preparing a client for an emergent cesarean delivery. Which action should the nurse prioritize?

A. Sign informed consent.

B. Prep her abdomen.

C. Ensure that a urinary catheter is in place.

D. Record EFM tracing.

Answer: A Rationale: Before the client can be transported and the cesarean can begin, the client must sign a consent form. The client should have an EFM from labor, and the urinary catheter is usually placed once the spinal is completed. The abdomen is clipped or shaved once the consent has been signed.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 229-230 11. For the past 18 hours, the client has been progressing slowly in labor in spite of various attempts to encourage the labor. The health care provider decides a cesarean birth is necessary to ensure the well-being of both the mother and fetus.

The nurse should point out to the client that this is due to which situation?

A. dystocia B. time factor C. prevent uterine rupture D. development of infection Answer: A Rationale: Dystocia is a general term used to describe difficult or abnormal labor.

Dystocia can lead to uterine rupture or the development of an infection of the uterine membranes. The time factor is one of the criteria for the physician to determine that the client is having dystocia.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 218 12. The nursing instructor has completed a session on the induction of labor and how it is occurring more frequently. The instructor determines the session is successful when the students correctly choose which factor to be contributing to the increased induction rates?

A. increase in clients with advanced maternal age B. elective inductions by choice of both physician and client C. number of pregnancies at risk for complications D. increase in high number of multiple gestation pregnancies Answer: B

Rationale: The number of elective inductions is on the rise and current research indicates the reason is due to physician and client preference. An elective induction is one in which the physician and woman decide to induce labor in the absence of a medical reason to do so. Neither the increase in advanced maternal age, the number of pregnancies at risk for complications, nor the increase in the number of multiple gestation pregnancies has impacted the increasing number of elective inductions.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 218 13. The nurse is assessing a new client who is being admitted for induction of labor.

The client is very upset and keeps mentioning that she has an infection. The nurse interprets this to indicate the client most likely has which condition?

A. chorioamnionitis B. endometritis C. peritonitis D. mastitis Answer: A Rationale: Chorioamnionitis is an infection of the fetal membranes and places both the fetus and mother at risk for morbidity or mortality if the pregnancy continues; it is one indication for induction of labor. Endometritis is an inflammation of the lining of the uterus. Cesarean birth, prolonged rupture of membranes, and long labor with multiple vaginal examinations are important risk factors. Peritonitis is inflammation of the peritoneum (the serous membrane which lines part of the abdominal cavity and some of the viscera it contains). Mastitis is an inflammation of the breast.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 218 14. A client with limited prenatal care presents in labor and is requesting a VBAC. What is the nurse's response after verifying the client had a classical incision with the last cesarean birth?

A. "There is no reason to stop you at this point; we will admit you to the unit."

B. "Based on your history, a vaginal delivery is not recommended, it might cause your uterus to rupture."

C. "We can do a trial of monitored labor, but may have to do a cesarean anyway."

D. "This will be up to your health care provider."

Answer: B

Rationale: The risk for uterine rupture during VBAC is much higher when the woman has a classical uterine incision from previous cesarean births. VBAC is contraindicated when this type of scar is present. She should not be allowed to labor. A client who is in labor will be admitted whether she is having a cesarean birth or is planning a vaginal birth. However, in the scenario described, the client should not be encouraged to attempt a vaginal birth. A trial of labor is not indicated.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 218 15. The health care provider has determined a client should be admitted for induction of labor and begins the process with cervical ripening overnight. Which teaching should the nurse prioritize for the client and her partner when describing this procedure?

A. "The doctor thinks your cervix is not ready for labor and we need to do some procedures to prepare it for labor."

B. "The cervix needs to be soft and thinning to be induced for labor; this helps soften the cervix."

C. "Cervical ripening will cause your membranes to rupture and start the labor process."

D. "Cervical ripening is using medications to start labor until the cervix dilates."

Answer: B Rationale: The cervix is in need of ripening, or softening for labor, if the provider feels the woman may need an induction and her cervix is not favorable. The idea of cervical ripening is to use pharmacologic or nonpharmacologic methods to prepare the cervix for labor. It will not cause the membranes to rupture, nor will it start the labor process. The LPN will not be doing any procedures; they will be performed by the health care provider. The LPN will monitor the client overnight.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 219 16. The nurse is preparing the client so that the health care provider can ripen the client's cervix for induction of labor. The nurse predicts the health care provider will probably use which most commonly used mechanical method?

A. membrane stripping B. insertion of laminaria C. PROM

D. Foley bulb with extra-amniotic infusion Answer: A Rationale: The most common method of mechanical induction of labor is the use of membrane stripping. In this instance, the provider will insert a finger between the sac of waters and the edge of the cervix and sweep 360 degrees to separate the membranes for the lower uterine segment. The theory is that this procedure irritates and stimulates the uterus to contract and enter labor. Laminaria, or cervical dilators, are sometimes used to soften and dilate the cervix. Laminaria are made from the root of seaweed. A Foley bulb with an extra-amniotic infusion is not a mechanical method of inducing labor. The premature rupture of membranes (PROM) may be used to help induce labor but not cervical ripening.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 219 17. The client has been progressing well through the labor process and the health care provider prepares to deliver the infant and performs an episiotomy. The nurse predicts which situation is the reason for this procedure?

A. prior episiotomy with last child B. shoulder dystocia C. client request so she does not tear D. previous perineal laceration with her last child Answer: B Rationale: There is no reason to perform an episiotomy because of having had a prior one, nor because of a prior laceration with a child. Each delivery is different and the same may not be needed with this birth. The provider should not perform one on client request. The common indication is a "stuck" baby, one with shoulder dystocia or difficulty exiting due to a tight vaginal and perineal area.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 220-221 18. The nursing instructor is leading a group discussion on the various types of birth. The instructor determines the session is successful when the students correctly categorize forceps or vacuum-assisted birth as what type?

A. spontaneous vaginal birth B. failed vaginal birth C. surgical birth

D. operative vaginal birth Answer: D Rationale: The use of instruments during birth to remove the fetus is invasive and with multiple risks. This type of birth is termed an operative vaginal birth (a baby was born vaginally with assistance). A spontaneous vaginal birth is one in which the baby is born without the assistance of the health care provider. A failed vaginal birth is one in which cesarean birth becomes necessary. A surgical birth is a cesarean birth.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 222 19. The nurse is conducting a prenatal class for a group of pregnant women and their partners. When illustrating the various potential complications that can necessitate a cesarean birth, which primary reason should the nurse point out?

A. placenta previa B. ruptured uterus C. nonreassuring fetal status D. preeclampsia Answer: C Rationale: The main reasons for performing cesarean births include a history of previous cesarean or other uterine incision; labor dystocia; nonreassuring fetal status; and fetal malpresentation. Less common indications include placenta previa, ruptured uterus, and preeclampsia.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 223-224 20. A client has been admitted for induction of labor and is asking the nurse what happens next. The nurse should point out that the health care provider will conduct which evaluation to determine what happens next?

A. fetal fibronectin B. Bishop score system C. endovaginal ultrasound D. validate gestational age Answer: B

Rationale: The Bishop score is a method used to determine cervical readiness for labor. Five factors are evaluated: cervical consistency, position, dilation (dilatation), effacement, and fetal station. The fetal fibronectin and an endovaginal ultrasound to determine the cervical size have not been found to be reliable indications of cervical readiness. Determining the gestational age will also not provide information concerning the readiness of the cervix for delivery.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 218 21. At 0500 hrs, a client was started on oxytocin. The nurse notes on assessment the client is dilated to 4 cm with contractions every 1 minute and increased signs of fetal distress. What action should the nurse prioritize after noting the time is now 1200 hrs?

A. Administer pain medication.

B. Increase IV fluids.

C. Stop the oxytocin infusion.

D. Notify the health care provider.

Answer: C Rationale: The drug oxytocin is used for induction of labor. It is a uterine stimulant.

In this client, the uterus is showing signs of overstimulation. The first intervention is to stop the infusion. The nurse should then contact the health care provider for further instructions. It would be inappropriate to administer pain medications or increase the IV fluids.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 219-220 22. The nurse is admitting a client who is to have labor induced at 37 weeks' gestation. When asked by the client what the fibronectin test is for, what is the nurse's best response?

A. to view the cells of the cervix for changes B. to look for amniotic fluid ferning patterns C. to check cervical secretions for the substance associated with readiness D. to assess the lung maturity of the fetus before inducing at 37 weeks Answer: C Rationale: A fetal fibronectin test checks cervical secretions for fibronectin and if present, is associated with cervical readiness for labor. The L/S test is performed to

assess for surfactant, which will reveal the maturity of the lungs of the fetus. The ferning test is performed to determine if the amniotic membranes have ruptured.

The cells are not usually viewed to determine their readiness for delivery.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 218 23. The nurse is preparing a client for administration of prostaglandin E2 to prepare for induction of labor. The nurse should explain this is administered via which route to the client?

A. rectal B. venous C. oral D. vaginal Answer: D Rationale: Prostaglandin E2 is a medication placed in the vagina against the cervix in either a gel form or via a vaginal insert. The preparation stays in place until spontaneous labor ensues. Prostaglandin E1 can be administered either orally or vaginally. Neither of these medications is administered rectally or via an IV. Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 219 24. A health care provider plans to use membrane stripping to ripen the cervix of a pregnant woman who is undergoing labor induction. The nurse determines that the client understands what will happen with this procedure based on which statement?

A. "My provider will use a catheter with a balloon filled with salt water to dilate my cervix."

B. "A seaweed-like substance put into my cervix will expand and cause my cervix to dilate."

C. "I will have a gel-type medicine put directly on my cervix."

D. "My provider will separate the thin layers of tissue from my lower uterus."

Answer: D Rationale: The client understands what will happen by the statement about the provider separating the thin tissues from the uterus. Membrane stripping is one of the most common mechanical methods used to hasten cervical readiness. With this technique, the health care provider inserts a gloved finger through the internal

cervical os and sweeps the finger 360 degrees to separate the membranes from the lower uterine segment. Other methods to ripen the cervix may be used. These include dilating the cervix using a catheter with the balloon filled with sterile saline, inserting laminaria (a seaweed-like substance) that absorbs moisture and expands to dilate the cervix, and using pharmacologic agents such as prostaglandins applied locally to the cervix.

Question format: Multiple Choice Chapter 11: Assisted Delivery and Cesarean Birth Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 219

Chapter 12 1. The nurse is caring for several postpartum clients on the unit. Which client's reaction should the nurse prioritize for possible intervention?

A. Hesitates to hold newborn, expressing disappointment with baby's appearance.

B. Neglects to engage or provide care or show interest in infant.

C. Tearful for several days, difficulty eating and sleeping.

D. Express doubt in ability to care for newborn.

Answer: B Rationale: A mother not bonding with the infant or showing disinterest is a cause for concern and requires a referral or notification of the primary health care provider. Some mothers hesitate to take their newborn and express disappointment in the way the baby looks, especially if they want a child of one sex and have a child of the opposite sex. Expressing doubt about the ability to care for the baby is not unusual, and being tearful for several days with difficulty eating and sleeping is common with postpartum blues.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 244-245 2. The nurse is monitoring a client who is recovering from a cesarean birth with spinal anesthesia. Which sign or symptom should the nurse prioritize if noted on assessment after the administration of morphine sulfate, simethicone, and diphenhydramine?

A. intense itching manifested by scratching B. abdominal distention and pain C. difficulty coughing and turning D. slow respiration, less than 12 breaths per minute Answer: D Rationale: Based on the history of medications, this client may be in respiratory compromise secondary to medications, most likely the morphine sulfate. The CRNA or anesthesiologist needs to be notified immediately and the nurse should prepare to administer naloxone. If the client demonstrates intense itching manifested by scratching the nurse would give the ordered diphenhydramine. The simethicone has been ordered for abdominal distension and pain. Difficulty coughing and turning are usually because of pain at the surgical site, and a client with these symptoms would need support and encouragement from the nurse.

Question format: Multiple Choice Chapter 12: The Postpartum Woman

Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 256-257 3. The nurse is preparing a client for discharge and notes an order for rubella vaccine. Which teaching should the nurse prioritize?

A. Advise the client that the vaccine is excreted in breast milk.

B. Do not to attempt another pregnancy for at least 3 months.

C. May experience rash, sore throat, headache, or general malaise within 2 to 4 weeks of the injection.

D. Will prevent hemolytic disease of the infant in next pregnancy.

Answer: B Rationale: The nurse should prioritize the fact that after the immunization, she needs to wait for at least 3 months before attempting to get pregnant again, if desired, so the fetus will not be exposed to the rubella vaccination. The rubella vaccine is a live virus and is considered teratogenic. The other choices are not priorities. Inform the breastfeeding woman that the rubella vaccine crosses over into the breast milk. The newborn benefits from short-term immunity but may become flushed, fussy, or develop a slight rash. Suggest that the woman speak to the pediatrician if she has concerns. The client may also experience a rash, sore throat, headache, and general malaise within 2 to 4 weeks after the injection. The nurse would not tell the new mother that the immunization will prevent hemolytic disease of the infant in her next pregnancy; this is incorrect information.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 259 4. The nurse is conducting a postpartum examination on a client who reports pain and is unable to sit comfortably. The perineal exam reveals an episiotomy without signs of a hematoma. Which action should the nurse prioritize?

A. Notify a health care provider.

B. Apply a warm washcloth.

C. Place an ice pack.

D. Put on a witch hazel pad.

Answer: C Rationale: The labia and perineum may be bruised and edematous after birth; the use of ice would assist in decreasing the pain and swelling. Applying a warm washcloth would bring more blood as well as fluid to the sore area, thereby increasing the edema and the soreness. Applying a witch hazel pad needs the order

of the health care provider. Notifying a health care provider is not necessary at this time as this is considered a normal finding.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 251 5. The nursing instructor is leading a discussion on the physical changes to a woman's body after the birth of the baby. The instructor determines the session is successful after the students correctly point out which process results in the return of nonpregnant size and function of the female organs?

A. Evolution B. Involution C. Decrement D. Progression Answer: B Rationale: Involution is the term used to describe the process of the return to nonpregnancy size and function of reproductive organs. Evolution is change in the genetic material of a population of organisms from one generation to the next.

Decrement is the act or process of decreasing. Progression is defined as movement through stages such as the progression of labor.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 241 6. The primigravida client is surprised by the continued uterine contractions while holding her newborn. Which explanation by the nurse explains the primary reason the contractions occur?

A. Returns the uterus to normal size B. Seals off the blood vessels at the site of the placenta C. Stops the flow of blood D. Closes the cervix Answer: B Rationale: The contractions of the uterus help to constrict the vessels where the placenta was located. This does decrease the flow of blood but is secondary in occurrence to the constriction of the blood vessels. Uterine contraction also leads to uterine involution, which normally occurs at a predictable rate. Uterine involution assists in closing the cervix. Again, the other options are secondary to the constriction of blood vessels at the placental site.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 241 7. The nurse is teaching a discharge session to a group of postpartum clients. When asked how long to expect the bleeding, which time frame should the nurse point out?

A. For 6 weeks B. On and off for 2 to 3 weeks C. Stops in 1 to 2 weeks D. In approximately 10 days Answer: D Rationale: The lochia may persist for 6 weeks after delivery; however, it should change in color and amount. For 3 to 4 days, lochia rubra is present in small to moderate amounts, mostly blood and dark red in color. Lochia serosa is present on days 4 to 10, decreasing to small amounts, brownish to pinkish in color. The lochia alba is present after 10 days and becomes white or pale yellow because the bleeding has stopped. This may continue until the end of the 6 weeks.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 241 8. The postpartum client and her husband are excited about their new baby.

However, they are also concerned about getting pregnant again too soon and ask about using birth control. Which instruction should the nurse include in their discharge education to address this issue?

A. "You may have intercourse until next month with no fear of pregnancy."

B. "Ovulation may return as soon as 3 weeks after birth."

C. "You will not ovulate until your menstrual cycle returns."

D. "Ovulation does not return for 6 months after birth."

Answer: B Rationale: Ovulation may start at soon as 3 weeks after birth. The client needs to be aware and use a form of birth control. She needs to be cleared by her health care provider prior to intercourse if she has a vaginal birth, but in the event that she has intercourse, needs to be prepared for the possibility of pregnancy.

Ovulation can occur without the return of the menstrual cycle, and ovulation does return sooner than 6 months after birth.

Question format: Multiple Choice

Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 241-242 9. The nurse is preparing to assess a client who is 1 day postpartum. The nurse predicts the client's fundus will be at which location on assessment?

A. At level of umbilicus B. 1 cm above the umbilicus C. 1 cm below the umbilicus D. At the symphysis pubis Answer: C Rationale: The fundus of the uterus should be at the umbilicus after birth. Every day after birth it should decrease 1 cm until it is descended below the pubic bone.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 241 10. The nurse has obtained the vital signs of a postpartum client 24 hours after delivery and records: 99°F (37.2°C), RR 18, HR 78, and BP 140/90 mm Hg. Which action should the nurse prioritize?

A. Notify the RN of the slight elevation in BP. B. Nothing; the vital signs are within normal limits.

C. Recheck all vital signs in 30 minutes.

D. Recheck only the BP in 30 minutes.

Answer: A Rationale: The LPN should prioritize notifying the RN immediately for further assessment of this client. An elevated BP may be a sign the client is developing preeclampsia after delivery. The other vital signs are within normal limits. Further assessment of the vital signs should be conducted depending on the client's situation.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 243

11. The nurse has completed assessing the vital signs of several clients who are from 36 to 48 hours postpartum. For which set of vital signs should the nurse prioritize for interaction?

A. Temp: 99.4° F (37.4° C), HR 90, RR 18, BP 112/67 B. Temp: 97.0° F (36.1° C), HR 80, RR 20, BP 120/72 C. Temp: 100.2° F (38° C), HR 65, RR 22, BP 130/78 D. Temp: 98.6° F (37° C), HR 74, RR 16, BP 150/85 Answer: D Rationale: Postpartum women may have an elevated temp to 100.4° F (38° C) for 24 hours after birth; they may also have decreased pulse a few weeks after birth.

The elevated BP of 150/85 is a concern, as a postpartum woman is still at risk of developing preeclampsia even after birth. The other choices are within normal limits.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 243 12. The nurse is performing an assessment on a 2-day postpartum client and discovers a boggy fundus at the umbilicus and slightly to the right. The nurse determines that this is most likely related to which situation?

A. Uterine atony B. Full bowel C. Bladder distention D. Poor bladder tone Answer: C Rationale: Most often the cause of a displaced uterus is a distended bladder. Ask the client to void and then reassess the uterus. According to the scenario described, the most likely cause of the uterine findings would not be uterine atony. A full bowel or poor bladder tone would not cause a boggy and displaced fundus.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 243 13. A woman who gave birth to her infant 1 week ago calls the clinic to report pain with urination and increased frequency. What response should the nurse prioritize?

A. "This is normal; give it a few days and then call back."

B. "After birth it is easier to develop an infection in the urinary system; we need to see you today."

C. "Are you washing and providing good perineal hygiene? If not, this may be the reason for the irritation."

D. "It is common for women to have yeast problems; try an over the counter cream and let us know if this continues."

Answer: B Rationale: The urinary system is more susceptible to infection during the postpartum period. The woman needs to be checked to rule out a urinary infection.

The other responses are incorrect because they do not acknowledge her in an appropriate manner.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 254-256 14. A client who is 3 days' postpartum calls the office and reports excessive night sweats. Which explanation should the nurse provide for the client?

A. Change in pregnancy hormone B. Body secreting the excess fluids from pregnancy C. The patient may be drinking too much fluid.

D. The body is trying to get rid of the extra blood made during pregnancy.

Answer: B Rationale: Copious diaphoresis occurs in the first few days after childbirth as the body rids itself of excess water and waste via the skin. The excessive diaphoresis is not caused by changes in hormones, nor because of the client drinking too much fluid, nor because of the body trying to rid itself of the excess blood made during pregnancy.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 243-244 15. The nurse is monitoring a client who is 3 hours postpartum. On assessment, the nurse notes a temperature of 102.4°F (39.1°C). Which action should the LPN prioritize?

A. Notify the RN who will then notify the health care provider.

B. Administer an antipyretic.

C. Assist the client in ambulation.

D. Continue to monitor for another hour.

Answer: A Rationale: A temperature elevated above 100.4°F (38°C) is a sign of possible infection. The LPN should notify the RN. The RN will then notify the provider and receive further care orders for the client. Administering an antipyretic can only be done at the physician's order. Assisting in ambulation and continuing to monitor the client for another hour are not indicated interventions for this client.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 259-260 16. The nurse is assisting a new mother who just transferred from the PACU. The nurse determines the client has already been adapting to her role as a mother by performing which actions of the first stage of adaptation?

A. achieving a maternal identity B. physical restoration and learning to care for infant C. shift in normal life to "new normal" D. beginning attachment and preparation for family Answer: D Rationale: The first stage is the beginning attachment to the fetus and idea of a family. This occurs during pregnancy. The four stages include: 1) beginning attachment and preparation for the infant during pregnancy; 2) increasing attachment, learning to care for the infant, and physical restoration during the early postpartum period; 3) moving toward a new normal in the first 4 months; and 4) achieving a maternal identity around 4 months.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 244 17. The nursing instructor is conducting a class exploring the various changes that occur in the early postpartum period. The instructor determines the session is successful when the students correctly point out which definition of bonding?

A. A process of developing an attachment and becoming acquainted with each other B. The skin-to-skin contact that occurs in the birth room C. An ongoing process in the year after birth D. Family growing closer together after the birth of a new baby Answer: A

Rationale: Bonding in the maternal-newborn world is the attachment process that occurs between a mother and her newborn infant. This is how the mother and infant become engaged with each other and is the foundation for the relationship.

Bonding is a process and not a single event. The process of bonding is not a yearlong process, and the family growing closer together after the birth of a new baby is not bonding.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 244 18. The nurse is questioning the effective bonding of a client and her 2-day-old infant after noting signs of impaired bonding and attachment. Which actions does the nurse find concerning?

A. Making eye contact with the baby B. Breastfeeding the infant on demand C. Calling the baby "it" or "they" D. Asking for assistance changing a diaper Answer: C Rationale: Many new parents will need assistance with diaper changes; this is not a flag for concern. Making eye contact and breastfeeding are positive interaction behaviors. If the mother calls the baby "it" and does not use the child's name, this is a sign that further information needs to be gathered and assessments should be completed.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 244-245 19. The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize?

A. infection B. dehydration C. hemorrhage D. bladder distention Answer: C Rationale: If a woman is going to hemorrhage, she is most likely to do so within the first postpartum hour. The nurse must assess a postpartum client every 15 minutes for the first hour. Infection, dehydration, and bladder distention are all assessment

parameters but do not take precedence over hemorrhage in the first postpartum hour.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 247-248 20. The nurse is conducting the initial postpartum assessment on a client. The nurse will assist the client into which position to properly assess the postpartum uterus?

A. semi-Fowler B. high Fowler C. supine D. left-lateral side lying Answer: C Rationale: The best position for a complete assessment of the uterus is lying flat, supine. The other positions will not allow for a true assessment of the location of the uterus in relation to the umbilicus.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 247-248 21. The nurse is preparing a nursing care plan for an immediate postpartum client.

Which nursing diagnosis should the nurse prioritize?

A. Acute pain related to afterpains or episiotomy discomfort B. Risk for infection related to multiple portals of entry for pathogens C. Risk for injury: postpartum hemorrhage related to uterine atony D. Risk for injury: falls related to postural hypotension and fainting Answer: C Rationale: The highest priority is the risk for injury related to postpartum hemorrhage. The client needs close observation and assessment for hemorrhage.

All of the options presented are appropriate nursing diagnoses for a postpartum client. However, the other options do not take precedence over the risk for postpartum hemorrhage.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process:

Reference: p. 254 22. The nurse is preparing a postpartum client for discharge 72 hours after birth.

The client reports bilateral breast pain around the entire breast on assessment. The nurse predicts this is related to which cause after noting the skin is intact and normal coloration?

A. Mastitis B. Blocked milk duct C. Engorgement D. Excessive oxytocin Answer: C Rationale: The client is only 72 hours postbirth and is reporting bilateral breast tenderness. Milk typically comes in at 72 hours after birth, and with the production of the milk comes engorgement. Mastitis or blocked milk ducts do not typically develop until there is fully established breastfeeding. Oxytocin would not be responsible for this.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 248 23. The nurse is preparing discharge for a client who plans to bottle-feed her infant.

Which instruction should the nurse prioritize for this client in the discharge teaching?

A. Run warm water over the breast in the shower.

B. Massage the breasts when they are painful.

C. Wear a tight, supportive bra.

D. Express small amounts of milk when they are too full.

Answer: C Rationale: The client trying to dry up her milk supply should do as little stimulation to the breast as possible. She needs to wear a tight, supportive bra and use ice.

Running warm water over the breasts in the shower will only stimulate the secretion, and therefore the production, of milk. Massaging the breasts will stimulate them to expel the milk and therefore produce more milk, as will expressing small amounts of milk when the breasts are full.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 251

24. The nurse is preparing discharge teaching for a client who is 2 days postpartum. Which action should the nurse prioritize to encourage prevention of constipation?

A. Use a stimulant laxative.

B. Encourage fiber-rich foods.

C. Increase coffee intake.

D. Get plenty of rest.

Answer: B Rationale: Encouraging fiber-rich foods will help with prevention of constipation.

The client needs plenty of water, needs to ambulate, and should take stool softeners (not a stimulant laxative) if ordered by the health care provider.

Increasing the coffee intake will not assist with preventing constipation. The client should get plenty of rest but it should be balanced with activity to help stimulate peristalsis of the GI tract.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 262 25. A woman who had a cesarean birth about 12 hours ago reports feeling bloated and "having gas pains." Which intervention would be helpful at this time?

A. Notify the RN that the woman needs an analgesic.

B. Encourage the woman to get up and walk around.

C. Offer the woman a cup of ice-cold soda.

D. Urge the woman to lie on the right side.

Answer: B Rationale: After cesarean birth, the woman is at increased risk for gas formation resulting from decreased peristalsis, the lingering effects of anesthesia and analgesia, and manipulation of the intestines during surgery. Gas pain is usually not relieved by analgesics. Many surgeons prescribe simethicone around the clock or PRN. Frequent and early ambulation stimulates peristalsis and the passing of flatus.

The nurse will instruct the woman to avoid very hot or very cold beverages, carbonated beverages, chewing gum, and drinking through straws. All of these actions can increase the formation and discomfort of gas. Other medical interventions may become necessary, such as rectal suppositories or enemas. The nurse will encourage the woman to lie on the left side. This position facilitates the release of gas. Having the woman rock in a rocking chair may also provide comfort from gas pains.

Question format: Multiple Choice Chapter 12: The Postpartum Woman Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Caring Reference: p. 252

Chapter 13 1. Why are newborns born to diabetic mothers prone to hypoglycemia?

A. Excess subcutaneous fat reduces blood flow to the tissues.

B. Metabolic stress is increased due to the stress on the mother's body.

C. Elevated insulin production metabolized glucose faster.

D. The liver is immature and cannot convert glycogen to glucose.

Answer: C Rationale: When the mother is diabetic, she has levels of insulin and blood sugars different from a pregnant woman without diabetes. Therefore the infant/fetus develops elevated levels of insulin to combat the elevated sugars. The infant is then at risk of low blood sugar once he or she is born. Infants born to diabetic mothers do not have excess subcutaneous fat that reduces blood flow to the tissues; they do not have increased metabolic stress because of stress on the mother's body; and their immature liver is not the reason the newborn is prone to hypoglycemia.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 269 2. When providing care for a newborn to a mother who was a smoker during her pregnancy, the nurse will anticipate the size of the infant to be what?

A. larger than average B. smaller than average C. average Answer: B Rationale: Smoking decreases the blood flow to the fetus. This is one cause for the infant to be smaller than average at birth. Mothers who smoke do not generally have infants who are larger than average; diabetic mothers generally have infants who are larger than average. An average size infant is not generally born to a mother who smokes.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 273

3. When taking the history of her postpartum client and infant couplet, the nurse is aware which prenatal factor might have resulted in the infant being larger than average?

A. smoking B. hypertension C. gestational diabetes D. poor maternal weight gain Answer: C Rationale: When a mother has gestational diabetes and it's not well controlled, this can result in having a baby who is large-for- gestational-age or larger than average. Smoking does not generally result in an infant who is larger than average.

Hypertension and poor weight gain in the mother do not generally result in an infant who is born larger than average.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 273 4. The nurse is monitoring an infant who was born at 0515 hrs. At 1315 hrs, the same day, the nurse determines the infant is starting to show yellowish staining on the head and face. Which action should the LPN prioritize?

A. Start phototherapy.

B. Document and report to RN. C. Continue monitoring, report if spreads.

D. Repeat bilirubin levels.

Answer: B Rationale: Jaundice that appears in the first 24 hours may be a sign of excessive bilirubin in the blood and is now seeping into the tissues. This needs to be further evaluated and should be reported to the RN immediately so further assessments, including lab work, can be ordered. Jaundice in the first 24 hours is considered pathologic and needs to be evaluated immediately. Physiologic jaundice usually occurs on the second or third day after birth and is considered a normal event as the bilirubin levels rise. It should clear up with the use of phototherapy.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 269 5. The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make

the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents?

A. Suggest they rock the baby to sleep.

B. Encourage the mother to breastfeed.

C. Commend the parents for making the right choice.

D. Encourage the parents to pick up the baby.

Answer: D Rationale: Dr. T. Berry Brazelton's Neonatal Behavioral Scale is often used to note the state of reactivity in newborns. This infant is in the quiet alert state with the eyes open and attentive to people. There is movement, but limited. This is a good time for the parents to interact with the infant, such as picking up the infant, touching, talking, and bonding with the infant. Other states of reactivity include: • Active alert: eyes are open and active body movements are present, newborn responds to stimuli with activity • Deep sleep: quiet, nonrestless sleep state, newborn is hard to awaken • Light sleep: eyes are closed but more activity is noted, newborn moves actively and may show sucking behavior • Drowsy: eyes open and close and the eyelids look heavy, body activity is present with intermittent periods of fussiness • Crying: eyes may be tightly closed, thrashing movements are made in conjunction with active crying.

This would not be the time for the parents to avoid interacting with the infant.

There is also no indication the infant is hungry or tired, so feeding or trying to get the infant to go to sleep would also be inappropriate at this time.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 270 6. A young mother is concerned for her baby and asks the LPN if her baby is okay.

What is the best response if the nurse notes RR 66, nostrils flaring, and grunting sounds during respiration?

A. "Your baby is fine, just learning how to breathe."

B. "Let's put a blanket around the baby; the baby is cold."

C. "Your baby is having a little trouble breathing. I'll let the RN know."

D. "Your baby is too warm. Let's take the blanket off."

Answer: C Rationale: The assessment findings discussed are signs of respiratory distress. An infant with a respiratory rate of greater than 60 with noise requires further assessment. This does not indicate the infant is either too cold or too warm, so using or not using a blanket would not be a factor in this scenario.

Question format: Multiple Choice

Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 272 7. The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

A. Conduction B. Convection C. Radiation D. Evaporation Answer: B Rationale: There are four main ways that a newborn loses heat; convection is one of the four and occurs when cold air blows over the body of the infant resulting in a cooling to the infant. Conductive heat loss occurs when the newborn's skin touches a cold surface, causing body heat to transfer to the colder object. Heat loss occurs by radiation to a cold object that is close to, but not touching, the newborn.

Evaporative heat loss happens when the newborn's skin is wet. As the moisture evaporates from the body surface, the newborn loses body heat along with the moisture. The cold air blowing on the infant's skin will cause heat loss.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 268 8. The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?

A. Bathe the infant immediately after birth.

B. Place the infant on the mother's abdomen after birth.

C. Wrap the infant in a warm, dry blanket.

D. Turn the temperature up in the birth room.

Answer: C Rationale: Evaporation is one of the four ways a newborn can lose heat. As moisture evaporates from the body surface of the infant, the newborn loses heat.

Wrapping the infant in a warm, dry blanket will allow the moisture to be absorbed, limiting heat loss from evaporation. Bathing the infant will only add to the evaporative heat loss. The newborn's skin is wet, so placing him on the mother' abdomen will not prevent evaporation and heat loss. Increasing the ambient temperature in the birth room does not address the evaporation problem.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 268 9. An infant born via a cesarean birth appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?

A. tachypnea B. cardiac murmur C. hypoglycemia D. hyperthermia Answer: A Rationale: The infant born from a cesarean birth has not had the opportunity to exit the birth canal and experience the squeezing of fluid from the lungs. The lungs have more amniotic fluid than the lungs of a baby from a vaginal birth and are at greater risk for respiratory complications, such as tachypnea. An infant born by cesarean birth is not at increased risk for hyperthermia, hypoglycemia, or a cardiac murmur.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 267 10. The nurse is conducting an assessment on a newborn male and the parents question why the nurse is using a penlight to examine the scrotal sac. The nurse should point out this helps to eliminate which potential disorder?

A. cryptorchidism B. hydrocele C. epispadias D. phimosis Answer: B Rationale: Hydrocele occurs when there is a buildup of fluid in the scrotal sac and should be noted on assessment. If there is fluid in the scrotal sac, it will be translucent when the penlight is placed against it. If there isn't fluid, the sac will remain dark. Cryptorchidism results when the testes do not descend into the scrotal sac during fetal life. These are checked by putting slight pressure on the scrotal sac to feel the testes. The urinary meatus should be positioned at the tip of the penis. If the opening is located abnormally on the dorsal (upper) surface of the glans penis, the condition is called epispadias. Phimosis, or tightly adherent foreskin, is a normal condition in the term newborn.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 279 11. A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize?

A. Immediately call the RN or health care provider.

B. Change and bathe the infant.

C. Check all of the baby's vital signs before calling the doctor.

D. Explain this is normal.

Answer: D Rationale: Erythema toxicum is otherwise known as normal newborn rash. The rash will resolve without intervention. There is no need to call the RN or health care provider, change and bathe the infant, or check the vital signs.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 274 12. The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation?

A. "How long has it been since you last breastfed?"

B. "Was the baby recently crying?"

C. "Was the baby sleeping on her back?"

D. "Did you hold the baby while she was sleeping?"

Answer: B Rationale: This is termed Harlequin sign and is related to dilation (dilatation) of blood vessels often following vigorous crying. This can also happen if the baby is sleeping on its side instead of its back. The condition will resolve without intervention. This is not caused by breastfeeding or holding the baby while the infant is sleeping.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 274

13. The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

A. lanugo B. milia C. vernix D. amniotic fluid Answer: C Rationale: Vernix is the coating on the infant that was covering fetal skin to prevent the skin from the drying effects of amniotic fluid. Lanugo is fine, downy hair that is present in abundance on the preterm infant but is found in thinning patches on the shoulders, arms, and back of the term newborn. Milia are frequently found on the infant's face. These tiny white papules resemble pimples in appearance. Normal amniotic fluid is not thick and white; it should be clear and give the baby a wet appearance.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 274 14. The newborn weighing 6 lb 6 oz (2856 g) now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?

A. "We need to do a more in-depth assessment."

B. "This is a normal response."

C. "How often are you feeding your baby?"

D. "You may need to supplement breastfeedings for a while."

Answer: B Rationale: The infant has a 5% to 10% loss of birth weight during the first few days of life as the body loses excess fluid and has limited food intake. This physiologic weight loss amounts to a total loss of 6 to 10 oz. There would be no need to assess for other problems. It is also not related to feeding, nor would a breastfeeding mother need to offer supplementary formula feedings.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 273

15. The nursing instructor is teaching a class on the physiologic prosperities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

A. It expands the lungs with breaths.

B. It keeps alveoli from collapsing with breaths.

C. It removes fluid from the lungs.

D. It allows oxygen to move in the lungs.

Answer: B Rationale: The role of surfactant is to act on surface tension and assist in keeping the alveoli open in the lungs so the lungs do not collapse with the respiratory effort of the newborn. Surfactant does not expand the lungs, remove fluid from the lungs, or allow oxygen to move in the lungs.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 267 16. The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

A. Oxygen is exchanged in the lungs.

B. Fluid is removed from the alveoli and replaced with air.

C. Pressure changes occur and result in closure of the ductus arteriosus.

D. The oxygen in the blood decreases.

Answer: C Rationale: The ductus arteriosus is one of the openings through which there was fetal circulation. At birth, or within the first few days, this closes and the heart becomes the source of movement of blood to and from the lungs. The exchange of oxygen in the lungs and increasing oxygen content in the blood are respiratory functions. The removal of the fluid from the alveoli occurs mainly during the birthing process and is completed by the lungs after birth.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 268 17. The nurse notes a newborn has a temperature of 97.0oF (36.1oC) on assessment. The nurse acts to prevent which complication first?

A. Seizure B. Respiratory distress

C. Cardiovascular distress D. Hypoglycemia Answer: B Rationale: It takes oxygen to produce heat and an infant who has an episode of cold stress is at risk for respiratory distress. The infant needs to be warmed. The temperature should be in the range of 97.7°F to 98.6°F (36.5°C to 37°C). After respiratory distress sets in, it can be followed by seizures, cardiovascular distress, or hypoglycemia.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 272 18. The parents are concerned their newborn appears to be cold all the time. The nurse should point out the infant is best helped by which primary method in the first few days?

A. External blankets put on the infant by the nursing staff B. Skin-to-skin (kangaroo) care with mother C. Brown fat store usage D. Shivering and increased metabolic rate Answer: C Rationale: Brown fat stores are used by the newborn infant to maintain warmth until feeding begins and the infant is able to maintain temperature without assistance. The infant's thermoregulatory system is not fully functional at birth.

Infants cannot shiver to warm themselves. The use of external blankets as well as skin-to-skin (kangaroo) care with the mother assists in keeping the baby's temperature within the normal range, but they are not the primary mechanism for temperature regulation in the newborn infant.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 268 19. The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0oF (36.1oC), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize?

A. Check the infant's temperature again.

B. Complete an entire set of vital signs.

C. Assess the infant's blood sugar.

D. Check oxygen saturation of the blood.

Answer: C Rationale: The poor muscle tone, low temperature, and jitteriness are signs and symptoms indicative of hypoglycemia. The nurse should assess the blood glucose first. Assessing the vital signs and oxygen saturation would be assessed again at the appropriate time. The main concern at the moment is assessing for hypoglycemia to prevent further complications.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 271 20. The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period?

A. 8 at 1 minute; 9 at 5 minutes B. 7 at 1minute; 8 at 5 minutes C. 6 at 1 minute; 7 at 5 minutes D. 5 at 1 minute; 6 at 5 minutes Answer: D Rationale: APGAR scores between 4 and 6 at 5 minutes of life indicate a newborn is having difficulty in adjusting to life outside the womb and needs close observation.

The infant would transition into the nursery under close observation. The other choices would indicate that the newborn is transitioning with minimal difficulty and will not need close monitoring for the entire transition period.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 270 21. The nurse is evaluating the morning blood glucose results from the laboratory of several 1-day-old infants. Which result should the nurse prioritize for further action?

A. Infant A - 52 mg/dl B. Infant B - 56 mg/dl C. Infant C - 48 mg/dl D. Infant D - 60 mg/dl Answer: C

Rationale: Blood glucose levels between 50 and 60 mg/dl during the first 24 hours of life are considered normal. Levels less than 50 are indicative of hypoglycemia in the newborn. Infant C is showing potential hypoglycemia. Infants A, B, and D have values within the normal range.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 271 22. The LPN is preparing to assist the RN with the initial admissions assessment of the newborn. The nurse should explain to the new mother that this will be completed in what time frame after birth?

A. 30 minutes B. 1 hour C. 2 hours D. 4 hours Answer: C Rationale: The infant and mother need time for bonding after delivery. While the nurse is monitoring and may take vital signs, the initial full exam must be completed within 2 hours of birth. The options of 30 minutes or 1 hour are options which would be based on the individual situation. Waiting for 4 hours is too long and may result in danger signs of potential complications being missed.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 271 23. A new mother of a newborn girl calls the clinic in a panic, concerned about the blood-tinged soiled diaper. What is the best response from the nurse?

A. "The baby may have a problem; let's schedule an appointment."

B. "This can be related to cleaning her perineal area; be more careful."

C. "This can be from the sudden withdrawal of your hormones. It is not a cause for alarm."

D. "If this continues, call us back; for now, just watch her."

Answer: C Rationale: The mother is describing pseudomenstruation and is usually the result of the infant no longer having the mother's hormones in the body. This is not a cause for alarm. It is always appropriate to offer to schedule an appointment if the mother continues to be upset. The nurse should know that the infant's "bleeding" is not indicative of a pathologic process and should be careful to not upset the mother

further. The statement of it being related to the way the mother is cleaning the perineum is incorrect for it places the blame on the mother for the infant's problem.

The instruction to call back if it continues does not meet the mother's need to know why this is happening to her baby, and it negates her concern for her infant.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 279 24. The LPN assists the RN while performing the Ortolani maneuver on a newborn.

When asked by the mother the reason for this maneuver, which is the best response from the nurse?

A. spinal column movement B. shoulder movement C. clavicles for dislocation D. hip for dislocation Answer: D Rationale: Ortolani maneuver is used to assess the possibility of a dislocated hip in an infant. Ortolani maneuver does not assess for spinal column movement, shoulder movement, nor does it assess the clavicles for dislocation. There is no specific movement to assess for spinal column movement, shoulder movement, or clavicle dislocation.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 280 25. The nurse is responding to an infant crying and notes it is very high-pitched and shrill. The nurse predicts this is most likely related to which situation?

A. normal cry from pain B. tired and stress from delivery C. neurologic dysfunction D. cold stress cry Answer: C Rationale: A high-pitched cry that is shrill is associated with a neurologic disorder.

The nurse will need to inform the RN and provider to assess the infant further. A high-pitched, shrill cry in a newborn is not a normal cry from pain; it does not indicate the infant is tired and stressed from delivery, and it is not a cry indicating cold stress.

Question format: Multiple Choice

Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 280-281 26. The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?

A. fencing B. Moro C. tonic neck D. rooting Answer: B Rationale: The Moro reflex is also known as the startle reflex. When the infant is startled, he/she extends the arms and legs away from the body. The fencing reflex is also called the tonic neck reflex and is a total body assessment. The rooting reflex assesses the infant's ability to "look" for food.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 281 27. The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?

A. Moro B. tonic neck C. rooting D. sucking Answer: C Rationale: This is the rooting reflex and is used to encourage the infant to feed.

This reflex and the sucking reflex work together to assist the infant with cues for feeding at the breast. The tonic neck (or fencing) reflex and the Moro (or startle) reflex are total body reflexes and assess neurologic function in the newborn.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 281

28. The nurse is caring for a newborn who was delivered via a planned cesarean delivery. The nurse determines the infant requires closer monitoring than a vaginal delivery infant based on which factor?

A. Oxygen was cut off when the umbilical cord was clamped, resulting in decreased oxygen and increased carbon dioxide.

B. Excessive fluid in its lungs, making respiratory adaptation more challenging.

C. Fetal lungs are uninflated and full of amniotic fluid that must be absorbed.

D. Much of the fetal lung fluid is squeezed out in cesarean delivery.

Answer: B Rationale: During a vaginal birth the infant is squeezed by uterine contractions, which squeeze fluid out of the lungs and prepare them for breathing. The infant who is born via cesarean delivery without labor first does not have the mechanical removal of the fluid from the lungs. This places the infant at increased risk for respiratory compromise, so there is a need to more closely assess a newborn after birth. The lungs should inflate once the baby is delivered and not wait until the amniotic fluid is absorbed. The umbilical cord is not clamped until the infant is out of the womb and starts to take its first breaths.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 267 29. The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 98.7oF (37.1oC), and blood pressure 70/40 mm Hg. Which action should the nurse prioritize?

A. Report tachypnea.

B. Recheck blood pressure in 15 minutes.

C. Put warming blanket over infant.

D. Document normal findings.

Answer: D Rationale: These vital signs are within normal limits and should be documented.

The heart rate should be 110 to 160 bpm; RR should be 30 to 60 breaths per minute. The axillary temperature can range from 97.7°F to 99.6 & 176;F (36.5°C to 37.5°C). Blood pressure should be 60 to 80/40 to 45 mm Hg. There is no need to contact the health care provider, recheck the blood pressure in 15 minutes, or place a blanket on the infant.

Question format: Multiple Choice Chapter 13: Nursing Care During Newborn Transition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process

Reference: p. 272

Chapter 14 1. A newborn infant at 36 hours of age is jaundiced. The mother is breastfeeding.

What intervention is appropriate to increase the excretion of bilirubin?

A. Stop breastfeeding and administer glucose water for 24 hours.

B. Instruct the mom to feed every two to three hours.

C. Restrict feedings and give glucose water every 4-6 hours for hydration.

D. Keep the skin protected by preventing light onto the baby's skin.

Answer: B Rationale: Bilirubin is excreted in the urine and feces. Encouraging the mother to breastfeed at least every two to three hours will increase the waste and help decrease the bilirubin level. Stopping breastfeeding and administering glucose water for 24 hours would not be appropriate for the mother. Restricting feedings and giving glucose water every 4 to 6 hours is not an appropriate nursing intervention for an infant showing signs of jaundice. Keeping light away from the baby's skin does not help to clear jaundice; it could only make it worse.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 291 2. A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

A. Check blood glucose.

B. Place child in a radiant warmer.

C. Assess for pain source.

D. Assess the baby's temperature.

Answer: A Rationale: One of the primary signs/symptoms of hypoglycemia in newborn infants is jitteriness and irritability. Anytime an infant is suspected of having hypoglycemia, the nurse needs to check the blood glucose level. Cold stress and pain are potential considerations to rule out if hypoglycemia is not the cause; however, jitteriness is not a recognized sign of these.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 288-289

3. The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

A. Instill 0.5% ophthalmic silver nitrate.

B. Instill 0.5% ophthalmic tetracycline.

C. Instill 0.5% ophthalmic erythromycin.

D. Watch for signs of eye irritation.

Answer: C Rationale: The standard eye care to prevent ophthalmia neonatorum is 0.5% erythromycin ointment or 1% tetracycline eye drops. Although 1% silver nitrate drops were once used, it has been discontinued due to its ineffectiveness. The nurse would not wait to see if the eyes show signs of irritation before administering the medication. Delaying could lead to preventable blindness.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 289-290 4. The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

A. Send a family member to accompany the infant when leaving the room.

B. Check the name on the baby's identification bracelet.

C. Provide a list of approved visitors who came spend time with the infant.

D. Check the identification badge of any health care worker before releasing baby from room.

Answer: D Rationale: Infant abduction is a concern, and all personnel should wear identification badges and introduce themselves to the parents before they enter the room or take the infant. If at any time the mother is suspicious, she has the right to not allow an individual to take the infant. There may not always be a family member around to accompany the infant and they may not be allowed admittance to treatment rooms or other such areas. Checking the name on the baby's identification bracelet will not stop abduction. Providing a list of approved visitors may help prevent abduction from individuals outside the medical facility but will not stop someone posing as an employee from abducting the infant.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process

Reference: p. 292 5. The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

A. Perform a 3-minute surgical-type scrub.

B. Wear clean gloves.

C. Use infection transmission precautions.

D. Clean hands with a betadine scrub.

Answer: B Rationale: Infection control is a priority nursing intervention. Gloves need to be worn when in contact with the infant who has not been bathed after birth. All options are valid options; however, a three-minute surgical scrub is generally only required at the beginning of a shift. The nurse should always wash the hands before putting on gloves to care for an infant and after taking gloves off. Standard precautions are used with every client.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 292 6. The nurse is giving a newborn his first bath. What should the nurse prioritize?

A. Give the sponge bath in the baby's bed.

B. Wash off all traces of blood and leave the vernix in place.

C. Use a soap such as hexachlorophene to prevent infection.

D. Apply talcum powder to the buttocks after washing.

Answer: B Rationale: During the bath, all blood and products from the delivery need to be washed off and the vernix should be left in place to allow it to gradually absorb into the infant's body. The infant's first bath is given under a radiant warmer, not in the infant's bed. If a radiant warmer is not used, the nurse should keep the infant wrapped and expose only the part which is being washed to avoid cold stress. If soap is used at all, it is a mild soap, not a soap like hexachlorophene. No special ointments are necessary on the perineal area and buttocks after washing. Talcum powder is contraindicated because of the possibility of respiratory distress.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 293

7. The nurse is teaching discharge instructions to the young parents of a healthy newborn boy whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?

A. A yellowish crusty substance on the circumcision site B. Crying for 2 hours or more each day C. Redness at the base of the umbilical cord D. Straining when he is passing stools Answer: C Rationale: The cord should dry and fall off in the 7 to 10 days after birth. If the cord base changes color or develops drainage, the health care provider needs to be notified as these could be signs of infection. A yellowish crusty substance on the circumcision site indicates normal healing. Crying for 2 hours or more each day and straining during bowel movements are normal in a newborn.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 292 8. The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step?

A. Position the newborn on side, and suction with a bulb syringe.

B. Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth.

C. Position the newborn on side with head slightly below body; use a small suction catheter to clear nose.

D. Position the newborn on side with head slightly below body; use a bulb syringe to clear nose.

Answer: B Rationale: The infant needs to have bulb suction used to remove the secretions from the mouth first; the head should be held slightly lower than the body to facilitate use of gravity. A bulb syringe, not a small suction catheter, is used to suction the mouth and nose of a newborn. The mouth should be cleared first to prevent possible aspiration of secretions. Suctioning the nose first could cause the infant to inhale the secretions in the mouth.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 299

9. The parents of a newborn are concerned that the different procedures are causing pain for their newborn. Which action should the nurse prioritize to address the parent's concerns?

A. Teach the infant's caregivers ways to soothe and comfort the child during any episode of pain.

B. Adhere carefully to the plan for administration of any analgesics to the child after procedures.

C. Advocate and use effective treatment methods that cause no pain or less pain.

D. Provide a soothing environment, swaddling and holding the newborn experiencing pain.

Answer: C Rationale: It is the ethical responsibility of the nurse to first prevent pain, and if that is not possible, then to treat pain. The nurse should advocate to the provider to provide the same. The other options are methods to treat the pain but would not necessarily prevent pain.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 295 10. The nurse is escorting the newborn to the transition nursery for the initial assessment and care. The nurse is prepared to carefully monitor the infant during the transition period, which occurs at which time interval?

A. First 12 to 24 hours B. First 6 to 12 hours C. First 1 to 6 hours D. First 1 to 12 hours Answer: B Rationale: The first 6 to 12 hours after birth are the critical transition hours for a newborn. The newborn may stay with the mother, but under close observation by a nurse. The newborn requires close monitoring throughout the entire period but the first 6 to 12 hours are the time when more complications may present and must be handled early to prevent long-term complications.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 2587

11. The parents of a 1-day-old newborn are concerned the newborn is cold. Which action should the nurse prioritize to best prevent heat loss?

A. Keep the newborn under the radiant heater when not with mother.

B. Cover the newborn with several blankets while under the warmer.

C. Warm all surfaces and objects that come in contact with the newborn.

D. Bathe and wash the newborn when temperature is 97.5° F (36.4° C).

Answer: C Rationale: The 1-day-old newborn will have regulated body temperature at this point in life, and the radiant heater is no longer used. Interventions are the best way to prevent heat loss for this newborn; these would include making sure surfaces such as scales, examination tables and instruments are warm. Keeping the newborn under a radiant heater and covering the newborn with several blankets while under the warmer could lead to hyperthermia, which can be just as detrimental to the newborn as hypothermia. Newborns are bathed when their temperatures are stable.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 288 12. The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2oF (36.2oC) an hour after birth. Which intervention should the nurse prioritize for this family?

A. Help the mother provide skin-to-skin (kangaroo) care.

B. Place a second stockinette on the baby's head.

C. Administer a warm bath with temperature slightly higher than usual.

D. Place the infant under a radiant warmer.

Answer: A Rationale: The nurse should encourage bonding to continue. One way to help the infant get warm is to help the parents provide kangaroo care, which involves skinto-skin contact and parent/baby coverage with blankets. Once the infant is taken for the initial assessment, placement under the radiant heater would then be appropriate. Placing a second stockinette is a potential option; however, it would not be as effective as the skin-to-skin contact. The bath would not be undertaken until the infant's temperature is stabilized within the normal range.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 288

13. The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?

A. temperature of 97.8°F (36.5°C) B. heart rate 158 bpm C. respiratory rate 42 breaths/min D. Blood sugar 42 mg/dl Answer: D Rationale: Any blood sugar lower than 50 mg/dl is considered hypoglycemic and should be further assessed. In the scenario described, the infant's temperature, heart rate, and respiratory rate are all considered within normal limits.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 288 14. The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

A. Soak the penis daily in warm water.

B. Cover the glans generously with petroleum jelly.

C. Cleanse the glans daily with alcohol.

D. Notify the primary care provider if it appears red and sore.

Answer: B Rationale: Covering the surgical site with an ointment such as petroleum jelly prevents it from adhering to the diaper and being continually irritated. Normal appearance is red and raw. Soaking the penis daily in warm water is not recommended. Washing the penis with warm water, dribbled gently from a washcloth at each diaper change, is the recommended way of keeping the penis clean. The nurse would not tell the parents to use alcohol on the glans.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 300 15. The nurse is conducting a prenatal class explaining the various activities that will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

A. Prevent infection of the umbilical cord B. Prevent infection of the eyes from vaginal bacteria

C. Protect tear ducts from vaginal bacteria D. Protect the urethra from fecal material Answer: B Rationale: Antibiotic ointment is used in the infant's eyes at birth to prevent ophthalmia neonatorum, an infection which can lead to blindness. It is not an acceptable practice to apply antibiotic ointment to the tear ducts, the umbilical cord, or the perineum and urethra.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 289 16. The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K? A. Provides blood clotting factors B. Speeds up drying of umbilical stump C. Stimulates population of normal gut flora D. Reduces complications from possible circumcision Answer: A Rationale: Vitamin K is necessary in the formation of certain clotting factors. The newborn male and female are both lacking in vitamin K, and the only method for the infant to receive it in the early hours after birth is to administer the vitamin IM. Vitamin K is manufactured by normal flora in the gut. Since the newborn has not yet eaten, there is no normal flora in the gut, so the infant cannot manufacture vitamin K. Vitamin K does not speed up drying of the umbilical stump or stimulate population of normal gut flora. It can help reduce possible bleeding from circumcision; however, that is not the only complication that can occur from a circumcision, nor is a circumcision the only reason an infant might bleed.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 290 17. The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

A. The tint is due to jaundice.

B. Yellow is the normal color for some newborns.

C. The infant needs to be in the sunlight to clear the skin.

D. It's a mild reaction to the vitamin K injection.

Answer: A Rationale: Newborns often have a yellow tint to the skin if the newborn develops jaundice. Any newborn developing jaundice needs to be assessed by the health care provider. Jaundice in the first 24 hours is pathologic and must be reported immediately to the health care provider. Jaundice after 2 days is considered physiologic and is due to the liver's inability to adequately process bilirubin which seeps into the tissues, giving the skin a yellowish color. It is not considered normal and does require assessment and intervention. Phototherapy is the recommended treatment of choice, not putting the child in sunlight. It is not a reaction to the vitamin K injection.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 302 18. The young mother is nervous about discharge with her first child. The nurse encourages the mother by pointing out various instructions, including to call her health care provider if the newborn does not void within which time period?

A. 6 hours B. 12 hours C. 18 hours D. 24 hours Answer: B Rationale: The mother should call the health care provider if her infant does not void at all within a 12-hour period. The mother should not wait 18 to 24 hours before calling. It is fine for the infant to go 6 hours without voiding; however, the mother should be aware that this needs to be monitored.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 300 19. The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in the bed, lying on her side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

A. Gastroesophageal reflux B. Sudden infant death syndrome C. Apnea episodes

D. Sleeping for short intervals Answer: B Rationale: The 'back to sleep' campaign is a national campaign used to educate the public concerning the fact that the proper position for sleep of infants is on their backs to help decrease the risk of SIDS. Placing the infant on his or her back to sleep does not reduce the risk for gastroesophageal reflux, apnea episodes, or sleeping for short intervals.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 299 20. The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

A. Ineffective thermoregulation related to heat loss to the environment B. Altered nutrition less than body requirement related to limited formula intake C. Altered urinary elimination related to postcircumcision status D. Ineffective airway clearance related to mucus and secretions Answer: D Rationale: Any airway clearance or obstruction issue is the highest priority for nursing interventions, whether the infant is born via vaginal or cesarean delivery.

The other options are valid nursing diagnoses for some newborns; however, they would not take precedence over an airway problem.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 291 21. The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

A. Use of pass codes onto the unit B. Use of monitor attached to babies C. Use of cameras at all doors D. Cooperation by the parents with the hospital policies Answer: D Rationale: The most essential piece to an effective infant abduction prevention plan is the cooperation of the parents. If the parents are not willing to participate in the

unit policy, the unit is at risk. Using pass codes, placing cameras at each door, and using monitors on the infants will all help, but only if the parents are cooperative.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 292 22. The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

A. Lower rate of urinary tract infections B. Reduced risk of penile cancer C. Fewer complications than if done later in life D. Anesthetic may not be effective during the procedure Answer: D Rationale: The anesthetic block is not always effective when used and not all providers will even use anesthetics prior to the procedure, thus the infant can feel the pain of the circumcision. A lower rate of urinary tract infections, a reduced risk of penile cancer, and fewer complications than if circumcised later in life are advantages to the procedure.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 296 23. The nurse is explaining to new parents the various vaccinations their newborn will receive before being discharged home. Which immunization should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

A. Vitamin K B. Hep B C. HBV immunoglobin D. HiB Answer: B Rationale: Hep B is the vaccination against hepatitis B and recommended by the CDC. It has been found to help prevent cirrhosis and liver cancer later in life. The HBV immunoglobin may be given in conjunction with the hep B if the mother is found to be HBV positive. The HiB is given later, usually at the 2-month visit.

VItamin K is given soon after birth to reduce the risk of bleeding.n Question format: Multiple Choice

Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 298 24. The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply.

A. Warmer bed B. Glucose water C. Suction equipment D. Identification bands E. Ophthalmoscope Answer: A, C, D Rationale: In preparing the delivery room, the nurse should preheat a warmer bed, have suction equipment at bedside, and have the identification bands ready for both the mother and newborn. Glucose water and an ophthalmoscope are not needed immediately after delivery to stabilize the newborn.

Question format: Multiple Select Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 287 25. A nurse is preparing to administer vitamin K to a newborn who was just birthed vaginally. Which site would be appropriate for the nurse to select?

A. deltoid B. ventrogluteal C. vastus lateralis D. dorsogluteal Answer: C Rationale: The nurse would select an injection site on the vastus lateralis (anterior lateral aspect of the thigh) muscle. The deltoid, ventrogluteal, or dorsogluteal would be inappropriate to use.

Question format: Multiple Choice Chapter 14: Nursing Care of the Normal Newborn Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 290

Chapter 15 1. A new mother asks when she can give her infant fruit juice. The nurse would most likely instruct the mother to wait until the infant is how old?

A. 3 months old B. 5 months old C. 8 months old D. 12 months old Answer: C Rationale: Fruit juice is not recommended for infants younger than 6 months because it supplies no protein and, if not pasteurized, can carry infectious organisms. The amount should be limited to 3 to 4 ounces.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 321 2. The nurse is preparing discharge instructions for a new mother who has been learning to breastfeed. Which response should the nurse prioritize when the mother questions her ability to produce enough milk for her infant?

A. Take a daily multivitamin.

B. Drink a lot of milk.

C. Drink a lot of fluids.

D. Consume a minimum of 3000 calories per day.

Answer: C Rationale: The mother needs to be sure to drink enough fluids, especially water, to handle her thirst. She only needs an additional 500 calories per day over her normal diet. Too much milk may cause gas and if her diet is appropriate she would not need a multivitamin.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 311-312 3. A first-time mother has been breastfeeding her baby for 3 days and is concerned she is not making enough milk. Which signs can the nurse teach the mother to look for that indicate the infant is getting enough milk?

A. should have at least 5 wet diapers and 1 bowel movement daily

B. The mouth is full of milk after feeding.

C. appears drowsy or asleep after feeding D. gains approximately 5 to 10 oz (140 to 280 g) each day Answer: C Rationale: The infant who is getting enough milk during breastfeeding sessions will be drowsy or asleep at the end of the feeding. There should be a small amount of milk (not large amount) in the mouth when finished. There should be at least 6 wet diapers and 3 bowel movements each day (not just 5 wet and 2 bowel movements). The infant will lose approximately 10% of the birth weight in the first few days and regain it within 7 to 10 days. Most families will not be prepared to weigh the infant in ounces, so this would not be a valid measure.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 315 4. The nurse is assisting a new mother with breastfeeding her infant, and she is concerned about producing enough milk. The nurse determines the mother needs more teaching when she makes which comment?

A. "My husband is bringing bottles of water for our baby."

B. "I should wait to start pumping my breasts for a few weeks."

C. "My baby needs to feed every 2 hours."

D. "Maybe I should have started breastfeeding sooner."

Answer: A Rationale: The mother should not offer her newborn supplemental water. The mother should nurse her infant every 2 to 4 hours. To increase or maintain her milk supply, the mother needs to continuously empty her breast to make more milk.

Offering supplementation would be a period where the breast would not be emptied and the production of milk would be decreased at that point. There is no need for the mother to start using a breast pump at this time. The time in which the mother starts breastfeeding after birth is not as important as how well the breasts are emptied to encourage the production of more milk.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 315 5. The nurse is preparing to assist a new mother to breastfeed for the first time.

Which action should the nurse prioritize?

A. Ensure privacy by closing the door or pulling the curtain.

B. Assist the woman with holding the infant correctly.

C. Assist the woman into a comfortable position.

D. Check the newborn's and woman's ID bands to make sure they match.

Answer: D Rationale: The first step before putting any infant to breast is confirmation of the infant and mother matching by proper identification. The other options are interventions that would follow ensuring the correct mother and infant are together.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 313 6. The nurse is helping a mother prepare to breastfeed her newborn for the first time. Which position should the nurse point out will be most appropriate with her cesarean incision site?

A. football hold B. side-lying position C. cradle hold D. whichever is most comfortable Answer: A Rationale: The football hold is ideal for women who have undergone surgery, have large breasts, or have twins. This position allows for the woman to see the infant while maintaining control of the infant's head. It will also avoid potentially putting pressure on the incision site. The side-lying position and the cradle hold are positions that the mother may try at a later session, once her abdominal incision is further healed.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 313 7. The nurse is monitoring a breastfeeding session and determines the infant is nursing well. Which assessment finding is the nurse using to make this determination?

A. The mother is free of painful engorgement.

B. The newborn has a dry mouth after feedings.

C. The mother has difficulty rousing the newborn for a feeding.

D. The mother is experiencing uterine contractions.

Answer: D

Rationale: When the infant is latched on and breastfeeding well, the body will release oxytocin and the result is uterine contractions. This is a good sign that the infant has a good latch. A lack of painful engorgement does not mean that the infant is getting an adequate supply of milk. The mucous membranes of an infant's mouth should be moist and pink. Being able to rouse an infant for feeding or having a difficult time rousing the infant are not indicators that the breastfeeding is going well. Indications that breastfeeding is going well include the following: a newborn that is correctly latched onto the breast will resist being pulled off of the breast; audible swallowing and rhythmic jaw gliding; leaking from the opposite breast or a let-down reflex.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 313-314 8. The nurse is teaching young parents discharge instructions. Which form of birth control should the nurse point out will be the best option for the breastfeeding mom who hopes to have more children later?

A. tubal ligation B. combination hormonal birth control pill C. estrogen-based pill D. condoms Answer: D Rationale: The breastfeeding client needs to avoid use of any type of hormonal birth control or her milk supply could be changed. The most appropriate choice is the condom. Tubal ligation is a surgical procedure that prevents the egg and the sperm from meeting. It is a method of birth control for people who do not want any more children.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 317 9. The new mother has decided to formula-feed her infant and is unsure when to introduce soft foods. Which age should the nurse point out will be appropriate to introduce her infant to mashed fruit and vegetables?

A. 4 to 6 months B. 6 to 8 months C. 8 to 10 months D. after 12 months

Answer: B Rationale: The AAP has recommended the introduction of solids at the age of 6 to 8 months. Starting before 6 months would be too early. Waiting until after 8 months may lead to malnutrition issues for the infant, as an infant's requirement for increased vitamins and minerals starts to increase and are not always met by formulas.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 320 10. The new mother is determined to breastfeed her baby exclusively for 6 months but will need to return to work before then. The nurse should encourage the mother to wait until the baby is what age before using expressed milk?

A. 2 weeks B. 4 weeks C. 6 weeks D. 8 weeks Answer: C Rationale: It is recommended to breastfeed for six weeks prior to introduction of bottles and pumping to establish a solid breastfeeding relationship. If bottles are introduced at much less than 6 weeks, the establishment of a solid breastfeeding relationship may be impaired. Waiting 8 weeks to introduce bottles of breast milk into the baby's routine is not necessary and should not be suggested by the nurse.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 317 11. The nurse is assisting the new mother who has chosen to feed her newborn formula. The nurse should encourage the mother to burp her baby at which time?

A. after every half-ounce B. after every ounce C. after every feeding D. only when the infant appears to be in discomfort Answer: A Rationale: The mother should stop to burp the newborn every half-ounce; as the newborn grows, the infant will be able to tolerate more formula at one time and burp less frequently. Waiting until the infant has consumed 1 oz of formula, waiting

until the end of the feeding, or waiting until the infant appears to be in distress are incorrect choices.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 319 12. The nurse is preparing a dietary care plan for a newborn who currently weighs 7 lbs (3182 g). How many kcal per day will the nurse plan for to ensure the infant's energy needs are met?

A. 300 kcal B. 350 kcal C. 400 kcal D. 450 kcal Answer: B Rationale: The healthy term newborn needs 110 to 120 kcal/kg/day to meet the energy needs for growth and development. To determine the kcal/kg/day, multiple 3.182 x 110 = 350 and 3.182 x 120 = 382. Therefore this infant should receive approximately 350 to 382 kcal each day to ensure it is meeting the energy needs for consistent growth and development. To give the infant less than 350 kcal could lead to failure to thrive, growth stump, and related problems. To give the infant too much can lead to the excess being converted to fat and create a potential obesity problem for the infant.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 307-308 13. The nurse is meeting with a group of expectant parents to discuss the feeding options available for their soon-to-be infant. The nurse predicts which factor will exert the strongest influence on their choice?

A. sociodemographics B. exposure to breastfeeding C. culture D. cost Answer: C Rationale: A woman's culture often strongly influences newborn feeding choices. If the woman feels it is culturally acceptable to breastfeed, she is more likely to breastfeed her infant. Sociodemographics are characteristics of a person or a group of people; the mother's exposure to breastfeeding and the cost of bottle-feeding all

can influence the mother's decision to breastfeed. However, they will not have the strongest influence on the mother's choice of feeding her infant.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Culture and Spirituality Reference: p. 308 14. A young couple are discussing how long the mother should breastfeed and cannot agree on a time frame. What is the best response from the nurse when they question the nurse about it?

A. "You should work toward a goal of 6 weeks and then you can probably switch to formula."

B. "It is recommended to breastfeed until 18 months, and possibly as long as 2 years."

C. "The recommendation is to use only breast milk for the first 6 months, then add other foods until 12 months."

D. "There are no recommended guidelines for breastfeeding."

Answer: C Rationale: The AAP (2016) recommends infants be exclusively breastfed for the first 6 months and breastfed with complementary foods for the first year of life. The mother should be encouraged to breastfeed for longer than six weeks to ensure the infant gains all the benefits from proper nutrition provided by breast milk. It is the mother's choice to continue breastfeeding after 12 months, but the child should be weaned at 2 years of age.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 309 15. The nurse is preparing a presentation for a health fair on the benefits of breastfeeding. Which noted long-term benefit should the nurse prioritize?

A. rapid uterine involution B. decreased stress levels C. increased immune system D. decreased risk of ovarian cancer Answer: D Rationale: The long-term benefits of breastfeeding include a decreased incidence of ovarian and premenopausal breast cancers. The other options (rapid uterine involution, decreased stress levels, and increased immune system) are short-term benefits.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 309 16. The nurse is assisting a primigravida woman make decisions and prepare for her baby. The nurse should point out that breastfeeding is not an option for this client based on which assessment finding?

A. breast implants B. galactosemia C. need to return to work quickly D. HIV infection Answer: D Rationale: Contraindications for breastfeeding include women who have HIV, use illegal drugs, have active untreated tuberculosis, are receiving chemotherapy, or have herpetic lesions on the breast. Women with active infections can pass these conditions on to their infants while breastfeeding. A woman with breast implants should be referred to a lactation consultant to assist and support this mother.

Galactosemia is a newborn disorder in which the infant has an inborn error of metabolism. The mother who needs to return to work should be taught how to pump her milk so that she can still provide breast milk to her infant.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 309-310 17. The young mother has been breastfeeding her newborn; however, the nurse is concerned the infant is not thriving and may need to be switched to a formula.

Which condition is a contraindication for the infant to continue breastfeeding?

A. cleft palate B. preterm delivery C. Down syndrome D. galactosemia Answer: D Rationale: Most infants are able to breastfeed, but infants who have certain metabolic disorders should not be breastfed. Galactosemia is an inborn error of metabolism and requires a specialty formula. Infants with a cleft palate or Down syndrome can be breastfed. An infant who is born preterm may have to take its mother's milk from a bottle but can still have breast milk.

Question format: Multiple Choice

Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 309-310 18. The nurse is leading a group discussion of new mothers about breastfeeding.

Which instruction should the nurse prioritize as the best method to increase their milk supply?

A. Massage breast while pumping or breastfeeding.

B. Double pump when away from the baby.

C. Only direct breastfeed.

D. Empty the breast as completely as possible.

Answer: D Rationale: Milk production is based on supply and demand. To maintain or increase breast milk supply, the mother should empty her breast as often and as completely as possible. Massaging the breast, double-pumping, and only direct breastfeeding are not ways to increase the mother's milk supply.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 310-311 19. The new mother is surprised to learn that oxytocin is helping her breastfeed her baby, especially after her health care provider used oxytocin to induce her labor.

Which additional function of oxytocin should the nurse point out to the mother?

A. increases production of milk B. stimulates the release of milk C. contracts breast cells to move the milk out of ducts D. interacts with lactogen to produce milk Answer: C Rationale: Oxytocin is a muscle stimulant; the role of oxytocin in breastfeeding is to move the milk down the ducts and out of the breast for feeding. Oxytocin does not increase the production of milk; only complete emptying of the breast stimulates an increase in the production of milk. Prolactin is responsible for stimulating the release of milk, which then moves into the ducts. The receptor sites in the breast are responsible for the increased production of milk. Lactogen aids in milk production by stimulating the receptor sites.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 311 20. A woman on the postpartum unit with her 1-day-old infant is asking when her milk will "come in." The nurse should point out this normally occurs at which time after delivery?

A. 1 to 2 days B. 3 to 5 days C. 6 to 9 days D. 2 weeks Answer: B Rationale: The breast has colostrum during the first few days after delivery. The breast begins to make milk between days 3 and 5 after delivery. At day 6 and beyond, the mother should be producing milk and will gradually increase the amount as she continues to breastfeed her infant.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 311 21. The nurse is assisting a new mother to develop a sample meal plan for her to meet the nutritional needs of herself and her breastfed infant. How many additional calories should the nurse encourage the mother to include?

A. 300 kcal/day B. 500 kcal/day C. 700 kcal/day D. 1000 kcal/day Answer: B Rationale: In order to meet the increased energy requirements for breastfeeding, women need an additional 500 kcal/day above prepregnancy diet needs. Less than 500 would not provide enough, and over 500 would be too much and could create additional issues such as obesity.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 311-312 22. The nurse is preparing a care plan for a new mother who desires to breastfeed.

Which action should the nurse prioritize if the mother has a history of breast implants?

A. Give the mother a trial of breastfeeding.

B. Encourage the mother to use formula.

C. Seek approval from health care provider for breastfeeding.

D. Consult a lactation specialist for assistance.

Answer: D Rationale: Any woman with a history of breast surgery or abnormal nipples may need additional assistance with breastfeeding by a lactation consultant. This consultant will know the best plan of action to assist this mother in breastfeeding.

The health care provider's permission is not required. The nurse should not advise the mother to just try breastfeeding to see if it works or to encourage formula feeding, but instead should provide the mother with the proper support.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 312 23. The nurse is assisting a new couple with breastfeeding. The nurse points out which common position will place the mother and baby "tummy-to-tummy?"

A. side-lying B. football hold C. cradle hold D. cross-cradle hold Answer: C Rationale: The cradle hold is the most common hold used in breastfeeding. It places the mommy and baby tummy-to-tummy, as the newborn's lower arm is tucked between the mom's arm and breast. This position works well for most infants and most sized breasts. A football hold is recommended for women with large breasts, who have undergone surgery, or have twins. In the side-lying position, the woman can rest while feeding her newborn. There is no hold referred to as the cross-cradle hold.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 313 24. The nurse is monitoring a new mother as she breastfeeds her 1-day-old infant.

The nurse determines more instruction is necessary when the infant uses which action to latch on?

A. wide open mouth B. tongue down

C. part of areola D. nipple tip only Answer: D Rationale: The infant needs to take the entire nipple and most of the areola to compress the milk ducts for let-down of the milk. If the infant is not latched on the breast, the most common problem is pain with breastfeeding. Instructions for latching the infant on the breast would include the infant having a wide-open mouth with the tongue down as if yawning.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 313 25. The nurse is assessing the breastfeeding sessions of a newborn by looking at a log of the duration of these sessions. The nurse determines the mother is successfully learning the process after noting which time frame for nursing?

A. 5 to 10 minutes each side B. 10 to 20 minutes each side C. 20 to 30 minutes each side D. 30 to 40 minutes each side Answer: B Rationale: Nursing sessions should last approximately 10 to 20 minutes per breast; this should allow the infant time to fully remove all milk from the breast in that duration. Nursing less than 10 minutes would not allow the infant time to empty the breast and will result in less milk production. Nursing for longer than 20 minutes will result in the infant suckling on empty breasts and can result in sore breasts. It will also frustrate the infant, as suckling will not provide the desired result of getting fed.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 314-315 26. A new mother brings her 2-week-old infant to the clinic for a well-baby visit and reports there are days when the baby wants to nurse all the time. Which instruction should the nurse prioritize to this mother?

A. Increase the feeding to on-demand.

B. Offer formula in addition to breastfeeding.

C. Pump and offer the breast milk in a bottle.

D. Offer only formula during the growth spurt.

Answer: A Rationale: As the infant enters growth spurts, the infant will demand more milk, which in turn increases the milk production, ensuring there will be enough to meet the needs. Nursing the infant on-demand and increasing the frequency of breastfeeding and the duration of the feedings will increase the milk supply.

Offering formula in addition to breastfeeding, or offering exclusively formula during the growth spurt, is not recommended. Pumping and offering the breast milk in a bottle is not necessary and is not recommended.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 316 27. A breastfeeding mother, 1-month postpartum, calls the clinic and reports left breast soreness, a temperature of 100.4°F (38°C), and feeling tired all the time.

The nurse suspects the mother is experiencing which situation after revealing she is still trying to breastfeed on a regular schedule?

A. plugged milk duct B. engorgement C. mastitis D. breast yeast infection Answer: C Rationale: Mastitis is a problem associated with breastfeeding and is an infection of the breast tissue. The woman will need antibiotic therapy to resolve this infection. A plugged milk duct is usually indicated by a sore, reddened, hard lump in one area of her breast. Engorgement is the filling of the breast with milk when the mother's milk comes in. Breast yeast infection is not indicated.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 315-316 28. The nurse is conducting a training session for breastfeeding mothers who are planning to return to work. As the nurse allows the mothers to examine the various pumps available, which instruction should the nurse prioritize to describe the best method for pumping?

A. Single pump and alternate breast every 5 minutes for a total of 30 minutes.

B. Double pump for a full 20 minutes.

C. Double pump for 10 minutes then change to single for another 5 minutes each.

D. Pump, either double or single, until the last drop is out.

Answer: B Rationale: The best method for pumping and return to work is to double pump with an electric pump. The other options are not as effective in totally pumping the breast to provide adequate milk; they also require more time to perform, which may be a factor if the woman does not have a break that will allow this time frame.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 317 29. A primigravida is trying to decide whether to breastfeed or use a formula to feed her infant. When asking the nurse about the disadvantages of using a formula, which response should the nurse prioritize?

A. increased risk of otitis media B. increased risk of allergies C. inferior nutrition with no immunologic properties D. harder to digest Answer: C Rationale: The most concerning disadvantage to formula over breast milk is the inferior nutrition of formula. Formula lacks any of the immunologic properties of breast milk. Formula feeding does increase the risk of otitis media and allergies, and it is also harder for the infant to digest; however, these factors do not have the most significant impact on the infant.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 318 30. The nurse is assigned to care for a new mother and her formula-fed 2-day-old infant. Which action should the nurse prioritize for this mother after receiving the report from the previous shift nurse?

A. Ask the mother what formula she wants to use.

B. Use the standard formula in the unit's supply room.

C. Check the provider order to confirm the type of formula ordered.

D. Offer the mother the opportunity to try breastfeeding.

Answer: C Rationale: The first action by the nurse after receiving the report is to check provider orders and confirm the information passed in the report. It would not be

appropriate for the nurse to ask the mother what formula she wants to use or to use the formula that is in the unit's supply room. It is also inappropriate to discuss the mother's choice of feeding in an attempt to sway her decision.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 318 31. The nurse is reviewing discharge instructions with a young couple. The nurse determines they understand how to properly use prepared formula and will discard any leftover refrigerated formula after which time frame?

A. 12 hours B. 24 hours C. 36 hours D. 48 hours Answer: B Rationale: Once formula is mixed it should be stored in the refrigerator until ready to use. Once a bottle is warmed and the infant has drank from it, any leftover contents need to be discarded. Any pre-prepared formula not used in a 24-hour period should be discarded as well.

Question format: Multiple Choice Chapter 15: Newborn Nutrition Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 320

Chapter 16 1. Between her regularly scheduled visits, a woman in her first trimester of pregnancy who is taking iron supplements for anemia calls the nurse at her obstetrician's office reporting constipation. She reports that she has never had this problem before and asks for some advice about how to get relief. What is the best advice the nurse can give her?

A. Stop taking iron supplements for a few days, exercise more, drink more fluids, eat high-fiber, low-iron foods until the constipation is relieved, then resume the iron supplement.

B. Continue taking iron supplements but increase fluids and high-fiber foods; exercise more.

C. Increase the iron supplements, fluid intake, and consumption of high-fiber foods; exercise more.

D. Take the iron supplement every other day, increase fluid intake and consumption of high-fiber foods; exercise more.

Answer: B Rationale: Constipation is a common side effect of iron supplementation. The diagnosis of anemia indicates a true need for the iron supplementation; she needs to increase fluid and fiber to relieve the constipation associated with the iron preparations. The nurse should not advise this client to stop taking her iron supplements, even for a few days. The nurse should not advise the client to increase her iron supplementation, nor take the supplements on an every other day basis. These supplements are ordered by the primary care provider based on the client's hematologic status.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 337 2. A 14-year-old client and her parents have presented at the obstetrician's office in the second trimester; the teen had been hiding the pregnancy. The nurse is helping them develop a plan of care. What is the best thing the nurse can say to the clearly angry parents?

A. "Your daughter needs to make decisions about this pregnancy for herself."

B. "I know you must be very upset and angry about your daughter's pregnancy, but because she's still an adolescent herself, she'll need your guidance in making nutritional and health choices that will be good for the baby and for herself."

C. "Anger won't help this situation at all. You'll only push your daughter away, and she'll be less likely to make good choices."

D. "I understand your anger, but if you had encouraged your daughter to use condoms she would probably not be in this situation."

Answer: B Rationale: The nurse needs to acknowledge the anger of the parents but remember her role is as the client advocate. The nurse needs to encourage the relationship of support between the parents and the client. The nurse should not attempt to lay down ground rules between the client and her parents, and the nurse should acknowledge the parents' feelings in this situation. It is inappropriate to lecture or place blame on the parents.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 351 3. A 43-year-old, physically fit, healthy woman who is newly married tells the nurse that she and her husband would like to have a child. What is an appropriate first response?

A. "You must know that's pretty risky. Have you thought about adopting instead?"

B. "Well, I'm sure you know there are some risks involved so it's helpful that you've been taking such good care of yourself."

C. "You're in great shape now, but are you sure that at your age you'll have enough energy to care for a child?"

D. "If you got pregnant now you'd be at risk for multiple fetal pregnancies, chromosomal abnormalities, spontaneous abortion (miscarriage), and hypertension among other things. Are you ready to take that risk?"

Answer: B Rationale: The nurse needs to be positive and supportive in client response and relationship, but honest about the risk involved with advanced maternal age. Option A is incorrect; the nurse should not suggest to the mother that she adopt instead of having her own child. Option C is incorrect as it is not supportive of the mother and it suggests that she could not care for a child if she had one. Option D is incorrect as it challenges the mother's thinking and indicates that the risks outweigh the desire for a child.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 352 4. A woman's baby is HIV positive at birth. She asks the nurse if this means the baby will develop AIDS. Which statement would be the nurse's best answer?

A. "She already has AIDS. That's what being HIV positive means."

B. "The antibodies may be those transferred across the placenta; the baby may not develop AIDS." C. "HIV is transmitted at birth; having a cesarean birth prevented transmission."

D. "HIV antibodies do not cross the placenta; this means the baby will develop AIDS." Answer: B Rationale: Infants born of HIV-positive women test positive for HIV antibodies at birth because these have crossed the placenta. An accurate disease status cannot be determined until the antibodies fade at about 18 months. Testing positive for HIV antibodies does not mean the infant has AIDS. Having a cesarean birth does decrease the risk of transmitting the virus to the infant at birth; it does not prevent the transmission of the disease. HIV antibodies do cross the placenta, which is why babies born of HIV positive mothers are HIV positive.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Caring Reference: p. 334 5. A pregnant single mom living alone tells the nurse she is considering getting a cat for her 2-year-old daughter. Which is the best response by the nurse?

A. "The exposure to the cat litter may cause you to need a C-section."

B. "This will cut down on the jealousy for your two-year-old when the baby comes."

C. "If you don't think caring for a cat is too much work, that would be great."

D. "You should wait until after you give birth to obtain the cat for your daughter."

Answer: D Rationale: Toxoplasma gondii is a protozoan that can be transmitted via undercooked meat and through cat litter. Having a cat is not an issue, but cleaning the litter box may expose the mother to the infection and result in fetal anomalies.

Exposure to the cat litter will not necessitate a cesarean section, and having a cat will not cut down on any jealousy the 2-year-old might feel when the new baby is born. The nurse would discourage the mother from getting cat until after the baby is born.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 341 6. A postpartum mother has the following lab data recorded: a negative rubella titer. What is the appropriate nursing intervention?

A. No action needed.

B. Administer rubella vaccine before discharge.

C. Assess the rubella titer of the baby.

D. Notify the health care provider.

Answer: B Rationale: Rubella is a virus, which when contracted during pregnancy has significant complications for the fetus. The illness is mild to the adult but can result in the infant being born deaf and blind. There is no cure; the CDC recommends all individuals be vaccinated against rubella. If the titer is negative, the mother does not have protection against rubella, and the next pregnancy would be at risk. She should receive the vaccination prior to discharge from the hospital. Assessing the rubella titer of the baby would not mean anything. The baby has not had rubella and has not received antibodies against rubella from the mother. Notifying the health care provider is not a priority, as most institutions have standing orders to administer the rubella vaccine if the mother's rubella titer is negative.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 342 7. When providing education to a prenatal care class for teenagers, the nurse states that infants born to teenage mothers are more likely to have which outcome?

A. genetic problems B. postdate birth C. low-birth-weight D. lower mortality rates Answer: C Rationale: Infants born to adolescent mothers are more likely to have a low birth weight and poor outcomes and higher mortality rates when compared to infants of older mothers. Infants born to teenage mothers are not more likely to have genetic problems; they are more likely to be born preterm rather than postterm.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 351 8. A 21-year old client arrives at the prenatal clinical at 12 weeks' gestation and has a positive STI. Which of the following should the nurse be aware of that would indicate the client is at high risk for noncompliance with treatment for the STI? A. has a job and health insurance B. noted to have history of substance abuse

C. lives with parents who are supportive of pregnancy D. monogamous relationship with father of the baby Answer: B Rationale: Clients with a history of substance abuse are less likely to follow the treatment plan. Substance abuse is an indicator of risky behaviors and a consideration for high-risk of developing other social problems such as multiple sexual partners. Having a job and health insurance, living with parents who are supportive of the pregnancy, and having a monogamous relationship with the father are indications of the client being likely to follow the treatment plan.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 345 9. A woman with class II heart disease is experiencing an uneventful pregnancy and is now prescribed bed rest at 36 weeks' gestation by her health care provider. The nurse should point out that this is best accomplished with which position?

A. Lie flat on her back.

B. Stay in high Fowler position.

C. Lie in a semi-recumbent position.

D. Use pillows and wedges to stay in a fully recumbent position.

Answer: C Rationale: Semi-recumbent position is the best position for circulation of the mother and fetus. Lying flat on the back can induce supine hypotensive syndrome and fully recumbent impedes other circulation. The high Fowler position would not be comfortable for sleeping, as well as possibly impede the blood flow through the hips and lower abdomen.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 335 10. A G4P3 client with a history of controlled asthma is upset her initial prenatal appointment is taking too long, making her late for another appointment. What is the nurse's best response when the client insists she knows how to handle her asthma and needs to leave?

A. Remind her to continue taking asthma medications, to monitor peak flow daily, and to monitor the baby's kicks in the second and third trimesters.

B. Acknowledge her need to leave but ask her to demonstrate the use of inhaler and peak flow meter before she goes; remind her to take regular medications.

C. Schedule an appointment for her to return to discuss her asthma management.

D. Note in the chart that the woman was not counseled about her asthma.

Answer: B Rationale: Management of asthma during pregnancy is very important; the nurse must document that the client has the proper ability to manage her asthma for her health and the health of the fetus. Reminding the client to continue taking her prescribed medication and to monitor her peak flow daily is not enough. It is the nurse's responsibility to know that the client knows how to take her medications.

Monitoring the baby's kicks in the second and third trimester is an appropriate action. Scheduling a return appointment to discuss asthma management is not appropriate. She could have an asthma attack between the time the nurse sees her and the time of the return appointment. Noting in the chart that the woman was not counseled does not relieve the nurse of his/her obligation to ensure that the woman knows how to use her inhaler and her peak flow meter.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 339 11. A 32-year-old woman with epilepsy mentions to the nurse during a routine wellvisit that she would like to have children and asks the nurse for advice. Which response is most appropriate from the nurse?

A. "You should talk to the doctor about that; the medications you're on can damage the fetus."

B. "Do you want to talk to a counselor who can help you weigh the pros and cons of having your own child rather than adopting?"

C. "I'll let the doctor know so you can discuss your medications. In the meantime, I'll give you a list of folate-rich foods you can add to your diet."

D. "That's great. I've got a 4-year-old and a 2-year-old myself."

Answer: C Rationale: Any woman with epilepsy needs to discuss medication management with her provider. The current research indicates the medications used for epileptic management are the major cause of birth defects for these clients. The nurse should be careful about mentioning that some epilepsy medications are teratogenic; some women may stop taking their medications in order to get pregnant.

Suggesting adoption is inappropriate as the mother has given no indication she is interested in adoption; also, the mother needs to discuss this with the physician so that she can get accurate information about being on anti-seizure medications and being pregnant. The nurse should not share personal information as it does not assist this client in making a serious decision. The client should be referred to the health care provider to help the client make the best decision.

Question format: Multiple Choice

Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 340 12. The nurse is assessing a primigravida woman who reports vaginal itching, a great deal of foamy yellow-green discharge, and pain during intercourse. The nurse suspects the woman has contracted which disorder?

A. chlamydia B. simple yeast infection C. trichomoniasis D. gonorrhea Answer: C Rationale: Trichomoniasis is caused by a one-celled protozoa. The symptoms include large amounts of foamy, yellow-green vaginal discharge. Treatment is with metronidazole, and her partner needs to be treated as well. A yeast infection presents with a cottage cheese-like discharge. Chlamydia often has no symptoms.

If the woman does experience symptoms, these may include vaginal discharge, abnormal vaginal bleeding, and abdominal or pelvic pain. Gonorrhea may have symptoms so mild that they go unnoticed in the woman. The woman who contracts gonorrhea may have vaginal bleeding during sexual intercourse, pain and burning while urinating, and a yellow or bloody vaginal discharge.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 345 13. The nurse is preparing a postpartum nursing care plan for a single HIV-positive primigravida client. The nurse should prioritize in the plan how to acquire which resource?

A. breast pump B. diapers C. car seat D. formula Answer: D Rationale: It is possible to transmit HIV via breastfeeding, and formula is the only option for feeding. The nurse needs to provide positive information and offer to make a referral or get assistance for clients who may be in financial need. In this case, acquiring adequate amounts of formula would be the priority. The diapers and a car seat are also necessary but would follow the formula. The client would not need a breast pump since she cannot give the milk to her baby.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 345 14. The nurse is assessing a client with type I diabetes who has just been informed she is 8 weeks' pregnant. The nurse should explain that her health care provider will probably refer her to which specialist to assist with this high-risk pregnancy?

A. endocrinologist B. obstetrician C. neonatologist D. perinatologist Answer: D Rationale: A perinatologist is a physician specializing in the care of women who have high-risk pregnancies. The endocrinologist would assist the perinatologist with controlling the diabetes but would not assume total care of the pregnancy. An obstetrician is a physician who specializes in the care of pregnancies. A neonatologist is a physician who specializes in the care of neonates (infants up to 28 days of age).

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 329 15. The nurse is leading a discussion with a group of pregnant women who have diabetes. The nurse should point out which situation can potentially occur during their pregnancy?

A. Small-for-gestational-age (SGA) infant B. Polyhydramnios C. Postterm birth D. Hypotension of pregnancy Answer: B Rationale: Polyhydramnios is an increase, or excess, in amniotic fluid and is a pregnancy-related complication associated with diabetes. An infant who is smallfor-gestational-age is not associated with a mother who had diabetes prior to pregnancy. Other pregnancy-related complications associated with pregestational diabetes mellitus include hypertensive disorders, preterm birth, and shoulder dystocia.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 334 16. The nurse is preparing information for a client who has just been diagnosed with gestational diabetes. Which instruction should the nurse prioritize in this information?

A. Maintain a daily blood glucose log B. Report any signs of possible urinary tract infection C. Plan daily menus with dietitian D. Long-term therapy goals Answer: A Rationale: Control of the blood glucose throughout the pregnancy is the primary goal to help decrease potential complications to both the mother and fetus. The mother should keep a daily log of her blood glucose levels and bring this log to each visit for the nurse to evaluate. The other choices of reporting possible signs of a UTI and working with a dietitian to plan menus would also be important but would be secondary to the blood glucose control. It would be inappropriate to discuss longterm goals at this time. This would be handled at a later time and would depend on the mother's situation.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 333 17. A G2P1 woman with type 1 diabetes is determined to be at 8 weeks' gestation by her health care provider. The nurse should point out which factor will help the client maintain glycemic control?

A. Vitamin supplements B. Oral hypoglycemic agents C. Exercise D. Plenty of rest Answer: C Rationale: The three main facets to glycemic control for the woman with pregestational diabetes are diet, exercise, and insulin. An individual with type 1 diabetes uses insulin and not oral hypoglycemic agents. Vitamin supplements may assist with helping to keep the woman healthy but not necessarily through glycemic control. It will be important for the woman to get enough rest throughout the pregnancy but this will not assist with glycemic control.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 330 18. A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?

A. "Your primary care provider will order safe doses of your medication."

B. "It's OK to not use them if you would feel more comfortable."

C. "They won't cause any major defects."

D. "I'll let your primary care provider know how you feel about it."

Answer: A Rationale: Women should take no medication during pregnancy except that prescribed by their primary care provider. The PCP will work with the mother to ensure the safest amount is given to adequately handle the mother's health issues and not injure the fetus. The PCP must weigh the risks against the benefits for both the mother and her fetus. The nurse should not encourage the client to stop her asthma medication as that may result in the client having an asthma attack, which could result in injury to the fetus or even miscarriage. The nurse should not tell the client a drug will not cause any defects, especially if it is known that it can. That could make the nurse liable for damages. The nurse should inform the PCP of the client's concerns; however, it is more important for the nurse to calm the client's anxiety and offer positive reinforcement that the PCP is working hard to protect the mother and infant from harm.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 339 19. A pregnant woman with sickle cell anemia is very concerned her infant will also develop the disease and questions the nurse about that possibility. Which is the best response from the nurse?

A. Both parents have to carry the trait.

B. There is a good chance the infant will inherit the disease from the mother.

C. The infant inherits the disease from the father.

D. If the mother goes into a crisis while pregnant, the baby will develop sickle cell anemia.

Answer: A Rationale: Sickle cell anemia is an autosomal recessive disease requiring that the person have two genes for the disease, one from each parent. If one parent has the disease and the other is free of the disease and trait, the chances of the child

inheriting the disease is zero. The infant will not develop the disease just because the mother has a crisis during the pregnancy.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 338 20. The nurse is preparing to teach a pregnant client with iron deficiency anemia about the various iron-rich foods to include in her diet. Which food should the nurse point out will help increase the absorption of her iron supplement?

A. Dried apples B. Fortified grains C. Dried beans D. Orange juice Answer: D Rationale: Anemia is a condition in which the blood is deficient in red blood cells, from an underlying cause. The woman needs to take iron to manufacture enough red blood cells. Taking an iron supplement will help improve her iron levels, and taking iron with foods containing ascorbic acid, such as orange juice, improves the absorption of iron. Dried fruit (such as apples), fortified grains, and dried beans are additional food choices that are rich in iron and should be included in her daily diet.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 337 21. A woman with a positive history of genital herpes is in active labor. Assessment reveals vesicles in the perineum area, membranes are ruptured, dilated 5 cm, and effaced 70%. The nurse should prepare the client for which type of birth?

A. Spontaneous vaginal B. Vacuum-assisted C. Cesarean D. Forceps-assisted Answer: C Rationale: An active herpes infection can be passed to the fetus during labor or with ruptured amniotic membranes. The nurse should anticipate the infant will be born via a cesarean birth. The risk of transmitting herpes to the baby would be increased if the baby were born by spontaneous vaginal birth, vacuum-assisted birth, or forceps-assisted birth.

Question format: Multiple Choice

Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 343 22. A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?

A. Decrease activity and rest more often.

B. Increase fluids and take more vitamins.

C. Bed rest and bathroom privileges only until birth.

D. Discuss induction of labor with the health care provider.

Answer: A Rationale: If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend an increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 335 23. The nurse is caring for a pregnant client who has a class II heart disease. The nurse is prepared to intensify monitoring during which period of the pregnancy?

A. first trimester B. second trimester C. third trimester D. All are at equal risk.

Answer: B Rationale: The periods of greatest risk for the pregnant woman with a cardiac disease are at the end of the second trimester (when blood volume peaks), during labor, and in the early postpartum period secondary to fluid shifts.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 335

24. A 17-year-old primigravida at 37 weeks' gestation has been unable to maintain adequate control of her blood glucose throughout her pregnancy. The nurse should prioritize which action after the health care provider suspects the infant has macrosomia based on the recent ultrasound?

A. Schedule induction of labor today.

B. Allow her to continue without plans for delivery.

C. Schedule cesarean birth at 39 weeks.

D. Prepare for assessment of fetal lung maturity.

Answer: D Rationale: If the infant has macrosomia, is large for gestational age, and the mother has had poor blood sugar control, the provider will want further information on the fetus and readiness for delivery before making any decisions on delivery.

This will best be accomplished by an amniocentesis to assess the fetal lung maturity. Scheduling an induction of labor, allowing the client to continue without plans for birth, or scheduling a cesarean birth at 39 weeks would not be appropriate nursing actions. Scheduling an induction or a cesarean birth is not in the province of a nurse without a physician's order.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 330 25. A nurse working at the local health district clinic assists numerous adolescents who become pregnant. Which factor will the nurse tell the teens is crucial for a positive pregnancy outcome?

A. Cultural sensitivity B. Support network C. Involvement of the father D. Acceptance by peers Answer: B Rationale: One crucial part of management of teenage adolescent pregnancy includes helping the teens to develop an adequate support network. The network may include parents, teachers, friends and the father of the baby, in addition to resources needed to provide care for the infant and self. Cultural sensitivity, involvement of the father, and acceptance by peers are important to the teenager who is pregnant, but they are not considered crucial for a positive pregnancy and outcome for the mother and fetus.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process

Reference: p. 351 26. A 38-year-old client, G4P3, at 10 weeks' gestation with an unplanned pregnancy, has concerns the fetus may have a genetic defect. The nurse should point out which test would be the best current choice to investigate the possibility of a chromosomal abnormality?

A. amniocentesis B. chorionic villus sampling (CVS) C. maternal serum alpha-fetoprotein D. triple screening Answer: B Rationale: Chorionic villus sampling is the earliest method (8 to 10 weeks' gestation) to test fetal genetics for anomalies. This testing might be offered if the mother wants specific information on the genetics of the fetus as early as possible in pregnancy. Amniocentesis is generally done between 14 and 18 weeks' gestation, but can be done as early as 10 weeks' gestation. Maternal serum alpha-fetoprotein test is usually done at 16 to 20 weeks' gestation, and triple screening is performed between 15 and 20 weeks' gestation.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 352 27. The nurse is educating a client with type 1 diabetes about the complications associated with diabetes and pregnancy. Which problems would the nurse include in her teaching? Select all that apply.

A. Decreased birth weight B. Increased risk of spontaneous abortion (miscarriage) C. Polyhydramnios D. Hypertension E. Cystic fibrosis Answer: B, C, D Rationale: Women with pregestational diabetes, which is type 1 diabetes, are at a higher risk of having an infant with complications during the pregnancy and at the birth. Spontaneous abortion (miscarriage) is higher in women who have pregestational diabetes. Also, they run a higher risk of having a pregnancy with polyhydramnios, and of developing maternal hypertension. The birth weight of an infant born to a mother with diabetes is increased, not decreased. Cystic fibrosis is not associated with maternal diabetes.

Question format: Multiple Select Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 329 28. An infant is born to a mother with gestational diabetes. Which long-term maternal complication is associated with this diagnosis?

A. Increased risk of development of type 2 diabetes B. Weight gain that is not lost after the pregnancy C. Development of long-term hypertension D. Heart disease Answer: A Rationale: A mother who had gestational diabetes is at a 30% to 50% higher risk of developing type 2 diabetes mellitus than the general population. Long-term hypertension and heart disease are not associated with gestational diabetes, nor is weight gain following pregnancy. There is no data that validates long-term weight gain as a complication of gestational diabetes.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 329 29. A pregnant client with type I diabetes asks the nurse about how to best control her blood sugar while she is pregnant. The best reply would be for the woman to: A. limit weight gain to 15 pounds during the pregnancy.

B. check her blood sugars frequently and adjust insulin accordingly.

C. exercise for 1 to 2 hours each day to keep the blood glucose down.

D. begin oral hyperglycemic medications along with the insulin she is currently taking.

Answer: B Rationale: The goal for a mother who has type I diabetes mellitus is to keep tight control over her blood sugars throughout the pregnancy. Therefore, she needs to test her blood sugar frequently during the day and make adjustments in the insulin doses she is receiving.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 330 30. The nurse is conducting a class for pregnant women on problems associated with infections seen in women during gestation. One mother tells the nurse that she

has never had chickenpox (varicella) and is worried she will contract it before she delivers. What would the nurse explain to this mother to ease her anxiety?

A. She can receive her varicella vaccine immediately after delivery, followed by a second dose at her 6-week postpartum visit.

B. The likelihood of her catching varicella is very slim, so tell her not to worry.

C. She needs to let her physician know that she has not had varicella so she can get immunized at her next visit.

D. Even if she does get varicella, her baby will be fine since varicella is not passed on to the fetus.

Answer: A Rationale: Varicella zoster is spread by respiratory droplets and is easily contracted if the mother is exposed. If the mother does contract varicella, especially from weeks 12 to 20 of gestation, it can be devastating to the fetus. Birth defects, central nervous system damage, low birth weight, cognitive delays and deafness can all occur. However, a mother cannot receive a varicella immunization during pregnancy since the immunization can cross the placenta and act like the actual disease, causing the same effects. The mother is immunized prior to discharge after delivery and at her 6-week postpartum visit.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 342 31. The nurse is assessing a 35-year-old woman at 22 weeks' gestation who has had recent laboratory work. The nurse notes fasting blood glucose 146 mg/dl (8.10 mmol/L), hemoglobin 13 g/dl (130 g/L), and hematocrit 37% (0.37). Based on these results, which instruction should the nurse prioritize?

A. Check blood sugar levels daily.

B. the signs and symptoms of urinary tract infection C. Include iron-enriched foods in the diet.

D. Take daily iron supplements.

Answer: A Rationale: An elevated blood glucose is concerning for diabetes. A fasting blood glucose level of greater than 140 mg/dl (7.77 mmol/L) or random level of greater than 200 mg/dl (11.10 mmol/L) is concerning; this must be followed up to ensure the client is not developing gestational diabetes. The hemoglobin and hematocrit are within normal limits for this client. The values should be hemoglobin greater than 11 g/dl (110 g/L) and hematocrit greater than 33% (0.33). Values lower than that are possible indications of anemia and would necessitate further evaluation. An individual with higher than normal blood glucose levels is at risk for developing urinary tract infection. This will usually happen after the glucose levels are

elevated. Anemia can be treated by increasing the consumption of iron-enriched foods and taking a daily iron supplement.

Question format: Multiple Choice Chapter 16: Pregnancy at Risk: Conditions that Complicate Pregnancy Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 330

Chapter 17 1. A woman at 8 weeks' gestation is admitted for ectopic pregnancy. She is asking why this has occurred. The nurse knows that which factor is a known risk factor for ectopic pregnancy?

A. high number of pregnancies B. multiple gestation pregnancy C. use of oral contraceptives D. history of endometriosis Answer: D Rationale: The nurse needs to complete a full history of the client to determine if she had any other risk factors for an ectopic pregnancy. Adhesions, scarring, and narrowing of the tubal lumen may block the zygote's progress to the uterus. Any condition or surgical procedure that can injure a fallopian tube increases the risk.

Examples include salpingitis, infection of the fallopian tube, endometriosis, history of prior ectopic pregnancy, any type of tubal surgery, congenital malformation of the tube, and multiple abortions (elective terminations of pregnancy). Conditions that inhibit peristalsis of the tube can result in tubal pregnancy. A high number of pregnancies, multiple gestation pregnancy, and the use of oral contraceptives are not known risk factors for ectopic pregnancy.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 366 2. An 18-year-old pregnant client is hospitalized as she recovers from hyperemesis gravidarum. The client reveals she wanted to have an abortion (elective termination of pregnancy) but her cultural background forbids it. She is very unhappy about being pregnant and even expresses a wish for a miscarriage. Which action by the nurse is most appropriate?

A. Encourage the client to be positive about the situation.

B. Continue to monitor the client's hyperemesis gravidarum.

C. Contact the health care provider to report the client's feelings.

D. Share the information with the client's family.

Answer: C Rationale: The client may be experiencing a psychological situation that needs intervention by a trained professional in the area of mental health. The hyperemesis gravidarum may worsen her feelings toward the pregnancy, so reporting her feelings to the health care provider is the best action at this time. Although the nurse will continue to monitor the client's hyperemesis gravidarum, this is not the

only action needed at this time and there is a better action. Encouraging the client to be positive about her situation may obstruct therapeutic communication. Sharing the information with the client's family is not appropriate, because the scenario described does not indicate that the nurse has the client's permission to share this information with the family.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 357 3. A 28-year-old client with a history of endometriosis presents to the emergency department with severe abdominal pain and nausea and vomiting. The client also reports her periods are irregular with the last one being 2 months ago. The nurse prepares to assess for which possible cause for this client's complaints?

A. Healthy pregnancy B. Ectopic pregnancy C. Molar pregnancy D. Placenta previa Answer: B Rationale: The most commonly reported symptoms of ectopic pregnancy are pelvic pain and/or vaginal spotting. Other symptoms of early pregnancy, such as breast tenderness, nausea, and vomiting, may also be present. The diagnosis is not always immediately apparent because many women present with complaints of diffuse abdominal pain and minimal to no vaginal bleeding. Steps are taken to diagnose the disorder and rule out other causes of abdominal pain. Given the history of the client and the amount of pain, the possibility of ectopic pregnancy needs to be considered. A healthy pregnancy would not present with severe abdominal pain unless the client were term and she was in labor. With a molar pregnancy the woman typically presents between 8 to 16 weeks' gestation reporting painless (usually) brown to bright red vaginal bleeding. Placenta previa typically presents with painless, bright red bleeding that begins with no warning.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 360 4. The nurse is giving discharge instructions to a client who experienced a complete spontaneous abortion (miscarriage). Which question should the nurse prioritize at this time?

A. "Are you going to wait a while before you try to get pregnant again?"

B. "Do you have someone to talk to, or may I give you the names and numbers for some possible grief counselors?"

C. "Did you know that 75% of women who are trying to get pregnant experience this same thing?"

D. "May I give you some resources that you can use to try to prevent this from happening again?"

Answer: B Rationale: When a woman has a spontaneous abortion (miscarriage) one important consideration is the emotional needs of the woman once she is home. She may not want to talk about the loss for a period of time, but the nurse needs to determine her support system for the future. Asking the woman if she is "going to try again" is an inappropriate question for the nurse to ask and diminishes the experience of having a spontaneous abortion (miscarriage). It would be inappropriate to point out the woman is not the only one to have this experience or to offer ways to prevent it from happening in the future. The woman needs to deal with this situation first before moving on to a possible "next" time.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 361 5. The nurse is preparing discharge instructions for several clients after their admission for emergent care of a pregnancy complication. The nurse will stress the importance of frequent and continuous office visits to the client with: A. a molar pregnancy.

B. an ectopic pregnancy.

C. a complete spontaneous abortion (miscarriage).

D. Rh negative blood.

Answer: A Rationale: Molar pregnancies can indicate the possibility of developing malignancy.

The woman will need close observation and follow-up for a year, every 1 to 2 weeks for hCG levels to detect cancer. A follow-up visit after an ectopic pregnancy or a complete spontaneous abortion (miscarriage) are typically scheduled at 6 weeks, not monthly. A woman who is Rh negative does not need a follow-up visit because of her Rh status, but would be scheduled as per routine postpartum visits.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Teaching/Learning Reference: p. 364

6. A woman at 31 weeks' gestation presents to the emergency department with bright red vaginal bleeding, reporting that the onset of the bleeding was sudden and without pain. Which diagnostic test should the nurse prioritize?

A. A digital cervical exam B. Nonstress test C. Electronic fetal monitoring D. A transvaginal ultrasound Answer: D Rationale: For any pregnant woman who presents with painless bleeding, placenta previa needs to be ruled out by either transvaginal or abdominal ultrasound. A digital cervical exam is contraindicated until placenta previa has been ruled out, as digital manipulation of placental tissue through the cervical os can cause uncontrollable bleeding. The nonstress test and electronic fetal monitoring would be utilized after the woman is stabilized and placenta previa has either been diagnosed or ruled out.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 366 7. A 24-year-old client is brought to the emergency department complaining of severe abdominal pain, vaginal bleeding, and fatigue. On assessment, the nurse notes cool, clammy skin; confusion; and vital signs as the following: HR 130, RR 28, and BP 98/60 mm Hg. Which action should the nurse prioritize?

A. Rule out shock.

B. Rule out pregnancy.

C. Attach EFM. D. Establish IV access.

Answer: A Rationale: Any time a client presents with hemorrhage, the initial nursing consideration is assessment and evaluation of shock. The next step would be to treat the shock, which could include establishing IV access and providing the client with fluids. After the client is more stable, then the source of the bleeding would be determined. In this case, that would include performing a pregnancy test to determine if the client is pregnant to rule out a placenta complication. If it is determined that the client is pregnant, the fetus would be assessed, which could include using an EFM depending on the approximate age of the fetus.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 370 8. A 28-year-old client and her current partner present for the first prenatal appointment with the ob/gyn. The client has no children but does question a possible miscarriage 2 years ago; however, she never sought medical attention because she felt fine. Labs reveal both client and partner are Rh negative. Which action should the nurse prioritize?

A. Perform direct Coombs test.

B. Assess client for anti-D antibodies.

C. Arrange for an amniocentesis.

D. Continue with routine procedures and tasks.

Answer: B Rationale: The client should be checked for sensitization to Rh-positive blood. It is unknown if the client did have a miscarriage earlier, and if so, what the blood type was of the fetus. The risk is high for the current fetus to be affected with hemolytic disease, and this can be easily ruled out by assessing the mother for sensitization.

If this screening is negative, then no further testing is required. If the father were Rh positive, then the mother be given Rho(D) immune globulin to prevent the woman from developing antibodies to the Rho(D) factor. However, if it is positive, the health care provider may order an amniocentesis to evaluate the fetus for hemolytic disease so proper treatment and monitoring may be given. It is too early to perform a direct Coombs test. It would be improper to ignore the potential of serious complications and simply continue with routine tasks and procedures at this time.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 358 9. The nurse is assisting a client who has just undergone an amniocentesis. Blood results indicate the mother has type O blood and the fetus has type AB blood. The nurse should point out the mother and fetus are at an increased risk for which situation related to this procedure?

A. Placental abruption (abruptio placentae) B. Preterm birth C. Baby developing hemolytic anemia D. Baby developing postbirth jaundice Answer: D Rationale: The infant and mother have ABO incompatibility. The result is a development of antibodies and breaking down of the blood, resulting in jaundice in the infant after delivery. The mixing of some fetal blood with maternal blood during the amniocentesis would not cause placental abruption or preterm birth. Hemolytic

anemia is caused by Rh incompatibility. ABO incompatibility will cause hemolytic disease.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 359 10. The nurse is assessing a 37-year-old woman who has presented in active labor and notes the client has an increased risk for placental abruption (abruptio placentae). Which assessment finding should the nurse prioritize?

A. Sharp fundal pain and discomfort between contractions B. Painless vaginal bleeding and a fall in blood pressure C. Pain in a lower quadrant and increased pulse rate D. An increased blood pressure and oliguria Answer: A Rationale: A placental abruption (abruptio placentae) refers to premature separation of the placenta from the uterus. As the placenta loosens, it causes sharp pain. Labor begins with a continuing nagging sensation. Painless vaginal bleeding and a fall in blood pressure are indicative of placenta previa. Pain in a lower quadrant and increased pulse rate are indicative of an ectopic pregnancy.

Hypertension and oliguria are indicative of preeclampsia.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 367-368 11. A woman in labor suddenly reports sharp fundal pain accompanied by slight dark red vaginal bleeding. The nurse should prepare to assist with which situation?

A. Premature separation of the placenta B. Preterm labor that was undiagnosed C. Placenta previa obstructing the cervix D. Possible fetal death or injury Answer: A Rationale: Premature separation of the placenta begins with sharp fundal pain, usually followed by dark red vaginal bleeding. Placenta previa usually produces painless bright red bleeding. Preterm labor contractions are more often described as cramping. Possible fetal death or injury does not present with sharp fundal pain.

It is usually painless.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 367-368 12. A 24-year-old client presents in labor. The nurse notes there is an order to administer Rho(D) immune globulin after the birth of her infant. When asked by the client the reason for this injection, which reason should the nurse point out?

A. promote maternal D antibody formation.

B. prevent maternal D antibody formation.

C. stimulate maternal D immune antigens.

D. prevent fetal Rh blood formation.

Answer: B Rationale: Because Rho(D) immune globulin contains passive antibodies, the solution will prevent the woman from forming long-lasting antibodies which may harm a future fetus. The administration of Rho(D) immune globulin does not promote the formation of maternal D antibodies; it does not stimulate maternal D immune antigens or prevent fetal Rh blood formation.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Communication and Documentation Reference: p. 358 13. A 24-year-old woman presents with vague abdominal pains, nausea, and vomiting. An urine hCG is positive after the client mentioned that her last menstrual period was 2 months ago. The nurse should prepare the client for which intervention if the transvaginal ultrasound indicates a gestation sac is found in the right lower quadrant?

A. Bed rest for the next 4 weeks B. Intravenous administration of a tocolytic C. Immediate surgery D. Internal uterine monitoring Answer: C Rationale: The client presents with the signs and symptoms of an ectopic pregnancy, which is confirmed by the transvaginal ultrasound. Ectopic pregnancy means an embryo has implanted outside the uterus. Surgery is necessary to remove the growing structure before damage can occur to the woman's internal organs. Bed rest, a tocolytic, and internal uterine monitoring will not correct the situation. The growing structure must be removed surgically.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply

Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 360 14. A client suffering a miscarriage at 12 weeks' gestation is very upset that the health care provider has ordered a dilatation and curettage (D&C). How should the nurse respond after the client states she didn't have a D&C the time she lost a previous baby at 5 weeks' gestation?

A. "This is the procedure ordered by the doctor."

B. "You have the option to refuse the surgery."

C. "This procedure is needed to adequately remove all the fetal tissue."

D. "Having the D&C will make it easier to get pregnant next time."

Answer: C Rationale: By this stage of pregnancy, the placenta has adhered to the uterine wall.

This was not the case when the client was only 5 weeks' pregnant. The total removal of the products of conception will be needed to ensure healing and prevent excessive bleeding and infection. To inform the client that the D&C is ordered by the health care provider is unprofessional and does not adequately explain the reason for the procedure. It also does not recognize the client's autonomy in choosing her health care. Informing the client that she can refuse the procedure would be unethical and could result in serious injury (including death if the client were to bleed to death). It would also be inappropriate for the nurse to imply the client will have an easier time getting pregnant again by having this procedure.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 361 15. A primigravida 28-year-old client is noted to have Rh negative blood and her husband is noted to be Rh positive. The nurse should prepare to administer RhoGAM after which diagnostic procedure?

A. Contraction test B. Nonstress test C. Biophysical profile D. Amniocentesis Answer: D Rationale: Amniocentesis is a procedure requiring a needle to enter into the amniotic sac. There is a risk of mixing of the fetal and maternal blood which could result in blood incompatibility. A contraction test, a nonstress test, and biophysical profile are not invasive, so there would be no indication for Rho(D) immune globulin to be administered.

Question format: Multiple Choice

Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 358 16. A 25-year-old client at 22 weeks' gestation is noted to have proteinuria and dependent edema on her routine prenatal visit. Which additional assessment should the nurse prioritize and convey to the RN or health care provider?

A. initial BP 120/80mm Hg; current BP 130/88 mm Hg B. initial BP 100/70 mm Hg; current BP 140/90 mm Hg C. initial BP 140/85 mm Hg; current BP 130/80 mm Hg D. initial BP 110/60 mm Hg; current BP 112/86 mm Hg Answer: B Rationale: A proteinuria of trace to 1+ and a rise in blood pressure to above 140/90 mm Hg is a concern the client may be developing preeclampsia. The blood pressures noted in the other options are not indicative of developing preeclampsia.

The edema would not necessarily be indicative of preeclampsia; however, edema of the face and hands would be a concerning sign for severe preeclampsia.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 371-372 17. A client at 37 weeks' gestation presents to the emergency department with a BP 150/108 mm Hg, 1+ pedal edema, 1+ proteinuria, and normal deep tendon reflexes. Which assessment should the nurse prioritize as the client is administered magnesium sulfate IV? A. urine protein B. ability to sleep C. hemoglobin D. respiratory rate Answer: D Rationale: A therapeutic level of magnesium is 4 to 8 mg/dl (1.65 to 3.29 mmol/L).

If magnesium toxicity occurs, one sign in the client will be a decrease in the respiratory rate and a potential respiratory arrest. Respiratory rate will be monitored when on this medication. The client's hemoglobin and ability to sleep are not factors for ongoing assessments for the client on magnesium sulfate. Urinary output is measured hourly on the preeclamptic client receiving magnesium sulfate, but urine protein is not an ongoing assessment.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications

Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 375 18. A primipara at 36 weeks' gestation is being monitored in the prenatal clinic for risk of preeclampsia. Which sign or symptom should the nurse prioritize?

A. A systolic blood pressure increase of 10 mm Hg B. Weight gain of 1.2 lb (0.54 kg) during the past 1 week C. A dipstick value of 2+ for protein D. Pedal edema Answer: C Rationale: The increasing amount of protein in the urine is a concern the preeclampsia may be progressing to severe preeclampsia. The woman needs further assessment by the health care provider. Dependent edema may be seen in a majority of pregnant women and is not an indicator of progression from preeclampsia to eclampsia. Weight gain is no longer considered an indicator for the progression of preeclampsia. A systolic blood pressure increase is not the highest priority concern for the nurse, since there is no indication what the baseline blood pressure was.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 371-372 19. The nurse is teaching a client who is diagnosed with preeclampsia how to monitor her condition. The nurse determines the client needs more instruction after making which statement?

A. "If I have changes in my vision, I will lie down and rest."

B. "I will weigh myself every morning after voiding before breakfast."

C. "I will count my baby's movements after each meal."

D. "If I have a severe headache, I'll call the clinic."

Answer: A Rationale: Changes in the visual field may indicate the client has moved from preeclampsia to severe preeclampsia and is at risk for developing a seizure due to changes in cerebral blood flow. The client would require immediate assessment and intervention. Gaining weight is not necessarily a sign of worsening preeclampsia.

The other choices are instructions which the client may be given to follow.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation

Integrated Process: Teaching/Learning Reference: p. 371-372 20. A pregnant woman at 38 weeks' gestation is receiving care for preeclampsia and suddenly complains of sharp abdominal pain. Which action should the nurse prioritize if the nurse notes a firm, distended, and painful abdomen and dark red vaginal bleeding?

A. Implement a tocodynamometer.

B. Obtain a full set of vital signs.

C. Place on the fetal heart monitor.

D. Dipstick the urine for protein.

Answer: B Rationale: The initial assessment is to determine if the client is going into shock from hemorrhaging. The abdominal pain and dark red bleeding indicate a possible abruption of the placenta related to the preeclampsia. The health care provider must be notified ASAP. Assessing the status of the fetus would be next. Assessing for contractions and the urine for protein are not priority assessments for the nurse.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 371-372 21. The nurse is caring for a client who has remained in stable condition at 37 weeks' gestation. The client's condition suddenly changes. Which assessment change should the nurse prioritize?

A. Vaginal bleeding and no pain B. Uterine contractions with vaginal mucus C. Fundal height and fetal heart rate D. Size and contour of the abdomen Answer: A Rationale: Placenta previa includes bright red and painless vaginal bleeding, which is different from the dark red bleeding of placental abruption (abruptio placenta) accompanied by severe pain. This differentiates the two conditions. Uterine contractions with vaginal mucus may be indications of the start of labor with the mucus plug being discharged. The fetal heart rate, fundal height, and contour of the abdomen are normal components that are assessed during the labor process.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 366-367

22. The nurse is preparing a woman for discharge after a birth and notes the mother's record indicates Rh negative and rubella titer is positive. Which nursing intervention will the nurse prioritize?

A. Administer Rho(D) immune globulin to the mother.

B. Administer rubella vaccine to the mother before discharge.

C. Assess the mother for isoimmunization.

D. Assess the Rh of the baby.

Answer: D Rationale: The cord blood should be assessed to determine the infant's Rh type. If it is negative, there is no need for any further treatment or concern. However, if it is Rh positive the mother needs to be assessed for possible administration of Rho(D) immune globulin. The criteria for giving Rho(D) immune globulin are as follows: • The woman must be Rho(D) negative • The woman must not have anti-D antibodies (must not be sensitized • The infant must be Rho(D) positive (fetus cord blood is checked after birth) • A direct Coombs test (a test for antibodies performed on cord blood at delivery) must be weakly reactive or negativ This all needs to be completed within the first 72 hours of birth, so the mother can receive Rho(D) immune globulin within the proper time frame.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 358-359 23. The nurse is comforting and listening to a young couple who just suffered a spontaneous abortion (miscarriage). When asked why this happened, which reason should the nurse share as a common cause?

A. Maternal smoking B. Lack of prenatal care C. Chromosomal abnormality D. The age of the mother Answer: C Rationale: The most common cause for the loss of a fetus in the first trimester is associated with a genetic defect or chromosomal abnormality. There is nothing that can be done and the mother should feel no fault. The nurse needs to encourage the parents to speak with a health care provider for further information and questions related to genetic testing. Early pregnancy loss is not associated with maternal smoking, lack of prenatal care, or the age of the mother.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications

Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 361 24. A nurse is preparing a nursing care plan for a client who is admitted at 22 weeks' gestation with advanced cervical dilation (dilatation) to 5 cm, cervical insufficiency, and a visible amniotic sac at the cervical opening. Which primary goal should the nurse prioritize at this point?

A. Give birth vaginally B. Bed rest to maintain pregnancy as long as possible C. Notification of social support for loss of pregnancy D. Education on causes of cervical insufficiency for the future Answer: B Rationale: At 22 weeks' gestation, the fetus is not viable. The woman would be placed on total bed rest with every attempt made to halt any further progression of dilation (dilatation) of the cervix. The nurse would not want this fetus to be born vaginally at this stage of gestation. It is not the nurse's responsibility to notify the client's social support of a possible loss of the pregnancy. It is not appropriate at this time to educate the mother on causes of cervical insufficiency for future pregnancies.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 364 25. A client at 27 weeks' gestation is admitted to the obstetric unit after reporting headaches and edema of her hands. Review of the prenatal notes reveals blood pressure consistently above 136/90 mm Hg. The nurse anticipates the health care provider will prescribe magnesium sulfate to accomplish which primary goal?

A. Decrease blood pressure B. Decrease protein in urine C. Prevent maternal seizures D. Reverse edema Answer: C Rationale: The primary therapy goal for any client with preeclampsia is to prevent maternal seizures. Use of magnesium sulfate is the drug therapy of choice for severe preeclampsia and is only used to manage and attempt to prevent progression to eclampsia. Magnesium sulfate therapy does not have as a primary goal of decreasing blood pressure, decreasing protein in the urine, or reversing edema.

Question format: Multiple Choice

Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 375 26. The following hourly assessments are obtained by the nurse on a client with preeclampsia receiving magnesium sulfate: 97.3oF (36.2oC), HR 88, RR 12 breaths/min, BP 148/110 mm Hg. What other priority physical assessments by the nurse should be implemented to assess for potential toxicity?

A. Lung sounds B. Oxygen saturation C. Reflexes D. Magnesium sulfate level Answer: C Rationale: Reflex assessment is part of the standard assessment for clients on magnesium sulfate. The first change when developing magnesium toxicity may be a decrease in reflex activity. The health care provider needs to be notified immediately. A change in lung sounds and oxygen saturation are not indicative of magnesium sulfate toxicity. Hourly blood draws to gain information on the magnesium sulfate level are not indicated.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 375 27. The nurse is appraising the medical record of a pregnant client who is resting in a darkened room and receiving oxytocin and magnesium sulfate. The nurse will continue to monitor this client for progression to which condition?

A. gestational hypertension B. eclampsia C. severe preeclampsia D. mild preeclampsia Answer: B Rationale: This woman is in severe preeclampsia and must be monitored for progression to eclampsia. The administration of magnesium sulfate is to relax the skeletal muscles and raise the threshold for a seizure. The administration of oxytocin is to stimulate uterine contractions to hasten birth. The client has already progressed from mild preeclampsia to severe preeclampsia, and the nurse need to follow measures to prevent advancement of the disease process. Although preeclampsia results in a high blood pressure, the scenario described does not indicate a client with hypertension.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 371-372 28. A woman at 28 weeks' gestation has been hospitalized with moderate bleeding that is now stabilizing. The nurse performs a routine assessment and notes the client sleeping, lying on the back, and electronic fetal heart rate (FHR) monitor showing gradually increasing baseline with late decelerations. Which action will the nurse perform first?

A. Administer oxygen to the client.

B. Notify the health care provider.

C. Reposition the client to left side.

D. Increase the rate of IV fluids.

Answer: C Rationale: The fetus is showing signs of fetal distress. The immediate treatment is putting the client in a side-lying position to ensure adequate perfusion to the fetus.

After placing the client on the side, the nurse should re-assess the FHR and determine if oxygen, IV fluids, and calling the health care provider are needed.

Question format: Multiple Choice Chapter 17: Pregnancy at Risk: Pregnancy-Related Complications Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 369

Chapter 18 1. Which statement describes why hypertonic contractions tend to become very painful?

A. More than one contraction may begin at the same time, as receptor points in the myometrium act independently of each other.

B. The myometrium becomes sensitive from the lack of relaxation and anoxia of uterine cells.

C. The number of uterine contractions is very low or infrequent.

D. There is an increase in the length of labor because so many contractions are needed to achieve cervical dilation (dilatation).

Answer: B Rationale: Hypertonic contractions cause uterine cell anoxia, which is painful.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 385 2. The nurse is assessing a multipara woman who presents to the hospital after approximately 2 hours of labor and notes the fetus is in a transverse lie. After notifying the RN and primary care provider, which action should the LPN prioritize?

A. Include a set of piper forceps when the table is prepped.

B. Apply pressure to the woman's lower back with a fisted hand.

C. Assist with nitrazine and fern tests.

D. Prepare to assist with external version.

Answer: D Rationale: Transverse lie is a fetal malposition and is a cause for labor dystocia. The fetus would need to be turned to the occipital position using external version or be born via cesarean birth. Piper forceps are used in the birth of a fetus that is in the breech position. Nitrazine and fern tests are done to assess if amniotic fluid is leaking from the sac into the vagina. Counterpressure applied to the lower back with a fisted hand sometimes helps the woman to cope with the "back labor" that is characteristic of occiput posterior (OP) positioning.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 385

3. The nurse is monitoring a primipara who has been receiving oxytocin and is now in hypertonic labor. If the nurse notes the fetal heart rate has suddenly dropped, which action should the nurse prioritize?

A. Decrease the oxytocin drip rate.

B. Turn the client on the left side.

C. Administer a tocolytic medication.

D. Assist with McRoberts maneuver.

Answer: A Rationale: The client will be receiving oxytocin to induce the labor. An adverse reaction would be a hypertonic uterus, in which the uterine contractions are manifested with increased frequency and intensity. When the infant is showing signs of distress, the nurse should first either stop or decrease the oxytocin drip rate, as per the primary care provider's orders. If this does not stop the contractions, then a tocolytic should be administered to stop the uterus from contracting and improve the fetal status. McRoberts maneuver is used when there is shoulder dystocia. Changing positions does not provide an immediate impact.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 386 4. A client at 36 weeks' gestation presents to the OB unit reporting continuous, heavy vaginal discharge and pelvic pressure. Assessment reveals no signs of labor and positive nitrazine test. The nurse prepares for which nursing intervention after admitting the client?

A. administering erythromycin IV B. performing daily pelvic exams C. administering IM corticosteroids D. administering oxytocin Answer: A Rationale: With preterm PROM and no signs of labor, the woman would be treated with IV antibiotics (usually ampicillin and erythromycin) for 48 hours, followed by oral antibiotics for 5 days to decrease the risk of infection. Labor would not automatically be induced at this time in a client who is 36 weeks' gestation. IM corticosteroids are given between 24 and 34 weeks' gestation to reduce the risk of neonatal respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis. Daily pelvic exams are contraindicated as the client will be at pelvic rest.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 388 5. A multigravida client at 31 weeks' gestation is admitted with confirmed preterm labor. As the nurse continues to monitor the client now receiving magnesium sulfate, which assessment findings will the nurse prioritize and report immediately to the RN or health care provider?

A. Low potassium or elevated glucose, tachycardia, chest pain B. Respiratory depression, hypotension, absent tendon reflexes C. Severe lower back pain, leg cramps, sweating D. Pain in the abdomen, shoulder, or back Answer: B Rationale: Magnesium sulfate is a smooth muscle relaxant and can cause vasodilation and results in respiratory depression and severe hypotension at toxic levels. The other options are incorrect indications of magnesium sulfate toxicity.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 390 6. A 39-year-old multigravida with diabetes presents at 32 weeks' gestation reporting she has not felt movement of her fetus. Assessment reveals the fetus has died. The nurse shares with the mother that the institution takes pictures after the birth and asks if she would like one. What is the best response if the mother angrily says no and starts crying?

A. Apologize and tell her that the photos will be destroyed immediately.

B. Console her with the fact that she has other children.

C. Tell her that the hospital will keep the photos for her in case she changes her mind.

D. Tell her that once she gets over her shock and grief, she will probably be happy to have the photos.

Answer: C Rationale: Emotional care of the woman is complex, especially one who has suffered the loss of a child. The woman will need time to move through the stages of grief and the responses of grief vary from person to person. The mother may request the items later and they should be stored or kept for a year after the birth.

There is no need to apologize to the client. It would be inappropriate to console her with the fact that she has other children. It negates her feelings and is not supportive of the woman at this time.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Analyze

Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 394 7. The nurse is assisting with a G2P1, 24-year-old client who has experienced an uneventful pregnancy and is now progressing well through labor. Which action should be prioritized after noting the fetal head has retracted into the vagina after emerging?

A. Use McRoberts maneuver.

B. Use Zavanelli maneuver.

C. Apply pressure to the fundus.

D. Attempt to push in one of the fetus's shoulders.

Answer: A Rationale: McRoberts maneuver intervention is used with a large baby who may have shoulder dystocia and requires assistance. The legs are sharply flexed by a support person or nurse, and the movement will help to open the pelvis to the widest diameter possible. Zavanelli maneuver is performed when the practitioner pushes the fetal head back in the birth canal and performs an emergency cesarean birth. Fundal pressure is contraindicated with shoulder dystocia. It is outside the scope of practice for the LPN to attempt birth of the fetus by pushing one of the fetus' shoulders in a clockwise or counterclockwise motion.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 395 8. A woman at 39 weeks' gestation is brought to the emergency department in labor following blunt trauma from an vehicle accident. The labor has been progressing well after the epidural when suddenly the woman reports severe pain in her back and shoulders. Which potential situation should the nurse suspect?

A. Fractured ribs B. Placental abruption (abruptio placentae) C. Uterine rupture D. Dystocia Answer: C Rationale: A uterine rupture should be suspected in a pregnant woman who has experienced blunt trauma to the abdomen and then complains of severe pain in her back and shoulder. Uterine rupture occurs when the uterus tears open, leaving the fetus and other uterine contents exposed to the peritoneal cavity. Traumatic rupture can occur in connection with a blunt trauma. Abrupt change in the fetal heart rate pattern is often the most significant sign associated with uterine rupture.

Other signs are reports of pain in the abdomen, shoulder, or back in a laboring

woman who had previous good pain relief from epidural anesthesia. The scenario presented does not indicate fractured ribs from the accident. Placental abruption (abruptio placentae) presents with pain; dark red vaginal bleeding; a rigid, boardlike abdomen; hypertonic labor; and fetal distress. Pain has a sudden onset and is constant, and the uterus may not relax well between contractions. Dystocia is the abnormally slow progression of labor, which is not indicated.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 397 9. At 31 weeks' gestation, a 37-year-old woman with a history of preterm birth reports cramps, vaginal pain, and low, dull backache accompanied by vaginal discharge and bleeding. Assessment reveals cervix 2.1 cm long; fetal fibronectin in cervical secretions, and cervix dilated 3 to 4 cm. Which interactions should the nurse prepare to assist with?

A. bed rest and hydration at home B. hospitalization, tocolytic, and corticosteroids C. an emergency cesarean birth D. careful monitoring of fetal movement (kick) counts Answer: B Rationale: At 31 weeks' gestation, the goal would be to maintain the pregnancy as long as possible if the mother and fetus are tolerating the continuation of the pregnancy. Stopping the contractions and placing the client in the hospital allows for monitoring in a safe place if the woman continues and gives birth.

Administration of corticosteroids may help to develop the lungs and prepare for early preterm birth. Sending the woman home is contraindicated in the scenario described. An emergency cesarean birth is not indicated at this time. Monitoring fetal movement (kick) counts is typically done with a postterm pregnancy.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 391 10. The nurse is admitting a woman at 32 weeks' gestation in preterm labor. The nurse should question the order for magnesium sulfate after noting which assessment finding?

A. cervical dilation (dilatation) of 5 cm B. strong, regular contractions C. fetus in a breech presentation D. a spontaneous abortion (miscarriage) in an earlier pregnancy

Answer: A Rationale: If cervical dilation (dilatation) has already progressed too far, labor cannot be halted. Tocolytics are usually not administered if cervical dilation is greater than 3 to 4 cm. A breech presentation of the fetus would not require the nurse to question the administration of a tocolytic agent, nor is a spontaneous abortion (miscarriage) in an earlier pregnancy.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 389 11. The nurse is caring for a primipara with PROM who appears extremely anxious and reveals that she is scared her birthing process will be extremely painful because it will be "dry". Which is the best response from the nurse?

A. "This is true but you can receive pain medication to help relieve this."

B. "No birth is ever really dry, because amniotic fluid continues to be manufactured."

C. "Don't think so far ahead; concentrate on the problem at hand."

D. "Although the birth will be dry, it won't be painful."

Answer: B Rationale: The nurse should let the client know that amniotic fluid is continuously formed; no birth is ever dry. The client will be given medication for pain as well as given the option to receive an epidural at the appropriate time. The nurse should not negate the woman's concerns by telling her to not worry about it. This would be a good time for informal teaching about the process and letting the woman know the options available to assist her through this process.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 388 12. A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?

A. Uterine rupture B. Hypertonic uterus C. Placenta previa D. Umbilical cord compression Answer: A

Rationale: The client with any prior history of uterus surgery is at increased risk for a uterine rupture. A falling blood pressure and increasing pulse is a sign of hemorrhage, and in this client a uterine rupture needs to be a first consideration.

The scenario does not indicate a hypertonic uterus, a placenta previa, or umbilical cord compression.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 397 13. A woman who had preterm labor and preterm PROM successfully halted has reached week 36 of pregnancy and is doing well on home care. Which of the following nursing diagnoses should the nurse prioritize for this client?

A. Risk for fetal infection related to early rupture of membranes B. Hopelessness related to potential loss of pregnancy C. Anticipatory grieving related to high probability for fetal death from placental dysfunction D. Powerlessness related to inability to sustain pregnancy Answer: A Rationale: Once membranes have ruptured, the seal to the fetus is broken and microorganisms may infect the uterus or fetus. There is no indication in the scenario that a potential loss of pregnancy is evident, nor is there an indication of anticipatory grieving. As described in this scenario there is not a high probability of fetal death from placental dysfunction. A woman at 36 weeks' gestation would not be feeling powerless because of an inability to sustain pregnancy.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 391 14. At 33 weeks' gestation, a woman experiencing preterm PROM is being prepared to discharge home after successful treatment with magnesium sulfate. The nurse should prioritize which instruction to the woman and her partner?

A. Continue taking nifedipine until you reach term.

B. Perform kick counts after each meal.

C. Complete the 10-day oral antibiotic course.

D. Use a barrier during sexual intercourse.

Answer: B

Rationale: When a client is being monitored at home, the well-being of the fetus must be assessed as well. The best method for assessing the fetus is with the kick count method, which should be done after each meal. Nifedipine is an oral tocolytic that would not be utilized at this time. Oral antibiotics are given for 7 days, not 10.

The woman will be on pelvic rest with no sexual intercourse at this time, as it may trigger uterine contractions leading to premature birth.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 388 15. The nurse notes the fetal heart rate has slowed in a woman in labor at 8 cm dilation (dilatation). Assessment reveals a prolapsed umbilical cord. Which action should the nurse prioritize?

A. Turn client to her left side.

B. Place client in a knee-chest position.

C. Use fingers to press upward on the presenting part.

D. Prep for immediate cesarean delivery.

Answer: C Rationale: If the woman presents with a visible prolapse of the cord, quickly place her in bed and gently palpate the cord for pulsations to verify fetal viability. Then use fingers to press upward on the presenting part. Continue to hold the presenting part of the cord until delivery of the infant. If you discover the condition and are unable to call for help, place the client in knee-chest position, call for help, and then continue to intervene as previously described. Keeping the pressure of the fetus off the cord improves fetal circulation. Replacing the cord could knot it; allowing it to dry would constrict cord blood vessels. Turning the woman to the left side is not the intervention of choice. Another nurse will be helping prepare this client for immediate cesarean delivery.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 397 16. The nurse is monitoring a woman who is receiving IV oxytocin to assist with uterine irritability. Which action should the nurse prioritize if the woman's contractions are determined to be 80 seconds in length after 1 hour of administration of the oxytocin?

A. Slow the infusion to under 10 gtts per minute.

B. Increase the flow rate of the main line infusion.

C. Discontinue the oxytocin infusion.

D. Continue to monitor contraction duration every 2 hours.

Answer: C Rationale: If uterine contractions lengthen beyond 70 seconds, there is apt to be an interference with fetal circulation. Discontinuing the infusion allows contractions to shorten in length and allow fetal nourishment. The nurse would not increase the flow rate of the main line infusion or slow the infusion without the health care provider's prescription. Uterine contractions are monitored continuously.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 385 17. A multipara woman at a birthing center is becoming very discouraged that her labor is taking so long. She is confused when her nurse-midwife indicates she has developed dystocia and needs to be transferred to a more advanced facility. What is the best response from the nurse to answer the woman's questions?

A. "Your difficult labor needs treatment we cannot provide here."

B. "We don't have the medication you need."

C. "Your blood pressure is getting too high and needs treatment we can't provide here."

D. "We need to consult with a surgeon in case a cesarean delivery is necessary."

Answer: A Rationale: Birthing centers are designed to handle uncomplicated births; they have agreements with more complex facilities to accept their clients if the situation changes and more advanced treatment is needed. This client is showing signs of dystocia, which is a general term used to describe difficult or abnormal labor. The client needs to be in a more advanced medical facility that can provide the medication needed to address uterine and/or blood pressure complications. More importantly, this client may require a cesarean birth that would require a surgeon and operating room facilities to safely deliver the fetus.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 385 18. The nurse assesses that a fetus is in an occiput posterior position. The nurse predicts the client will experience which situation related to this assessment?

A. Shorter dilation (dilatation) stage of labor B. Experience of additional back pain C. Need to have the baby manually rotated

D. Necessity for vacuum extraction for birth Answer: B Rationale: Most women whose fetus is in a posterior position experience back pain while in labor. Pressure against the back by a support person often reduces this type of pain. An occiput posterior position does not make for a shorter (dilation) dilatation stage of labor. OP position does not indicate the need to have the baby manually rotated, nor does it indicate a necessity for a vacuum extraction birth.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 385 19. A client in preterm labor is receiving magnesium sulfate IV and appears to be responding well. Which finding on assessment should the nurse prioritize?

A. depressed deep tendon reflexes B. tachypnea C. bradycardia D. elevated blood glucose Answer: A Rationale: The nurse should assess the woman at least once hourly and report any dyspnea (not tachypnea), tachycardia (not bradycardia), productive cough, adventitious breath sounds, and absent or decreased deep tendon reflexes in a client receiving magnesium sulfate; these are all signs of possible magnesium toxicity. Elevated blood glucose is a potential adverse reaction if the woman is receiving terbutaline.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 391 20. The nurse is assessing a multipara client at 28 weeks' gestation who may be experiencing labor. Which findings should the nurse prioritize?

A. positive ferning B. irregular mild contractions every 10 to 15 minutes C. positive fetal fibronectin D. cervical length of 2.7 cm Answer: C

Rationale: Fetal fibronectin is a positive indicator of preterm labor, either active or imminent. The mother can be dilated and effacing for weeks prior to delivery, as long as there are no changes. Ferning is a positive sign of amniotic fluid leaking.

Irregular contractions do not indicate true labor. A cervical length of less than 2.5 cm at 20 to 26 weeks' gestation is associated with preterm labor.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 390 21. The nurse is preparing discharge instructions for a client at 32 weeks' gestation who was admitted for PROM. What is the best response from the nurse when the client asks when she can have intercourse with her husband again?

A. "You will not be able to have intercourse again until 6 weeks after you give birth."

B. "The need to keep the infant safe should be of more concern than when to have sex."

C. "That is a question to ask your health care provider; at this point you are on pelvic rest to try and stop any further labor."

D. "Intercourse has nothing to do with preterm labor; you can have sex with your husband."

Answer: C Rationale: The client needs to be on pelvic rest until the health care provider says otherwise. The intercourse can cause excitability in the uterus and encourage cervical softening and should be avoided unless the provider says it is safe. The nurse should be professional in all communications and not talk down to the client.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 388 22. A woman at 41 weeks' gestation is progressing well in labor; however, the nurse notes the amniotic fluid is greenish in color. When questioned by the client for the reason for this, which explanation should the nurse provide?

A. "Amniotic fluid is normally green."

B. "This is meconium-stained fluid from the baby."

C. "You have an infection and need antibiotics."

D. "Green might be a yeast infection and we need to culture the discharge."

Answer: B

Rationale: Green-tinted amniotic fluid is most often a sign of the infant having a bowel movement in the uterus, called meconium-stained fluid. This is more typical in a postdate pregnancy. Green-stained amniotic fluid is not a normal color for amniotic fluid. However, it does not mean the mother has an infection and needs antibiotics, nor does it does mean there might be a yeast infection present or indicate the need for a culture of the fluid.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 393 23. The nurse is admitting a client at 23 weeks' gestation in preparation for induction and delivery after it was determined the fetus had died secondary to trauma. When asked by the client to explain what went wrong, the nurse can point out which potential cause for this loss?

A. genetic abnormality B. premature rupture of membranes C. preeclampsia D. placental abruption Answer: D Rationale: The most common cause of fetal death after a trauma is placental abruption (abruptio placentae), where the placenta separates from the uterus, and the fetus is not able to survive. Genetic abnormalities typically cause spontaneous abortion (miscarriage) in the first trimester. Trauma does not cause preeclampsia (which is related to various issues in the mother) nor does trauma usually cause PROM. Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 394 24. A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

A. Put the client in bed immediately, call for help, and lift the presenting part of the fetus off the cord.

B. With the client in lithotomy position, hold her legs and sharply flex them toward her shoulders.

C. Place the client in Trendelenburg position and gently attempt to reinsert the cord.

D. Contact the health care provider and prepare the client for an emergent vaginal birth.

Answer: A Rationale: The nurse must put the woman in a bed immediately, while calling for help, and holding the presenting part of the fetus off the cord to ensure its safety.

Umbilical cord prolapse occurs when the umbilical cord slips down in front of the presenting part, which can result in the presenting part compressing the cord, cutting off oxygen and nutrients to the baby, and the baby is at risk of death. This is an emergency. When a prolapsed cord is evident the nurse does not put the woman in lithotomy position, and cannot attempt to reinsert the cord. A vaginal birth is contraindicated in this situation.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 397 25. A client with preterm labor is receiving terbutaline therapy. Which assessment will the nurse take?

A. deep tendon reflexes B. respiratory status C. serum potassium levels D. fluid loss Answer: C Rationale: If a client s receiving terbutaline, it is important to monitor the client's serum potassium and glucose levels. Low potassium or elevated glucose levels should be reported to the RN and health care provider. Monitoring deep tendon reflexes and respiratory status are critical assessments for a client receiving magnesium sulfate. Monitoring fluid status is an important nursing function for the client with preterm labor. However, the client is at risk for fluid overload, not fluid loss.

Question format: Multiple Choice Chapter 18: Labor at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 391

Chapter 19 1. The nurse is caring for a mother within the first four hours after a cesarean birth.

Which nursing intervention would be most appropriate to prevent thrombophlebitis in the mother?

A. Roll a bath blanket or towel and place it firmly behind the knees.

B. Limit oral intake of fluids for the first 24 hours to prevent nausea.

C. Assist client in performing leg exercises every 2 hours.

D. Ambulate the client as soon as her vital signs are stable.

Answer: D Rationale: The best prevention for thrombophlebitis is ambulation as soon as possible after recovery. Ambulation requires blood movement throughout the cardiovascular system, decreasing thrombophlebitis risks. Placing a bath blanket behind the knees interrupts circulation and could cause a thrombus. Fluids are encouraged not limited. Leg exercises may put strain on the abdominal incision.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 418 2. A client who delivered approximately 18 hours ago suddenly reports pelvic pain that is unrelieved by comfort measures and medication. Assessment reveals HR 110, BP 96/68 mm Hg, firm fundus, and dark red, flowing lochia in moderate amounts with no pooling. The most recent hematocrit is 31.9% and hemoglobin 10.5 g/dl. Which complication should the nurse prioritize?

A. retained placental fragments B. deep vein thrombosis C. lacerations in the uterus D. deep pelvic hematoma Answer: D Rationale: The assessment data indicate blood loss in the body, and the lack of active bleeding is indicative of a hematoma. Retained placental fragments are characterized by late postpartum bleeding. Along with an abrupt onset of bleeding, the woman's uterus is not well contracted. The woman with DVT may have no symptoms. If the client does exhibit signs, these typically include swelling and calf pain or tenderness in the affected leg. The area may be warm, tender, and red.

Lacerations can occur as small tears or cuts in the perineal tissue, vaginal sidewall, or cervix. The normal range of hematocrit for women is 34.9% to 44.5% and hemoglobin is 12.0 to 15.5 g/dl.

Question format: Multiple Choice

Chapter 19: Postpartum Woman at Risk Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 405 3. A G4P4 client is recovering from dystocia for which oxytocin was administered to assist with the contractions. On assessment 24 hours later, the nurse notes moderate to heavy lochia with numerous large clots and the uterus in the midline, above the umbilicus, and boggy. Which action should the nurse prioritize?

A. Ensure that her bladder is empty.

B. Initiate fundal massage.

C. Draw blood for hemoglobin and hematocrit STAT. D. Encourage breastfeeding to stimulate uterine contractions.

Answer: A Rationale: A boggy fundus with active bleeding and clots the day after birth is indicative of uterine atony. The first step is to ensure the woman has an empty bladder; otherwise, the uterus will not remain contracted once the massage stops.

A full bladder can also impede uterine contraction, which will predispose her to hemorrhage. If the bladder is full, the uterus would be displaced to the side of the umbilicus instead of in the midline. The nurse should then prepare to initiate fundal massage by placing one hand over the symphysis pubis while the other hand gently palpates and massages the uterus to encourage contractions. The use of firm, steady, gentle fundal pressure will help express any clots that may have collected in the uterus. Obtaining blood work for H&H or encouraging breastfeeding would not be the first choice for handling this situation. The client is at risk of hemorrhaging and this needs to be addressed quickly.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 405 4. Initial measures to stop a client's bleeding have not proved successful, and she is being transferred to the ICU. Her family is frightened by the IV lines and the nasal cannula. The client's brother suddenly says to her partner, "This is all your fault!"

What is the best response by the nurse?

A. Leave the room quietly; this is a family matter.

B. Draw the brother aside and tell him that if he cannot control himself, he will have to leave.

C. Explain the client's care, focus on signs of improvement, and acknowledge this is a difficult time.

D. Tell them that the RN will be notified and will explain the client's treatment to them.

Answer: C Rationale: The nurse's first responsibility is to the client. She needs to be aware of the interaction and focus the family on the client, explaining the cares and acknowledging the difficult time for all involved. Leaving the room is not an appropriate action. The nurse would only ask the client's brother to leave if he could not be redirected and continued to cause a disruption. The nurse would not have the RN explain the client's treatment.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 407 5. The nurse is caring for several postpartum clients and notes various warning signs that are concerning. Which client should the nurse suspect is developing endometritis?

A. A woman with diabetes, vaginal birth, HR 110, temperature 101.7°F (38.7°C) on the third postpartum day. The next day, appears ill; temperature now 102.9°F (39.3°C); WBC 31,500/mm3; negative blood cultures.

B. A woman with a history of infection and smoking, temperature 101°F (38.3°C) on the fourth postpartum day; reports severe perineal pain; edges of the episiotomy have separated.

C. An obese woman with temperature 100.4°F (38°C) at 12 hours after birth; lochia is moderate; negative vaginal cultures.

D. A woman with PROM before birth; reports severe burning with urination, malaise and severe temperature spikes on the 7th postpartum day. WBC is 21,850/mm3; temperature 101°F (38.3°C); skin pale and clammy.

Answer: A Rationale: Endometritis is an infection of the endometrium of the uterus. Clinical manifestations include a fever of 100.4°F (38°C) or higher, usually between the 2nd and 10th day after delivery; tachycardia, chills, anorexia, and general malaise; client may also report abdominal cramping and pain. Reports of severe perineal pain and signs of fever and separation of the episiotomy edges would be suspicious for a wound infection. An elevated temperature of up to 100.4°F (38°C) within the first 24 hours is a normal response to the birthing process. Reports of severe burning on urination accompanied by fever and malaise would be suspicious of a UTI. Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 410

6. The nurse is caring for a woman who delivered via a cesarean birth approximately 16 hours earlier. Which assessment finding should the nurse prioritize?

A. gradually decreasing temperature and pulse rate B. uterine height at umbilicus C. steadily decreasing volume of urine D. excessive diaphoresis Answer: C Rationale: Decreasing amounts of urine indicate hypovolemic complications and need to be further assessed by the RN and/or health care provider. This may be an indication the client is hemorrhaging and is in danger of going into shock and must be evaluated immediately. A gradually decreasing temperature and pulse rate and excessive diaphoresis are normal findings at this stage and would not need prioritized attention. The uterine height would not be a priority at this time.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 404 7. The nurse is preparing discharge instructions for a client who has developed endometritis after a cesarean birth. As the client is to be discharged on antibiotic therapy, which instruction should the nurse prioritize?

A. Handwashing B. Complete the antibiotic course C. Proper perineal care D. Get plenty of sleep Answer: A Rationale: Handwashing is the best defense against the spread of infections. The client is at a higher risk of developing further infections due to her current situation; handwashing before and after using the restroom and doing perineal care will help prevent an infection from occurring. It will also be important for the woman to wash her hands to ensure the infection is not passed to her infant or other family members. The other options of completing the antibiotics, completing proper perineal care, and getting plenty of rest are also important but not a priority.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 412

8. The nurse is explaining the discharge instructions to a client who has developed postpartum cystitis. The client indicates she is not drinking a glass of fluid every hour because it hurts too much when she urinates. What is the best response from the nurse?

A. Advise her to take acetaminophen to ease symptoms.

B. Ask primary care provider to prescribe an analgesic.

C. Instruct to use a sitz bath while voiding.

D. Teach that adequate hydration helps clear the infection quicker.

Answer: D Rationale: Adequate hydration is necessary to dilute the bacterial concentration in the urine and aid in clearing the organisms from the urinary tract. Encourage the woman to drink at least 3000 ml of fluid a day, suggesting she drink one glass per hour. Drinking fluid will make the urine acidic, deterring organism growth. The other choices are also options but address the symptoms and not the root cause.

The goal should be to rid the body of the infection, not concentrate on counteracting the results of the infection.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 415 9. The nurse is caring for a client who has been diagnosed with a deep vein thrombosis. Which assessment finding should the nurse prioritize and report immediately?

A. Calf pain B. Pyrexia C. Edema D. Dyspnea Answer: D Rationale: A DVT is often suspected when an individual with an increased risk develops calf pain, pyrexia, and edema in one lower extremity. After the individual has been positively diagnosed with a DVT, any signs of dyspnea should be suspect of possible pulmonary embolism and should be handled as an emergency. The RN and/or primary care provider should be notified immediately so emergent care can be started, as this is often fatal.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 418

10. The father of a 2-week-old infant presents to the clinic with his disheveled wife for a postpartum visit. He reports his wife is acting differently, is extremely talkative and energetic, sleeping only 1 or 2 hours at a time (if at all), not eating, and appears to be totally neglecting the infant. The nurse should suspect the client is exhibiting signs and symptoms of which disorder?

A. Postpartum blues B. Postpartum depression C. Postpartum psychosis D. Maladjustment Answer: C Rationale: Postpartum psychosis in a client can present with extreme mood changes and odd behavior. Her sudden change in behavior from normal, along with a lack of self-care and care for the infant, are signs of psychosis and need to be assessed by a provider as soon as possible. Postpartum depression affects the woman's ability to function; however, her perception of reality remains intact.

Postpartum blues is a transitory phase of sadness and crying common among postpartum women.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 422 11. The nursing instructor is leading a discussion exploring the various conditions that can result in postpartum hemorrhage. The instructor determines the session is successful when the students correctly choose which condition is most frequently the cause of postpartum hemorrhage?

A. Hematoma B. Uterine atony C. Perineal lacerations D. Disseminated intravascular coagulation Answer: B Rationale: Early postpartum hemorrhage usually results from one of the following conditions: uterine atony, lacerations, or hematoma. Most cases of early postpartum hemorrhage result from uterine atony, which is due to the uterine muscles remaining relaxed and not contracting as they should. Disseminated intravascular coagulation is a complication which can occur with excessive postpartum hemorrhage.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

Reference: p. 404 12. The nurse is assessing a client who is 14 hours postpartum and notes very heavy lochia flow with large clots. Which action should the nurse prioritize?

A. Assess her blood pressure.

B. Palpate her fundus.

C. Have her turn to her left side.

D. Assess her perineum.

Answer: B Rationale: The nurse should assess the status of the uterus by palpating the fundus and determining its condition. If it is boggy, the nurse would then initiate fundal massage to help it contract and encourage the passage of the lochia and any potential clots that may be in the uterus. Assessing the blood pressure and assessing her perineum would follow if indicated. It would be best if the woman is in the semi-Fowler position to allow gravity to help the lochia to drain from the uterus. The nurse would also ensure the bladder was not distended.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 405 13. The nurse is caring for a postpartum woman who is diagnosed with endometritis. Which position should the nurse encourage the client to maintain?

A. Flat in bed B. On her left side C. Trendelenburg D. Semi-Fowler Answer: D Rationale: A semi-Fowler position encourages lochia to drain so it will not become stagnant and cause further infection. Placing the woman flat in bed, on her left side, or in the Trendelenburg position would not accomplish this goal and could result in the infection spreading to other parts of the body.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 411 14. The nurse observes an ambulating postpartum woman limping and avoiding putting pressure on her right leg. Which assessments should the nurse prioritize in this client?

A. Bend the knee and palpate the calf for pain.

B. Ask the client to raise the foot and draw a circle.

C. Blanch a toe, and count the seconds it takes to color again.

D. Assess for warmth, erythema, and pedal edema.

Answer: D Rationale: This client is demonstrating potential symptoms of DVT, but is avoiding putting pressure on the leg and limping when ambulating. DVT manifestations are caused by inflammation and obstruction of venous return and can be assessed by the presence of calf swelling, warmth, erythema, tenderness, and pedal edema. The client would not need to bend the knee to assess for pain in the calf. Asking the client to raise her toe and draw a circle is assessing reflexes, and blanching a toe is assessing capillary refill (which may be affected by the DVT but is not indicative of a DVT).

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 418-419 15. The nurse assesses the client who is 1 hour postpartum and discovers a heavy, steady trickle of bright red blood from the vagina in the presence of a firm fundus.

Which potential cause should the nurse question and report to the RN or primary care provider?

A. Uterine atony B. Laceration C. Perineal hematoma D. Infection of the uterus Answer: B Rationale: A steady trickle of blood with a firm uterus is more likely to occur from a laceration rather than from the uterine atony. This type of bleeding is usually bright red in color rather than the dark red color of lochia. A perineal hematoma presents as a bulging, swollen mass on the perineum. Uterine infection typically presents with a foul smelling discharge.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 408 16. The nurse is monitoring a client who is 5 hours postpartum and notes her perineal pad has become saturated in approximately 15 minutes. Which action should the nurse prioritize?

A. Initiate Ringer's lactate infusion.

B. Assess the woman's vital signs.

C. Call the woman's health care provider.

D. Assess the woman's fundus.

Answer: D Rationale: The nurse should prioritize assessing the uterine fundus to eliminate it as a source of the bleeding. Assessing the vital signs would be the next step, especially if the massage is ineffective, to determine if the client is becoming unstable. The nurse would then alert the RN or health care provider about the increased bleeding and/or unstable vital signs. The LPN would not initiate an IV infusion without an order from the health care provider but should be prepared to do so, if it is ordered.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 407 17. The nurse is monitoring the woman who is 1 hour postpartum and notes on assessment the uterine fundus is boggy, to the right, and approximately 2 cm above the umbilicus. The nurse would conclude this is most likely related to which potential complication?

A. Urinary infection B. Excessive bleeding C. A ruptured bladder D. Bladder distention Answer: D Rationale: The displacement of the uterus to one side is suggestive of bladder distention. The bladder should be emptied and then fundal massage instituted to encourage the uterus to contract and stop the excessive bleeding. If the uterus was in the midline, then this would be related solely to uterine bleeding. It's important to ensure the bladder is empty before starting the fundal massage to ensure the uterus will stay contracted. A urinary infection would be noted to cause burning on urination. A ruptured bladder would be indicative of hematuria as well as pelvic pain.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 407

18. A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the health care provider?

A. Warm and flushed skin B. Weak and rapid pulse C. Elevated blood pressure D. Decreased respiratory rate Answer: B Rationale: Excessive hemorrhage puts the client at risk for hypovolemic shock.

Signs of impending shock include a weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin. These findings should be reported immediately to the health care provider so that proper intervention for the client may be instituted.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 404 19. The LPN has reported that uterine massage is ineffective on a client. The nurse anticipates the health care provider will prescribe which medication to address this issue?

A. Ibuprofen B. Oxytocin C. Penicillin D. Digoxin Answer: B Rationale: Oxytocin is the drug used first for uterine atony. Other medications which may be ordered include ergonovine, methylergonovine, carboprost, and misoprostol. Ibuprofen, penicillin, or digoxin would have no effect on uterine atony.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 406 20. The nurse is monitoring several postpartum women for potential complications related to the birthing process. Which assessment should a nurse prioritize on an hourly basis?

A. Complete blood count B. Vital signs C. Pad count

D. Urine volume excreted Answer: C Rationale: The way to monitor for bleeding every hour is to assess pads and percentage of the pad saturated by blood in the previous hour. It would not be necessary to do a complete blood count every hour, nor hourly urines. Vital signs are not typically taken every hour.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 407 21. The nurse is assessing a client 48 hours postpartum and notes on assessment: temperature 101.2oF (38.4oC), HR 82, RR 18, BP 125/78 mm Hg. The nurse should suspect the vital signs indicate which potential situation?

A. Dehydration B. Normal vital signs C. Infection D. Shock Answer: C Rationale: Temperatures elevated above 100.4° F (38° C) 24 hours after birth are indicative of possible infection. All but the temperature for this client are within normal limits, so they are not indicative of shock or dehydration.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 410 22. A woman presents to the clinic at 1-month postpartum and reports her left breast has a painful, reddened area. On assessment, the nurse discovers a localized red and warm area. The nurse predicts the client has developed which disorder?

A. Breast yeast B. Mastitis C. Plugged milk duct D. Engorgement Answer: B Rationale: Mastitis usually occurs 2 to 3 weeks after birth and is noted to be unilateral. Assessment should reveal a localized reddened area that is warm and

painful to palpation. The scenario described is not indicative of a plugged milk duct or engorgement. Yeast is not recognized to cause mastitis.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 413 23. The nurse is preparing discharge instructions for a postpartum woman who has developed DVT after a long and difficult birthing process. The nurse will include instruction on which medication for this client?

A. NSAIDS B. Anticoagulants C. Opioid analgesics D. Beta-blockers Answer: B Rationale: The nurse should instruct the client on the anticoagulant, which will be prescribed due to the DVT. The client may be advised to use NSAIDs for pain control. Opioid analgesics would not be appropriate, especially if the client is breastfeeding her infant. Beta-blockers would not be appropriate for this situation.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 418 24. A client who underwent a cesarean birth suddenly complains of shortness of breath and pain approximately 2 hours after delivery. Which action should the nurse prioritize?

A. Ensure the head of the bed is at 45 degrees.

B. Apply oxygen.

C. Obtain arterial blood gas.

D. Increase IV fluid rate.

Answer: A Rationale: The immediate response by the nurse is to ensure the head of the bed is at 45 degrees. Then the LPN must notify the RN and/or health care provider.

Applying oxygen, obtaining an arterial blood gas specimen, or increasing the IV fluid rate will be done on orders from the health care provider.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process Reference: p. 420 25. The nurse is assessing a postpartum client at a 6-week well-care check and notes questionable behavior on assessment. Which behaviors should the nurse prioritize and report to the RN or health care provider?

A. Tearful during appointment B. Talkative and asking questions C. Restless and agitated, concerned with self and not the infant D. States being tired and happy at same time Answer: C Rationale: When a woman presents with restlessness, irritability and concern only for self needs and not the infant's needs, further evaluation for possible postpartum psychosis should be a priority. The other choices would be considered normal reactions for a postpartum woman.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 422 26. The nurse is interacting with a young mother and her 2-week-old infant. Which behavior by the mother should the nurse prioritize and report to the RN or health care provider?

A. Talking to the infant and rocking the infant B. Not responding to the infant crying C. Discussing her birth with another new mom D. Breast-feeding the infant in public Answer: B Rationale: When a mother is not engaged with the infant and is demonstrating signs of not providing care or responding to the infant, there is a concern about malattachment. This needs to be reported to the health care provider for follow-up.

The other options are normal activities for a new mother who is 2 weeks postpartum.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 421 27. A client presents to the clinic with her 3-week-old infant reporting general flulike symptoms and a painful right breast. Assessment reveals temperature 101°8F

(38.8°C) and the right breast nipple with a movable mass that is red and warm.

The client is diagnosed with mastitis. Which instruction should the nurse prioritize for this client?

A. Complete the full course of antibiotic prescribed, even if you begin to feel better.

B. Use NSAIDs, warm showers, and warm compresses to relieve discomfort.

C. Breastfeed or otherwise empty your breasts at least every 3 hours.

D. Increase your fluid intake to ensure that you will continue to produce adequate milk.

Answer: A Rationale: Mastitis is an infection of the breast tissue with common reports of general flu-like symptoms that occur suddenly, along with tenderness, pain, and heaviness in the breast. Inspection reveals erythema and edema in an area localized to one breast, commonly in a pie-shaped wedge. The area is warm and moves or compresses on palpation. Nursing care focuses on supporting continued breastfeeding, preventing milk stasis and administering antibiotics for a full 10 to 14 days. The woman should empty her breasts every 1.5 to 2 hours to help prevent milk stasis and the spread of the mastitis. The use of analgesics, warm showers, and warm compresses to relieve discomfort may be encouraged; increasing her fluid intake will keep the mother well-hydrated and able to produce an adequate milk supply. However, these actions would not be considered the most important aspects of self-care for this client at this time.

Question format: Multiple Choice Chapter 19: Postpartum Woman at Risk Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 413

Chapter 20 1. When assisting in the delivery of a postterm baby, as soon as the baby's head is delivered, the nurse is most likely to be called upon to help the physician perform what action?

A. administer oxygen B. perform a gastric lavage C. suction the baby's mouth and nose D. start IV glucose Answer: C Rationale: Often the postterm infant has expelled meconium in utero. At birth, the meconium may be aspirated into the lungs, obstructing the respiratory passages and irritating the lungs. This may lead to pneumonia. To reduce the chances of meconium aspiration, upon delivery of the postterm newborn's head and just before the baby takes his first breath, the physician or clinical nurse will suction the infant's mouth and nose and also check for respiratory problems related to meconium aspiration. After delivery, gastric lavage also may be performed to remove any meconium swallowed and to prevent aspiration of vomitus. The stressed postterm newborn will not tolerate the labor and delivery process too well; supplemental oxygen therapy might be ordered for respiratory distress. Typically postmature newborns are ravenous eaters at birth. With this in mind, if the newborn is free from respiratory distress, the practical nurse can offer feedings at 1 or 2 hours of age, being observant for potential aspiration and possible asphyxia.

Intravenous glucose infusions may be ordered to stabilize the newborn's glucose level.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 444 2. Four weeks before the birth of a client's already large child, the health care provider has told the client that if the baby gets bigger and the baby's lungs are ready, a cesarean birth is preferred. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?

A. "If the health care provider has recommended the procedure, it's likely that the benefits outweigh the risks."

B. "The procedure isn't risky for the baby, but your healing takes longer, and you'll have a scar."

C. "As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."

D. "Some women don't have any problem giving birth to large babies. You might want to get a second opinion."

Answer: C Rationale: Transient tachypnea of the newborn (TTN) involves the development of mild respiratory distress in a newborn. TTN results from a delay in absorption of fetal lung fluid after birth. As the fetus passes through the birth canal during birth, some of the fluid is expelled as the thoracic area is compressed. TTN is commonly seen in newborns born by cesarean birth. It typically occurs after birth with the greatest degree of distress occurring approximately 36 hours after birth. TTN commonly disappears spontaneously around the third day.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Caring Reference: p. 444 3. The nurse is accepting a new mother and her term infant into the unit after delivery and notes the newborn is documented as low-birth-weight. How much does the nurse expect the newborn to weigh?

A. 1450 grams B. 2000 grams C. 2550 grams D. 2950 grams Answer: B Rationale: There are three classifications based on weight which may be used to classify newborns. Low-birth-weight (LBW) newborns are those who weigh from 2,499 grams to 1,500 grams; very-low-birth-weight (VLBW) newborns weigh from 1,499 grams to 1,000 grams; and extremely-low-birth-weight (ELBW) newborns weigh less than 1,000 grams.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 428 4. The nurse is evaluating the neonate for gestational age. Which assessment finding will the nurse note when determining the infant is post-term?

A. A scarf sign shows resistance and the elbow is unable to reach midline.

B. Breast buds are 4.5 mm and have a raised areola.

C. Flexed positions show good muscle tone.

D. Ear cartilage is thick and the pinna is stiff.

Answer: D Rationale: In the post-term newborn, the ear cartilage is thick and the pinna is stiff; in the term newborn, cartilage is present within the pinna and the ear shows the ability for natural recoil when folded. In both post-term and term newborns, a scarf sign test shows resistance and the elbow is unable to reach midline. A postterm newborn will have full areolas with 5 to 10 mm breast buds and will be capable of full flexion of arms and legs.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 430 5. The nurse is weighing and measuring a term newborn. Which assessment findings would indicate that this newborn is suffering from asymmetrical growth restriction?

A. looks wasted and has poor skin turgor B. is pale with loose, dry skin C. has cracked and leathery skin D. has very thin skin and has multiple visible veins Answer: B Rationale: Asymmetrically growth-restricted newborns typically appear thin and pale with loose dry skin. The symmetrically growth-restricted newborn typically appears wasted with poor skin turgor. Post-term babies have skin that is leathery, cracked, and wrinkled. Preterm babies have skin that is very thin with little subcutaneous fat and easily visible veins.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 430 6. The nurse is caring for a pregnant woman who is struggling with controlling gestational diabetes mellitus. What effect does the nurse predict this situation may have on the fetus?

A. have a serious birth defect B. grow to an unusually large size C. suffer from symmetrical intrauterine growth restriction D. suffer from asymmetrical intrauterine growth restriction Answer: B

Rationale: Maternal diabetes is the most widely known contributing factor to largefor-gestational-age newborns. LGA babies are frequently born to mothers with diabetes and poor glucose control. Continued high blood glucose levels in the mother lead to an increase in insulin production in the fetus. Increased insulin levels act as a fetal growth hormone causing macrosomia, an unusually large newborn with a birth weight of greater than 4,500 grams (9 pounds, 14 ounces).

The incidence of birth defects in newborns born of a mother with gestational diabetes is not greatly increased. IUGR is not a typical outcome of uncontrolled gestational diabetes. It is more likely that the newborn will be large-for-gestationalage.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 432 7. The nurse is preparing a presentation for a health fair presenting the risks which can lead to sudden infant death syndrome (SIDS). Which factors would the nurse include as increasing the risk for SIDS? A. a low-birth-weight baby girl, March birth, middle-class, 25-year-old G2P2 nonsmoker B. an average weight baby boy, January birth, a poor, 16-year-old G1P1 nonsmoker C. a low-birth-weight baby boy, November birth, wealthy, educated, 19-year-old G1P1 smoker D. An average weight baby boy, April birth, poor, 27 year old G2P2 nonsmoker Answer: C Rationale: No single cause of SIDS has been identified but there are contributing factors. Infants who die of SIDS are usually 2 to 4 months old, although some deaths have occurred during the first or second week of life. Few infants older than 6 months of age die of SIDS. It is a greater threat to low-birth-weight infants than to term infants. It occurs more often in winter and affects more male infants than female infants as well as more infants from minority and lower socioeconomic groups. Infants born to mothers younger than 20 years of age, infants who are not a firstborn child, and infants whose mothers smoked during pregnancy also have been found to be at greater risk.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 445 8. The nurse is caring for a 22-hour-old neonate male and notes on assessment at the beginning of the shift: Apgar score of 9, nursing without difficulty, and appeared healthy. As the nurse's shift goes on, subsequent assessment reveals his

sclera and skin have begun to take on a yellow hue. The nurse would report this as a possible indication of what condition?

A. heroin withdrawal B. hypoglycemia C. hypoxia D. hemolytic disease Answer: D Rationale: Any infant admitted to the newborn nursery should be examined for jaundice during the first 36 hours or more. Early development of jaundice (within the first 24 hours) is a probable indication of hemolytic disease. Heroin withdrawal symptoms commonly include tremors, restlessness, hyperactivity, disorganized or hyperactive reflexes, increased muscle tone, sneezing, tachypnea, vomiting, diarrhea, disturbed sleep patterns, and a shrill high-pitched cry. The hypoglycemic newborn's blood glucose would be low, and a newborn with hypoxia would show signs of respiratory distress.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 447 9. The nurse is assessing a toddler at a well-child visit and notes the following: small in stature, appears mildly developmentally delayed; short eyelid folds; and the nose is flat. Which advice should the nurse prioritize to the mother in response to her questions about having another baby?

A. "It's a good idea to stop drinking alcohol 3 months before trying to get pregnant."

B. "It's important to add iron and vitamin B supplements to your diet."

C. "It would be good to stop smoking before getting pregnant."

D. "It's important to keep insulin levels controlled during pregnancy."

Answer: A Rationale: Alcohol is one of the many teratogenic substances that cross the placenta to the fetus. Fetal alcohol spectrum disorder is often apparent in newborns of mothers with chronic alcoholism and sometimes appears in newborns whose mothers consume low-to-moderate amounts of alcohol. No amount of alcohol is believed to be safe, and women should stop drinking at least 3 months before they plan to become pregnant. The ability of the mother's liver to detoxify the alcohol is apparently of greater importance than the actual amount consumed. Fetal alcohol spectrum disorder is characterized by low birth weight, smaller height and head circumference, short palpebral fissures (eyelid folds), reduced ocular growth, and a flattened nasal bridge. These newborns are prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia. Their growth continues to be slow, and their mental development is delayed despite expert care and nutrition.

Smoking is related to respiratory issues. Proper nutrition and glucose control are also important but do not result in fetal alcohol spectrum disorder.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 449 10. The nurse is assessing a newborn and notes that the size of the infant will necessitate classification as large for gestational age. When questioned by the mother as to what this means, the nurse should point out the infant is at which percentile?

A. 86th percentile B. 88th percentile C. 90th percentile D. 92nd percentile Answer: D Rationale: The large-for-gestational-age (LGA) infant is above the 90th percentile for gestational age using the weight, length, and head circumference as a guideline.

Appropriate-for-gestational-age infants are in the 10th percentile to 90th percentile.

Infants below than 10th percentile are considered small-for-gestational-age.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 428 11. The nursing instructor is conducting a discussion centered on the various methods used to describe an infant. The instructor determines the session is successful when the students correctly choose which as an indication of gestational age?

A. the weight, height, and length of the newborn at birth B. the length of time between fertilization of the egg and birth C. the age of the newborn who is born before 40 weeks D. the newborn according to their birth assessment Answer: B Rationale: Gestational age is the length of time between fertilization of the egg and birth. Size classifications consider the newborn's weight, length, and head circumference and include SGA, AGA, and LGA. Infants born between 20 and 37 weeks' gestation are considered preterm. Infants born between 38 and 42 weeks' gestation are considered term, but this does not determine gestational age. Birth

assessment can help establish gestational age based on the findings; however, it is not what defines gestational age.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 428 12. The nurse is assessing a newborn to establish a gestational age. Which factors will the nurse prioritize when assessing the newborn's neuromuscular maturity?

Select all that apply.

A. skin B. posture C. arm recoil D. heel to ear E. plantar creases F. scarf sign Answer: B, C, D, F Rationale: The Ballard scoring system is a common gestational age assessment tool used in assessing the newborn. Posture, arm recoil, heel to ear, and scarf sign are the categories used to assess neuromuscular maturity. In addition, the square window and popliteal angle are categories used in this assessment tool for neuromuscular maturity. The skin and plantar creases are categories used by the Ballard scoring system to assess physical maturity of the infant.

Question format: Multiple Select Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 428 13. The nurse has completed an assessment on a newborn and documents a score of 17 for the physical maturity in the records. Which elements has the nurse prioritized for this assessment? Select all that apply.

A. skin B. posture C. breast buds D. square window E. plantar creases F. lanugo Answer: A, C, E, F Rationale: The Ballard scoring system assessment tool is used to determine gestational age of an infant. The skin, lanugo, plantar creases, breast buds, and

ears are the categories which measure the physical maturity of an infant. Posture and square window are categories used in the neuromuscular maturity assessment of the Ballard scoring system.

Question format: Multiple Select Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 428 14. The nurse is caring for a new infant and notes on assessment the newborn is small for gestational age and also has indications of intrauterine growth restriction.

Which assessments should the nurse prioritize about the mother as a potential cause for the infant's condition?

A. previous smoking history B. blood glucose levels C. number of normal pregnancies D. use of food stamp program during pregnancy Answer: B Rationale: Uncontrolled maternal diabetes can be a contributing factor for the infant with intrauterine growth restriction. Smoking during pregnancy could be a contributing factor, but being a previous smoker would not affect this pregnancy.

Inadequate maternal nutrition is a contributing factor, but because this mother was on a food stamp program she was more likely to have had adequate nutrition during pregnancy. Previous pregnancies with a history of IUGR or other poor pregnancy outcomes would be a possible contributing factor, but not normal pregnancies.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 4361 15. A nurse is caring for a newborn who is determined to be small-for-gestationalage with intrauterine growth restriction. Which finding would lead the nurse to also question if this infant has asymmetric growth restriction?

A. The head is large in comparison with the body.

B. The head and body parts are in proportion.

C. The length falls below the 10th percentile.

D. The length is above the 10th percentile.

Answer: A Rationale: The asymmetrically growth-restricted newborn's head is large in comparison with the body. When weight, length, and head circumference are

plotted on a standard growth chart, one or two of the measurements falls below the 10th percentile. These newborns typically have normal measurements for head circumference and length. Although the infant's length may fall below the 10th percentile, this is not common. When the growth pattern is symmetrical, both head and body parts are in proportion but are below normal size for gestational age.

Weight, length, and head circumference fall below the 10th percentile when plotted on a standard growth chart.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 430 16. During a clinical conference, a group of nursing students are discussing a newborn that is large-for-gestational-age. The instructor determines the students have successfully differentiated the potential cause after choosing which contributing maternal factor?

A. being 30 pounds overweight before getting pregnant B. mother is 5 feet 3 inches (1.6 m) tall and the father is 5 feet 10 inches (1.78 m) tall C. a blood glucose of 100 several times during the pregnancy D. being a 19-year-old G2P2 Answer: A Rationale: Obesity is a strong contributing factor in infants who are large-forgestational-age. Parents of large stature have an increased tendency to reproduce an LGA newborn. Maternal diabetes, particularly if it is poorly controlled, is the strongest known contributing factor, but a glucose level of 100 would not indicate the mother was diabetic. Multiparous women have a higher incidence of large-forgestational-age infants.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 432 17. The nurse is preparing a presentation for a health fair that will illustrate various factors that contribute to preterm births. Which contributing factor should the nurse prioritize?

A. tocolytics used to relax the uterus B. corticosteroids that are used to enhance lung maturity C. fertility treatments that are resulting in multiple births D. Antibiotics used to treat prenatal infections Answer: C

Rationale: The main cause of an increase in the incidence of preterm birth is advances in fertility treatments resulting in multiple births. Multiple births are often preterm because of polyhydramnios (excessive amniotic fluid), a larger than average intrauterine mass, and/or early cervical dilation (dilatation). Tocolytics help to decrease the number of preterm births and corticosteroids are used if preterm birth is anticipated. Although intrauterine infections can contribute to preterm births, the use of antibiotics is less likely to cause a preterm birth.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 433 18. The nurse is assessing the newborn male of a teen mother who was afraid to seek appropriate prenatal care. Which assessment finding should lead the nurse to question if this infant is preterm?

A. smooth skin B. lanugo on the back and shoulders C. descended testicles D. subcutaneous fat on the extremities Answer: B Rationale: The preterm infant has lanugo over the extremities, back, and shoulders.

Compared with the term infant, the preterm infant has translucent and usually wrinkled skin, little muscle or subcutaneous fat, and the testes are undescended in the male.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 430 19. The nursing instructor is leading a discussion with a group of nursing students who are analyzing the preterm infant's physiologic immaturity and the associated difficulties the newborn and family must deal with. The instructor determines the session is successful when the students correctly choose which body system that presents with the most critical concerns related to this immaturity?

A. the genitourinary system B. the musculoskeletal system C. the endocrine system D. the respiratory system Answer: D

Rationale: Immaturity causes difficulties involving all body systems, the most critical of which is the respiratory system, the last to fully develop. Typically, respirations are shallow, rapid, and irregular with periods of apnea (absence of breathing) that lasts for at least 20 seconds or that causes cyanosis and/or bradycardia. Although difficulties may occur in the other systems, the most critical is the respiratory system.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 433 20. The nurse cares for preterm infants and assesses them for potential complications to provide adequate countermeasures to prevent father complications. Which complication should the nurse prioritize and initiate proper measures to protect the newborn?

A. decreased muscle tone B. loss of body heat C. excess antibodies acquired from the mother D. increased caloric intake Answer: B Rationale: Thermoregulation and maintaining fluid and electrolyte balance are major problems for the preterm newborn because he or she loses heat and fluids more quickly and has fewer compensatory mechanisms than does the term newborn. Although the preterm newborn does have decreased muscle tone, the loss of body heat is a more critical concern. The preterm newborn does not receive enough antibodies from the mother and cannot produce them, and subsequently has a decrease rather than an excess. The preterm newborn has high caloric needs but has a small stomach and a digestive system that may be unprepared to receive and digest food; therefore, the newborn often has a decreased caloric intake.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 433 21. The nurse is teaching new parents about their premature newborn who was born with respiratory distress syndrome (RDS). The nurse determines the teaching session is successful when the parents correctly choose which explanation as being the cause of their newborn's condition?

A. The lungs are hyperextended due to increased load of work.

B. The infant has inherited allergies from the mother.

C. The lungs are immature and deficient in surfactant.

D. The mother has a history of asthma which interfered in lung development.

Answer: C Rationale: In RDS, the premature infant's lungs are deficient in surfactant and thus collapse after each breath, greatly increasing the work of breathing. The other choices do not contribute to the immaturity of the infant's lungs and may not have any effect on the infant's lungs at all. The lungs will more likely be hypoextended instead of hyperextended. Inherited allergies and asthma should not effect the lack of surfactant.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 435 22. The nurse assesses preterm infants as they come for routine well-baby checkups. The nurse will carefully assess the infant's vision to assess for which potential complication related to their birth?

A. cataracts B. amblyopia C. nystagmus D. retinopathy Answer: D Rationale: Retinopathy of prematurity (ROP) is a form of retinopathy (degenerative disease of the retina) commonly associated with the preterm newborn. Cataracts is common among older adults and results from the lens becoming opaque.

Amblyopia, or lazy eye, is not related to gestational age and is assessed when the child is a toddler. Nystagmus is also not related to gestational age but to neurologic dysfunction of the eye.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 435 23. The nurse is preparing a nursing care plan for a preterm infant in the newborn nursery. Which nursing diagnoses could the nurse determine to be appropriate for this infant? Select all that apply.

A. Ineffective breathing pattern B. Ineffective thermoregulation C. Risk for fluid volume excess D. Risk for imbalanced nutrition: more than body requirements E. Risk for impaired skin integrity

Answer: A, B, E Rationale: Nursing diagnoses for a preterm newborn could include the following: Ineffective breathing pattern related to an immature respiratory system; Ineffective thermoregulation related to immaturity and transition to extrauterine life; and Risk for impaired skin integrity related to prematurity and exposure to phototherapy light. Additional diagnoses could include the following: Risk for ineffective infant feeding pattern related to an inability to suck instead of imbalanced nutrition, more than body requirements; and Risk for deficit fluid volume instead of Risk for fluid volume excess.

Question format: Multiple Select Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 436 24. The nurse is admitting a newborn into the nursery and notes the newborn was born at 42 weeks' gestation. Which action should the nurse prioritize when caring for this infant?

A. Monitor the newborn's blood glucose levels.

B. Wrap the newborn lightly in a single blanket.

C. Ensure feedings are offered every 4 hours.

D. Anticipate a blood transfusion will be required.

Answer: A Rationale: The infant is a post-term infant because of the gestational age. In the last weeks of gestation, the infant relies on glycogen for nutrition. This depletes the liver glycogen stores and may lead to neonatal hypoglycemia, which will require monitoring of serial blood glucose levels. The newborn may require intravenous glucose infusions to stabilize the glucose level. Post-term newborns can have thermoregulation concerns, so a thermoneutral environment such as a radiant heat warmer or isolette may be needed. Use measures to minimize heat loss. Post-term newborns are ravenous eaters at birth and may be offered feedings at 1 or 2 hours of age and as desired after that. Although exchange transfusion may be done to prevent or treat hyperviscosity, this is not a common concern so the glucose levels are a higher priority.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 444 25. The nursing instructor is conducting a session with a group of nursing students researching potential respiratory difficulties in newborns. The instructor determines

the session is successful after the students correctly choose which contributing factor for transient tachypnea of the newborn?

A. usually occurs with maternal history of hypertension B. associated with fetal distress during labor C. often seen with advanced gestational age D. often seen with cesarean births Answer: D Rationale: Transient tachypnea of the newborn (TTN) commonly occurs in newborns born via cesarean birth. The newborn does not experience the compression of the thoracic cavity that occurs with passage through the birth canal, so he or she retains some fluid in the lungs that usually squeezes out as the thoracic area is compressed during a vaginal birth. Maternal hypertension (which can advance into preeclampsia or eclampsia); fetal distress; and advanced gestational age can all be contributing factors for the decision of the health care provider to perform a cesarean, but they are not recognized as a direct cause for TTN. Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 444 26. The nurse is examining the morning laboratory results of the newborns of mothers with diabetes. Which report finding should the nurse prioritize?

A. hypocalcemia B. hypermagnesemia C. hypobilirubinemia D. hyperkalemia Answer: A Rationale: The newborn of the mother with diabetes is at risk for hypoglycemia, hypocalcemia, hypomagnesemia (not hypermagnesemia), polycythemia with hyperviscosity, and hyperbilirubinemia (not hypobilirubinemia). Potassium concerns (hyperkalemia or hypokalemia) are not a risk for these newborns.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 448 27. The nurse is admitting to the nursery a newborn of a mother who continued to drink alcohol during her pregnancy. Which finding does the nurse predict to encounter on the newborn's assessment?

A. above average birth weight

B. large head circumference C. lethargic and sleepy D. hyperactive and irritable Answer: D Rationale: The newborn that is withdrawing from alcohol typically is hyperactive, irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of fetal alcohol spectrum disorder include low birth weight, and small height and head circumference. This newborn is prone to respiratory difficulties, hypoglycemia, hypocalcemia, and hyperbilirubinemia.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 449 28. The nurse is caring for a newborn who is receiving phototherapy for hemolytic disease. As the nurse explains the procedure to the mother, which instruction should the nurse prioritize?

A. Leave the light off for 1 hour six times a day.

B. Dress the newborn in a lightweight gown at night.

C. Turn the newborn every 3 to 4 hours.

D. Remove and change the eye patches every hour.

Answer: C Rationale: The nurse should turn the newborn every 2 hours to rotate the area of exposure. Do not turn off the lights except to feed and to change the diaper. The infant is nude to maximize the skin surface area exposed to the light. Remove the patches every 4 hours to cleanse the eyes and examine for irritation, inflammation, and/or dryness. Clean and change the patches daily.

Question format: Multiple Choice Chapter 20: The Newborn at Risk: Gestational and Acquired Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 446

Chapter 21 1. The nurse is preparing pre- and postoperative instructions for a family whose 6month-old infant is scheduled for an initial surgical repair of a cleft lip and palate.

Which activity should the nurse prioritize in the instructions to the caregivers of this infant?

A. Feed the infant with a drinking straw.

B. Feed the infant with a rubber covered spoon.

C. Train the infant to drink from a glass or cup.

D. Let the infant become accustomed to being in elbow restraints.

Answer: D Rationale: The thumb, although comforting, may quickly undo the repair or cause undesirable scarring along the suture line. The infant's ultimate happiness and wellbeing must take precedence over immediate satisfaction. Acclimating the infant to elbow restraints gradually before admission is helpful. For an infant who has had a palate repair, no nipples, spoons, or straws are permitted; only a drinking glass or a cup is recommended.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 473 2. The parents of a newborn are struggling with the news that their infant has spina bifida. Which technique should the nurse prioritize teaching to the parents that will help increase the infant's comfort and development?

A. Diaper the baby safely.

B. Hold the baby during feeding.

C. Cuddle the baby in a chest-to-chest position.

D. Clean and moisturize the myelomeningocele sac.

Answer: C Rationale: The family of a newborn with such a major anomaly is in a state of shock on first learning of the problems. Be especially sensitive to their needs and emotions. Encourage family members to express their feelings and emotions as openly as possible. If possible, encourage the family members to cuddle or touch the newborn using proper precautions for the safety of the defect. With the permission of the physician, the newborn may be held in a chest-to-chest position to provide closer contact. The preoperative goals for care of the newborn with myelomeningocele include preventing infection, maintaining skin integrity, preventing trauma related to disuse, increasing family coping skills, education about the condition, and support. Diapering is not advisable with a low defect.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 458-459 3. A nurse is providing postoperative care to an infant who had a ventriculoarterial shunt placed. Approximately 8 hours after surgery, the nurse notes on assessment shrill crying and projective vomiting. Which response should the nurse prioritize at this time?

A. Assess surgical site for signs of infection.

B. Increase the flow of IV fluids and maintain NPO status.

C. Assess and administer pain medication.

D. Notify the primary care provider immediately.

Answer: D Rationale: The projectile vomiting should raise suspicions of increasing intracranial pressure and requires emergent intervention, so the nurse should notify the primary care provider immediately. Symptoms of increased intracranial pressure (ICP) may also include irritability, restlessness, personality change, high-pitched cry, ataxia, failure to thrive, seizures, severe headache, changes in level of consciousness, and papilledema. At least every 2 to 4 hours, the nurse should monitor the newborn's level of consciousness, check the pupils for equality and reaction, monitor the neurologic status, and observe for a shrill cry, lethargy, or irritability. Edema and localized redness at the surgical site are potential indications of an infection. Assessing for pain and administering pain medication in this situation can result in the symptoms being masked and the infant could die.

Increasing the fluid rate could contribute to the increased volume of fluids in the brain and would exacerbate the situation.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 459 4. The nurse is assessing a 4-year-old male born with a heart condition who is brought in for a routine well-child visit by his parents. The parents report he is very curious, active, and very social; however, they often see him take breaks in his play by squatting for a few minutes or sitting on the sidelines at which time they insist he take a nap. Assessment reveals a child small for his age, mildly cyanotic, and tires easily. What is the best response to the parents when they ask the nurse for suggestions on how to encourage their son to take the naps they insist on but he doesn't want to take?

A. "It's important to limit Stevie's physical exertion, so it is good to bring him inside when you think he needs to rest."

B. "Children are often aware of their limitations, and because he has shown that he knows when he needs to take a break he should be encouraged to control his own activity level."

C. "He might do well with a scheduled 15-minute break for every 30 minutes of active play."

D. "He might not need to nap, but it would be sensible to call him in so that you can check his pulse if he squats or takes a rest."

Answer: B Rationale: Children are rather sensible about finding their own limitations and usually limit their activities to their capacity if they are not made unduly apprehensive. A child with congenital heart disease should be allowed to lead as normal a life as possible. Families are naturally apprehensive and find it difficult not to overprotect the child. They often increase the child's anxiety and cause fear in the child about participating in normal activities. The child may assume a squatting position, which reduces the return flow to the heart, thus temporarily reducing the workload of the heart. The other choices take the control away from the child and can increase his or her anxiety level, thereby increasing the work of the heart.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 467 5. A 2-year old child has gone home following successful hip dysplasia surgery in a spica cast. Her caregiver calls 2 days later to report the child has been vomiting after eating, but has no fever. Which response should the nurse prioritize in response to this caregiver?

A. "If the child develops a fever or isn't able to hold anything down over the next 24 hours she should come back to the hospital."

B. "The vomiting is a possible sign of infection, and the child should be brought back in."

C. "The child may be reacting to the analgesics. Observe the child for the next 8 hours and see what happens."

D. If there is no fever and the child wants to eat, the cast may be too tight; she should be brought back in for recasting."

Answer: D Rationale: For a child in a spica cast, vomiting after a feeding may be an indication that the cast is too tight over the stomach. The cast may have to be removed and reapplied. Although vomiting may be a sign the child is ill or is reacting to analgesics, the child needs to be seen by the care provider to rule out complications relating to the cast, rather than to wait for further symptoms to develop.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 482 6. The nurse is working with an adult female who has PKU and desires to become pregnant. The nurse notes on her assessment her current serum phenylalanine level is 10 mg/dl. Which instruction should the nurse prioritize for this client?

A. "Think carefully about the decision. The child might be intellectually disabled since your PKU is inherited, especially if your levels stay high.

B. "It will be best if you cut back on meat, fish, and dairy products before you become pregnant to get your serum phenylalanine level down under 8 mg."

C. "It will be best if you cut back on vegetables and fruit before you become pregnant to get your serum phenylalanine level down under 8 mg."

D. "The baby won't be able to breastfeed. You know breastfeeding is really the best way to care for a newborn."

Answer: B Rationale: If a woman with PKU decides to have a child and is not following a diet low in phenylalanine, she should return to following the dietary treatment for at least 3 months before becoming pregnant. A low-phenylalanine diet is a very restricted one: foods to be omitted are breads, meat, fish, dairy products, nuts, and legumes. The diet is continued through the pregnancy to help prevent the child from being born with an intellectual disability. Routine blood testing is done to maintain the serum phenylalanine level at 2 to 8 mg/dl. A formula low in phenylalanine should be started as soon as the condition is detected; Lofenalac and Phenyl-free are low-phenylalanine formulas. Best results are obtained if the special formula is started before the newborn is 3 weeks of age.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 483 7. A nurse is providing information for a pregnant woman who has just discovered that the fetus she's carrying is likely to have Down syndrome. Which statement by the nurse is most accurate regarding the possible concerns for a child with Down syndrome?

A. They all suffer from severe intellectual disabilities.

B. They have a higher risk of developing leukemia than those in the general population.

C. They are cognitively impaired and often threaten the safety of others in their homes and neighborhoods.

D. They have so many needs and demands on the family that the family structure rarely holds up.

Answer: B Rationale: People with Down syndrome have a greater susceptibility to leukemia than that of the general population. Mental status is usually within the moderate to severe range of intellectual disability, with most children being moderately disabled.

A cognitively impaired child who is undisciplined or improperly supervised may threaten the safety of others in the home and the neighborhood, and caring for the child may demand so much sacrifice from other family members that the family structure may be significantly affected. However, with consistent care, patience, and guidelines, families of children with Down syndrome often find joy and pleasure in the gentle and loving nature of the child.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 485 8. A caregiver brings a 13-year-old male for a pre-high school checkup and reports he has spent lots of time in the principal's office or serving detention during junior high, and questions if he is too immature to be in high school. The nurse's assessment reveals evident breasts, little underarm or chest hair, and a highpitched voice. Which condition should the nurse suspect and discuss with the primary care provider?

A. Turner syndrome B. Klinefelter syndrome C. ambiguous genitalia D. hypothyroidism Answer: B Rationale: The presence of an extra X chromosome causes Klinefelter syndrome, most commonly seen in males. Characteristics are not often evident until puberty, when the child does not develop secondary sex characteristics. The testes are usually small and do not produce mature sperm. Increased breast size and a risk of developing breast cancer are frequently seen. Boys with Klinefelter syndrome often have normal intelligence but frequently have behavior problems, show signs of immaturity and insecurity, and have difficulty with memory and processing.

Characteristics of Turner syndrome include short stature, low set ears, a broadbased neck that appears webbed and short, a low-set hairline at the nape of the neck, broad chest, an increased angle of the arms, and edema of the hands and feet. Females are most often affected by Turner syndrome and do not develop secondary sex characteristics with the exception of pubic hair. If it is not possible to determine by observation at birth if the child is a male or female, the condition is called ambiguous genitalia. In hypothyroidism, the thyroid hormone must be

replaced as soon as the diagnosis is made. Unless therapy is started in early infancy, intellectual disability and slow growth occur. The later that therapy is started, the more severe the intellectual disability.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 486 9. The nursing instructor is teaching a session on techniques that the nursing students can use to properly address concerns of parents with children who are born with a cleft lip and palate. The instructor determines the session is successful when the students correctly choose which nursing intervention as being the most effective in these situations?

A. Help the child to understand his or her limitations.

B. Keep the family informed about new and effective treatments.

C. Model good medical practices for the child's family.

D. Use reflective listening with nonjudgmental support.

Answer: D Rationale: Families are naturally apprehensive and find it difficult not to overprotect a child who is ill. They often increase the child's anxiety and cause fear in the child about participating in normal activities. Children are rather sensible about finding their own limitations and usually limit their activities to their capacity if they are not made unduly apprehensive. Some families can adjust well and provide guidance and security for the sick child. Others may become confused and frightened and show hostility, disinterest, or neglect; these families need guidance and counseling.

The nurse has a great responsibility to support the family. The nurse's primary goal is to reduce anxiety in the child and family. This goal may be accomplished through open communication and ongoing contact.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Psychosocial Integrity: Psychosocial Integrity Integrated Process: Caring Reference: p. 469-470 10. A nursing instructor is preparing a discussion which will illustrate the different forms of spina bifida. The instructor determines the session is successful after the students correctly choose which form as being spina bifida with myelomeningocele?

A. The spinal cord, meninges, and nerve roots protrude out the lower back.

B. There's a cystic sac containing the spinal meninges protruding out the back.

C. There is only soft-tissue inflammation without protrusion.

D. There is a bony defect that occurs without soft-tissue involvement.

Answer: A

Rationale: In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. When part of the spinal meninges protrudes through the bony defect and forms a cystic sac, the condition is termed spina bifida with meningocele. A bony defect that occurs without soft-tissue involvement is called spina bifida occulta. No pressure is placed on the cyst.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 456-457 11. The nurse is preparing to teach the young parents of a newborn who is diagnosed with spinal bifida occulta how to care for their newborn. Which information should the nurse prioritize when explaining this defect?

A. There is protrusion of the spinal cord and meninges, with nerve roots embedded.

B. The spinal meninges protrude through the bony defect and form a cystic sac.

C. There is no protrusion of the spinal cord, only soft-tissue inflammation occurs.

D. There is a bony defect that occurs without soft-tissue involvement.

Answer: D Rationale: A bony defect that occurs without soft-tissue involvement is called spina bifida occulta. In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst.

When part of the spinal meninges protrudes through the bony defect and forms a cystic sac, the condition is termed spina bifida with meningocele.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 456-457 12. The community health nurse is preparing a presentation which will illustrate the various forms of spina bifida for a health fair. Which explanation should the nurse use to explain spina bifida with meningocele?

A. There is protrusion of the spinal cord and meninges, with nerve roots embedded.

B. The spinal meninges protrude through the bony defect and form a cystic sac.

C. There is no protrusion of the spinal cord, only soft-tissue inflammation occurs.

D. There is a bony defect that occurs without soft-tissue involvement.

Answer: B Rationale: When part of the spinal meninges protrudes through the bony defect and forms a cystic sac, the condition is termed spina bifida with meningocele. In spina

bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. A bony defect that occurs without soft-tissue involvement is called spina bifida occulta.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 456-458 13. The nurse is preparing a nursing care plan for an infant who was born with spina bifida with myelomeningocele. Which nursing goal should the nurse prioritize for this child?

A. Reducing family anxiety B. Preventing infection C. Providing caregiver teaching D. Promoting comfort measures Answer: B Rationale: The highest priority nursing goal is preventing infection because of the vulnerability of the myelomeningocele sac. Promoting comfort is important but not as high a priority because the child does not usually have severe pain with this diagnosis. Reducing anxiety and teaching are lower priorities; physical is a higher priority than psychosocial.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 457 14. A nursing instructor is leading a group discussion on congenital hydrocephalus.

The instructor determines the session is successful after the students correctly choose which factor that determines the noncommunicating type?

A. Decreased production of cerebrospinal fluid B. Obstruction that keeps CSF from passing between the ventricles and the spinal cord C. Opening between the ventricles and the spinal cord that usually closes at birth D. Defective absorption of cerebrospinal fluid Answer: B Rationale: In the noncommunicating type of congenital hydrocephalus, an obstruction occurs, and CSF is not able to pass between the ventricles and the spinal cord. The blockage causes increased pressure on the brain or spinal cord. In the communicating type of hydrocephalus, no obstruction of the free flow of CSF exists between the ventricles and the spinal theca; rather, the condition is caused

by defective absorption of CSF. There is no concern of decreased production of CSF and no opening between the ventricles and spinal cord in hydrocephalus.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 459 15. A newborn is diagnosed with the communicating type of congenital hydrocephalus. Which explanation should the nurse prioritize when preparing a teaching session for the parents?

A. There is a decreased production of cerebrospinal fluid.

B. There is an obstruction that keeps cerebrospinal fluid from passing between the ventricles and the spinal cord.

C. There is an opening between the ventricles and the spinal cord that usually closes at birth.

D. There is defective absorption of cerebrospinal fluid.

Answer: D Rationale: In the communicating type of hydrocephalus, no obstruction of the free flow of cerebral spinal fluid (CSF) exists between the ventricles and the spinal theca; rather, the condition is caused by defective absorption of CSF. In the noncommunicating type of congenital hydrocephalus, an obstruction occurs and CSF is not able to pass between the ventricles and the spinal cord. The blockage causes increased pressure on the brain or spinal cord. There is no concern of decreased production of CSF and no opening between the ventricles and spinal cord in hydrocephalus.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 459 16. The nurse is monitoring a newborn who exhibited a large head at birth and is exhibiting an increasing head growth on continued assessment. Which additional findings on assessment should lead the nurse to suspect hydrocephalus in this infant?

A. The scalp is dull and becoming dark red.

B. Eyes appear to be pushed downward.

C. Hands short with curved fingers.

D. Neck area is thickened and strong.

Answer: B

Rationale: In hydrocephalus, the eyes appear to be pushed downward slightly with the sclera visible above the iris, the so-called setting sun sign. The fontanels (fontanelles) are bulging and tense, with the suture lines separating and the spaces palpable through the scalp. The scalp also becomes shiny and its veins dilate. In Down syndrome the hands are short with an incurved finger. In congenital hypothyroidism, the neck is short and thick.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 459-460 17. The nurse is preparing to assess an infant who is diagnosed with a ventricular septal defect. Which assessment finding should the nurse be prepared to document?

A. fatigue and dyspnea B. delayed growth and development C. loud, harsh murmur D. bounding pulse Answer: C Rationale: Children with ventricular septal defects have a characteristic loud, harsh murmur. Fatigue and dyspnea, delayed growth and development, and a bounding pulse are seen in the child with patent ductus arteriosus.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 464 18. The nurse is working with a group of parents of children who have congenital heart disorders. Which statement made by the parents should the nurse prioritize for further assessment?

A. "She gets so tired when she is eating."

B. "They say he has a heart murmur but it may go away."

C. "His chest measurement is the same as his head."

D. "When I move her legs up toward her chest I hear a click."

Answer: A Rationale: Newborns with cardiac anomalies that may be developing congestive heart failure have a history of being poor eaters, tiring easily from the effort to suck, and failing to grow or thrive normally. A murmur is not a sign of congestive heart failure. At times during infancy the chest and head would measure the same

without this being a concern. With a congenital dislocation of the hip, an audible click may be heard.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 464 19. The nurse is providing care for a child following a cardiac catheterization. Which nursing action should the nurse prioritize during the first 12 hours after the procedure?

A. keeping the head of the bed elevated 45 degrees B. observing the site and extremity C. changing the dressing at least every 3 hours D. monitor vital signs every 4 hours Answer: B Rationale: During the first 12 hours after the procedure the site needs to be monitored and the extremity observed for pulses, edema, skin temperature and color, and any other signs of poor circulation as well as infection. The child should be flat in bed and the pressure dressing snug and left in place until the day after the procedure. The vital signs should be monitored closely.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 468 20. The nurse is caring for a preterm infant and notes frothing and excessive drooling. Which additional assessment finding should the nurse prioritize and report immediately?

A. Bright red blood from the mouth B. Bradycardia C. Vomiting D. Severe cyanosis Answer: D Rationale: Esophageal atresia is the absence of a normal esophageal passage from the pharynx to the stomach, which results in fluids and mucus spilling into the lungs. This can lead to respiratory distress manifested by excessive drooling and periods of respiratory distress with choking and cyanosis. No feeding should be given until the newborn has been examined. If feeding is attempted, the newborn chokes, coughs, and regurgitates; becomes deeply cyanotic; and appears to be in

severe respiratory distress. Bright red blood from the mouth is not an indication of esophageal atresia. Bradycardia and vomiting are not signs of respiratory distress.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 475 21. The nurse is caring for a newborn diagnosed with a diaphragmatic hernia. The nurse will prepare to teach the parents concerning which potential treatment modality?

A. immediate surgery to correct B. will likely not need surgery C. will likely have surgery by age 1 D. will require several surgeries during the first 2 years of life Answer: A Rationale: In a congenital hernia of the diaphragm, some of the abdominal organs are displaced into the left chest through an opening in the diaphragm. The heart is pushed toward the right, and the left lung is compressed. Rapid, labored respirations and cyanosis are present on the first day of life, and breathing becomes increasingly difficult. Surgery to repair a diaphragmatic hernia is essential and may be performed as an emergency procedure. The outcome of surgical repair depends on the degree of pulmonary development. Further treatment depends on the degree of herniation.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 476 22. The nurse is teaching the caregivers of an infant diagnosed with hypospadias how to properly care for the infant. The nurse determines the session is successful when the caregivers make which statement?

A. "At least he won't have to have surgery until he is almost ready to start school."

B. "Being able to most likely correct this in one stage rather than several is reassuring."

C. "It is upsetting to me that he is in pain when he urinates."

D. "We hadn't decided about circumcision, but he will have to be circumcised before they do the surgery."

Answer: B Rationale: Surgical repair is often accomplished in one stage and is often done as outpatient surgery. Surgical repair is desirable between the ages of 6 and 18

months, before body image and castration anxiety become problems. Urination is not affected, but the boy cannot void while standing in the normal male fashion.

These newborns should not be circumcised because the foreskin is used in the repair.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 478 23. The nurse is answering questions from the parents of a newborn diagnosed with clubfoot (congenital talipes equinovarus). When asked by the parents which treatment will be used, what would the nurse predict?

A. Putting the child in Bryant's traction B. Doing passive range of motion C. Placing the child in special shoes D. Application of a splint or cast Answer: D Rationale: Clubfoot (congenital talipes equinovarus) is the most common congenital foot deformity. Treatment is started during the neonatal period, and correction usually is accomplished by manipulation and bandaging or by application of a plastic splint or cast. The child is not put in Bryant's traction. Passive range of motion is used for positional deformities, and although special shoes may be used later in treatment, the treatment for the newborn is casting.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 479 24. The nurse is assessing a newborn and suspects developmental dysplasia of the hip (DDH). For which sign is the nurse prioritizing in this potential diagnosis?

A. Symmetry of the gluteal skin folds B. Limited abduction of the affected hip C. Lengthening of the femur D. Bilateral adduction of the legs Answer: B Rationale: The infant with DDH usually has limited abduction of the affected hip.

The infant has asymmetry of the gluteal skin folds and shortening of the femur.

Adduction is not a concern.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 480 25. The nurse is caring for an infant in a hip spica cast. Which nursing intervention would the nurse prioritize to promote skin integrity?

A. Place the child on a soft mattress following surgery.

B. Use powder on the perineal area to avoid irritation.

C. Give daily sponge baths and clean around the edges of the cast.

D. Offer pacifiers to encourage the infant to suck.

Answer: C Rationale: Daily sponge baths are important and must include close attention to the skin under the straps of the device or around the edge of the cast. Place the infant on a firm mattress and support position changes with firm pillows. Avoid using powders and lotions. Sucking is important but not related to skin integrity.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 481 26. The nurse is caring for a newborn with congenital hip dysplasia. Which nursing diagnoses would the nurse prioritize for this infant after the application of a hip spica cast? Select all that apply.

A. Risk for aspiration B. Risk for imbalanced nutrition C. Risk for fluid volume excess D. Risk for delayed growth and development E. Risk for impaired skin integrity Answer: D, E Rationale: Nursing diagnosis for this newborn would include Risk for delayed growth and development, and Risk for impaired skin integrity. Risk for aspiration, imbalanced nutrition, and fluid volume excess are not related to congenital hip dysplasia.

Question format: Multiple Select Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 481

27. The parents of an infant diagnosed with phenylketonuria are not sure they agree with the diagnosis and proposed treatment. The nurse should point out that this condition can result in which additional condition if left untreated?

A. intellectual disability B. congenital heart defects C. increased intracranial pressure D. strangulated intestine Answer: A Rationale: Phenylketonuria (PKU) is a recessive hereditary defect of metabolism that, if untreated, causes severe intellectual disability. The nurse should provide the parents with information describing the pros and cons of the treatment. This disorder is not related to congenital heart defects, increased intracranial pressure, or to a strangulated intestine.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 483 28. The nurse is monitoring a new mother changing her newborn's diaper and notices a musty smell to the infant's urine. Which condition should the nurse prioritize in further assessments to rule out?

A. Galactosemia B. Congenital hypothyroidism C. Phenylketonuria D. Turner syndrome Answer: C Rationale: There is a characteristic musty smell to the urine in the child with phenylketonuria. None of the other disorders affect the urine or the smell of the urine.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 483 29. The nurse is assessing a group of infants and notes one of the infants has chronic constipation and an enlarged abdomen. The nurse would determine this infant is showing indications of which condition?

A. galactosemia B. congenital hypothyroidism C. phenylketonuria

D. Turner syndrome Answer: B Rationale: Two common features seen in the infant with congenital hypothyroidism are chronic constipation and abdomen enlargement caused by poor muscle tone.

Infants with galactosemia will present with vomiting and diarrhea resulting in dehydration, weight loss, and jaundice. Infants with phenylketonuria show progressive mental deficiency, frequent vomiting, aggressive and hyperactive traits, as well as a musty urine smell. Infants with Turner syndrome present with short stature, low set ears, broad-based neck, broad chest, increased angle of the arms, and edema of the hands and feet.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 484 30. The nurse caring for a newborn notes a distended abdomen approximately 24 hours after birth. Which action should the nurse take after review of the medical record reveals an apparent healthy newborn at birth but no documentation of a bowel movement?

A. Attempt to take a rectal temperature.

B. Inform the health care provider immediately.

C. Schedule radiography to diagnose the problem.

D. Inform the parents that the newborn might need surgery.

Answer: B Rationale: If the newborn does not pass a stool within the first 24 hours, the health care provider should be notified. In some newborns, a shallow opening may occur in the anus with the rectum ending in a blind pouch some distance higher. Thus, being able to pass a thermometer into the rectum does not guarantee that the rectoanal canal is normal. More reliable presumptive evidence is obtained by watching carefully for the first meconium stool. Abdominal distention also occurs.

Definitive diagnosis is made by radiographic studies which would be ordered by the primary care provider. The nurse would not discuss the potential of surgery with the parents. That is beyond the scope of the nurse and would be discussed by the surgeon after the diagnostic studies are completed.

Question format: Multiple Choice Chapter 21: The Newborn at Risk: Congenital Disorders Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 475

Chapter 22 1. The nurse is caring for a 4-year-old who is upset that the nurse is leaving at the end of a shift. Which statement by the nurse will most help the child understand why the nurse is leaving?

A. "My shift is over and now you will have another nurse."

B. "I need to go out to my car and drive home."

C. "I have a 4-year-old son and I need to go play with him."

D. "The hospital is not paying me to stay here any longer."

Answer: C Rationale: Preschool thinking is strongly influenced by role fantasy, or how a child would like something to turn out according to his or her understanding. Because this 5-year-old is a child, he/she can understand the nurse returning home after work to her children. While the other options are true statements, the best option is a statement to which the child can relate.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 502 2. The nursing instructor is conducting a class on the development of an infant. The instructor determines the class is successful when the students correctly illustrate which as the proximodistal development in an infant?

A. Kick and to wave the arms, then learns to grasp the foot and pull it to the mouth B. Roll over, then learns to follow an object with the eyes C. Walk for several steps, then learns to run D. Imitate speech-like sounds, then learns to speak a language Answer: A Rationale: Proximodistal growth starts in the center of the body and progresses toward the periphery; learning progresses from the simple to the complex. Kicking and waving require only gross motor skills originating close to the trunk that move entire limbs, whereas grasping the foot and guiding it to the mouth each require fine control of the extremities. The other examples show other normal growth and development, but not the progression from proximal/gross to distal/fine movements.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning

Reference: p. 493 3. A homeless mother arrives in the emergency department with her 5-year-old son who appears to have the mumps. During assessment, the nurse discovers the child is behind on his immunization schedule. Which information should the nurse prioritize for this family?

A. a list of primary care physicians who are taking new clients B. a chart depicting the recommended immunization schedules for infants and children C. a list of organizations that assist families to get food, shelter, and medical benefits D. A list of organizations that provide referral and counseling for partner abuse, drug and alcohol addiction, and mental illness Answer: C Rationale: A list of organizations that will help them to get food, shelter, and medical benefits will likely be most useful because it offers practical, down-to-earth information. She is unlikely to be able to afford a primary care physician, and their living situation is too unstable to guarantee regular visits. Knowing about recommended vaccination schedules would likewise not be useful if the family does not have access to regular care. Although some homeless families have problems with partner abuse, drug and alcohol addiction, or mental illness, you cannot assume that this family is one of them.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 496 4. The daughter of a divorced couple is hospitalized for injuries received in an automobile accident. The custodial father is at work when the mother arrives extremely agitated and demanding to see her daughter immediately. Which action will be most appropriate for the nurse to take at this time?

A. Tell the mother what room the child is in.

B. Check to see who is allowed to have contact with the child.

C. Ask the child if she would like to see her mother.

D. Ask the mother if she is allowed to see the child.

Answer: B Rationale: The instructions from the custodial parent or courts should be honored.

The nurse should check to find out if the mother is allowed access to the child.

Asking the child may cause problems with one or both parents and could inflict fear or guilt on the child. In addition, even when a parent has been hurtful to a child, the child will often desire to have contact with that parent. Asking the mother if she

has access to the child is unlikely to produce a truthful answer if that answer is "no."

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 497 5. A 14-year-old boy presents to the emergency department alone with facial lacerations and a fractured left arm. Assessment reveals blue hair, several body piercings, homemade tattoos, scars on his arms that appear to be track marks, evasive answers when questioned about where he lives, and responses indicating that he has no parents when contact information is requested. In addition to being treated for the fracture and lacerations, what additional care would be the highest priority for this child?

A. Provide information for organizations which provide shelter.

B. Attempt to find the parents and contact them.

C. Ensure the child's immunizations are up-to-date.

D. An HIV test and counseling would be done.

Answer: D Rationale: This child's age, appearance, and evidence of drug abuse—together with his evasiveness about his living arrangements—indicate that he is likely a runaway.

He is at high risk for HIV infection both from his drug abuse and because he is vulnerable to sexual predators. It is not within the scope of the nurse's responsibilities to try to find the parents, especially if the child is from out-of-state.

There is no reliable way to ensure the information provided by the child could be verified to ensure the proper immunizations would be given. Providing the child with the information about shelters is not the priority and the child may reject the information, depending on his situation.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 496 6. A single woman brings her 10-year-old daughter in for the first well-child visit at the clinic. The nurse discovers they recently relocated to that area due to the mother's job, the child is now attending a "tough" school and she is home, scared and alone, for several hours after school. Which action should the nurse prioritize to assist this family?

A. Discuss concerns about anxiety and depression.

B. Provide information for preventing drug and alcohol use among teens.

C. Provide a list of local after-school programs.

D. Provide a list of emergency contact numbers.

Answer: C Rationale: A list of local after-school programs will provide this latchkey child with some safe, constructive alternatives to being home alone. A list of emergency contact numbers is important for a child in this situation but her mother should compile the list to ensure it has the correct individuals for the child to contact.

Addressing anxiety, depression, and drug and alcohol abuse would be topics for later sessions. The priority for the nurse at this time is assisting with providing a safe environment for the child.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 498 7. The nurse is assessing a 5-year-old boy in the presence of his parents and notes they are concerned he is learning bad habits by "playing with himself." They ask the nurse for the best punishment to address this issue. Which theorist should the nurse reference when answering their question to help the parents address this issue and ensure they are providing the child with the best attitude toward his body and sexuality?

A. Carl Jung B. Erik Erikson C. Lawrence Kohlberg D. Arnold Gesell Answer: B Rationale: Both Sigmund Freud and Erik Erikson identified the parents' reactions to the child's discovery of his or her own body as crucial to the child's later attitudes toward the body and sexuality. Jung believed that what happens to a child is not so critical to the child's development as are the child's responses to these events, so the parents' reaction is less important than how the child responds to it. Kohlberg was concerned with the development of moral reasoning in children. Arnold Gesell developed a series of developmental landmarks noting that the child progresses through a series of "easy" and "difficult" phases.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 502 8. The parents of a 6-year-old boy express frustration and worry that he doesn't seem to be developing a sense of responsibility. For example, he recently drew on the walls of his room and was told he had to clean the walls by dinnertime.

Although he agreed and was shown how to do it and was provided cleaning materials, he had not even started when the deadline arrived. What aspect of child development should the nurse prioritize to explain to the parents how best to handle similar situations?

A. The boy is not yet able to see a moral reason to comply with his mother's demand.

B. The boy has not yet developed a desire to please his parents.

C. The boy has no interest yet in performing tasks independently.

D. The boy has not yet developed a sense of time.

Answer: D Rationale: At 6, this boy is old enough to perform tasks independently and to want to be good and please his parents. Morally, he is becoming aware of the feelings of others and likely wants to live up to his parents' expectations. He accepted the punishment and was willing to perform it. However, his concept of time may not be very well developed yet, so a deadline is unlikely to be meaningful to him.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 502 9. The mother of a 3-year-old girl is asking for suggestions for feeding a child who constantly complains there is not enough food on her plate while still not eating the foods provided to her. Which suggestion should the nurse prioritize for this mother?

A. Use a smaller plate with the same portions of food.

B. Use a larger plate with the same portions of food.

C. Scold the child for her poor behavior.

D. Promise the child more food after she eats what she has.

Answer: A Rationale: The same portion of food on a smaller plate will cover more of the surface area of the plate and will thus look to her like more food. By contrast, putting the same portion on a larger plate will make the portion look even smaller.

Because she cannot yet see things from another's point of view, your feelings about giving her more will not be important to her. Because her sense of time is not developed yet, a promise of more later is likely to be meaningless to her.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 503

10. The nurse is admitting a 10-year-old child the night before surgery, and the child is very concerned about what will happen. Which action should the nurse prioritize in caring for this child to minimize the possible trauma related to this hospitalization?

A. Sedate the child and allow unlimited TV. B. Briefly explain the procedure and tell the child not to worry.

C. Encourage the child to ask questions and express fears.

D. Joke with the child and arrange a visit from a clown.

Answer: C Rationale: The child will naturally be frightened and apprehensive; expecting a child to mask or deny these feelings will only make the child feel worse. Distraction with humor or entertainment is unlikely to succeed. Enabling the child to express fears and answering the child's questions and concerns is most likely to help the child weather the experience.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 501 11. A 5-year-old child is brought to the emergency room with an open chin laceration following a bike accident. The child appears extremely frightened and asks if he will bleed to death. Which nursing action should the nurse prioritize to best assist this child?

A. Seat him where he can watch TV with his parents.

B. Tell him that big boys like him must be brave.

C. Reassure him that he will not run out of blood.

D. Allow him to sit on his parent's lap until time to suture the laceration.

Answer: D Rationale: According to Piaget, a 5-year-old is in the preoperational stage. The child's thinking is based on intuition and is not logical. Allowing him to sit with his mother is comforting. Encouraging TV watching, denying his feelings, or joking that he will not run out of blood is not likely to distract or calm him.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 507 12. The nursing instructor is explaining the various aspects of growth and development to a group of nursing students. The instructor determines the session

is successful when the students point out which example best illustrates the concept of development?

A. the 5-month-old whose head circumference and chest measurement are the same B. the 3-year-old who has been toilet trained for 6 months C. the 5-year-old who is 2 inches taller than she was 4 months ago D. The 10-year-old who weighs the same amount as his 8-year-old brother Answer: B Rationale: Development is the progressive change in the child toward maturity.

Toilet training in the child shows evidence the child is moving toward maturity. The other choices have to do with physical increase in the body's size and appearance, which relates to the concept of growth.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 493 13. The nursing student is preparing a presentation that will illustrate the various stages of growth and development starting with a newborn. Which example should the student point out will best illustrate cephalocaudal growth pattern?

A. grasping the foot and pulling it to the mouth B. controlling the head and neck before being able to control the arms and legs C. walking for several steps, stopping, and then running for several steps D. using the fingers to pick up an object and put it back down Answer: B Rationale: Cephalocaudal development starts with the head and moves downward.

The child is able to control the head and neck before being able to control the arms and legs. Grasping the foot and pulling it to the mouth and using the fingers to pick up objects shows development of fine motor skills, but not cephalocaudal development. Walking and running show development of gross motor skills.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 493 14. The nursing instructor is leading a discussion on the theories of Sigmund Freud with a group of nursing students. The instructor determines the session is successful when the students correctly choose which example as indicating a child is in the anal stage of development?

A. finds satisfaction through making noises and crying

B. recognizes the physical differences between boys and girls C. has a desire to mold and control the environment D. beginning to develop a sense of moral responsibility Answer: C Rationale: During the anal stage, according to Freud, elimination is one of the child's first experiences of creativity. It represents the beginnings of the desire to mold and control the environment. Finding satisfaction through making noise and crying occurs in the oral stage, in which satisfaction comes through the mouth.

Recognizing the physical differences between boys and girls is in the phallic stage, where the child's interest moves to the genital area as a source of pride and curiosity. Beginning to develop a sense of moral responsibility occurs during the latency stage, when the child's sense of moral responsibility (the superego) develops, based on what has been taught through the parents' words and actions.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 500 15. The nurse is assessing a young client at a well-visit and notes a normal progression in growth and development. Which assessment finding would lead the nurse to determine this client is in the stage Sigmund Freud referred to as the latency stage?

A. finds satisfaction through making noises and crying B. can recognize the physical differences between boys and girls C. has a desire to mold and control the environment D. beginning to develop a sense of moral responsibility Answer: D Rationale: During the latency stage, the child's sense of moral responsibility (the superego) develops, based on what has been taught through the parents' words and actions. In the oral stage, satisfaction come through the mouth. In the phallic stage, the child's interest moves to the genital area as a source of pride and curiosity and they begin to recognize the differences between the sexes. In the anal stage, according to Freud, elimination is one of the child's first experiences of creativity; it represents the beginnings of the desire to mold and control the environment.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 501

16. A nurse at a pediatric clinic is assessing a young client at a well-child visit. After the assessment, the nurse determines the child is in Erikson's autonomy stage based on which finding?

A. learning to trust that needs are met when they cry B. will perform tasks by themselves, even when it takes a long time C. They want to know the rules and enjoy being good and getting approval.

D. will interact with others and like to compete Answer: B Rationale: Autonomy occurs when the child feels in control and learns to perform tasks independently. Getting their needs met when crying describes trust that is developed in the infant. The preschool-aged child wants to know the rules; he or she enjoys being good and getting approval when developing initiative. Interacting and competing with others occurs with the development of industry seen in the school-aged child.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 502 17. The nurse is caring for a young client who was admitted to the hospital. The nurse concludes this client is in Erikson's developmental stage of industry based on which action by the child?

A. has learned to trust their needs are met when they cry B. insists on performing tasks by themselves, even if it takes a long time C. wants to know what they can and cannot do and enjoys being good and getting approval D. is seeking interaction and competition with others on the unit Answer: D Rationale: The development of industry is seen in the school-age child when they interact and compete with others, seeking achievement. When needs are met after crying, this describes trust that is developed in the infant. Performing tasks by themselves, no matter how long it takes, relates to autonomy; this occurs when the child feels in control and learns to perform tasks independently. Knowing the rules and enjoying being good and getting approval is noted in the preschool-aged child as they develop initiative.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 502

18. The nursing instructor is preparing a class discussion covering the theories of Erikson and the growth and development of infants and children. Which example would best illustrate the phase referred to as initiative by Erikson?

A. learning to trust when needs are met after crying B. performing a task by oneself, even if it takes a long time C. knowing the rules, enjoys being good, being independent, and receiving approval D. interacting and competing with others Answer: C Rationale: The development of initiative is noted in the preschool-age child as they develop a conscience and accepts punishment for doing wrong. This child wants to know the rules and enjoys being good and independent and likes getting approval from the adults in their life. The infant learns that crying will get their needs met which describes trust that is developed. The toddler who performs tasks by themselves even when it takes a long time begins in the autonomy stage. This occurs when the child feels in control and learns to perform tasks independently.

The child interacting and competing with others describes industry seen in the school age child.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 502 19. The mother of an 8-year-old is concerned her child is developing too slowly when compared to a cousin. Which activities, based on Piaget's theories, would the nurse predict this child should be active in?

A. The child can classify and organize information about their environment.

B. The child has developed an understanding of cause and effect.

C. The child can understand abstract concepts described only in words or symbols.

D. The child has no concept of quantity; if it looks like more, it is more.

Answer: A Rationale: According to Piaget, the concrete operations phase should occur at the ages of 7 to 11 years. The child develops the ability to begin problem-solving in a concrete, systematic way during this stage. Demonstrating an understanding of cause and effect occurs at the ages of 0 to 2 years and occurs in the sensorimotor phase. Between the ages of 12 to 15 years, the formal operations phase occurs and involves understanding abstract concepts, which are described only in words or symbols. The preoperational phase is noted at ages 2 to 7 years and this child has no concept of quantity; if it looks like more, it is more.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 503 20. The nursing instructor is leading a discussion on the theories of growth and development as described by Piaget. The instructor determines the session is successful when the students correctly choose which action as an example of the sensorimotor phase?

A. classifying and organizing information about the environment B. developing an understanding of cause and effect C. understanding abstract concepts described only in words or symbols D. having no concept of quantity; if it looks like more, it is more Answer: B Rationale: In the sensorimotor phase, an understanding of cause and effect develops. When random arm motions strike the string of bells stretched across the crib, the newborn hears the sound made and eventually can manipulate the arms deliberately to make the bells ring. Classifying and organizing information about the environment occurs in the concrete operations phase. Understanding abstract concepts described only in words or symbols occurs in the formal operations phase.

When it looks like more and the child believes that it is, this is due to no concept of quantity; it occurs in the preoperational phase.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 503 21. The nurse is assessing a 10-year-old child who has come to the clinic with a caregiver and three other children. Which question would be most appropriate for the nurse to ask to clarify the family structure?

A. "Do all of these children have the same father?"

B. "Who lives in your home?"

C. "Are you the grandmother of any of these children?"

D. "I don't see that you are wearing a wedding ring. Are you married?"

Answer: B Rationale: It is more appropriate to ask open-ended questions to encourage the client to provide information. It is important to identify the family caregivers and recognize the family structure. To avoid embarrassment, ask direct and clear questions about other family members. The other responses are inappropriate and may be seen as judgmental. They are also closed-end questions and will not allow for the needed information to be shared.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply

Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 507 22. The school nurse is aware that providing proper care involves cooperation from the adolescent. Which technique will the nurse prioritize to develop open communication with the adolescents?

A. Ask the parents questions first and then ask the adolescent the same question.

B. Focus the interview on the problems rather than on the adolescent themselves.

C. Show interest in the adolescent and develop a rapport before asking questions.

D. Avoid asking questions about their friends, hobbies, and school activities.

Answer: C Rationale: Adolescents respond positively to individuals who show an interest in them and make an effort to connect with them. Focus the interview on the adolescent rather than the problem. Sharing about friends, hobbies, and activities is a way to connect with the adolescent. Parents may need to be interviewed as well, but the adolescent is the first and primary focus.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 507 23. An elementary school nurse is leading a group session discussing nutrition with a group of students and their caregivers. The nurse should provide additional teaching if which statement is made by one of the participants?

A. "Eating too much could affect my child's ability to do some activities."

B. "If my child has good nutrition she won't get childhood illnesses."

C. "I ate healthy as a child and that has a lot to do with the way I eat now."

D. "My children are at various ages and they all have different daily requirements."

Answer: B Rationale: Although good nutrition is important in the child's ability to resist infection and diseases, adequate nutrition alone will not prevent childhood illnesses, so further teaching is needed with this response. The other responses are correct and would not need further follow-up or clarification by the nurse.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 495

24. The nurse is developing a care plan for several clients who were seen in the clinic that day. Which situation will the nurse conclude is most likely to experience challenges in the growth and development of the children?

A. A family lives with the parents of the mother who is working two jobs.

B. Both parents work during the day and the child comes home after school to an empty house.

C. Children attend school while the father works and then sleep in their car at night.

D. A divorced mother shares an apartment with her best friend and her children.

Answer: C Rationale: Homelessness creates many stresses for the family, including affecting the growth and development of the children in the family. Job loss, loss of housing, drug addiction, insufficient income, domestic turmoil and higher rates of abuse, drug use, and mental health problems are often seen in homeless families. Living with an extended family, being a latchkey kid, and children of divorce also can affect growth and development, but homelessness is the most likely of these choices to affect the family and child.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 496 25. The nurse is completing the growth chart of a 2-month-old infant at the wellchild visit. When asked by the mother what purpose this chart serves, which response would be most appropriate by the nurse?

A. These charts give us a good indication of the child's nutritional status.

B. By plotting height and weight, we get an indication of what the adult measurements will be.

C. Comparing your child with others of the same age and sex gives us statistics about height and weight.

D. We are comparing the child's current measurements with the child's previous measurements.

Answer: D Rationale: A growth chart is used for comparison only and is used to plot and monitor a child's growth through the years. Although a weight loss or failure to gain weight might indicate a nutritional issue, this is not the way growth charts are used. Growth charts do not indicate adult measurements. Statistics may be gathered from growth charts but that is not the primary reason they are used.

Question format: Multiple Choice Chapter 22: Principles of Growth and Development Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process

Reference: p. 493-494

Chapter 23 1. The caregivers of an infant state that their child cries when her mother leaves for even a short amount of time. What might the nurse suggest as a way to console the infant and develop a sense of security when the child's primary caregiver is out of sight?

A. Pick the child up as soon as she begins to cry.

B. Play peek-a-boo with the child when happy.

C. Slowly increase the amount of time allowed to cry before being picked up.

D. Give her dolls and stuffed animals so she learns to distract herself.

Answer: B Rationale: For the infant, self-assurance is necessary to confirm that objects and people do not cease to exist when out of sight. This is a learning experience on which the infant's entire attitude toward life depends. The ancient game of "peek-aboo" is a universal example of this learning technique. It is also one of the joys of infancy as the child affirms the ability to control the disappearance and reappearance of self. In the same manner by which the infant affirms selfexistence, she learns to confirm the existence of others, even when they are temporarily out of sight.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 518 2. A first-time mother calls the pediatrician's office to ask the nurse about her baby's tooth eruption. The baby is 8 months old and still does not have any teeth.

What information can the nurse share with this mother that would correctly respond to her anxiety about her baby's dentition?

A. A baby's first teeth should erupt by 8 to 10 months of age and are the two lower front teeth.

B. Tooth eruption is often genetically based, with some families having babies with early tooth eruption, while others have late tooth eruption.

C. If the baby does not have any teeth come in by next month, the mother needs to bring him back for x-rays.

D. Look for the baby to start running a fever and develop a stuffy nose and that will indicate his teeth are coming in.

Answer: B Rationale: Teeth eruption normally begins around age 6 to 8 months but infants' teething patterns vary greatly between children. Genetics plays a big role in both the timing and the actual pattern of eruption.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 514 3. A breastfeeding mother asks the nurse about when she can begin feeding her 5month-old infant some solids and vitamins. Which information provided by the nurse would most accurately address this mother's concerns?

A. You can begin feeding the infant fruits and vegetables now followed by ironenriched cereal to ensure that he gets enough iron.

B. The first food offered to an infant is iron-enriched rice cereal and can be started now. Additionally, the infant needs to receive vitamin D and iron.

C. If you give him one or two bottles of juice each day, he should get all the vitamins he needs. You can begin fruits and cereal in 1 month.

D. At 6 months, you need to quit breastfeeding because he is not getting enough iron or vitamin C and D and that should help him transition to solids better.

Answer: B Rationale: Breastfeeding is the best method for feeding infants, according to the Academy of Pediatrics Committee on Nutrition. However, by 4 to 6 months of age, breastfed infants need supplements of iron and vitamin D. Solids are introduced at the same age and parents should begin with iron-fortified rice cereal. The infant may also have diluted fruit juice in small portions.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 518 4. The nurse is assessing a 1-year-old at the well-child annual visit and notes the child is meeting the growth parameters. After noting the birth weight was 8 pounds (3.6 kg) and length was 20 inches (50.8 cm) long, which measurements reflecting height/weight would the nurse expect to document for this visit?

A. 16 lb (7.2 kg) and 26 inches (65 cm) B. 20 lb (9.1 kg) and 28 inches (70 cm) C. 24 pounds (10.8 kg) and 30 inches (75 cm) D. 28 pounds (12.7 kg) and 32 inches (80 cm) Answer: C Rationale: By 1 year of age, the infant should have tripled his or her birth weight and grown 10 to 12 inches (25 to 30 cm). If this infant was 8 pounds (3.6 kg) at birth, at 1 year, this child should weigh 24 pounds (8 x 3 = 24) and grown to 30 to 32 inches (20 + 10 to 12 = 30 to 32 inches). Most of the growing occurs during the

first 6 months with the infant's birth weight doubling and height increasing about 6 inches (15 cm). Growth slows slightly during the second 6 months but is still rapid.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 513 5. The nurse is assessing an 6-month-old infant at a well-baby visit and is answering questions from the new mother. Which response should the nurse prioritize when addressing the mother's question concerning what the infant should be learning at this point in life?

A. Trust B. Feel anger C. Love D. Fear Answer: A Rationale: Erikson identifies various developmental stages which all children accomplish as they grow and develop into adults. The primary psychosocial developmental task for the infant is learning to trust. This task creates the foundation for the developmental tasks of the next stages of the child's life. If the infant does not receive food, love, attention, and comfort, the infant learns to mistrust the environment and those who are responsible for caring for the child.

Learning to feel anger, love, and fear come at later times in development.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 513 6. The nurse is reviewing the diet of an 8-month-old infant with the mother who reveals she has been using evaporated milk to make the formula. Which additional ingredient should the nurse ensure she is including in the formula?

A. Vitamin D B. Vitamin E C. Iron D. Calcium Answer: C Rationale: Infants who are fed home-prepared formulas (based on evaporated milk) need supplemental vitamin C and iron. Evaporated milk has adequate amounts of vitamin D, which is unaffected by heat used in the preparation of formula. Calcium and vitamin E would not be a concern in this infant's formula.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 518 7. A frustrated mother with a 9-month-old baby comes to the clinic because her son is refusing all solid food. When talking with this mother, the nurse discovers the mother has struggled with a weight problem all her life, which she attributes to being forced to eat even when she was full. Not wanting to treat her child the same way, each time her son pushes food away with his tongue she believes that he doesn't want it. Which statement would be most appropriate for the nurse to say to this mother?

A. "The baby might be allergic to the particular foods you offered, so try different kinds of food."

B. "Because your baby is a fussy eater, have more than one food available at each feeding so he can choose a food he likes."

C. "The baby might not be ready for solid food, so wait a month or so and try again."

D. "The baby needs to learn how to swallow, so catch the food and offer it again until the baby learns this."

Answer: D Rationale: The infant knows only one way to take food: namely to thrust the tongue forward as if to suck. This is called the extrusion (protrusion) reflex and has the effect of pushing solid food out of the infant's mouth. The process of transferring food from the front of the mouth to the throat for swallowing is a complicated skill that must be learned. If the food is pushed out, the caregiver must catch it and offer it again. The baby soon learns to manipulate the tongue and comes to enjoy this novel way of eating.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 519 8. The nurse is preparing to teach a class to a group of young parents with infants the basics of introducing solid foods into the diet. Which factor about the food should the nurse point out the infants respond to best when introducing solid foods into the diet?

A. well-heated B. thickened C. an interesting texture D. bland

Answer: D Rationale: Babies like their food smooth, thin, lukewarm, and bland. If the food is too hot, thick, or an unusual texture, the infant may refuse to eat it.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 519 9. An 8-month-old child is diagnosed with a second ear infection and the father is concerned the infections are being caused by something he is doing or by something in the child's development. Which question should the nurse prioritize to collect more information to answer this father's questions?

A. "Does the baby go to bed with a bottle of formula each night?"

B. "Does the baby's teething appear to be teething?"

C. "Are the baby's scalp and hair shampooed often?"

D. "Are you supplementing the baby's home-prepared formula with vitamin C?" Answer: A Rationale: In addition to nursing bottle caries, liquid from milk, formula, or juice can pool in the mouth and flow into the eustachian tube, causing otitis media if an infant falls asleep with a bottle. Teething and shampooing the scalp and hair would not be a factor in the development of ear infections. Vitamin C is a needed supplement for the infant who is fed home-prepared formula; it does not cause ear infections.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 522 10. The nurse takes a call from a concerned mother whose infant received routine immunizations the day before and now has a temperature of 101oF (38.3oC), is fussy, and pulling at the injection site. The mother wants to know what she should do. Which is the best response from the nurse to this mother?

A. "You need to bring the baby to the emergency department to be sure he is not having an allergic reaction."

B. "All babies have similar reactions but you should call back if he is still fussy in 24 hours."

C. "This is a common reaction. Give your child acetaminophen, cuddle him, and apply a cool compress to the injection site."

D. "You can give your child ice-cold fluids and cover the injection site so that he doesn't scratch the site and get it infected."

Answer: C Rationale: Adverse reactions vary with the type of immunization but usually are minor in nature. The most common adverse reaction is a low-grade fever within the first 24 to 48 hours and possibly a local reaction such as tenderness, redness, and swelling at the injection site. The child may be fussy and eat less than usual. These reactions are treated symptomatically with acetaminophen for the fever and cool compresses applied to the injection site. The child is encouraged to drink fluids but not necessarily ice-cold fluids. Holding and cuddling are comforting to the child.

These reactions may last longer than 24 hours and should subside. These are not signs of an allergic reaction. There is no need to cover the site.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 523 11. A 6-month-old arrives for a well-baby visit with a case of diaper rash that the parent believes is normal for infants. The parent reports changing the baby's diaper when he wakes up and before naps or bedtime. Which frequency should the nurse point out will better help heal and prevent future incidences of diaper rash?

A. every hour B. every 1 to 2 hours C. every 2 to 4 hours D. every 3 to 5 hours Answer: C Rationale: To prevent diaper rash, soiled diapers should be changed frequently.

Check every 2 to 4 hours while the infant is awake to see if the diaper is soiled.

Waking the baby to change the diaper is not necessary.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 524 12. A new mother reports that she is exhausted and that the little sleep she gets is determined by her baby. Which suggestion should the nurse prioritize to help the mother establish healthy sleeping patterns in her infant?

A. Put the baby to bed at various times of the evening.

B. Let the baby cry during the night and she will eventually fall back to sleep.

C. Use the crib for sleeping only, not for play activities.

D. Wake the baby from afternoon naps after 1 hour to ensure she is sleepy by nighttime.

Answer: C Rationale: A consistent bedtime routine is usually helpful in establishing healthy sleeping patterns and in preventing sleep problems. Using the crib for sleeping only helps the child associate the bed with sleep. Depriving the baby of sleep during the afternoon or evening will make the baby over-tired and less able to establish a healthy sleeping pattern. While letting a baby cry for a while is acceptable, this does not promote consistency in the baby's sleeping pattern.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 526 13. The pediatric nurse is meeting with a group of young mothers of newborn infants who are questioning the "soft spot" on the head and when it will close.

Which fact should the nurse point out to the mothers?

A. It can be expected to close between months 2 and 3 of life.

B. It will close and the bones hardened by the time the child is 1 year old.

C. It may increase slightly in size the first few months of life.

D. It decreases in size rapidly during the first month of life.

Answer: C Rationale: The anterior fontanel (fontanelle) may increase slightly in size during the first few months of life. After 6 months it begins to decrease in size, closing between months 12 and 18. The posterior fontanel is usually closed by month 2 or 3 of life. The sutures between the cranial bones do not ossify until later childhood.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 513 14. The nurse is assessing a 12-week-old infant in the clinic at a well-baby visit.

Which assessment finding does the nurse predict to assess in this healthy infant?

A. Able to sit up and roll over B. Smiles at significant others C. Grasps objects and brings them to the mouth D. Bears weight on legs when held in standing position Answer: B Rationale: By 12 weeks of age the infant smiles at their mother and significant others. The other choices are seen in the infant who is about 20 weeks of age.

Question format: Multiple Choice

Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 516 15. The mother of an 8-month-old infant appears frustrated and shares with the nurse she can't leave the room without her infant son crying. Which is the best response from the nurse to help this mother?

A. "He knows you are in the next room and he is attempting to get your attention."

B. "By ignoring his crying you will help him develop patience."

C. "It is important for him to be with you, so you should take him with you."

D. "If he cannot see you, he thinks you are gone and that is frightening."

Answer: D Rationale: An infant cannot apply abstract reasoning but understands only through the five senses. As the infant matures enough to recognize the mother or primary caregiver, the infant becomes fearful when this person disappears. To the infant, out of sight means out of existence, and the infant cannot tolerate this. For the infant, self-assurance is necessary to confirm that objects and people do not cease to exist when out of sight. As the infant grows and develops, they will grow out of this stage.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 518 16. The nurse is meeting with a group of new mothers of infants and is leading the discussion related to weaning. Which suggestion should the nurse prioritize to this group of mothers concerning weaning their infant?

A. "It is best to just pick a day and stop breast or bottle feeding and wean the infant to a cup."

B. "If the infant is eating from a dish and drinking from a cup, they no longer need a bottle or breastfeeding."

C. "It is important to let the infant set the pace for weaning, no matter what age they are."

D. "The infant who is interested in watching others drink from a cup is ready to be weaned."

Answer: C Rationale: Weaning must be attempted gradually, letting the infant set the pace.

The abrupt removal of a main source of satisfaction (sucking) may be detrimental to normal development. At the age of 5 or 6 months, the infant who has watched

others drink from a cup may be ready to try a sip when it is offered but is seldom ready at this point to be weaned.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 522 17. The mother of an infant is confused after being told by her dentist not to let her baby go to bed with a bottle of milk. She does not agree with that suggestion.

Which response should the nurse prioritize when addressing this situation with the mother?

A. "Giving a bottle of milk when the infant goes to bed can lead to obesity."

B. "Bottles given at bedtime can cause erosion of the enamel on the teeth."

C. "Giving your baby a pacifier at bedtime will satisfy the need to suck."

D. "You could occasionally give your baby a bottle of water at bedtime."

Answer: B Rationale: The sugar from formula or sweetened juice coats the infant's teeth for long periods and causes erosion of the enamel on the deciduous teeth. While giving water in a bottle at bedtime is acceptable and a pacifier will satisfy the sucking need, the most appropriate response is to warn of possible enamel erosion. Giving a bottle at bedtime is not a factor that leads to obesity.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 522 18. The nurse is conducting a class at the local health department office for new mothers of infants who are in the various stages of weaning. Which alternative food should the nurse prioritize when questioned by a mother whose infant is refusing to drink milk from a cup to ensure the infant is consuming enough calcium?

A. cottage cheese B. pudding C. rice cereal D. bananas Answer: A Rationale: Cottage cheese is a good source of calcium and is nutritious. Although pudding is a source of calcium, it is not the best choice because of the sugar in the pudding. Rice cereal may be fortified with iron and bananas are a good source of potassium.

Question format: Multiple Choice

Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 522 19. The mother has presented to the pediatric clinic with her 1-year-old infant for the next round of immunizations. The nurse would question administering the immunizations if which situation is noted on assessment?

A. The infant has had a runny nose for several days.

B. The infant is being treated for a case of eczema.

C. The infant was given an antipyretic last week.

D. The infant has a rash in the perineal area.

Answer: B Rationale: An immunization should be postponed if the child has an acute febrile condition or a condition causing immunosuppression, or if he or she is receiving corticosteroids, radiation, or antimetabolites. Corticosteroid treatment may be used for the infant with eczema. Immunizations need not be postponed if the child has a cold, runny nose, diaper rash, or had antipyretics.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 523 20. The nurse is conducting a class for new parents of infants. The nurse determines the session is successful when the parents correctly choose which instruction concerning bathing their infant?

A. "When I bathe my baby, I shampoo his hair each time as well."

B. "Giving my baby a bath every day during cold weather will help her stay warm."

C. "My husband uses plain water on our baby's face but I use mild soap."

D. "Now that my baby is bigger, she seems to enjoy having powder applied after her bath."

Answer: A Rationale: Regular shampooing is important to prevent seborrheic dermatitis (cradle cap). The infant does not need to be bathed every day; plain water should be used on the infant's face (not soap), and powder should not be used after the bath because it can cause irritation and possible respiratory problems when inhaled by the infant.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 524 21. The nurse is meeting with a group of older siblings of infants to discuss various aspects of infant care.The group will be helping the parents with infant care. Which instruction should the nurse prioritize with this group?

A. The infant should be dressed more warmly than older children and caregivers.

B. The infant should wear hard-soled shoes in order to protect their feet from injury.

C. The infant sleeps 10 to 12 hours at night and can take two to three naps during the day.

D. The infant should be sound asleep before being put into the crib for sleeping.

Answer: C Rationale: Most infants sleep 10 to 12 hours at night and take two to three naps during the day. By being put to bed while awake and allowed to fall asleep, the infant learns good sleeping habits. The infant should be dressed in the same amount of clothing the adult finds comfortable. Hard-soled shoes are not needed by infants and may hamper the development of the foot.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 526 22. The nurse is conducting a training session for families who are to receive assistance from the Women, Infants, and Children (WIC) supplemental food program. The nurse determines the session is successful after the participants correctly choose which food items they will be able to receive through the program?

Select all that apply.

A. milk B. dry beans C. peanuts D. juice E. bread F. eggs Answer: A, B, D, E, F Rationale: The foods prescribed by the WIC program include iron-fortified infant formula and cereal, milk, dry beans, peanut butter, cheese, juice, whole wheat bread, fruits and vegetables, canned fish, and eggs. Peanuts are not included.

Question format: Multiple Select Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 520 23. A group of nursing students are preparing a presentation illustrating basic safety measures which can be utilized for infants. Which measures should the students prioritize in their presentation? Select all that apply.

A. Bottle should only be propped for infants 8 months or older.

B. Crib and playpen bars should be no more than 2 3/8 inches apart.

C. Only small pillows should be used in cribs.

D. Car seats should be placed in back seats.

E. A safe temperature for hot water heaters in households with infants is 120°F (48.9°C).

Answer: B, D, E Rationale: Crib and playpen bars should be no more than 2 3/8 inches apart so the infant can be safe from getting body parts caught between the bars. Car seats are placed in the back seat and manufacturers' instructions are followed regarding forward or backward facing depending on the age and size of the child. Water heaters should be set no higher then 120°F (48.8°C) to prevent potential burns.

Bottles should never be propped and pillows are not placed in cribs of infants.

Question format: Multiple Select Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 526 24. The pediatric nurse is careful to monitor and assess the growth and development of all clients. Which characteristic should the nurse prepare to assess in the infants?

A. Has an increased attention span and can be interested in an activity for a long length of time.

B. Takes in new information at a rapid rate and asks "why" and "how".

C. Insists they can "do it" and the next moment they revert to being dependent.

D. Grows and develops skills more rapidly than at any other time in their life.

Answer: D Rationale: The infant grows and develops skills more rapidly than he or she ever will again. The toddler insists he or she can do things one minute and then becomes dependent the next minute. The preschool age child soaks in information and asks "why" and "how" over and over. The school-age child has a longer attention span and can become absorbed in a craft or activity for several hours.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Understand Client Needs: Health Promotion and Maintenance

Integrated Process: Nursing Process Reference: p. 512 25. The nurse is assessing the motor skills of an infant who is 9 months old. Which motor skills should the nurse prepare to assess in an infant achieving normal growth and development milestones?

A. startles then cries when hearing a loud noise B. is eating cereal using the thumb and index finger C. moves from a prone to sitting to standing position D. can stand and walk around furniture Answer: B Rationale: The pincer grasp, use of the thumb and index finger, is a fine motor skill that develops by 32 weeks of age. The Moro or "startle" reflex disappears by 10 to 12 weeks; the child can change from prone to sitting to a standing position and walks around 40 weeks to 1 year of age.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 517 26. The nurse is preparing a presentation for a health fair illustrating the major milestones of infants as they grow and develop. Which fact should the nurse point out when illustrating an infant's teeth?

A. The first tooth usually erupts by 6 months.

B. The upper incisors are most often the first teeth to erupt.

C. Fluoride should not be used on a child's teeth before 4 or 5 years of age.

D. Swollen or inflamed gums during teething indicate a serious concern.

Answer: A Rationale: The first deciduous teeth, usually the lower central incisors, erupt by 6 months of age, but may be anytime between 4 to 8 months. Swollen or inflamed gums during teething is common. A cold teething ring can help soothe the baby's discomfort. The American Dental Association recommends administration of fluoride to infants and children in areas where the fluoride content of drinking water is inadequate or absent.

Question format: Multiple Choice Chapter 23: Growth and Development of the Infant: 28 Days to 1 Year Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 514

Chapter 24 1. Every time a toddler's mother asks her a question, the response is "No!" regardless of what the mother asks the child. What would the nurse recommend to the mother to help alleviate this behavior?

A. Don't ask the child any questions; just tell her what to do each day.

B. Allow the child choices when asking questions, such as "Do you want to wear the red or the blue top?"

C. Ask the child to please quit saying no to everything asked of her.

D. Respond negatively back to the child each time the child responds in a negative fashion.

Answer: B Rationale: Negativism is commonly seen in toddlers and is an expression of independence, not defiance. The best way to reduce the number of negative responses is to ask fewer questions and be sure that any question asked allows the toddler a choice of behavior or response. Berating the child or telling the toddler what to do all the time will only make matters worse.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 532 2. A mother brings her 2-year-old child to the pediatrician's office, voicing concerns about her toddler's growth over the last year. According to the child's records, the toddler has gained 6 pounds (2.7 kg ) and grown 2.5 in (6.25 cm) since the child's last visit a year ago. How should the nurse respond to this mother's concerns?

A. Tell her that her child's growth is less than is expected and gather a nutritional history on the child.

B. Inform the mother that her toddler's growth is within normal limits and there is nothing to be worried about.

C. Ask the mother if there are other small people in her family.

D. Tell the mother that she needs to return to the pediatrician's office in 3 months to re-weigh the child and measure his height for any changes.

Answer: B Rationale: Normally, a toddler's growth is 5 to 10 pounds per year and about 3 inches in height. This child falls within the recommended parameters of growth and the mother has nothing to be worried about.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 531-532 3. A first-time parent asks the nurse what toys would be appropriate for her son's second birthday next month. What recommendations would be nurse make?

A. dress-up clothing B. play lawn mower C. water gun D. colorful rattle Answer: B Rationale: Toys for toddlers should include imitative toys, toys that encourage fine and gross motor development, and toys that involve socialization. A play lawn mower meets these criteria by being something the child can push and imitate the parent's activities. A 2-year-old is too old for a rattle and dress-up clothing and a water gun are too advanced.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 533 4. A nurse is presenting a class on discipline for a group of parents of toddlers.

What information would be important for the nurse to teach this group? Select all that apply.

A. Toddlers cannot learn self-control until at least 3 to 4 years of age.

B. Consistency in the rules is important so the child understands what is expected.

C. If a child does something wrong, the parent must address the behavior immediately so the child understands what they did wrong.

D. Even at this young age, children need boundaries.

E. If a child hits or bites another child, the parents should scold them, saying such things as "You are very naughty for biting Rachel."

Answer: B, C, D Rationale: Discipline for toddlers must have consistency and correct timing. Parents need to come to a consensus on how to discipline their child and do so consistently and in a unified fashion. Also, the toddler needs to receive negative feedback for negative behavior as soon as the infraction occurs so the child understands what they did wrong. Parents should never label the child as bad, just their behavior.

Every child needs boundaries—it is just that every family's boundaries may vary.

Discipline begins early in life and toddlers can learn self-control.

Question format: Multiple Select Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 533-534 5. A mother calls the pediatrician's office upset because her 2-year-old son has begun acting out now that the new baby is home. He wants to have a bottle like the newborn and has begun to have accidents in his pants. Which statement by the nurse would best address this problem?

A. "Often, the first child is jealous of the new baby. Just ignore his acting out and he will stop."

B. "You need to scold him for wetting his pants and have him change his underwear himself."

C. "Offer to let him drink some formula in a cup. He will see that being a baby is not so much fun. " D. "Set aside time to spend one-on-one with your older child and make him understand that he is still loved and very special."

Answer: D Rationale: When parents have a second child, the first-born is often jealous and feels pushed aside by the new baby. Parents need to make time for the first child and set aside one-on-one time with them, showing them that they are still loved and that there is enough time and love for both children. Ignoring the jealous behavior will not help the situation, nor will scolding him for his accidents.

Regression is commonly seen with the arrival of a new baby. Offering him formula in a cup does not address the underlying problem of jealousy and feeling neglected.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 534 6. A 2-year-old child is reported to be a "picky eater" by his father. What pointers could the nurse provide the parent to help minimize stress related to mealtime?

Select all that apply.

A. Offer small portions of 1 to 2 teaspoons to the child.

B. Food jags needs to be addressed and not given in to.

C. Mealtime for a toddler should not exceed 20 minutes.

D. Do not use sweets as a reward for cleaning their plate.

E. Feed the toddler before the rest of the family.

Answer: A, C, D Rationale: Mealtime with toddlers should not be stressful for families if they follow some simple feeding tips. Food jags are common and are not harmful. Portion control of one to two teaspoons is less overwhelming for the toddler, making them more likely to eat all their food. Limiting mealtime to 20 minutes prevents

excessive dawdling. Toddlers should never be rewarded with sweets or desserts for good eating habits. Toddlers need the socialization of mealtime with the family and should eat with the family.

Question format: Multiple Select Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 535 7. A nurse is reviewing important concepts related to bathing and tub baths with a parent of a toddler. Which statement by the parent indicates the need for additional teaching?

A. "I can let my toddler have toys in the tub during bath time."

B. "I should never leave the toddler alone in the tub at any time."

C. "It's okay to let my toddler take bubble baths and play in the bubbles."

D. "I will give my toddler a bath every day at the same time."

Answer: C Rationale: Bubble baths are not recommended for children, especially girls, due to the increased incidence of urinary tract infections associated with the use of bubble bath soap. All other behaviors are appropriate.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 536 8. A toddler is hospitalized and the nurse wants to make the transition from home to hospital as easy as possible for him. Which action by the nurse would be most beneficial to assist the toddler in adapting to the hospital?

A. Tell the child what is expected of him to help with compliance.

B. Instruct the parents to allow the nurse to do everything for the child to aid in attachment.

C. Follow the child's home routines as much as possible while in the hospital.

D. Allow the child to dictate when and what they want to do and adhere to their requests.

Answer: C Rationale: Ritualism is used by toddlers to help them adjust to new situations and provide security for them. By adhering to the home routines regarding such things as bedtime rituals or how they get dressed, the child is much more comfortable and more likely to positively adjust to the hospitalization. Telling the toddler what to do, preventing the parents from performing care tasks, and giving control over to the child for decisions all would be counterproductive to adjusting to hospitalization.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 542 9. Parents are beginning to potty train their 2-year-old child and seek advice from the nurse on how to be successful in this endeavor. Which statement by the parents indicates that further teaching is needed?

A. "We will place him on the potty for 5 minutes for each session."

B. "I bought him 'big boy' underwear for him to use instead of diapers."

C. "He wants to accompany me to the bathroom but I prefer to go alone."

D. "I will wait until he is off the toilet before flushing it."

Answer: C Rationale: Allowing a toddler to observe a parent or older sibling going to the bathroom serves as a positive role model and helps the child understand what he or she is to do there.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 538 10. A mother tells the nurse that her toddler does not want to go to bed at night and keeps getting back up when she is put to bed. What recommendations would the nurse make to this mother to foster sleep in the toddler?

A. Place the child in her bed, tell her goodnight, and then lock the door.

B. Read the child a book in bed and take time to calm the child down before turning out the lights.

C. Instruct the toddler to stay in bed or she will have her favorite stuffed animal taken away from her.

D. If she does not want to go to sleep at her normal bedtime, let her stay up for a little while longer.

Answer: B Rationale: Bedtime rituals are commonly used to prepare children for going to bed.

By slowing down, reading a book in bed with the lights down, it calms the child and transitions them to a state of sleepiness, when they can then go to sleep. Parents are never advised to lock the child in the room, threaten them with taking away a favorite toy or stuffed animal, or allow the child to stall and prolong their bedtime.

Parents must be firm but kind when enforcing bedtimes.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 539 11. Which statement by a parent would best prepare the toddler for the parent's return if the parent must leave the hospital?

A. "I will be back in the morning. Mommy loves you."

B. "I will be back after you eat your dinner and SpongeBob goes off."

C. "I will be back later this afternoon."

D. "I will come back when it is time for your bath tonight."

Answer: B Rationale: Toddlers have no real concept of time and equate time to events in their lives. So, the best way for the mother to tell the child when she will be back at the hospital is to relate her arrival to events such as the child's dinner and TV programs the child likes.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 542 12. The nurse is preparing to assess a 2-year-old at a well-child visit and notes the child was 22 lbs (9.98 kg) and 24 in (60.96 cm) tall at 1 year old. The nurse determines the child is following a normal pattern of growth after obtaining which set of current measurements?

A. 27 lbs (12.27 kg) and 26 in (66.04 cm) tall B. 32 lbs (14.54 kg) and 27 in (68.58 cm) tall C. 38 lbs (17.27 kg) and 32 in (81.28 cm) tall D. 40 lbs (18.18 kg) and 33 in (83.82 cm) tall Answer: B Rationale: Toddlerhood is a time of slowed growth and rapid development. Each year the toddler gains 4.5 to 6.0 lb (2. to 2.7 kg) and about 3 in (7.62 cm). A child weighing 22 lbs (9.98 kg) at age 1 year would be expected to now weigh 31 to 34 lbs (14.1 to 15.45 kg). A height of 24 in at age 1 year (60.96 cm) should now be approximately 27 in (68.58 cm).

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 531-532

13. A nursing instructor is leading a class discussion exploring the various aspects of Erikson's theories of the developmental tasks of toddlers. The instructor determines the session is successful when the students correctly choose which task as a priority for toddlers?

A. Learning to trust B. Learning to speak C. Learning to act on one's own D. Learning to understand and respond to discipline Answer: C Rationale: Erikson's psychosocial developmental task for toddlers is to achieve autonomy (independence) while overcoming doubt and shame. Erikson's psychosocial developmental task for infants is to develop a sense of trust. Learning to speak and to understand and respond to discipline are not developmental tasks according to Erikson.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 532 14. A grandmother who is the primary caregiver of a 2-year-old is expressing concern about how to best handle the temper tantrums that can occur two or three times a day, often in public places. She explains she spanked her own children for this but she is worried this is not the best way to handle the situation. Which response from the nurse will best address this concern?

A. "Spanking is controversial but sometimes necessary, so use it if it works."

B. "Warn the child that they will be punished when they are back at home then follow through with the punishment."

C. "Remain calm, pick the child up, and move to a quiet and neutral place until the child gains self-control; don't give in to the child's demands."

D. "Remind the child that they are in a public place and ask the child to respect those around them; reward the child if the child responds by calming themself."

Answer: C Rationale: Remaining calm is a must. It is not easy to handle a small child who drops to the floor screaming and kicking in rage in the middle of the supermarket or the sidewalk, nor are comments from onlookers at all helpful. The best a caregiver can do is pick up the out-of-control child as calmly as possible and carry him or her to a quiet, neutral place to regain self-control. Reasoning, scolding, or punishing during a tantrum is useless. Do not yield the point or give in to the child's whim.

That would tell the child that to get whatever one wants, a person need only throw oneself on the floor and scream. The child would have to learn painfully later in life that people cannot be controlled in this manner. Spanking or other physical punishment usually does not work well because the child is merely taught that

hitting or other physical violence is acceptable and a child who is spanked frequently becomes immune to it.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 533 15. The caregivers of a 2-year-old are concerned the child is not learning how to share and play well with other children. While acknowledging their concern and devotion, the nurse should point out which activity would be best for this child's developmental level?

A. Mowing the lawn with a toy lawnmower B. Looking at large print magazines C. Sharing finger paints and painting with the caregiver D. Throwing a baseball-sized ball Answer: A Rationale: Toddlers enjoy talking on a play telephone. They like pots, pans, and toys such as brooms, dishes, and lawnmowers that help them imitate the adults in their environment and promote socialization. Toys that involve the toddler's new gross motor skills, such as push-pull toys, rocking horses, large blocks, and balls are popular. Fine motor skills are developed by use of thick crayons, modeling clay, finger paints, wooden puzzles with large pieces, toys with pieces that fit into shaped holes, and cloth books. The toddler will not be interested in sharing toys until the later stage of toddlerhood; adults should not make an issue of sharing at this early stage.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 533 16. The nurse is preparing a presentation for a health fair which will illustrate various ways to help introduce siblings to a new member of the family. Which suggestion should the nurse prioritize to help older siblings, especially toddlers, understand the change in the family dynamics?

A. Plan time for the secondary caregiver to focus on the toddler while the primary caregiver focuses on the infant.

B. Plan time for the primary caregiver to focus on the toddler while the secondary caregiver focuses on the infant.

C. Have a grandparent or another special adult in the child's life take the toddler on an errand or a special visit.

D. Move the toddler to a new bedroom with a "grown-up-bed."

Answer: B Rationale: The secondary caregiver can occasionally take over the care of the new baby while the mother or other primary caregiver devotes herself to the toddler.

The primary caregiver might also plan special times with the toddler when the new infant is sleeping and the caregiver has no interruptions. This approach helps the toddler feel special. Moving the older child to a larger bed lets the toddler take pride in being "grown up" now, but it should be done some time before the new baby appears. While acknowledging that time with another adult can be a special time, the main concern is for the toddler to understand they are not being replaced by the newest member of the family.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 534 17. The nurse is conducting an assessment on a 1-year-old healthy child and commends the parents for maintaining routine visits. When questioned by the parents as to the recommended schedule for future visits, which schedule should the nurse recommend?

A. quarterly until year 2, then every 6 months until the child enters school B. at 15 months, 18 months, then every 6 months until the child enters school C. at 15 months, 24 months, then annually until the child enters school D. at 15 months and at least annually thereafter Answer: D Rationale: The child who has been seen routinely up to 1 year old should be seen next at 15 months for immunization boosters and at least annually thereafter. If the child has not maintained the routine schedule for immunizations and other assessments, then the schedule will depend on which immunization boosters and/or assessments are deemed appropriate.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 536 18. The mother of a 15-month-old son is returning to work and wants to place her son in the day care close to work; however, they will only accept potty-trained children. Which response from the nurse will best address this situation in answering the mother's questions of how best to potty train her son?

A. "Encourage your son to watch his older siblings use the toilet."

B. "Get your son a potty chair and have him sit on it for a few minutes each day."

C. "Each time you change his diaper, tell your son how important and fun it is to use the potty chair."

D. "Wait a few more months until your son has more muscle control and shows signs that he's ready to be potty trained."

Answer: D Rationale: To be able to cooperate in toilet training, the child's anal and urethral sphincter muscles must have developed to the stage where the child can control them. Control of the anal sphincter usually develops first. The child also must be able to postpone the urge to defecate or urinate until reaching the toilet or potty and must be able to signal the need before the event. In addition, before toilet training can occur, the child must have a desire to please the caregiver by holding feces and urine rather than satisfying his/her own immediate need for gratification.

This level of maturation seldom takes place before the age of 18 to 24 months.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 538 19. The pediatric nurse is presenting basic safety tips at a local health fair for families. The nurse should point out the majority of hospital visits for toddlers can be prevented by exercising which precaution?

A. properly use car seats B. safely store all chemical substances C. use plastic protectors in all electrical outlets D. close supervision during bath time Answer: B Rationale: Poisoning is still the most common medical emergency in children with the highest incidence between the ages of 1 to 4 years. Even with precautionary labeling and "child-resistant" packaging of medication and household cleaners, children display amazing ingenuity in opening bottles and packages that catch their curiosity. Medications such as acetaminophen, salicylates (aspirin), laxatives, sedatives, tranquilizers, analgesics, antihistamines, cold medicines, and birthcontrol pills are commonly associated with poisoning and also need to properly be stored out of reach of the toddler. The proper use of car seats, preventing access to electrical outlets, and bath time supervision are also noted to be the cause of medical emergencies. However, poisoning remains the number one reason.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 540-541

20. A single mother with three young children is reluctant to leave her crying and upset 16-month-old daughter overnight in the hospital but needs to go home to care for the other children. Which suggestion from the nurse will best address the fears and concerns of both the child and mother?

A. Remind them staying in the hospital now will help the child get well quicker and be home soon, but the other children should not be alone.

B. Distract the child with a special blanket, stuffed animal, or other "lovey" from home while the mother quietly slips out.

C. Encourage the mother to give the child a personal item of the mother's to hold on to until she returns and to tell the child a specific time she will return, such as "when breakfast comes in the morning."

D. Tell both the mother and child that the child will be carefully guarded and won't be in as much danger as she might be if she were home exploring her environment.

Answer: C Rationale: When the family caregiver must leave the toddler, it may be helpful for the adult to give the child some personal item to keep until the adult returns. The caregiver can tell the child he or she will return "when the cartoons come on TV" or "when your lunch comes." These are concrete times that the toddler will probably understand. The toddler is too young to understand that staying is important for her recovery. Distracting the child while the mother leaves may increase the child's anxiety when she realizes her mother is gone. Although the child will be watched closely in the hospital setting, toddlers explore their environment wherever they are.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 542 21. The nurse is caring for a toddler in the pediatric unit and notes the child is responding according to expected developmental stages. Which characteristic will the nurse predict this toddler to exhibit while in the hospital?

A. will be interested in an activity for a long period of time B. learns new things quickly by asking questions C. insists on doing a new skill and then asking for help D. will go home knowing how to do more things Answer: C Rationale: The toddler insists they can do things one minute and then becomes dependent the next minute. The preschool-age child soaks in information and asks "why" and "how" over and over. The school-age child has a longer attention span and can become absorbed in a craft or activity for several hours. The infant grows and develops skills more rapidly than he or she ever will again.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 542-543 22. The nurse is presenting an in-service training to a group of pediatric nurses on the topic of play. The nurse determines the session is successful when the group correctly chooses which example as best displaying toddlers playing?

A. Playing apart from others without being part of a group B. Playing together in an activity without organization C. Playing in an organized group with each other D. Playing independently and are side by side Answer: D Rationale: Parallel play occurs when the toddler plays alongside other children but not with them. During cooperative play children play in an organized group with each other, as in team sports. Associative play occurs when children play together and are engaged in a similar activity but without organization, rules, or a leader— and each child does what she or he wishes. Solitary independent play means playing apart from others without making an effort to be part of the group or group activity.

Question format: Multiple Choice Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 533-534 23. The nurse is supervising a play group of children on the unit. The nurse expects the toddlers will most likely be involved in which activity?

A. Pretending to be mommies and daddies in the play house B. Playing with the plastic vacuum cleaner and pushing it around the room C. Painting pictures in the art corner of the room D. Watching a movie with other children their age Answer: B Rationale: Playtime for the toddler involves imitation of the people around them such as adults, siblings, and other children. Push-pull toys allow them to use their developing gross motor skills. Preschool children have imitative play, pretending to be the mommy, the daddy, a policeman, a cowboy, or other familiar characters.

The school-age child enjoys group activities and making things, such as drawings, paintings, and craft projects. The adolescent enjoys activities they can participate in with their peers.

Question format: Multiple Choice

Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 533 24. A 15-month-old toddler is brought to the pediatrician's office for a well-child checkup and the nurse is reviewing health promotion with the family. What recommendation(s) would the nurse make to the family to help ensure the child's health? Select all that apply.

A. Begin dental examinations at age 1 year.

B. Provide foods rich in calories and carbohydrates for the child.

C. Keep all medications locked up and out of reach for the child.

D. Turn the hot water heater temperature down to 120℉ (48.9℉).

E. Never allow the child to ride in the car unless secured in a car seat.

Answer: C, D, E Rationale: Health promotion begins by properly educating the parents on how to care for their child. Dental visits begin at age 1 year. Foods need to be nutritious but not highly seasoned or disproportionately high in carbohydrates or calories. All medications and toxic substances need to be locked up and out of reach of the toddler. Hot water temperatures should be lowered to 120℉ (48.9℉) and the child must be secured in a federally approved child safety seat prior to starting the car.

Question format: Multiple Select Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 536 25. A 2-year-old child is shopping with her mother when she suddenly falls to the ground and begins to scream, "I want it!" over and over regarding a bag of candy.

What would the nurse recommend to the mother to deal with this behavior? Select all that apply.

A. Reason with the toddler and explain that the candy is not nutritious for her.

B. Remain calm and ignore the tantrum.

C. Acknowledge the behavior by giving into the toddler's demands and buying the candy.

D. Pick the toddler up and take her to the restroom for a spanking.

E. Stay nearby to ensure the child's safety without giving in to the child's desires.

Answer: B, E Rationale: Temper tantrums in toddlers are very common as they try to control their environment and the caregiver's environment. They become frustrated at their inability to do so or to verbalize their desires. If a toddler has a temper tantrum, the best thing for the parent to do is ignore them and protect them from harm.

Parents cannot reason with a toddler—they lack the ability to understand or the desire to change their behavior. Never give in to their demands; they will only learn that if you scream loud enough, they get their way. However, spanking is not recommended. The child has just lost control and needs time to regain self-control.

Question format: Multiple Select Chapter 24: Growth and Development of the Toddler: 1 to 3 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 533

Chapter 25 1. The nurse is assessing a 3-year-old at a routine well-child visit. Which assessment should the nurse prioritize in the vision check?

A. visual acuity B. eye coordination C. depth perception D. color perception Answer: B Rationale: During the preschool years, the child's vision should be checked to screen for amblyopia (dimness of vision from disuse of the eye, or "lazy eye"). This can result from the eyes not coordinating eye movements and working together to use both eyes to see. Usually by age 6 the child has achieved 20/20 vision, but mature depth perception may not occur in some children until 8 to 10 years of age.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 548 2. The pediatric nurse is discussing the daily activities of a 4-year-old with the caregiver to assess growth and development status. The nurse would document that the child has reached the initiative stage of development if the caregiver indicates the child participates in which activity?

A. tries to sweep up spilled cereal but cries when can't do well B. broke a dish but blamed it on a friend the caregivers don't know C. refuses to hold anyone's hand while crossing the street D. gets upset when a babysitter is in charge, but will do what is asked by the babysitter Answer: A Rationale: According to Erikson, the developmental task of the preschool age is initiative versus guilt. Preschoolers often try to find ways to do things to help, but they may feel guilty if scolded when they fail because of inexperience or lack of skill. Family caregivers need to remember that preschoolers are developing initiative and a sense of guilt. They want to be good and follow instructions; they feel bad when they do not, even if they are not physically punished. Imaginary playmates are common in the preschool child, but blaming the incident on the imaginary playmate or refusing to hold the mother's hand does not show initiative.

A younger child would commonly show anxiety when being left with the caregiver.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 553-554 3. During a well-child visit, the caregiver expresses concern that the 3-year-old child often stutters when speaking. Which response should the nurse prioritize to best assist this family?

A. "Stuttering is common in young children because they are not physically capable of forming all the sounds."

B. "Stuttering is usually indicative of a hearing loss."

C. "Difficulties with speaking generally indicate that the adults in the child's life are not reading to the child enough."

D. "Children of this age may stutter while they search for just the right word."

Answer: D Rationale: Between ages 3 and 5, language development is generally rapid. Most 3year-old children can construct simple sentences, but their speech has many hesitations and repetitions as they search for the right word or try to make the right sound. Stuttering can develop during this period but usually disappears within 3 to 6 months. Physical capability, hearing loss, or lack of being read to are not reasons stuttering occurs.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 549 4. The parents of 5-year-old boy are concerned about the how a recent motorcycle accident to his father will affect the child. Although the father has fully recovered, the child is very concerned if the father is away longer than expected; the child is not as talkative but appears withdrawn and quiet. The nurse should point out the child's behavior is likely related to which factor?

A. The child is afraid of losing his father and trying show how much he loves him.

B. The boy is afraid of being hurt himself and thinks being "especially good" will protect him from accidents.

C. The boy believes he caused the accident by telling his father he "hoped he crashed" when the boy couldn't go along.

D. The child is imitating the adults' behavior and just trying to be nice to everyone.

Answer: C Rationale: Preschoolers have learned to think about something without actually seeing it: to visualize or imagine. This normal development, sometimes called magical thinking, makes it difficult for them to separate fantasy from reality.

Preschoolers believe that words or thoughts can make things real, and this belief

can have either positive or negative results. The child needs reassurance that the accident was not his fault. The other choices do not demonstrate the "magical thinking" that preschoolers tend to demonstrate later in life.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 550 5. The nurse is meeting with a group of young parents to discuss nutrition and their preschooler. Which response should the nurse prioritize when asked if using desserts as a reward for good behavior is an appropriate idea?

A. The child may only behave on days when dessert is something that is liked.

B. The child will learn to choose sweets over nutritious food.

C. This will result in the child being overweight.

D. The child can use food to manipulate others' behavior.

Answer: D Rationale: Food should never be used as a reward or bribe; otherwise, the child will continue to use food as a means to manipulate the environment and the behavior of others. Because of the high fat and sugar content of most desserts, the nutritional value of desserts is usually less than a balanced diet of healthier foods and could add to the concern of obesity in some children. A child might prefer sweets over nutritious foods and behave differently if dessert were a reward, but these choices are not the most appropriate answer.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 553-554 6. While the nurse is taking a blood pressure on a 4-year-old, the child states that the blood-pressure cuff is too tight and angrily says, "That hurt, you big poo-poo head." What is the most appropriate response by the nurse?

A. Scold the child for the insult while apologizing for hurting her, and loosen the cuff.

B. Calmly explain that you don't mean to hurt her, loosen the cuff, and tell her that is isn't nice to call you names.

C. Explain that the cuff will only hurt for minute and ask the child's caregiver to please tell the child not to speak to you that way.

D. Ask the child's caregiver to please hold the child on their lap until she calms down.

Answer: B

Rationale: Four- and 5-year-olds delight in using "naughty" words or swearing.

Bathroom words become favorites and taunts, such as "you're a big doo-doo," bring heady excitement to them. Caregivers may become concerned by this turn of events, but the child simply may be trying out words to test their impact. By using a calm, matter-of-fact response when a preschooler uses naughty or swear words, some of the power of using that type of language will be defused. The child learns that this is not language to use in the company of others.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 549 7. A first-time father calls the pediatric nurse stating he is concerned that his 4year-old daughter still wets the bed almost every night. Remembering his own experience of being punished for wetting the bed at 4 years old, he is not sure punishment is the best approach to address this. Which nursing instruction is the most appropriate?

A. "Disciplining is not likely to be effective, but if the child keeps wetting the bed it may be necessary."

B. "Bedwetting is not uncommon in young children. Try to calmly change the bed without showing your frustration."

C. "Setting rules is a parent's job to help the child have acceptable social behavior, so take away a privilege each time she wets the bed."

D. "Nightly bedwetting up to age 12 is developmentally typical, so you will need to practice patience with your daughter."

Answer: B Rationale: Occasional bedwetting is not uncommon for young preschoolers and is not a concern unless it continues past the age of 7. When the child does have an accident, treating it in a matter-of-fact way and providing the child with clean, dry clothing is best. The child should not be disciplined or made to feel he or she is socially unacceptable when bedwetting occurs.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 555 8. The nurse is preparing a safety presentation for a health fair for families. Which instruction should the nurse prioritize when illustrating car safety and the family?

A. "Stop the car any time the preschooler unbuckles the restraints."

B. "Explain that wearing a seat belt is a law and the police officer will give a ticket if the seat belt is not buckled."

C. "Set a good example. Wear your own seat belt every time you drive."

D. "Reward the child with candy or some other treat each time the child keeps the seat belt on."

Answer: C Rationale: A preschooler wants to please, and if the caregiver consistently wears the seatbelt, that will become the standard for riding in the car. All states have laws that define safety seat and restraint requirements for children. Adults must teach and reinforce these rules. One primary responsibility of adults is always to wear seat belts themselves and to make certain that the child always is in a safety seat or has a seat belt on when in a motor vehicle. A child can also be calmly taught that the vehicle "won't go" unless everyone in it is properly restrained. The child should be taught respect of rules and laws, but making threats or giving rewards is not appropriate.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 555-556 9. The nurse is caring for a 5-year-old who has been hospitalized after an episode of asthma. As the nurse prepares to teach the child how to use the nebulizer, which action should the nurse prioritize?

A. Allow the child to touch and play with the nebulizer for a few minutes before the treatment.

B. Show the child how to use the nebulizer and tell the child how much easier it is to breathe afterward.

C. Explain that the child will feel better after the treatment and allow the child to ask questions.

D. Use a poster or brochure to illustrate to the child how the machine works.

Answer: A Rationale: Children are often less anxious about procedures if they are allowed to handle equipment beforehand— and perhaps "use" it on a doll or another toy. Play is an effective way to let children act out their anxieties and to learn what to expect from the hospital situation. Explaining how the treatment will help him or her feel better, using posters, and encouraging the child to ask questions would be appropriate for the older child, not the preschool-aged child.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 557

10. The nurse is caring for several clients on the pediatric unit. When interacting with the preschool-age child, which action does the nurse predict will occur?

A. Increased attention span and can be interested in an activity for a long length of time B. Takes in new information at a rapid rate and asks "why" and "how" C. Insists doing something and the next moment reverts to being dependent D. Grows and develops skills more rapidly than at any other time in their life Answer: B Rationale: The preschool-aged child soaks in information and asks "why" and "how" over and over. The school-aged child has a longer attention span and can become absorbed in a craft or activity for several hours. The toddler insists he or she can do things one minute and then becomes dependent the next minute. The infant grows and develops skills more rapidly than he or she ever will again.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 548 11. The nurse is presenting an in-service on the types of playing that children may engage in. The nurse determines the session is successful when the attending nurses correctly choose which example as representing cooperative play?

A. Playing apart from others without being part of a group.

B. Playing together in an activity without organization.

C. Playing in an organized group with each other.

D. Playing independently and are side-by-side.

Answer: C Rationale: During cooperative play, children play in an organized group with each other as in team sports. Solitary independent play means playing apart from others without making an effort to be part of the group or group activity. Associative play occurs when children play together and are engaged in a similar activity but without organization, rules, or a leader, and each child does what she or he wishes. Parallel play occurs when the toddler plays alongside other children but not with them.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 551 12. The nurse is monitoring children playing in the unit's playroom. The nurse notes that some children are involved in associative play by which actions?

A. drawing pictures in the art area

B. pushing toy cars around on a large rug with roads C. playing a board game with each other D. several children engrossed in their own tool-and-bench set Answer: B Rationale: Associative play occurs when children play together and are engaged in a similar activity, but without organization, rules, or a leader; each child does whatthey wish, such as pushing toy cars around on a rug that has roads. Solitary independent play means playing apart from others without making an effort to be part of the group or group activity, such as drawing a picture in the art area. During cooperative play, children play in an organized group with each other as in team sports or a board game. Parallel play occurs when the toddler plays alongside other children but not with them, such as each having their own tool-and-bench set to play with the hammers and other tools.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 551 13. The parents of a toddler are concerned their child is not developing correctly and are questioning the nurse concerning the child's lack of effort to join other children in a group activity. Which response should the nurse prioritize in answering the parents?

A. "This is normal for this age group. It's referred to as solitary independent play."

B. "You should try to get your child involved in a local Boys and Girls club to encourage more interaction."

C. "Perhaps getting your child interested in sports will improve their other play habits."

D. "Your child is involved with others, just indirectly. See how they sit next to the other children and play with the same toys?"

Answer: A Rationale: Solitary independent play means playing apart from others without making an effort to be part of the group or group activity, which is normal for this age group. Associative play occurs when children play together and are engaged in a similar activity but without organization, rules, or a leader, and each child does what she or he wishes. During cooperative play, children play in an organized group with each other as in team sports. Parallel play occurs when the toddler plays alongside other children but not with them. As the child continues to mature, they will be more prepared and willing to join with others to play alongside in organized or unorganized situations.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply

Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 551 14. The nursing instructor is illustrating the various types of play. The instructor determines the class is successful when the students correctly choose which example as best representing onlooker play?

A. playing apart from others without being part of a group B. acting out a troubling situation C. playing in an organized group with each other D. observing without participating Answer: D Rationale: Onlooker play occurs when there is observation without participation, such as watching television. Solitary independent play means playing apart from others without making an effort to be part of the group or group activity. Dramatic play allows a child to act out a troubling situation. During cooperative play, children play in an organized group with each other as in team sports.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 551 15. A nurse is preparing a presentation for a health fair discussing various aspects of preschoolers. Which example should the nurse use to best illustrate dramatic play?

A. Playing apart from others without being part of a group B. Acting out a troubling or stressful situation C. Playing a video game with several other children D. Watching television or videos Answer: B Rationale: Dramatic play allows a child to act out a troubling or stressful situation.

Solitary independent play means playing apart from others without making an effort to be part of the group or group activity. During cooperative play, children play in an organized group with each other as in team sports or video games.

Onlooker play occurs when there is observation without participation, such as watching television or videos.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 551

16. The nurse has brought a group of preschoolers to the playroom to play. Which activity would the nurse predict the children to become involved in?

A. Pretending to be mommies and daddies in the playhouse B. Playing a board game C. Painting pictures in the art corner of the room D. Watching a movie with other children their age Answer: A Rationale: Preschool children have imitative play, pretending to be the mommy, the daddy, a policeman, a cowboy, or other familiar characters. The school-aged child enjoys group activities, such as board games, and making things, such as drawings, paintings, and craft projects. The adolescent enjoys activities he or she can participate in with their peers.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 551-552 17. When collecting data on a preschool-aged child during a well-child visit, the nurse discovers the child has gained 12 lb (5.4 kg) and grown 2.5 inches (6.3 cm) in the last year. The nurse interprets these findings to indicate which situation?

A. Weight and height are within expected patterns of growth.

B. Weight falls within an expected range and height is less than what would be expected.

C. Weight is above an expected range and height is within an expected range.

D. Weight is below an expected range and height is above an expected range.

Answer: C Rationale: The preschool period is one of slow growth. The child gains about 4 to 5 lb each year (1.4 to 2.3 kg) and grows about 2.5 inches (6.3 cm). The child's weight is above the expected gain and the height is what would be expected.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 548 18. The nurse is assessing a 3-year-old at a well-child visit and the child appears to be progressing well. Which activity will the nurse ask the child to attempt to appropriately assess the fine motor skills of this preschooler?

A. Use scissors.

B. Button clothes.

C. Tie shoelaces.

D. Print a few letters.

Answer: B Rationale: The 3-year-old should be able to button his clothes and use a pencil or crayon. By the age of 4 to 5, the child should be able to use scissors, tie shoelaces, and print his first name.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 549 19. The parent of a 4-year-old is expressing concern that this child is not talking as much—or as well—as her other children did at that age. Which question should the nurse prioritize when assessing this preschooler for this concern?

A. "How often do you or a family member read to your child?"

B. "Has your child had their hearing tested?"

C. "Does your child have opportunities to have conversations with other people?"

D. "Do you praise and give your child encouragement when the child tries to talk with you?"

Answer: B Rationale: Delays or other difficulties in language development may result from hearing impairment or other physical problems. Although reading to the child, having conversations with family members and other people, and praising and encouraging the child's efforts to communicate help the child develop language skills, most importantly a hearing concern would need to be assessed and treated.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 549 20. The father of a 4-year-old is concerned his child is not telling the truth and blaming others for things that have happened. Which response should the nurse prioritize after the father shares that the child is blaming someone named "Andrew" for a broken tool, and they have no idea who this is?

A. "You should punish your son because no child should be telling lies at this age."

B. "You need to show your child the broken tool since at this age they must see something in order to understand."

C. "Your son may have a friend named Andrew, but it could be an imaginary friend."

D. "You should watch this type of behavior closely since most children this age tell the truth."

Answer: C Rationale: The preschool-aged child may have imaginary playmates who are very real to them. The imaginary friend often has the characteristics that the child might wish for. Sometimes the child blames the imaginary friend for breaking a toy or engaging in another act for which the child does not want to take responsibility. The child should not be punished because the child is not intentionally telling a lie. At this age the child can think about things without actually seeing them.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 550-551 21. The pediatric nurse is meeting with a group of preschoolers' family members to discuss various health topics. The nurse determines the sexual development session is successful after overhearing which comment by one of the participants?

A. "When I find my son masturbating, I will tell him that is unacceptable."

B. "I will tell my daughter that she will have time to explore her body as she gets older."

C. "I will encourage my son to ask his father any questions that are sexual in nature."

D. "I feel better knowing that her curiosity is normal."

Answer: D Rationale: The child's sexual curiosity is a normal, natural part of total curiosity about oneself and the world. Exploration of the genitalia is natural for the preschooler. It is one way the child learns to perceive the body as a possible source of pleasure and is the beginning of the acceptance of sex as natural and pleasurable. Caregivers can be reassured that this is not uncommon behavior.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 551 22. The nurse is presenting nutritional information at a community health fair.

Which suggestion should the nurse prioritize when illustrating proper nutrition for preschoolers?

A. Need three big meals a day due to rapid growth B. Need extra calcium for proper muscle growth C. Snacks throughout the day help the child meet nutritional requirements

D. Should drink at least 4 cups of milk each day Answer: C Rationale: The preschool period is not a time of rapid growth, so children do not need large quantities of food. Protein needs are high to provide for muscle growth.

Portions are smaller than adult-sized portions, so the child may need to have meals supplemented with nutritious snacks. The preschool child needs 2 to 3 cups of milk each day.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 553 23. The mother of a 4-year-old is concerned her child is not eating well. In addressing the concerns of this mother, which foods should the nurse point out are high in protein? Select all that apply.

A. cheese and crackers B. cookies and juice C. whole grain granola with yogurt D. strawberries and bananas E. turkey sandwich Answer: A, C, E Rationale: Meat, poultry, fish, milk products, and eggs are good sources of protein.

Whole wheat grains, nuts, peanut butter, and legumes are also good sources of protein but need to be supplemented by some animal protein, such as meat, eggs, milk, cheese, cottage cheese, or yogurt. Cookies are usually high in sugar and not the best for supplying good nutrition. Fruit juices and fruit are good sources of vitamin C. Question format: Multiple Select Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 554 24. The nurse is assessing a 4-year-old on a routine well-child visit. When assessing the gross motor skills of this preschooler, which activity will the nurse predict the child to be able to successfully accomplish?

A. Hop on one foot B. Walk backwards with heel to toe C. Ride a bicycle D. Jump rope

Answer: A Rationale: The 4-year-old should be able to hop on one foot and can control movements of the hands. By the age of 5 the child can walk backwards heel to toe, throw and catch a ball well, and jump rope.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 549 25. The nurse is observing 4-year-old twins during their well-child appointment.

Which observation by the nurse would indicate the children are demonstrating cooperative play?

A. They competitively stack blocks and keep score of who stacks the highest number of blocks.

B. They play with dollhouse furniture, each with different room furnishings.

C. They are building a house for their dolls with blocks in the room.

D. They sit on the floor, near each other, and look at different picture books.

Answer: C Rationale: Cooperative play is when children work toward a common goal together, with a distinct theme. The 4-year-old twins demonstrate cooperative play when they build a house with blocks. Associative play occurs when children play together and are engaged in similar activity, but without organization, rules, or a leader, and when each child does what she or he wishes, such as playing with the dollhouse furniture separately. In parallel play, children play alongside each other but independently, such as looking at different picture books. Competing for the most blocks stacked would be an example of competitive play.

Question format: Multiple Choice Chapter 25: Growth and Development of the Preschool Child: 3 to 6 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 551

Chapter 26 1. The 6-year-old at a well-child office visit tells the nurse, "I can't play on teams because I am not as good at doing things as my big sister is." What suggestion should the nurse point out to the caregiver that will help increase the child's feelings of self-confidence?

A. Ask the child's older siblings to compliment her more often.

B. Praise the child for trying even when she can't complete the same activities as the older sibling.

C. Set up some playdates that include projects or activities in which the child can be successful.

D. Start a rock collection with the child to show her that she can have fun doing activities that don't involve other children.

Answer: C Rationale: As they reach school age, children show an increasing interest in group activities and in making things. Children of this age work at many activities that involve motor, cognitive, and social skills. Success in these activities provides the child with self-confidence and a feeling of competence, but excessive or unrealistic goals set by a teacher or caregiver will defeat a child and possibly lead to the child feeling inferior rather than self-confident. Erikson's developmental task for this age group is industry vs. inferiority. Children who are unsuccessful in completing activities during this stage, whether from physical, social, or cognitive disadvantages, develop a feeling of inferiority.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 562 2. The nurse is preparing a variety of projects for the pediatric clients on the unit to work on in the playroom. In deciding on projects, the nurse determines the 8-yearold will be best suited to work on which activity?

A. stack blocks in a tower B. build a sandcastle with a water-filled moat C. form vases from blocks of clay D. put together a model plane Answer: C Rationale: At about age 7, the child enters the concrete operational stage (as identified by Piaget). The skills of conservation (the ability to recognize that a change in shape does not necessarily mean a change in amount or mass) are significant in this stage. This begins with the conservation of numbers (when the

child understands that the number of cookies does not change even though they may be rearranged) and the conservation of mass (when the child can see that an amount of cookie dough is the same whether in ball form or flattened for baking).

This is followed by conservation of weight, in which the child recognizes that a pound is a pound, regardless of whether plastic or bricks are weighed. Conservation of volume (for instance, understanding that a cup of water is the same amount regardless of the shape of the container) does not come until late in the concrete operational stage at about 11 or 12 years of age.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 563 3. An 8-year-old boy's foster mother is concerned about three recent cavities found in his permanent teeth and reports the child eats a nutritional diet, doesn't eat junk food, and the town water supply is fluoridated. Which suggestion should the nurse prioritize to this mother in regard to the child's dental health?

A. Encourage the child to abstain from eating sugary snacks at school.

B. Accept that the child is genetically predisposed to having more cavities than most children.

C. Ensure that the child brushes his teeth after each meal and snacks.

D. Have the child's teeth professionally cleaned every 3 months.

Answer: C Rationale: Proper dental hygiene includes a routine inspection and conscientious brushing after meals. A well-balanced diet with plenty of calcium and phosphorus and minimal sugar is important to healthy teeth. Foods containing sugar should be eaten only at mealtimes and should be followed immediately by proper brushing.

The school-aged child should visit the dentist at least twice a year for a cleaning and application of fluoride.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 567-568 4. The school nurse is preparing to conduct routine health screenings of the elementary school students. Which screening will the nurse prioritize for students ages 6 to 8?

A. signs of scoliosis B. vision and hearing C. review immunization records D. nutritional needs

Answer: B Rationale: Vision and hearing screening are often conducted by the school nurse, who then alerts the caregivers if there is a need for further evaluation from the health care provider. Most states have immunization requirements that must be met when the child enters school. Signs of scoliosis are usually evaluated at about the age of 10 to 11 years. There are no specific tests that the school nurse would use to evaluate nutrition; however, the nurse would be monitoring all students who come to the nurse's office for potential nutritional situations as deemed appropriate.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 567 5. The 11-year-old arrives in the emergency department presenting with the following: nosebleed with no apparent trauma, disoriented, confused, difficulty walking, nausea, and coughing. The nurse should question the child concerning which potential activity?

A. falling on the playground at school B. experimenting with an inhalant C. eating a food he is allergic to D. exposure to a respiratory disease Answer: B Rationale: Children may experiment with inhalants (substances whose volatile vapors can be abused) because they are readily available and may seem no more threatening than an innocent prank. Inhalants classified as deliriants contain chemicals that give off fumes that can produce symptoms of confusion, disorientation, excitement, and hallucinations. The fumes are mind-altering when inhaled. The child initially may experience temporary intoxication, giddiness, nausea, coughing, nosebleed, fatigue, lack of coordination, or loss of appetite.

These symptoms do not indicate the child fell on the playground, has eaten a food containing an allergen, or that he has been exposed to a respiratory disease.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 569 6. The mother of a 6-year-old is asking the nurse how to handle the child's lying and fabricated stories when confronted with questionable actions. Which response would be most appropriate by the nurse?

A. "Your child could be in serious trouble in school if he continues to tell lies."

B. "The child should have privileges taken away for several days each time he tells a lie."

C. "Is there any possibility he is telling the truth and you just don't know it is the truth?"

D. "Children this age sometimes can't distinguish between fantasy and reality."

Answer: D Rationale: Children in the age group 6 to 7 years often engage in magical thinking.

They may still believe in the tooth fairy, Santa Claus, monsters under the bed, and other imaginary characters. These keen imaginations may also conjure up fears— especially at night—about remote, fanciful, or imaginary events. If a child of this age has trouble distinguishing fantasy from reality, it may incline them to lie to escape punishment or to boost self-confidence. The other choices do not consider this child's stage of development or give the mother the most appropriate information for the situation.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 564-565 7. The nurse is assessing a 9-year-old girl during her well-child checkup and notes the child weighs 86 lb (39 kg). After noting she weighed 9.5 lb (4.30 kg) at birth and her growth has been within normal patterns, the nurse determines this girl is within which category?

A. slightly underweight B. slightly overweight C. significantly overweight D. significantly underweight Answer: B Rationale: By age 7, a child weighs about seven times as much as at birth, so at 7, Jasmine should have weighed approximately 66.5 lb (30.16 kg). Because average annual weight gain is about 5 to 6 lb (2.26 to 2.72 kg), by the time she is 9, Jasmine should weigh approximately 76.5 to 80.5 lb (34.69 to 36.51 kg) . The child's current weight puts her 5.5 to 9.5 lbs overweight (2.49 to 4.30 kg).

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 564 8. The school nurse is meeting with a 10-year-boy who is concerned about his weight. He reports he doesn't eat much candy but loves fruit, pasta, potatoes, and

bread. Which suggestion should the nurse prioritize to help him maintain a healthy weight?

A. Encourage portion control at each meal B. Change to a very low-fat and no-carbohydrate diet.

C. Encourage activities that will increase his physical activity.

D. Encourage the child to not worry about weight until he is older.

Answer: C Rationale: Encouraging daily physical activity and following the dietary standards (such as ChooseMyPlate guidelines) will help the child meet necessary nutritional guidelines. Following popular fad diets or using weight-loss supplements must be avoided because they do not supply adequate nutrients for the growing child. The child is aware of the weight problem, but it would not be beneficial to just ignore it because the child may develop harmful eating habits such as bingeing.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 566 9. The nurse is addressing a caregiver's concerns regarding adequate sleep for an 11-year-old child who gets up at 6:30 a.m. each morning. The nurse should point out which time as the most appropriate bedtime for this child?

A. 7:30 p.m.

B. 8:00 p.m.

C. 9:00 p.m.

D. 10:00 p.m.

Answer: C Rationale: Exercise and sufficient rest are important for school-age children. The school-aged child needs 10 to 12 hours of sleep per night. The 6-year-old needs 12 hours of sleep wherease an 11-year-old child needs closer to 10 hours of sleep per night, which would mean going to bed at 8:30 to 9:00 p.m. The older adolescent could go to bed slightly later and get adequate sleep.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 567-568 10. The nurse is admitting a 10-year-old for surgery. What action should the nurse prioritize when caring for this child?

A. Offer to help with bathing.

B. Answer questions regarding pain.

C. Encourage family caregivers to stay with the child.

D. Avoid prolonged discussions about the child's anxiety.

Answer: B Rationale: School-age children need privacy more than younger children do and may not want to have physical contact with adults; this wish should be respected.

These attitudes should be recognized and handled in a way that ensures as much privacy as possible. Children's questions, including those about pain, should be answered truthfully. An opportunity to verbalize anxieties will help a child deal with them. Family caregivers may feel guilty about the child's need for hospitalization and, as a result, may overindulge the child. The child may regress in response to this, but this regression should not be encouraged.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 570-571 11. The nurse is preparing a care plan for a school-age child to address the child's hospitalization. Which factor should the nurse incorporate into this plan?

A. increased attention span and interest in an activity for a long length of time B. can take in new information at a rapid rate and asks "why" and "how" a lot C. insists he or she can "do it" and then reverts to being dependent D. Grows and develops skills more rapidly than at any other time in his or her life Answer: A Rationale: The school-aged child has a longer attention span and can become absorbed in a craft or activity for several hours. The preschool-aged child soaks in information and asks "why and "how" over and over. The toddler insists he or she can do things one minute and then becomes dependent the next minute. The infant grows and develops skills more rapidly than he or she ever will again.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 562 12. The nurse is monitoring a playgroup of children on the pediatric unit. The nurse predicts the school-age child will most likely be participating in which activity?

A. pretending to be mommies and daddies in the playhouse B. playing with the plastic vacuum cleaner, pushing it around the room C. painting pictures in the art corner of the room D. watching a movie with other children their age

Answer: C Rationale: The school-aged child enjoys group activities and making things, such as drawings, paintings, and craft projects. Preschool children enjoy imitative play, pretending to be the mommy, the daddy, a police officer, a cowboy, or other familiar characters. Playtime for the toddler involves imitation of the people around them, such as adults, siblings, and other children. Push-pull toys allow them to use their developing gross motor skills. The adolescent enjoys activities he or she can participate in with peers.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 565 13. A 7-year-old seen in the clinic for a routine well-child visit is noted on assessment to have gained 5 lb (2.26 kg) and grown 5 in (12.70 cm) over the past year. The nurse determines this child is within which parameters?

A. Weight and height are within expected patterns of growth.

B. Weight is within expected range and height is less than expected.

C. Weight is above expected range and the height is within an expected range.

D. Weight is within expected range and height is above expected range.

Answer: D Rationale: Between the ages of 6 and 10 years, average annual weight gain is about 5 to 6 lb (2 to 3 kg). By age 7, the child weighs about seven times as much as at birth. Annual height increase is about 2.5 inches (6 cm). For this child, the weight increase of 5 lbs (2.2 kg) is within expected range and the increase of 5 in.

(12.5 cm) is double what would be expected for this age.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 562 14. The nurse is preparing an in-service training session on Erikson's theories for the pediatric nurses. Which task should the nurse prioritize as an example for the school-aged child?

A. insists on doing things their way instead of their caregivers B. will work on a picture until it is finished C. wants to tie their own shoes no matter how long it takes D. understands the need for discipline Answer: B

Rationale: The developmental task for the school-aged child is to develop a sense of industry, and completing activities builds that feeling of confidence. This can include working with arts and crafts. The adolescent developing his or her own personality is trying to break from their caregivers' methods. Erikson's psychosocial developmental task for toddlers is to achieve autonomy (independence) and do things on their own. This can include tasks such as tying shoelaces—no matter how long it may take. Understanding the need for discipline is not one of Erikson's theories.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 572 15. The school nurse is assessing a 6-year-old child's dentition. Which assessment should the nurse prioritize for this child?

A. has first permanent molars B. has at least six permanent teeth C. has two cuspid or canine teeth D. has lost all deciduous teeth Answer: A Rationale: At about age 6, the child starts to lose the deciduous teeth, usually beginning with the lower incisors. They will continue to lose the deciduous teeth while they are school-aged. The first permanent molars usually erupt about the age of 6. The child would not have six permanent teeth until between 7 and 8 years of age. The upper two cuspid or canine teeth erupt about 9 or 10 years or age. The lower cuspid teeth erupt about 11 or 12 years of age.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 562 16. The nursing instructor is conducting a class discussion exploring the normal dentition progression of the school-aged child. The instructor determines the session is successful when the students correctly choose which factor as most likely occurring in 10-year-olds?

A. All four central incisors have erupted.

B. The child has only six permanent teeth.

C. Two of the cuspid teeth have erupted.

D. There are eight molars.

Answer: C

Rationale: The upper two cuspid or canine teeth erupt about 9 or 10 years or age.

The lower cuspid teeth erupt about 11 or 12 years of age. The central incisors erupt between 6 and 8 years of age. The child will have approximately 16 permanent teeth by the age of 10. At 10 years of age, the child will have four molars.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 562 17. A 6-year-old male has come to the clinic for a routine well-child visit. The nurse, after noting in the medical record that this child has followed basic growth and development standards, anticipates documenting which common assessment finding?

A. flat abdomen B. swayed back C. long legs D. slender body Answer: B Rationale: The 6-year-old's silhouette is characterized by a flatter but still protruding abdomen and lordosis (swayback). By the time the child has reached the age of 10 years, the spine is straighter, the abdomen flatter, and the body generally more slender and long-legged.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 563 18. The nurse is working with a group of 8-year-olds who are learning about the concept of conservation of numbers. Which activity will help teach this concept to these school-aged children?

A. Stacking blocks in a tower and counting how many can be stacked without falling B. Rearranging a group of coins first into a circle, then a triangle and then a square C. Forming vases from blocks of clay that are of various weights D. Measuring the weight of a handful of popcorn and then the weight of a handful of pennies Answer: B Rationale: In understanding the concept of conservation of numbers, the child understands that the number of objects does not change even though they may be rearranged. Conservation of weight can be accomplished by weighing different objects. Conversation of mass is demonstrated by forming vases out of clay.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 563 19. The nursing students working with a group of 8-year-olds have determined they will illustrate the concept of conservation of weight. Which activity would best help these children grasp this concept?

A. weighing and measuring each child and comparing the number of pounds to the number of inches for each person B. using a balance scale to weigh a variety of objects and counting how many pennies must be used to balance the scales C. weighing a pound of oranges and a pound of bricks and counting how many of each make a pound D. measuring the weight of a handful of popcorn and then the weight of a handful of pennies Answer: C Rationale: In learning about conservation of weight, the child recognizes that a pound is a pound, regardless of whether oranges or bricks are weighed. Comparing pounds and inches, noting the number of pennies needed to balance the weight of objects, and measuring the weight of handfuls of popcorn and pennies does not illustrate conservation of weight.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 563 20. The nurse is preparing a presentation for a community health fair on the topic of helping school-aged children develop the self-confidence they will need to mature into responsible adults. Which suggestion should the nurse prioritize to caregivers to enable them to help their children in this area?

A. Encourage the child to cheer on their friends at games.

B. Caregivers should maintain consistent rules and expectations.

C. Ensure that the child has the best teacher possible.

D. Encourage older siblings to include the child in their activities.

Answer: B Rationale: The school-age child needs consistent rules, positive attention, and clear expectations in order to develop self-confidence. Although peers are important, caregivers have more influence over the school-age child relating to building

confidence. Reactions from teachers and trying to keep up with older siblings may lead to lack of self-confidence.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 564 21. The nurse notes a school-aged child in the pediatric unit playroom is busy sorting through the Legos and putting them in certain groupings. The nurse determines this child is illustrating which developmental concept?

A. conservation of numbers B. decentration C. reversibility D. hierarchical arrangement Answer: D Rationale: The ability to group objects into a grouping by some common system is known as hierarchical arrangement. Conservation of numbers is when the child understands that the number of cookies does not change even though they may be rearranged. Decentration is being able to see several aspects of a problem at the same time and to understand the relation of various parts to the whole situation.

Reversibility is the ability to think in either direction.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 565-566 22. The caregiver of a 6-year-old is concerned the child is not getting proper nutrition because on some days, the child will only eat one type of food. Which response should the nurse prioritize for this caregiver?

A. "It is important that each time she eats, she has a variety of foods."

B. "Food jags are common in this age. This probably won't last long."

C. "Try having her eat with the family and she will want what others are eating."

D. "She should be discouraged from having food likes or dislikes. Have her eat everything."

Answer: B Rationale: Food "jags" (the desire for only one kind of food for a while) are typical of the 6-year-old child. This stage soon passes and is unimportant if the child generally gets the necessary nutrients. A variety of foods is important but not each time the child eats. Eating with the family will encourage her to eat what others are eating, but it is not the most appropriate answer. Allowing the child to express food

dislikes and permitting refusal of a disliked food item is usually the best way to handle the school-aged child.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 566-567 23. The nurse is presenting information about school-aged children at a community event. Which statement from the group should the nurse prioritize to address with further teaching and more information?

A. "Sometimes we have to be firm, but our children wash their hands before eating."

B. "I make sure they have good teeth by giving them calcium and phosphorus."

C. "Food is so expensive, we always make our children eat everything on their plates."

D. "Even if the weather is cool and cloudy, our children play outside every day."

Answer: C Rationale: Obesity can be an issue in the school-aged child, especially if they are urged to clean their plates even if they have more food than they want or need on the plate. The parents should be encouraged to use smaller plates for the children so they will still appear to have a full plate but smaller portions. Firm guidance and direction is important with the school-aged child. Calcium and phosphorus are important to healthy teeth. Exercise each day is important, especially outdoor exercise.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 566-567 24. The school nurse is discussing obesity with a group of caregivers of school-aged children. Which statement by the caregivers best illustrates that they are prepared to help their child prevent obesity?

A. "I always cook foods that are low in fat."

B. "We eat fast foods only on weekends because we are too busy to cook."

C. "Neither my husband nor I have ever had any concerns with weight."

D. "I keep lots of snacks on hand because my child eats all day long."

Answer: A Rationale: Limiting dietary fat intake to no more than 35 percent of total calories helps control the child's weight. Fast foods tend to have high fat and calorie content and contribute to obesity. Some children may have a genetic tendency to obesity,

but environment and a sedentary lifestyle are a concern related to obesity.

Caregivers must carefully supervise children's snacking habits to be sure that snacks are nutritious and not too frequent since this can lead to obesity.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 566-567 25. The nursing instructor is leading a discussion on school-aged children. The instructor determines the session is successful when the students correctly choose which factor as being a priority for the school-aged child?

A. Needs 10 to 12 hours of sleep per night B. Should brush their teeth at bedtime C. Have a routine physical exam every 6 months D. Be screened for scoliosis once a year Answer: A Rationale: The school-aged child needs 10 to 12 hours of sleep per night. They need to brush their teeth after every meal and at bedtime. A routine physical exam once a year is all that is necessary. Children are screened around the age of 10 or 11 for scoliosis.

Question format: Multiple Choice Chapter 26: Growth and Development of the School-Aged Child: 6 to 10 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 567

Chapter 27 1. The nurse is measuring the height of a 13-year-old girl who was 56 in (142.24 cm) tall at age 9. The nurse predicts the girl will be approximately how tall if following the normal pattern of growth?

A. 58 in (147.32 cm) B. 62 in (157.48 cm) C. 68 in (172.72 cm) D. 76 in (193.04 cm) Answer: C Rationale: Preadolescence begins in the female between the ages of 9 and 11 years and is marked by a growth spurt that lasts for about 18 months. Girls grow about 3 inches each year until menarche, after which growth slows considerably. The four years between age 9 and 13 would mean the girl should have grown approximately 12 inches, making her now 68 in (172.72 cm) tall (56 + 12 = 68 in).

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 575 2. The parents of a 16-year-old male are worried about recent changes in his behavior, ignoring his schoolwork and sports, and spending almost all of his free time interacting with his girlfriend. Which suggestion should the nurse point out would best address this situation?

A. He is not developmentally mature enough to make healthy choices about the ways in which he spends his time, so it would be helpful if they would make a schedule for him that includes about a half-hour per day to talk with his girlfriend.

B. He has developed his own identity by now; being able to establish close relationships with girls is important preparation for all of his adult relationships.

They should honor his need to be with, or talk to, his girlfriend as long as he has completed his schoolwork for the day.

C. He is not developmentally mature enough to have an intimate relationship with one girl; they should encourage him to spend time with groups of friends rather than time alone with his girlfriend.

D. He has chosen a girl who is overly dependent on him. They should talk to him about making sure he meets his own needs, including doing the schoolwork he enjoys, in any relationship.

Answer: B Rationale: When identity has been established, generally between the ages of 16 and 18 years, adolescents seek intimate relationships, usually with members of the

opposite sex. Intimacy, which is mutual sharing of one's deepest feelings with another person, is impossible unless both persons have established a sense of trust and a sense of identity. Intimate relationships are a preparation for long-term relationships, and people who fail to achieve intimacy may develop feelings of isolation and experience chronic difficulty in communicating with others.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 577-578 3. The father of a 15-year-old daughter is concerned she is not getting adequate nutrition to play high school basketball. Her games are on Friday nights. Which suggestion should the nurse point out will best suit the needs of this adolescent?

A. Pasta with a small amount of meat sauce and two slices of bread for dinner on Wednesday and Thursday evenings and again at 2 p.m. on Friday.

B. Boiled eggs with bacon or ham and a glass of orange juice for breakfast on Thursday and Friday mornings along with some sliced turkey and a salad at noon on Friday.

C. Three daily meals that include choices from each of the food groups with an additional serving of fruit and several extra glasses of water on Friday.

D. Three daily meals that include choices from each of the food groups; Friday's lunch eaten around 2 p.m. with a small amount of fat and a somewhat larger than usual portion of complex carbohydrates.

Answer: D Rationale: A meal that is low in fat and high in complex carbohydrates, eaten 3 to 4 hours before an event, is appropriate for the teen athlete. Carbohydrate-loading, which some practice during the week before an athletic event, increases the muscle glycogen level to 2 to 3 times normal and may hinder heart function. The other suggested menus would not provide the additional muscle glycogen needed for optimal functioning.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 579-580 4. The parent of an adolescent has called to talk to the pediatric nurse over concern that her daughter is not getting proper nutrition now that she has started following a vegetarian diet. Which response should the nurse prioritize for this parent?

A. Vegetarian diets can be healthy; ensure she includes whole-grain products, legumes, nuts, seeds, and soy dairy substitutes.

B. Lacto-ovo vegetarian diets are acceptable for teens but, until the body's growth cycle is complete, she needs some egg and dairy products for good health.

C. Vegetarian diets can be healthy for teens but should be supplemented with protein drinks and megavitamins.

D. A vegetarian diet is unhealthy for growing bodies, and teens are too immature to make a healthy decision.

Answer: A Rationale: If planned with care, vegetarian diets can provide all needed nutrients.

All vegetarians should include whole-grain products, legumes, nuts, seeds, and fortified soy substitutes. If the individual is following the lactovegetarian approach, then low-fat dairy products are also appropriate. The lacto-ovo vegetarian diet includes eggs and dairy products but excludes meat, poultry, and fish. The vegetarian diet does not need to be supplemented with protein drinks and megavitamins if the food choices are carefully chosen to provide adequate nutrition.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 579-580 5. The nurse is assessing an adolescent in the clinic at a routine well-visit. Which question should the nurse prioritize to encourage the adolescent to share detailed information?

A. "Do you like members of the opposite sex?"

B. "Do you go out on dates frequently?"

C. "Are you sexually active?"

D. "Do you have oral, anal, or vaginal sex?"

Answer: D Rationale: The nurse should ask open-ended questions which will encourage continued conversation versus closed-ended questions which can be answered with just a simple "yes" or "no". It's important for the nurse to encourage the adolescent to give direct answers. The interviewer must be alert to verbal and nonverbal clues.

Being specific about the type of sex, versus just sex, will alert the nurse to closely evaluate specific areas of the body which might have signs of STIs. Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 580 6. The nurse is assessing a teenage client and notes his lower front teeth are slightly crossed over. The nurse points out to his caregiver that he should see an orthodontist about this to prevent which potential situation?

A. Leaving even slightly crooked teeth will lead to more cavities later in life.

B. Even slight malocclusions make chewing and jaw function less efficient.

C. This could have a lasting effect on his future to include everything from dating to hiring.

D. Uncorrected malocclusions lead to infection and ultimately tooth loss.

Answer: B Rationale: Dental malocclusion (improper alignment of the teeth) is a common condition that affects the way the teeth and jaws function. Correction of the malocclusion with dental braces improves chewing ability and appearance. Crooked teeth do not lead to more cavities, nor do they lead to infection and tooth loss.

While appearance and acceptance in society is important to the adolescent, that is not the most important reason for orthodontic care for the adolescent.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 581-582 7. A 15-year-old client tells the nurse he has been having wet dreams and is ashamed and afraid he will get into trouble because he believes his parents think he is too young to understand or know about sex. To which statement would be the most appropriate for the nurse to respond?

A. "Since your parents feel you are not ready to talk about sex, you need to honor their wishes and not bother them with this."

B. "Don't worry, it is perfectly normal for 15-year-olds to have the kinds of fantasies that lead to wet dreams. You should tell your parents about this."

C. "Wet dreams are not the result of anything you are doing but are simply the body's way of ridding itself of excess semen."

D. "You don't need to feel ashamed. I will speak to your parents about the importance of allowing you to experiment with and feel good about your sexuality."

Answer: C Rationale: Boys who are unprepared for nocturnal emissions may feel guilty, believing that they have caused these "wet dreams" by sexual fantasies or masturbation. They need to understand that this is a normal occurrence and is simply the body's method of getting rid of surplus semen. The other suggestions do not address the situation in a professional manner.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 582

8. The school nurse is conducting a health class with a group of high school students on the topic of sex and sexuality issues. The nurse determines the session is successful when the students correctly choose which aspect as most important?

A. "It is important for adolescents to abstain from sexual activity."

B. "Males, as well as their partners, are responsible for avoiding an unwanted pregnancy."

C. "Adolescents need to know how to use condoms correctly to avoid sexually transmitted infections."

D. "Girls should carry their own condoms and use them to avoid pregnancy."

Answer: C Rationale: The priority is to prevent STIs. Adolescents need to understand that STIs can be acquired via oral sex as well as vaginal sex. They also need to understand that using contraceptive pills will not prevent STIs. They need contraceptive information to prevent pregnancy but more importantly, they need straightforward information about using condoms to protect them against HIV and other infections.

Both male and female adolescents need this information, and girls should be advised to carry their own condoms if they believe there is any possibility of having sexual intercourse.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 585 9. The nurse is preparing to participate in a community discussion on the needs of the adolescents in the local school. The nurse should point out which goal is the primary concern for these young individuals as the committee makes plans?

A. Teens are busy developing their own personal identity.

B. They want to successfully complete activities.

C. Each child is learning to do things on his or her own.

D. They understand and respond to discipline.

Answer: A Rationale: According to Erikson, the central task of adolescence is to develop unique personality and identity. The developmental task for the school-age child is to develop a sense of industry, and completing activities builds that feeling of confidence. Erikson's psychosocial developmental task for toddlers is to achieve autonomy (independence) and do things on their own. Learning to speak and to understand and respond to discipline are not developmental tasks, according to Erikson.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 575 10. The nursing instructor is leading a class discussion on the various aspects of adolescents. The instructor determines the class is successful after the students correctly choose which milestone as the beginning of adolescence?

A. The deciduous teeth falling out B. The beginning of puberty C. The child becoming self-supported D. The fine motor skills fully developed Answer: B Rationale: Early adolescence (preadolescence, pubescence) begins with a dramatic growth spurt that signals the advent of puberty or reproductive maturity. The deciduous teeth are all out around the age of 10 or 11. Children usually are not self-supported. Fine motor skills continue to develop through adolescence.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 582 11. The nurse is assessing a 16-year-old girl at an annual well-clinic visit and notes the girl started menses at 13 years of age and grew 1 inch (2.5 cm) over the past year. When questioned by the young lady if this is normal, which answer should the nurse prioritize?

A. "Your height is less than expected."

B. "You're taller than what would be expected."

C. "Your weight is more revealing than your height."

D. "You're following expected patterns of growth."

Answer: D Rationale: Girls grow about 3 inches (7.6 cm) each year until menarche, after which growth slows considerably. This height increase would be within expected patterns of growth. Height is not dependent on weight.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 575 12. The school nurse is meeting with a group of 11-year-old girls to discuss expected puberty changes in their bodies. When one of the girls states, "I just feel

like my whole body is changing and I don't know why" what should the nurse point out to this group?

A. "You will feel better about yourself as you get older."

B. "You have lots of hormone changes going on right now."

C. "You may feel like you are changing, but you still look the same."

D. "Your other friends are feeling like this too."

Answer: B Rationale: Preadolescents need information about their changing bodies and feelings. Sex education that includes information about the hormonal changes that are occurring or will occur is necessary to help them through this developmental stage. Although adjustments will occur as the child gets older and friends are important, these responses are not the most direct and appropriate.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Communication and Documentation Reference: p. 575 13. A male nurse is meeting with a group of 12-year-old boys to discuss expected bodily changes. After one of the boy's says, "My older brother told me my bed might be wet and that means I had a wet dream. Is that true?" What is the best response from the nurse?

A. "When you are thinking about people you find sexually attractive or dating those people you might have a wet dream."

B. "It is not common to wet the bed or urinate when you have a wet dream."

C. "Having wet dreams indicates that your body is going through a process of maturing."

D. "It will be several years before you will start having wet dreams."

Answer: C Rationale: In boys, the appearance of nocturnal emissions ("wet dreams") is often used as the indication that the preadolescent period has ended and that the adolescent is maturing into an adult. Nocturnal emissions usually occur at about the age of 11 in boys. Wet dreams are not associated with urination. Boys at this age start thinking of relationships with people they find sexually attractive, but this is not the best response.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 575-576

14. The nurse is preparing a presentation for a local health fair depicting the differences in maturity between preadolescents. Which differing factor should the nurse prioritize in the presentation?

A. Boys grow at a slower, steadier rate than do girls.

B. Girls grow at a slower, steadier rate than do boys.

C. Boys grow at a rapid, sporadic rate.

D. Boys and girls grow at the same rate.

Answer: A Rationale: Preadolescent boys grow generally at a slower, steadier rate than do girls. Girls grow more rapidly during preadolescence and then their growth rate slows dramatically after menarche.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 575 15. The nurse is meeting with a group of caregivers of adolescents and discussing sex and sexuality, including how to discuss these issues with their children. Which comment should the nurse prioritize with this group of caregivers?

A. Teenagers spend so much time with their peers, and that is usually how they find out about sex.

B. Being honest and straightforward with teenagers will encourage them to ask about subjects like sexuality.

C. Most schools have excellent programs to teach adolescents about sex and sexuality.

D. Internet resources, movies, and television have the most accurate and current information for your adolescent to learn about sexuality issues.

Answer: B Rationale: The most important aspect of discussions about sexuality with adolescents is giving honest, straightforward answers in an atmosphere of caring concern. Children whose need for information is not met through family, school, or community programs will get the information—often inaccurately—from peers, movies, television, or other media.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 576 16. A 17-year-old female is meeting with the nurse for an annual well-visit and is asking the nurse questions about how to know when one is in love. The nurse

should point out which factor to help decide if both individuals have reached a mutual agreement and are ready for an intimate relationship?

A. A sense of trust and identity B. An ability to be autonomous C. A willingness to take initiative D. An understanding of socialization and of isolation Answer: A Rationale: In order to be intimate or to share one's deepest feelings with another person, it is impossible unless both persons have established a sense of trust and a sense of identity. Being autonomous or taking initiative are not aspects that lead toward intimate relationships. Socialization and isolation are not relevant to the establishment of intimate relationships.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 578 17. The nurse is meeting with a group of caregivers of adolescents. Which example should the nurse point out is most effective for the caregiver to support the adolescent?

A. Leave pamphlets about topics such as drugs and alcohol in their room so they can read them.

B. Let them choose their hairstyle, even though it may not look the best for them.

C. Discourage spending too much time with school friends since we know they can be a negative influence.

D. Our house rules are stricter than their friends but everyone follows the same rules in our home.

Answer: B Rationale: The adolescent whose family caregivers make it difficult to conform are adding another stress to an already emotion-laden period. By allowing the adolescent to follow trends and fads in clothing choices, hairstyles, and music, the caregiver decreases the stress for the child. Information about drugs and alcohol is important to share, but these topics would be better discussed with the child. It is important the adolescent spend time with peers.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 577

18. The school nurse is preparing for a career fair at the local high school. Which factor should the nurse point out when presenting various medical career options to the students?

A. The adolescent should seriously consider the parents' choice for the best career.

B. The career choices may be limited after high school depending on location.

C. Many individuals have already chosen what they want to do.

D. The individual's sex no longer decides which career options are available.

Answer: D Rationale: Sex role stereotypes have been shattered in most careers and professions. More women are becoming lawyers, physicians, plumbers, and carpenters; more men are entering nursing or choosing to become stay-at-home fathers while their wives earn the primary family income. The adolescent should consider what the parents are saying, but the final choice is theirs. With the use of the Internet, travel to other areas, and a variety of school options, there are ways for the students to go to a school in a different area. There are also numerous resources that will help the student seek higher education. It just may mean they have to work a little harder to achieve their goal. There are many career choices for the adolescent to choose from.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 577 19. The nurse is leading a discussion in a health class at the high school on adolescent relationships. The nurse determines the session is successful when the students correctly choose which type of relationship as involving a member of the opposite sex?

A. gay or lesbian relationship B. unhealthy relationship C. heterosexual (straight) relationship D. bisexual relationship Answer: C Rationale: Heterosexual (straight) relationships are formed between members of the opposite sex. Relationships formed with members of the same sex are gay or lesbian relationships. Bisexual relationships are those in which the individual has both same-sex and opposite-sex relationships. Any relationship can be an unhealthy relationship.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Caring

Reference: p. 578 20. The nurse is meeting with a group of adolescent athletes to discuss their nutritional needs. The nurse should encourage the adolescents to include which foods in the diet to increase iron intake? Select all that apply.

A. dried fruits B. peanuts C. milk shakes D. grapes E. hard-boiled eggs F. cheese sticks Answer: A, B, E Rationale: Dried fruits, peanuts, and eggs (especially the egg yolk) are high in iron.

Milk shakes, grapes, and cheese sticks are low or have little iron content.

Question format: Multiple Select Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 580 21. The school nurse is teaching a health class on nutrition with some adolescents.

Which comment by a student should the nurse prioritize and provide more teaching?

A. "I hate eating with my family. I would much rather snack all day."

B. "I had lunch with my boyfriend before his game and all he ate were carbohydrates."

C. "I am feeling so fat. I think I need to exercise a few extra hours today."

D. "I don't really like it, but I have been drinking lots of skim milk."

Answer: C Rationale: Even after the body has become emaciated, the adolescent may believe that he or she is still fat and, therefore, unattractive. This condition is called anorexia nervosa and is a serious health concern related to adolescents and their nutritional status. Even if the adolescent doesn't eat with the family, he or she can still consume needed nutrients. Although carbohydrate-loading is a concern, this statement does not indicate the adolescent girl was following this eating pattern.

Skim milk has adequate nutrients.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 579-580

22. The nurse is teaching a nutritional class to a group of adolescents who are lactose-intolerant. Which food should the nurse point out will help these adolescents consume the calcium they need for proper nutrition?

A. chocolate pudding B. nonfat milk C. soybean curd D. cottage cheese Answer: C Rationale: For a lactose-intolerant client, the nurse can recommend other products high in calcium, such as tofu (soybean curd), soybeans, and greens, to increase calcium intake. Chocolate pudding, nonfat milk, and cottage cheese are all high in lactose.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 579-580 23. The nutritionist is presenting information about vegetarian diets to a group of nursing students. The nutritionist determines the session is successful when the students correctly choose which factor concerning the semi-vegetarian diet?

A. "The diet excludes red meat and possibly poultry."

B. "The diet excludes red meat, poultry, and fish."

C. "The diet excludes meat, poultry, fish, and eggs."

D. "The diet excludes dairy products, meat, poultry, fish, and eggs."

Answer: A Rationale: The semi-vegetarian diet includes dairy products, eggs, and fish and excludes red meat and possibly poultry. The lacto-ovo-vegetarian diet includes eggs and dairy products but excludes meat, poultry, and fish. The lacto-vegetarian diet includes dairy products and excludes meat, fish, poultry, and eggs. The vegan diet excludes all food of animal origin, including dairy products, eggs, fish, meat, and poultry.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 579-580 24. The school nurse is presenting information to a group of high school students who are asking about vegetarian diets. The nurse determines that the group needs more information when they identify which foods as being included in a vegan diet?

A. red meat and possibly poultry

B. red meat, poultry, and fish C. meat, poultry, fish, and eggs D. dairy products, meat, poultry, fish, and eggs Answer: D Rationale: The vegan diet excludes all food of animal origin, including dairy products, eggs, fish, meat, and poultry. The semi-vegetarian diet includes dairy products, eggs, and fish and excludes red meat and possibly poultry. The lacto-ovovegetarian diet includes eggs and dairy products but excludes meat, poultry, and fish. The lacto-vegetarian diet includes dairy products and excludes meat, fish, poultry, and eggs.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 579-580 25. A group of nursing students are preparing sample menus for the lacto-ovovegetarian diet. The instructor determines the presentation is successful after noting the students avoided the use of which foods in planning the menus?

A. red meat and possibly poultry B. red meat, poultry, and fish C. meat, poultry, fish, and eggs D. dairy products, meat, poultry, fish, and eggs Answer: B Rationale: The lacto-ovo-vegetarian diet includes eggs and dairy products but excludes meat, poultry, and fish. The semi-vegetarian diet includes dairy products, eggs, and fish and excludes red meat and possibly poultry. The lactovegetarian diet includes dairy products and excludes meat, fish, poultry, and eggs. The vegan diet excludes all food of animal origin, including dairy products, eggs, fish, meat, and poultry.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 579-580 26. A male nurse is meeting with a group of high school boys to discuss various health topics. After the session on testicular self-exam, the nurse determines the session is successful when one of the students responds with which comment?

A. "It sounds like we will need to know how to do this when we are in our 20s, so we might as well learn now."

B. "My uncle had testicular cancer after he got married and had my cousin."

C. "I am almost 15 now, so that means I could possibly get this disease."

D. "Men my grandfather's age will probably die if they don't do these exams."

Answer: C Rationale: Testicular cancer is one of the most common cancers in young men between the ages of 15 and 34. Teaching the boys how and when to perform testicular self-examination is an important health maintenance activity. It is easier to treat testicular cancer if it is caught early and the best way to catch it is routine self-exams. A family history of testicular cancer increases the chances of the younger family members developing the cancer. The self-exam should be continued on a routine basis at least until the individual is 35 years old.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 584 27. The nurse in an emergency department is assessing an 18-year-old who is reporting a gap in memory for the previous night. The client reports feeling dizzy and disoriented after drinking only one drink. The client woke up in a friend's bed but has no recollection of getting there. What action should the nurse prioritize for this client?

A. Call social services to counsel the client about blackouts related to alcohol use disorder.

B. Call the neurology department so they can see the client to rule out a neurological impairment.

C. Have the client call a caregiver to get permission to treat and counsel the client.

D. Complete a rape kit to rule out possible sexual abuse while the client was blacked out.

Answer: D Rationale: In recent years the use of rohypnol, also known as the "date rape drug," has become a concern for the adolescent. Rohypnol is not sold legally in the United States but is brought in from countries where it is sold legally. The drug, especially in combination with alcohol, causes memory loss, blackouts, and an inability to resist sexual attacks. Often the drug is secretly slipped into a person's drink. The drug has no taste or odor, but within a few minutes after ingesting the drug, the person feels dizzy, disoriented, and nauseated, and then rapidly passes out. After several hours, the person awakens and has no memory of what happened while under the influence of the drug. Waking up in someone's bed should raise suspicions that the individual was raped. Completing a rape kit will provide the authorities with the evidence they will need to further pursue the case.

Question format: Multiple Choice Chapter 27: Growth and Development of the Adolescent: 11 to 18 Years Cognitive Level: Analyze

Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 585

Chapter 28 1. The nurse is interviewing the mother of a child who is at the local clinic. When asked why she brought her toddler in today, she replies that the child has been running a fever and coughing a lot since last weekend. This information would be noted in the chart as what data?

A. heath history B. present health concern C. chief complaint D. biographical history Answer: C Rationale: The reason for a child's visit to a health care facility on a specific day is called the chief complaint. A health history is information encompassing the maternal and pregnancy history as well as the child's health occurrences up to this time. The present health concern is further information about the reason for the visit, such as the quality of the cough, frequency of the cough, and how high the fever was. A biographical history of a child would be the child's name, address, and other contact information.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 594 2. The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason?

A. The number of family members that have a certain health problem will help the nurse know if the child will have the same problem.

B. Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems.

C. The nurse needs to know everything about a family to take care of the child.

D. By establishing family behavior, the nurse forces the parents to alter their care of their child and make them healthier.

Answer: B Rationale: Collecting a complete family health history helps the nurse learn if there are certain behaviors or risk factors for the family; this will hopefully educate the family in how to improve both their health and the child's health, as well as reduce the incidence of diseases and chronic conditions.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection)

Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 594 3. As part of an admission to the pediatric floor, the nurse gathers a lifestyle history. What components would be included in this part of the client history?

Select all that apply.

A. the child's grade in school B. habits such as thumb sucking or nail biting C. the child's developmental milestones D. client allergies and medications E. custody of the child if parents are divorced Answer: A, B, E Rationale: A lifestyle history includes data related to the school history, social history, personal history and nutritional history. Asking about what grade the child is in, his or her habits, and who has primary custody in the case of divorced parents are all part of a lifestyle history. Developmental milestones and client allergies and medications fall under other history categories.

Question format: Multiple Select Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 597 4. The nurse is observing an infant and notes that the infant is restless, wide-awake but quiet. The mother reports that her baby often is awake for hours at a time and is very fidgety. How would the nurse respond to her observation?

A. The nurse should report the infant's behavior to her supervisor for further investigation.

B. Since the infant is often awake for long periods, the nurse needs to talk to the doctor about prescribing some medication to calm the child.

C. The nurse should do a more in-depth investigation to determine why the infant is awake so much and is restless.

D. Because the mother reports that the infant's behavior is normal, there is no need for further observation.

Answer: D Rationale: Often, the nurse observes what she would consider concerning behavior in an infant or child but, when talking with the parent, determines that the child's behavior is normal for them. If this happens, there is no need for further evaluation. The nurse would simply document the findings.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection)

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 598 5. An 8-month-old infant in being held by her mother and the nurse needs to obtain the infant's vital signs. Which approach would most likely ensure accurate readings?

A. Place the infant on the examination table, take the temperature rectally and listen to the heart rate and note respirations.

B. Allow the mother to continue to hold the infant, listen to the child's heart rate, count respirations by the abdominal rise, then take an axillary temperature.

C. Have the mother hold the infant in her lap lying down, take a rectal temperature, and listen to heart and breath sounds from there.

D. Lay the infant on the examination table, have the mother help hold the infant still, and take an axillary temperature and count both heart rate and respiratory rate by auscultation.

Answer: B Rationale: The best method for obtaining vital signs on an infant is to keep the infant calm and begin with listening to heart and breath sounds, followed by temperature. Respiratory rate is easily obtained by watching an infant's abdomen rise and fall since infants are abdominal breathers. Keeping the infant calm is best accomplished by allowing the parent to hold the client.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 600-601 6. Which physical assessment data would the nurse find concerning and would warrant reporting to the primary care provider?

A. Head circumference is 2 inches less than the chest circumference in a 5-year-old child.

B. A school-aged child has a heart rate of 90.

C. a blood pressure of 128/80 in a preschool-aged child D. an infant who has a closed posterior fontanel (fontanelle) at age 4 months Answer: C Rationale: The normal blood pressure for a preschooler is 89-112 systolic and 4672 diastolic, so a blood pressure of 128/80 is abnormal and needs reporting to the physician. The chest circumference for a child is 2 to 3 inches greater than the head circumference. The normal heart rate for a school-aged child is 60-110. The posterior fontanel (fontanelle) closes around 2 to 3 months of age in infants.

Question format: Multiple Choice

Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 604 7. A mother observes the office nurse charting her son's height and weight on a growth chart and asks the nurse the purpose of plotting this information for her child. The nurse would reply with which explanation?

A. The height and weight of each client is plotted on a growth chart at each visit to note how the child is growing and compare the growth to the norm.

B. The doctor wants to see how fast he is growing over the last year.

C. Each child grows at a certain rate and the doctor wants to see her child's rate of growth.

D. Boys and girls grow differently and the doctor wants to compare her son's growth to her daughter's growth at the same age.

Answer: A Rationale: Plotting a child's height and weight are very important to determine if a child is growing normally or is too large or too small for their age. This is determined by plotting these measurements on a standardized growth chart. This data gives the health care provider a good clue as to the child's health status.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 598-600 8. The caregiver of a 3-year-old boy presents at the receptionist desk and reports that the child is nauseated. In interviewing the child's caregiver, which question should the nurse prioritize when starting the assessment?

A. "Why did you decide to bring your son to the clinic today?"

B. "How often does your son complain of being nauseated?"

C. "Does anyone else in the family have the same symptoms?"

D. "Has your son had anything to eat that he might be allergic to?"

Answer: A Rationale: To provide the best care for the child, it is important to get the most complete explanation of what brought the child to the health care setting. The nurse may not have heard the entire conversation and asking an open-ended question will allow the caregiver to provide the nurse with all the information necessary to provide the best care. The other questions could be asked depending on the answers given by the caregiver.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection)

Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 594 9. A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his parent. Which statement by the parent should the nurse prioritize for further investigation after noting the father has a history of alcohol use disorder?

A. "I wish there was a blood test for alcohol use disorder. I know my son is at risk."

B. "Our next door neighbor is older than my son, and he drinks when they hang out together."

C. "I think I know how my son feels about drinking. He has had substance use disorder education in school."

D. "Sometimes my son asks me questions about his father's low tolerance for alcohol."

Answer: B Rationale: Some diseases and conditions are seen across families, and this is important in prevention as well as detection for the child. The caregiver can usually provide information regarding family health history. The nurse should use this information to do preventive teaching with the child and family. Early adolescence is a time when experimental use of substances, especially alcohol and tobacco, might be seen. It would be important to assess the use of substances and follow up regarding the behaviors of the adolescent.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 594 10. The nurse is assisting with the physical exam on a 2-year-old child. The nurse predicts the order of the exam will be in which sequence?

A. Head and neck; eyes; ears; nose, mouth; then the back and extremities B. Back and extremities; eyes, ears, nose, mouth; then the head and neck C. Back and extremities; head and neck; then the eyes, ears, nose, and mouth D. Eyes, ears, nose, mouth, back, and extremities; then the head and neck Answer: C Rationale: Data are collected by examination of the body systems. Often the exam for a child is not done in a head-to-toe manner, as is done with adults, but rather in an order that takes the child's age and developmental needs into consideration.

Aspects of the exam that might be more traumatic or uncomfortable for the child, such as examining the nose and mouth, are done last.

Question format: Multiple Choice

Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 607 11. The nurse is assessing a 5-month-old infant at a well-child visit. In measuring and weighing the child, the nurse will prioritize which action?

A. Wipe the scale with an alcohol-based cleanser.

B. Cover the scale with a clean piece of paper or paper towel.

C. Straighten the child's legs and hold the knees flat.

D. Hold one hand within 1 inch (2.54 cm) of the child.

Answer: D Rationale: Safety is always the priority. The nurse must have a hand near to be able to prevent the child from any type of fall or injury. The infant is weighed nude while lying on an infant scale; when the infant is big enough to sit, he or she can also be weighed while sitting. The scale is covered with a fresh paper towel or clean sheet of paper as a means of infection control. To measure an infant, place the child flat, with the knees held flat, on an examining table. Measure the child's height by straightening the child's body and measuring from the top of the head to the bottom of the foot. The measurement can be done by making marks on the paper table covering and then measuring between the marks.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 598 12. The nurse is caring for a child in the emergency department who is on a cardiac monitor. Which nursing action should the nurse prioritize?

A. Clean the skin with alcohol before placing the electrodes.

B. Confirm the alarms are set with maximum and minimum settings.

C. Check the site and skin condition every couple of hours.

D. Check to be sure that the electrodes are secure when the alarm sounds.

Answer: B Rationale: Cardiac monitors are used to detect changes in cardiac function. The highest priority would be to ensure the alarms are set with maximum and minimum settings and that the alarm is turned on. Many of these monitors have a visual display of the cardiac actions. Electrodes must be placed properly to obtain accurate readings of the cardiac system. The skin is cleaned to remove dirt, lotions, and powder before the electrodes are applied. The electrode sites must be checked every two hours to detect any skin redness or irritation and to determine that the electrodes are secure.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 603 13. The nurse is admitting a child to the intensive care unit. The child arrives with a cardiac monitor, pulse oximeter, and an IV infusion. As the nurse begins collecting data on the child, which nursing interventions should the nurse prioritize?

A. Verify that the alarms on the monitor are still properly set.

B. Assess the neurologic function using the Glasgow coma scale.

C. Change the probe on the pulse oximeter.

D. Check the apical pulse rate using a pediatric stethoscope.

Answer: A Rationale: At the beginning of each shift and after transport of the client, the nurse must check that alarms are accurately set and have not been inadvertently changed. This is true for all types of monitors. The neurologic status will most likely be checked, as well as the apical pulse, but they are not priorities. The probe on the pulse oximeter is changed if needed, but not routinely and not as a priority.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 603 14. The nurse is caring for a child admitted with a head injury and is conducting an ongoing assessment. The nurse prepares to utilize the Glasgow coma scale to achieve which priority nursing intervention?

A. Look back at the client's neurologic status the last time the nurse cared for this client.

B. Create reports based on using a consistent tool.

C. Have a comparison of the child's status from one check to another.

D. Report to the oncoming nurse any significant changes.

Answer: C Rationale: The nurse often is responsible for using neurologic assessment tools to monitor a child's neurologic status after the initial neurologic exam. The nurse uses a neurologic assessment tool such as the Glasgow coma scale. The use of a standard scale for monitoring allows for the comparison of results from one time to another and from one examiner to another. If a child is hospitalized with a neurologic concern, the neurologic status is monitored closely and a neurologic assessment tool is used every 1 or 2 hours to observe for significant changes.

Question format: Multiple Choice

Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 607 15. The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?

A. Between the sternum and the left nipple B. Above the sternum, slightly to the right C. Below the ribs about one half of an inch D. Above the clavicle on the left side Answer: A Rationale: When taking an infant's apical pulse, the stethoscope is placed between the child's left nipple and sternum. The other locations will not assist with localizing over the apex of the heart.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 602 16. The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process?

A. Interviewing the child's caregiver B. Weighing and measuring the child C. Reinforcing teaching with the child's caregivers D. Taking the child's vital signs Answer: A Rationale: Information spoken by the child or family is called subjective data.

Interviewing the family caregiver and child allows you to collect information that can be used to develop a plan of care for the child. Collecting objective data would include weighing and measuring the child and taking the child's vital signs.

Reinforcing teaching would involve client education to ensure the caregivers are aware of the treatments and/or further care.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning

Reference: p. 593 17. A toddler is brought to the pediatric clinic by the caregiver because the child "doesn't feel well." As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

A. Obtaining the health history B. Interviewing the client C. Obtaining biographical data D. Determining the chief complaint Answer: D Rationale: The reason for a visit to a health care setting is called the chief complaint. In a well-child setting, this reason might be a routine check or immunizations, or an illness or other condition. The nurse will obtain this information by interviewing the caregiver. Obtaining the health history and biographical data will also be completed during the assessment process.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 594 18. The nursing instructor is conducting a clinical session on the proper techniques for assessing a child's head circumference. The instructor should point out which factor concerning this assessment?

A. Measure the head circumference routinely on children up to the age of 6 years.

B. Place the tape measure around the head just above the eyebrows.

C. Expect the head circumference and the chest circumference measurements to be equal up to the age of 6 years.

D. Place the tape measure around the head with the tape touching just below the eyes.

Answer: B Rationale: The head circumference is measured routinely in children to the age of 2 or 3 years, or in any child with a neurologic concern. Place a paper or plastic tape measure around the largest part of the head just above the eyebrows and around the most prominent part of the back of the head. During childhood the chest exceeds the head circumference by 2 to 3 inches.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 600

19. The nurse is explaining to a group of nursing students the proper technique for obtaining an accurate temperature on a child. The instructor determines the session is successful when the students correctly choose which factor as related to taking a temperature?

A. "A rectal temperature is usually 0.5° to 1.0° lower than the oral measurement."

B. "Tympanic temperatures should not be taken on a child who is sleeping."

C. "An axillary temperature usually measures 0.5° to 1.0° higher than the oral measurement."

D. "Rectal temperatures should not be taken on a child with diarrhea."

Answer: D Rationale: A rectal temperature should not be taken in the newborn because of the danger of irritation to the rectal mucosa or in children who have had rectal surgery or who have diarrhea. A rectal temperature is usually 0.5° to 1.0° higher than the oral temperature and the axillary temperature is usually 0.5° to 1.0° lower than the oral temperature. It is easier to obtain a tympanic temperature in a sleeping child as the temperature can be obtained without walking them up.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 601 20. The caregiver of an infant keeps removing the pulse oximetry sensor claiming it is too tight and hurting her baby. Which response should the nurse prioritize in addressing this situation?

A. Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin.

B. Place the probe of the oximeter on the child's chest and secure it with tape.

C. Ensure the oximeter probe site is checked every 8 hours for possible reactions.

D. Explain that pulse oximetry is done to detect respiratory retractions.

Answer: A Rationale: Pulse oximetry measures the oxygen saturation of arterial hemoglobin.

The probe of the oximetry unit can be placed on the finger, toe, or clipped on the earlobe. In an infant, the foot or toe is often used. In certain situations the probe is left in place to continually monitor the oxygen saturation. Check the site every 2 hours to ensure that the probe is secure and tissue perfusion is adequate. Change the site at least every 4 hours to prevent skin irritation. The probe cannot be taped to the chest wall and still collect the desired information. Respiratory retractions are determined by direct inspection of the chest wall.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential

Integrated Process: Nursing Process Reference: p. 603 21. The nurse in the pediatric unit is using the Glasgow coma scale to monitor a child admitted with a neurologic disorder. The nurse will prioritize the continued use of the Glasgow coma scale based on which reason?

A. measures the verbal and motor responses of the child B. used one or two times a day to note changes in the neurologic status C. used to compare the child's results with other children of the same age D. monitors the child's vision by using a bright flashlight Answer: A Rationale: The Glasgow coma scale is used to monitor a child's neurologic status after the initial neurologic exam. Motor, verbal, and papillary responses are monitored. The use of a standard scale for monitoring permits the comparison of results from one time to another and from one examiner to another. Use the tool every 1 or 2 hours to observe for significant changes. This scale is not used to compare children's results nor is it used to monitor vision.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 607 22. A new client arrives for a first visit to the pediatric clinic. The nurse will prioritize which step in this appointment?

A. recording the health history B. interviewing the caregiver C. obtaining biographical data D. determining the chief complaint Answer: C Rationale: The nurse begins a client history by obtaining the biographical data first.

The nurse should collect and record identifying information about the child, including the child's name, address, and phone number, as well as information about the caregiver. This information will assist the nurse in ensuring the right information is documented with the right client. The other information will then be collected. All this information will be obtained by interviewing the caregiver, as well as possibly using a questionnaire.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 594

23. The nurse is collecting data on a 3-year-old child whose caregiver is present.

Which action should the nurse take?

A. Instruct the caregiver to fill out the paperwork outside the room while the nurse is measuring the child's height and weight.

B. Escort the child to another room to take the child's vital signs.

C. Perform a head-to-toe assessment starting with the eyes, ears, and nose.

D. Show the caregiver the process for collecting a urine specimen and ask the caregiver to help the child.

Answer: D Rationale: If comfortable with helping, the caregiver may help with the data collection. For example, the caregiver might help take a young child's temperature and obtain a urine specimen. Arrangements should be made so that the caregiver also may be present, if possible, for tests or examinations that need to be performed. Often the examination for a child does not proceed in a head-to-toe manner as in adults but rather in an order that takes the child's age and developmental needs into consideration. Examining the nose and mouth may be uncomfortable and traumatic for the child; the nurse should save these for last. The paperwork should be completed before the physical assessment begins. It will be less traumatic for the child if as many aspects of the assessment can be done in one location.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 598 24. The nurse is assisting with the physical examination on a sleeping10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment?

A. head and neck; eyes, ears, nose, mouth; then the back and extremities B. back and extremities; eyes, ears, nose, mouth; then the head and neck C. back and extremities; head and neck; then the ears, nose, mouth, and eyes D. eyes, ears, nose, mouth; back and extremities; then the head and neck Answer: C Rationale: Data are collected by examination of the body systems. Often the exam for an infant is not done in a head-to-toe manner, as is done with adults, but rather in an order that takes the infant's age and developmental needs into consideration.

Because the infant is asleep and held against the parent's shoulder, the nurse would begin by assessing the infant's back and extremities. The infant's eyes would be inspected last to allow the infant to be most comfortable until the end of the assessment. Aspects of the examination that might be more traumatic or uncomfortable for the infant are completed last.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 598 25. A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care clinic by the caregiver. The nurse determines the child's axillary temperature is within the normal range based on which finding?

A. 99.3°F (37.4°C) B. 96.6°F (35.8°C) C. 100.3°F (38.4°C) D. 99.8°F (37.9°C) Answer: B Rationale: Axillary temperatures are taken on newborns, on infants and children with diarrhea, and in other cases when a rectal temperature is contraindicated. An axillary temperature usually measures 0.5 to 1.0 degrees lower than the oral measurement. A normal oral temperature range is 97.6°F to 99.3°F (36.4°C to 37.4°C). A rectal temperature is usually 0.5° to 1° higher than the oral measurement.

Question format: Multiple Choice Chapter 28: Assessment of the Child (Data Collection) Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 601

Chapter 29 1. The nurse is doing the preoperative preparation for a 6-year-old who is having surgery. What is most important for the nurse to document in the child's preop chart?

A. the name and phone number of the individuals who will be in the waiting room during the surgical procedure B. the number of loose teeth the child has and which teeth are missing C. the number of times the child has voided in the past 8 hours and if the child has had a stool D. the type and amount of pain medication the child has been given in the past 24 hours Answer: B Rationale: Loose teeth are also a potential hazard for the child having a surgical procedure done and should be counted and recorded according to hospital policy.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 622 2. The nurse administering the preoperative medications to the child going to surgery would anticipate which of the following related to giving preoperative medications?

A. A sedative and an analgesic-atropine mixture to be sent to the operating room with the child.

B. A sedative to be given one-and-a-half to two hours before surgery and an analgesic-atropine mixture given just before the child leaves for the operating room.

C. A sedative and an analgesic-atropine mixture to be given just before the child goes to sleep the night before the surgery.

D. A sedative to be given three to four hours before surgery and an analgesicatropine mixture given one to two hours before the child leaves for the operating room.

Answer: B Rationale: Preoperative medications usually are given in two stages: a sedative is administered about one-and-a-half to two hours before surgery, and an analgesicatropine mixture may be administered immediately before the client leaves for the operating room.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child

Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 622 3. What actions can a pediatric hospital staff take to lessen the stress of hospitalization for a child? Select all that apply.

A. Have the parents stay with the client at all times.

B. Allow children to wear their own clothing.

C. Perform any treatments in the procedure room.

D. Select foods for the child that they normally like.

E. Involve Child Life in teaching about upcoming surgeries.

Answer: B, C, E Rationale: By allowing a child to have some control over their lives while hospitalized, their transition to the hospital is smoother and less traumatic. Wearing their own clothing makes the hospital feel more like home. Performing procedures in another room outside the child's hospital room maintains the feeling of safety in their own room. Child Life is an integral part of educating children about upcoming surgeries and procedures and is designed to lessen the stress the children are experiencing.

Question format: Multiple Select Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 619 4. The nurse is reviewing a client's chart and notes that the child is in droplet precautions for pneumonia. What protection would she need to take in caring for the child?

A. gown, handwashing and gloves B. handwashing and gloves C. gown, gloves, and mask D. mask and handwashing Answer: C Rationale: For droplet precautions, the nurse needs to wear a mask, gown, and gloves for client care since the transmission is airborne and is spread through contact with secretions from the mouth, nose, and lungs when a client sneezes or coughs.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process

Reference: p. 616 5. The nurse has been assigned to care for a child who is on transmission-based precautions. This nurse has not cared for this child before. Which action would be the best way to help the child feel comfortable with the nurse?

A. Ask the parent to introduce the new nurse.

B. Let the child see the nurse's face before the mask is put on.

C. Read to the child for a few minutes before starting care.

D. Remind the child that her caregivers will be in to visit soon.

Answer: B Rationale: If masks or gloves are part of the necessary precautions, the child may experience even greater feelings of isolation. Before putting on the mask, the nurse should allow the child to see his or her face; this process will help the child easily identify the nurse. Being introduced by the parents may be effective but is not likely to be possible. Reading to the child, or explaining that the caregiver will visit soon, are appropriate actions but are not the best ways to help the child feel less isolated and more comfortable with the nurse in the isolation setting.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 617 6. A 5-year-old boy is brought to the emergency room with a possible broken arm.

His 18-year-old sister, who is also his primary caregiver, has come with him. The boy is relatively calm, but his sister is so upset she is nearly hysterical. The nurse notes that as her behaviors show more anxiety, the boy is getting more upset and his anxiety is also increasing. What initial action would be best for the nurse to take in this situation?

A. While attending to the child, reassure the sister and suggest interventions she can help with.

B. Ask his sister to calm down so that she can help her brother remain calm as well.

C. Reassure the child that he is going to be fine and that his sister is just nervous.

D. Ask the sister if she prefers to leave the exam room.

Answer: A Rationale: In an emergency, physical needs assume priority over emotional needs.

The emergency itself is frightening to the child and the family and the need for treatment is urgent. Even though a caregiver tries to act calm and composed, the child often may sense the anxiety. If the hospital is still a great unknown, it will only add to the child's fear and panic. It is best if the caregiver can be present to reassure the child.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child

Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 619-620 7. The nurse is providing care for a 4-year-old being treated in the emergency department. Which intervention demonstrates a nurse's understanding of the basic principle of emergency care when addressing the child's need for a sense of security?

A. The parents are asked to keep the child distracted until the admission process is conducted.

B. The nurse conducts the assessment while gently reassuring both the child and the parents.

C. The nurse keeps the parents informed so they may remain calm and composed, thus minimizing the child's anxiety.

D. The child is sedated so that his or her anxiety level can be managed effectively.

Answer: B Rationale: In an emergency, physical needs assume priority over emotional needs.

By addressing the child's need for an assessment while attempting to acknowledge the existing emotional needs, the nurse is providing quality care. Sedation would be used only as a last resort. The other options can affect the child's sense of security, but the factor most affecting feelings of security is that emotional needs cannot be adequately responded to in an emergency situation.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 619-620 8. The nurse is caring for a 14-year-old child who is scheduled to have surgery the next day. What would be the most appropriate intervention for the nurse to implement to help prepare this child for surgery?

A. Allow the child to use the equipment that will be seen in the operating room, such as masks, gowns, and gloves.

B. Explain to the caregivers while they are in the room with the child the reason the child will be kept NPO. C. Show the child models of the body that include the organs or parts of the body the child will be having surgery on.

D. Give the child a book to read which describes the people who are involved in the preoperative, surgical, and postoperative areas.

Answer: C Rationale: The older child or adolescent may have a greater interest in the surgery itself, what is wrong and why, how the repair is done, and the expected

postoperative results. Models of a child's internal organs or individual organs, such as a heart, are useful for demonstration, or the client may be involved in making a drawing showing the process.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 621-622 9. The nurse at a pediatric clinic is preparing a 5-year-old child for admission to the hospital for surgery. Which response should the nurse prioritize when asked by the child what happens at the hospital?

A. "Remember? It's where your mom went to get your baby brother."

B. "People go there when they have a bad accident and get fixed."

C. "Some people go here to have babies, or when they're sick or hurt, so they can try to get better."

D. "It's like a big doctor's office with lots of people and beds."

Answer: C Rationale: Young children need to know that the hospital is more than a place where "mommies go to get babies." It is also important to both avoid fostering the view of the hospital as a place where people go to die and to avoid the impression that everyone who comes in will definitely get well. Comparing the hospital to a doctor's office minimizes the seriousness and breadth of services of the hospital.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 613-614 10. The grandmother of a 1-year-old with cancer comes to visit the child in the PICU. She sits close to the bed but doesn't touch the child. Which action by the nurse would be most appropriate?

A. Respect their privacy and leave the room.

B. Pick up the child so that the grandmother sees he can be touched.

C. Ask the grandmother if she would like to talk to the child.

D. Encourage the grandmother to rock the child in a rocking chair.

Answer: D Rationale: The nurse should promote the relationship between the family caregiver and the child as much as possible. The caregiver should be encouraged to touch and talk to the child. If possible, the caregiver may hold and rock the child; if not, he or she can comfort the child by caressing and stroking. The nurse can often be a support to the family by staying in the room rather than leaving them alone.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 614-615 11. A 3-year-old client has been hospitalized for 1 week with her mother roomingin; however, the mother has gone home to tend to other family responsibilities for a few days. After being inconsolable for the first 24 hours after the mother's departure, the nurse notes the child is now lying quietly in bed sucking her thumb.

Which response should the nurse prioritize in this situation?

A. "Are you feeling sad? Your mom didn't want to leave, but she will be back after two more breakfasts."

B. "I'm glad you're feeling better. You must be tired from all that crying."

C. "Do you miss your mom? Your sister missed her, too, so she had to go home to visit for a few days."

D. "Should I read a story to you or would you like to play a game?"

Answer: A Rationale: Three characteristic, consecutive stages of response to separation have been identified: protest, despair, and denial. During the protest stage, the young child cries, often refuses to be comforted by others, and constantly seeks the primary caregiver. When the caregiver does not appear, the child enters the despair stage and becomes apathetic and listless. Health care personnel often interpret this as a sign that the child is accepting the situation, but this is not the case; rather, the child has given up. She needs a chance to talk about her feelings, and facts should be framed in a way she can understand. Young children have no concept of time, so separation from their primary caregivers is especially difficult for them to understand.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 618 12. The mother of a 4-year-old returns to the hospital after being away for 3 days.

She is anxious and excited to be back; however, the toddler turns his back to her and scoots away as she attempts to pick him up. Which response should the nurse prioritize in this situation?

A. "He is probably just tired from the many tests run while you were away."

B. "His distrust is abnormal. It may or may not go away in a day or two; we will just have to wait and see."

C. "His distrust is normal and may have lingering effects, but you should touch and soothe him as much as possible."

D. "Now that he has seen that you have returned he will feel better, but you should leave the room for a few minutes to help him feel in control."

Answer: C Rationale: Three characteristic, consecutive stages of response to separation have been identified: protest, despair, and denial. In the denial stage, the child begins taking interest in his or her surroundings and appears to accept the situation.

However, the damage is revealed when the caregivers do visit: the child may turn away from them, showing distrust and rejection. It may take a long time before the child accepts them again; even then remnants of the damage may linger. The child may always have a memory of being abandoned at the hospital.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 618 13. In a preadmission visit, a 9-year-old girl says she is afraid her tonsillectomy will hurt too much. Which statement by the nurse would be best to help the child feel more comfortable and less afraid?

A. "I'm sure you are worried about the pain, but lots of people have tonsillectomies and they're fine after a few days."

B. "There's nothing to worry about. You will forget about the pain because you can have all the ice cream and pudding you want."

C. "It won't hurt too much, so there is nothing to worry about. Besides, you need to be brave for the younger ones."

D. "I understand that you're worried. It will hurt for only a few days; we'll give you something to help stop the pain when you need it."

Answer: D Rationale: In a successful preadmission visit, children's feelings are explored and validated. The children are told that some things will hurt but that doctors and nurses will do everything they can to make the pain go away. Honesty must be central to any discussion of this kind. The other responses do not take seriously the child's concerns and fears.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 619 14. A few days after discharge, the parent of an 8-year-old calls the pediatric clinic, expressing concern about the child's behavior now that she is home. The child has been treating her siblings badly and using inappropriate language. Which

suggestion should the nurse prioritize to this caregiver as an appropriate way to handle this situation?

A. "Coming home is a difficult adjustment. Warn your daughter that you expect her to begin to behave better over the next few weeks."

B. "Respond to her behavior in a firm, loving, consistent way."

C. "Children often feel guilty for the attention they've taken away from their siblings and act out as a way of earning the attention."

D. "Tell her you don't like her behavior and have her stay in her room until she can be nicer to her siblings."

Answer: B Rationale: The return home may be a difficult period of adjustment for the entire family. The older child may demonstrate anger or jealousy of siblings. The family may be advised to encourage positive behavior and to avoid making the child the center of attention because of the illness. Discipline should be firm, loving, and consistent. The child may express feelings verbally or in play activities. The family may be reassured that this is not unusual.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 620 15. The nurse is caring for an adolescent just transferred from PACU to the inpatient unit. As the nurse helps the child settle into the unit, which nursing intervention should the nurse prioritize?

A. Turn the child every 2 hours.

B. Create an IV flow sheet.

C. Administer ice chips.

D. Monitor for any change in vital signs.

Answer: D Rationale: After the child has been returned to his or her room, nursing care focuses on careful observation of the vital signs for any signs or symptoms of complications: shock, hemorrhage, or respiratory distress. An IV flow sheet is begun that documents the type of fluid administered, the amount of fluid to be absorbed, the rate of flow, any additive medications, the site, and the site's appearance and condition. The physician should be notified if anuria (absence of urine) persists longer than 6 hours. Postoperative orders may or may not provide for ice chips or clear liquids to prevent dehydration; these may be administered with a spoon or in a small medicine cup. Frequent repositioning is necessary to prevent skin breakdown, orthostatic pneumonia, and decreased circulation.

Coughing, deep breathing, and position changes are performed at least every 2 hours.

Question format: Multiple Choice

Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 621 16. A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?

A. Tell him to let you know if he begins to feel pain.

B. Explain to his caregiver that his pain level shows he is getting better quickly.

C. Observe him for physical signs which might indicate pain.

D. Ask him to show you his pain level using the color pain scale.

Answer: C Rationale: Nursing judgment is in order. Some children may try to hide pain because they fear an injection or because they are afraid that admitting to pain will increase the time they have to stay in the hospital. To use the color scale, a child younger than 7 is given crayons ranging from yellow to red or black. Yellow represents no pain; the darkest color (or red) represents the most pain. The child selects the color that represents the amount of pain he or she feels. The most appropriate pain scale to use with this child would be the 1 to 10 (with 10 being the worst pain) or the faces scale.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 623 17. The nurse is meeting with a group of families to assist them in dealing with the hospitalization of their child. Which comment by a family member should alert the nurse to assist the family in coping with the situation?

A. "We have really good insurance—it covered everything the last time she was in the hospital."

B. "When my sister was in the hospital before, the nurse let me get up on her bed while she read me a story."

C. "Sometimes I wonder if the reason she is sick is because I have so many responsibilities at work and at home."

D. "My husband was so relieved when he heard that after the next surgery our son will probably not need to have any more, and will be fine."

Answer: C Rationale: The child's family suffers stress for a number of reasons. In this situation, the caregiver felt guilt about the illness. The cause of the illness, its

treatment, guilt about the illness, past experiences of illness and hospitalization, disruption in family life, the threat to the child's long-term health, cultural or religious influences, coping methods within the family, and financial impact of the hospitalization all may affect how the family responds to the child's illness.

Although some of these are concerns of the family and not specifically the child, they nevertheless influence how the child feels.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 613 18. A team of nurses has been chosen to devise a program to help educate children and their families about the hospital and being hospitalized. Which activity should the nurses plan to best achieve this goal?

A. Ask the school nurse to do a presentation to groups of schoolchildren about what it is like to be in the hospital.

B. Offer guided tours to an organized group such as Boy Scouts or Girl Scouts.

C. Plan an open house and invite the families of the community to come tour the hospital.

D. Work with the local library to provide resources (books, pamphlets, or DVDs) explaining the admission process and hospitalization, which the families can check out and view together.

Answer: C Rationale: The first choice should be working with the family and caregivers with the open house. The family and caregivers have the most important role in educating children about hospitals and hospitalization. The child trusts and feels safer most often with the caregiver. During a tour of the hospital, a room is set aside where children can handle equipment, try out call bells, try on masks and gowns, have their blood pressure taken to feel the squeeze of the blood pressure cuff, and see a hospital pediatric bed and compare it with their bed at home. The caregivers can reinforce what the child has seen in the home setting. Not all children are involved in an organized group such as Boy Scouts or Girl Scouts. The library could be a potential source; however, with many homes now having internet access, the same materials may be viewed online. This can reinforce what the child saw at the open house.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 613-614 19. The pediatric unit in the hospital is designed to make the child feel comfortable and secure. Which action will best accomplish this goal?

A. The hallways are painted with bright colors and characters familiar to children.

B. Procedures and treatments are done in a room other than the child's hospital room.

C. Staff members wear clothes that are a variety of colors, designs and patterns.

D. A playroom stocked with toys and activities for a variety of ages is readily available.

Answer: B Rationale: Treatments are performed in a treatment room, not in the child's room.

Using a separate room to perform procedures promotes the concept that the child's bed is a safe place. All treatments, with no exceptions, should be performed in the treatment room to reassure the child. The other options may make the pediatric unit appear more pleasing to the child, but performing treatments in an area separate from the bed will be the priority.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 614 20. The nurse working in the pediatric unit of the hospital is always monitoring for safety issues on the unit. The nurse determines the greatest concern related to safety of the hospitalized child is related to which situation?

A. The child is out of the home environment he or she is used to, without safety locks on doors and cabinets and things being placed in safe storage.

B. The caregivers are in a high-stress situation and are unable to concentrate and pay attention to what the child is doing at all times.

C. Taking a child in and out of bed, doing frequent checks and procedures, and caregivers sitting at the side of the bed all bring on an opportunity for the side rails to be left down.

D. A variety of nursing staff and other hospital staff are in and out of the child's room during hospitalization, and close observation of the child by the staff is difficult.

Answer: C Rationale: Hospital staff must encourage family members to keep crib sides/bed rails up when not directly caring for an infant or child. One unguarded moment may mean that the infant falls out of a crib or the child slides off the bed. Depending on the age of the child, the use of safety locks and safe storage would also be important at home. Although keeping track of the child at every waking moment can be challenging, it would eliminate the need to maintain a safe environment. The variety of nursing staff in and out of the room would enable closer observation due to the many interactions; however, the priority here is to ensure the side rails are up so the child cannot fall out of bed.

Question format: Multiple Choice

Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 615 21. The nursing instructor is discussing the various modes of transmission for pathogens. The instructor determines the session is successful when the students correctly point out that microorganisms transmitted by food, water, or blood are spread via which mechanism?

A. contact B. vehicle C. airborne D. vector Answer: B Rationale: Microorganisms are spread by contact (direct, indirect, or droplet), vehicle (food, water, blood, or contaminated products), air (dust particles in the air), or vector (mosquitoes, vermin) means of transmission. Each type of microorganism is transmitted in a specific way, so precautions are tailored to prevent the spread of specific microorganisms.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 615 22. The nurse is preparing a presentation depicting the various ways pathogens are spread around. The nurse will illustrate that pathogens passed around via insects is referred to as which mechanism?

A. contact B. vehicle C. airborne D. vector Answer: D Rationale: Microorganisms are spread by contact (direct, indirect, or droplet), vehicle (food, water, blood, or contaminated products), air (dust particles in the air), or vector (mosquitoes, vermin) means of transmission. Each type of microorganism is transmitted in a specific way, so precautions are tailored to prevent the spread of specific microorganisms.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control

Integrated Process: Teaching/Learning Reference: p. 615 23. The nurse must follow certain precautions in order to protect everyone from the spread of disease. Which action will the nurse prioritize when utilizing transmission-based precautions?

A. Precautions are followed if a client has a disease that can be easily spread.

B. Precautions apply when coming in contact with blood.

C. Precautions are followed if a child is immunosuppressed to protect them from other children.

D. Precautions apply to contact with stool and urine.

Answer: A Rationale: In children who are documented or suspected of having highly transmissible pathogens, health care providers must follow transmission-based precautions. Standard precautions blend the primary characteristics of universal precautions and body substance isolation. Standard precautions apply to blood; all body fluids, secretions, and excretions (except sweat); nonintact skin; and mucous membranes. Standard precautions are intended to reduce the risk of transmission of microorganisms from recognized or unrecognized sources of infection in hospitals.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 615 24. The nurse is preparing discharge teaching for a child and the caregivers after a week of hospitalization. Which activity should the nurse prioritize in this plan?

A. Begin the teaching sessions just prior to the child leaving the facility.

B. Provide written instructions which can be taken home to read and follow.

C. Ensure the caregiver has assistance to handle the complex treatments at home.

D. Plan to review information and procedures with the family caregivers before discharge.

Answer: D Rationale: Shortly before the child is discharged from the hospital, it is important to review information and procedures with the family caregivers. The nurse should not wait until the client is almost out the door before starting discharge training.

Depending on the training, it can begin shortly after admission. Not all families will need home health care to assist with transitioning from the hospital to the home setting. Written instructions may not always be appropriate if the family cannot read the literature or if it is not in their native language. The best option is to spend time with the family, demonstrating what needs to be done and observing them performing the various treatments.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 620 25. The nurse is caring for a child who is recovering from a surgical procedure. The nurse will contact the primary care provider if anuria is noted within which time frame?

A. within the first 30 minutes after surgery B. within the first hour after leaving PACU C. within the first 2 hours following surgery D. within the first 6 hours following surgery Answer: D Rationale: The first voiding is an important milestone in postoperative progress because it indicates the adequacy of blood flow and urinary output. The nurse should notify the primary care provider if a child is still experiencing anuria within the first 6 hours after surgery.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 623 26. The nurse is preparing a child for surgery and is demonstrating and evaluating the child for using a patient-controlled analgesia device after surgery. The nurse would determine which client would be most appropriate to use this device?

A. a 3-year-old who has a caregiver at the bedside at all times B. a 6-year-old who is able to use the call light to call the nurse when needed C. a 7-year-old who has told the nurse about using the control button D. a 10-year-old with a history of behavior issues who has been compliant with care Answer: C Rationale: Patient-controlled analgesia may be used for children 7 years of age or older who have no cognitive impairment and undergo a careful evaluation. The child with a history of behavior issues may not be appropriate to use the PCA; however, further evaluation would be needed to determine this.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 623

27. The nurse is working with a child-life specialist to assist a young preadolescent who is preparing for treatment for cancer. Which technique will the nurse and specialist prioritize to assist this child in better understanding what will be happening in the treatment of the cancer?

A. play therapy B. therapeutic play C. onlooker play D. cooperative play Answer: B Rationale: Therapeutic play is a play technique used to help the child better understand what will be happening to him or her in a specific situation. For instance, the child who will be having an IV started before surgery might be given the materials and encouraged to "start" an IV on a stuffed animal or doll. By observing the child, you can often note concerns, fears, and anxieties the child might express. Therapeutic play helps the child express feelings, fears, and concerns. The other types of play will not accomplish this goal.

Question format: Multiple Choice Chapter 29: Care of the Hospitalized Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 625-626

Chapter 30 1. The nurse is caring for a 5-year-old hospitalized child who needs to have blood drawn for the third time. When the lab technician arrives, the child says to the nurse, "You can't take my blood, my mama isn't here." The child's caregiver is not in the hospital and is not expected to return for several hours. Which action taken by the nurse would best meet the needs of the child while supporting medical treatment?

A. Check with the floor administrator to see if the blood draw can wait until the caregiver returns.

B. Recognize the statement is a stalling technique, reassure the child, and continue with the procedure.

C. Tell the child that if he will let the phlebotomist take his blood without putting up a fuss, he will get a lollipop.

D. Remind him that he has said that before and that he knows that the blood must be taken.

Answer: B Rationale: During any painful procedure, children must be allowed to cry if necessary, should always be listened to, and have their questions answered. It takes maturity and experience on the nurse's part to know exactly which questions are stalling techniques and which call for firmness and action. Children need someone to take charge in a kind, firm manner that tells them the decision is not in their hands. They are too young to take this responsibility upon themselves.

Because the pain caused by the procedure has nothing to do with the child's behavior, if a reward is given, it should not be a reward for being brave or good or mature; it is simply a part of the entire treatment. The reward will mitigate the unpleasant part of the experience.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 632 2. Tess is a 5-year-old client who must receive an IV infusion of antibiotics. She is anxious, resistant, and wiggly. To keep her safe during the time the IV is in place, the nurse would choose which method to restrain her?

A. Restrain her with a mummy restraint and loosen and rewrap it every 3 hours.

B. Restrain her on a papoose board and release her as soon as the IV is in place.

C. Use a clove-hitch restraint to keep her arm still and loosen it every 2 hours.

D. Allow her caregiver to hold her during the time the IV is in place.

Answer: C

Rationale: Restraints often are needed to protect a child from injury during a procedure or an examination, or to ensure the infant's or child's safety and comfort.

Clove-hitch restraints are used to secure an arm or leg, most often when a child is receiving an IV infusion. The site should be checked and loosened at least every 2 hours. A mummy restraint can be used for an infant or small child during a procedure. This device is a snug wrap that is effective when performing a scalp venipuncture, inserting a nasogastric tube, or performing other procedures that involve only the head or neck. Papoose boards are used with toddlers or preschoolers but are not as appropriate as a clove-hitch restraint for this procedure.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 633 3. The nurse is teaching a couple who are first-time parents. They are being discharged with their newborn. The mother tells the nurse she has heard about sudden infant death syndrome and is worried about that happening to her baby. In teaching about the prevention of SIDS, the nurse teaches the new parents to: A. let the newborn sleep on his stomach in their bed.

B. prop the baby on his side or put him to sleep on his back.

C. lay him on his stomach with a small pillow under his abdomen.

D. prop him up with a pillow so his head is at a slightly elevated angle.

Answer: B Rationale: Infants should be positioned on their backs or supported on their sides for sleeping. The nurse working with family caregivers teaches and reinforces this information. These positions seem to have decreased the incidence of sudden infant death syndrome (formerly called "crib death"). Railings or sides will help prevent falls.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 635 4. The nurse is teaching a group of first-time parents who are being discharged with their newborns. One parent asks the nurse what to do if the child has a temperature. After conducting teaching regarding how to care for a child with an elevated temperature, the caregivers make the following statements. Which statement would indicate a need for further teaching?

A. "A rectal temperature above 102.5 ℉ (39.1 ℉) should be lowered."

B. "Giving extra fluids is the way I have always heard to lower a temperature."

C. "I don't plan to give my child medications, but the pediatrician might tell us to give our child acetaminophen every 4 to 6 hours if she has a fever."

D. "If my child starts to shiver I will know that what I am doing is working and that her fever will soon come down."

Answer: D Rationale: "Normal" body temperature varies from 97.6 ℉ (36.4 ℃) orally to 100.3 ℉ (37.9 ℃) rectally. The body temperature generally should be maintained below 101℉ (38.3 ℃) orally or 102℉ (38.9 ℃) rectally, although the health care facility or practitioner may set lower limits. Methods used to reduce fever include maintaining hydration by encouraging fluids and administering acetaminophen. Excess coverings should be removed from the child with a fever to permit additional cooling through evaporation. Changing to lightweight clothes, removing clothes, lowering the room temperature, or applying cool compresses to the forehead may help to lower the temperature. If a child begins to shiver, whatever is being done to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase again. Because of their ineffectiveness in reducing fever and the discomfort they cause, tepid sponge baths are no longer recommended for reducing fever.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 636 5. The nurse is assigned to care for a child diagnosed with a chronic illness. The child has just been admitted but has been on the unit many times before. From the report the admitting nurse gives, the child is sicker than the last time she was admitted. In planning the child's care, the nurse notes that the provider has ordered a nasogastric gavage feeding, but the nurse remembers that even the last time the child was on the unit, she was unable to tolerate the nasogastric feedings.

The most appropriate nursing action would be for the nurse to: A. begin the nasogastric gavage feeding to see if the child can tolerate it.

B. begin an orogastric gavage in hopes the child can handle the feeding.

C. ask the nursing supervisor to decide which type of feeding to give.

D. talk with the health care provider and request further instruction and orders.

Answer: D Rationale: Sometimes infants or children who have had surgery or have a chronic or serious condition are unable to take adequate food and fluid by mouth and must receive nourishment by means of nasogastric or orogastric gavage feedings.

Gavage feedings provide nourishment directly through a tube passed into the stomach. This procedure is particularly appropriate in infants but also may be used in the older child. If gavage feedings are not well tolerated, the nurse should report it and await alternate orders from the provider.

Question format: Multiple Choice Chapter 30: Procedures and Treatments

Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 636-637 6. The nurse is conducting teaching with the caregivers of a child who is being discharged from the pediatric unit. The care provider has recommended the child have moist heat applications at home. In conducting teaching with this caregiver, the nurse will teach the caregiver to use which of the following to provide the moist heat?

A. an electric heating pad B. towels dampened and heated in the microwave C. a hot water bottle D. towels dampened with hot water Answer: D Rationale: Towels can be used to provide moist heat. They should not be warmed in the microwave because the microwave may unevenly heat the towels, which in turn may burn the child. Dry heat may be applied by means of an electric heating pad, a K-pad (a unit that circulates warm water through plastic-enclosed tubing), or a hotwater bottle. Many children, however, have been burned because of the improper use of hot-water bottles; therefore, these devices are not recommended.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 641 7. The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care?

A. Clean the outside of the collection device.

B. Check for leakage around the stoma.

C. Leave the ileostomy open to the air.

D. Apply a sterile dressing around the stoma.

Answer: B Rationale: An ileostomy is made by bringing a part of the small intestine through the abdominal wall to create an outlet for fecal material. The drainage from the ileostomy contains digestive enzymes, so the stoma must be fitted with a collection device to prevent skin irritation and breakdown. A colostomy is a similar opening in the colon that allows fecal material to be eliminated. A new colostomy may be left open to the air; alternatively a bag, pouch, or other appliance may be used to collect the stool. A urostomy may be created to help in the elimination of urine.

Ostomy bags should be checked for leakage, emptied frequently, and changed when needed.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 642 8. A urine specimen has been ordered for a 1-year-old girl. Which method would be the best way for the nurse to obtain this urine specimen?

A. Clean the child's genital area thoroughly and when she has urinated, squeeze the urine from her diaper into a specimen cup.

B. Give the child some water or juice, leave off her diaper, ask the caregiver to call you when the child needs to void, and obtain the specimen in a sterile container.

C. Place a sterile cotton ball into the child's diaper; after the child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab.

D. Get down on the child's level and speak to her explaining that you need her to tell you when she needs to use the bathroom and when she does, obtain the specimen.

Answer: C Rationale: If a urine specimen is needed for diagnostic purposes, a cotton ball can be placed in the diaper of an infant; the urine squeezed from the cotton ball can be collected and used for many urine tests. Because toddlers and young children cannot usually void on command, they should be offered fluids 15 to 20 minutes before the urine specimen is needed. In preparation for collecting a urine specimen, the infant or child is positioned so that the genitalia are exposed and the area can be cleansed. In the female patient, the labia majora are cleansed front to back using one cotton pad for each wipe. The labia minora are then exposed and cleansed in the same fashion. The area is rinsed with a cotton ball saturated with sterile water.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 642 9. The nurse is helping assist the care provider in doing a lumbar puncture on a 9month-old infant. Which method will be the safest and most appropriate method of restraining the child?

A. Hold the child snugly against the chest, pass one arm below the child's legs; with the other arm, hold the child's hands.

B. Wrap the child in a mummy restraint, then place your hands over the infant's hands tightly on top of the restraint.

C. Show the caregiver how to hold the child in a seated position securely on the caregiver's lap.

D. Use a jacket restraint to keep the child snugly held to a bed or gurney.

Answer: A Rationale: When analysis of cerebrospinal fluid is necessary, a lumbar puncture is performed. During this procedure, the nurse must restrain the client until the procedure is completed. Grasp the child's hands with the hand that you have passed under the child's lower extremities and hold the child snugly against your chest. This position enlarges the intervertebral spaces for easier access with the aspiration needle. A mummy board can be used for procedures that involve only the head and neck. Safety belts are used if a child is being transported from one place to another.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 644 10. The nurse is helping the care provider with a scalp venipuncture on an infant.

Which of the following restraints would be most appropriate for this procedure?

A. mummy restraint B. clove-hitch restraint C. elbow restraint D. jacket restraint Answer: A Rationale: Mummy restraints are snug wraps used to restrain an infant or small child during a procedure. This device is effective when performing a scalp venipuncture, inserting a nasogastric tube, or performing other procedures that involve only the head or neck.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 633 11. The nurse is caring for a preschool-aged child who is used to being able to get out of bed at any time. Which of the following restraints would be the most appropriate for the nurse to ensure the child remains in the bed?

A. mummy restraint B. clove-hitch restraint C. elbow restraint D. jacket restraint Answer: D

Rationale: Jacket restraints are used to secure the child from climbing out of bed or a chair or to keep the child in a horizontal position.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 634 12. The nurse is caring for a child with an elevated temperature. Which of the following nursing interventions would be the highest priority in caring for this child?

A. The nurse should dress the child in lightweight clothing.

B. The nurse should monitor the child for seizure activity.

C. The nurse should encourage oral fluids at frequent intervals.

D. The nurse should keep the temperature of the child's room cool.

Answer: B Rationale: The highest priority is to monitor the child for any seizure activity. The other interventions are appropriate but not as high a priority as monitoring for seizures.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 635 13. The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority?

A. The nurse positions the child in a sitting position.

B. The nurse verifies the position of the feeding tube.

C. The nurse replaces stomach content that has been aspirated.

D. The nurse documents how the child tolerated the feeding.

Answer: B Rationale: Verifying the position of the tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority. This is a top priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 637

14. After the provider has written a prescription for the use of heat therapy, the nurse will apply heat using a K-pad or heating pad as ordered. Which of the following is most accurate regarding the use of heat therapy?

A. Heat is a vasoconstrictor and decreases circulation.

B. Heat may be used to prevent swelling.

C. Heat should be used 1 hour at a time and then removed.

D. Heat causes muscle relaxation and decreases pain.

Answer: D Rationale: The local application of heat increases circulation by vasodilatation and promotes muscle relaxation, thereby relieving pain and congestion.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 641 15. As part of the admitting process for a child on the pediatric unit, the nurse instills a small amount of saline into the nose, aspirates, and then places the solution into a sterile specimen container. What is the most likely reason this will be done?

A. to diagnose an infection B. to clear the nasal passages C. to remove a foreign body D. to detect the presence of old blood Answer: A Rationale: Specimens from the nose and throat are used to help diagnose infection.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 642 16. A toddler is being discharged home with oxygen by nasal cannula. In educating the parents about oxygen safety, which statement by the father indicates that further teaching is needed?

A. "We will keep all flammable materials out of his room."

B. "They showed us how to wash the equipment to keep down bacteria."

C. "I will use only cotton blankets in his bed for sleeping."

D. "We will let him play with his Leap Frog tablet to keep him entertained."

Answer: D

Rationale: When a client is on oxygen, all electric or battery-powered toys need to be removed from the bed to avoid the possibility of sparking and a fire.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 640 17. Under which conditions would the nurse be justified in restraining a child in the hospital? Select all that apply.

A. The child is a toddler and continues to attempt to crawl out of the crib.

B. The mother has to go home for a short time and there is no one to sit in the room with the child.

C. The parents request that their child be restrained.

D. The child had a new gastrostomy tube placed today.

E. The preschool-aged client needs to have an IV started.

Answer: A, D Rationale: The nurse only uses restraints when it is necessary for safety reasons, and when no other option is available. Restraints must be ordered by the physician and are not applied per parent request. If a young client is attempting to climb over the top of the crib railings, a jacket restraint or a crib top restraint are needed to keep the child from falling out. Also, with new gastrostomy tube insertions, the nurse needs to prevent the child from pulling it out, so restraints are necessary.

The nurse cannot use restraints in place of a caregiver for procedures.

Question format: Multiple Select Chapter 30: Procedures and Treatments Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 633 18. A young client has a temperature of 102 ℃ (38.9 ℃). In addition to the scheduled antipyretic the child received, the nurse is treating the fever with nonpharmacologic methods by removing the blanket that covers the child. What is the rationale for this action?

A. The blanket adds heat to the child.

B. Removing excess coverings allows for evaporation, which aids in cooling the child.

C. The blanket soaks up the sweat, making the child warmer.

D. Covering the child with a blanket leads to shivering, which will only generate more heat.

Answer: B

Rationale: Removing covering from a child when he or she is febrile aids in additional cooling by allowing evaporative heat loss. The rationale is not that the blanket warms the child further, or that it will soak up sweat. Nor will covering the child lead to shivering. Shivering occurs when the child is chilled by some intervention; shivering serves as a sign that the cooling procedure needs to be stopped.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 635-636 19. A child on oxygen reports a "sore nose" and the nurse assesses that the child is experiencing dry nasal passages. What action can the nurse take to help relieve the child's discomfort?

A. Turn the oxygen flow rate down to reduce the amount of air passing through the child's nose.

B. Apply a petroleum-based lubricant such as Vaseline on and around the nose to ease the discomfort.

C. Place lotion on a cotton swab and gently place some inside each nostril to moisturize the nasal passages.

D. Use a water-based gel or spray for lubrication of the dry nasal passages.

Answer: D Rationale: Any time a client is on oxygen, he or she needs to be instructed to use a non-petroleum or water-based product for dry nasal passages. Petroleum products greatly increase the risk of catching fire since they are so flammable. The nurse cannot reduce the amount of needed oxygen for the client by turning down the flow rate nor should the nurse insert lotion into the nasal passages.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 639 20. A 5-year-old client is scheduled to have an influenza injection before being discharged from the hospital. When the nurse explains what she has to do, the client begins to cry and asks the nurse if she can have the shot after her movie is over in 2 hours. Which response by the nurse would be the best choice for the client?

A. Agree to postpone the injection until after the movie is done.

B. Tell the child that you need to give her the injection now.

C. Negotiate with the child to give the injection in 1 hour.

D. Offer to contact the pediatrician's office to have it given at the next visit.

Answer: B Rationale: Children often try to postpone frightening or painful procedures by stalling. The nurse needs to take responsibility for making the decisions of care and when and what needs to be done. In this case, the best response would be to tell the client that you need to give the injection now and get it over with. Postponing events that the child dreads only heightens their anxiety.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 632 21. A child is undergoing a painful procedure and is upset. Which statement by the nurse would be the best approach in dealing with the child?

A. "If you hold still and be quiet, I will give you a popsicle."

B. "You were brave and good, so you get a sucker."

C. "I know that this hurts some but you are being so strong. It is OK to cry."

D. "Please don't bite or kick me; that would be very naughty."

Answer: C Rationale: Children should be given the right to cry and be verbally praised for cooperating. Pediatric clients should not routinely be rewarded for acting appropriately during a procedure or for being brave or good, but if they are given a small reward such as a sticker or small toy afterward, the child's memory of the experience is more positive. A nurse never tells a child to be quiet during a painful procedure nor tells the child that he/she is naughty for acting out in pain.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 632 22. The charge nurse is explaining the use of a papoose restraint to a newly hired nurse in the emergency department. Which client would the charge nurse recommend using the papoose board to restrain?

A. a school-aged child having stitches on the arm B. a toddler who is having a nasogastric tube placed C. an infant who needs a suppository D. a preschool-age child needing his fractured leg set Answer: B Rationale: The papoose board is used for the restraint of toddlers and preschoolage children who need to have procedures performed on their head or neck, such

as a venipuncture, passage of a nasogastric tube, or stitches for a scalp laceration.

Older children do not need restraining in such a manner and infants receiving rectal medications are never restrained. When a child is having a fracture set, he or she is not restrained.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 633 23. An 8-month old infant has a colostomy placed following abdominal surgery for removal of a section of bowel. The stoma is 2/3 full, draining liquid stool and the bag appears inflated. What actions would the nurse take in caring for this client?

Select all that apply.

A. Remove the stoma bag and discard it every day.

B. Empty the bag and record the output.

C. Examine the skin around the stoma site for redness or irritation.

D. Look at the infant's intake to determine if any foods could be causing gas.

E. Remove the stoma bag and allow the stoma to remain open to air for 1 to 2 hours.

Answer: B, C, D Rationale: In caring for an infant with a colostomy, the nurse empties the contents of the bag on a regular basis, rinses it out, closes it again, but does not discard it each time it is emptied. The nurse also inspects the skin around the stoma for any redness or skin breakdown. Since the bag was inflated initially, the nurse should review the infant's intake to note if the infant is consuming any gas-causing foods and recommend limiting them. The bag is never left off for any length of time due to the constant stooling pattern of the infant.

Question format: Multiple Select Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 642 24. A nurse is discussing post-procedure interventions with new pediatric nurses.

Which statement addresses the most immediate safety action required?

A. "Remove all equipment related to the procedure from the child's environment."

B. "Handle all contaminated linens in accordance with the facility policies."

C. "Assess to ensure that the side rails are up and the bed is lowered to the floor."

D. "Document the procedure and the response of the child as soon as the procedure is completed."

Answer: C

Rationale: When the procedure is completed, leave the child in a safe position with side rails raised and bed lowered. For the older child, place the call light within reach. While the other options are safety related, the child's immediate safety relates to the side rails and bed position.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 632 25. The nurse demonstrates appropriate knowledge when making what statement related to gavage feedings of a child?

A. "A gastrostomy tube is a tube passed into the stomach through the nose or mouth."

B. "An enteral tube is surgically inserted through the abdominal wall into the stomach."

C. "A bolus feeding is given continuously at a slow rate of speed. " D. "For long-term gavage feedings, a gastrostomy button may be inserted."

Answer: A Rationale: Gavage feeding, also called enteral tube feeding, provides nourishment directly through a tube passed into the stomach through the nose or mouth. These feedings may be given intermittently as a bolus feeding or may be given continuously at a slower rate over a longer period of time. If feedings will be given continuously, a gastrostomy tube, surgically inserted through the abdominal wall into the stomach, may be considered. For long-term gastrostomy feedings, a gastrostomy button may be inserted. Some advantages of buttons are that they are more desirable cosmetically, are simple to care for, and cause less skin irritation.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 636 26. The nurse is presenting a post-conference seminar to a group of nursing students on the topic of nasal/oral suctioning of a child. Which statement made by a student demonstrates a need for further instruction on the procedure?

A. "The purpose of this form of suctioning is to removes secretions from the nose and mouth."

B. "Sterile normal saline drops are used to loosen the dried secretions prior to nasal suctioning."

C. "Such suturing is only done with a bulb syringe."

D. "If possible, the child should be asked to cough before suctioning."

Answer: C

Rationale: Excess secretions in the nose or mouth can obstruct the infant's or child's airway and decrease respiratory function. Coughing often clears the airway, but when the infant or child is unable to remove secretions, they are removed by suctioning. A bulb syringe can remove secretions from the nose and mouth but nasotracheal suctioning with a sterile suction catheter may be needed if secretions cannot be removed by the bulb syringe. Sterile normal saline drops may be used to loosen dried nasal secretions.

Question format: Multiple Choice Chapter 30: Procedures and Treatments Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 640

Chapter 31 1. The nurse at a camp for children with asthma is teaching these children about the medications they are taking and how to properly take them. The nurse recognizes that many medications used on a daily basis for the treatment of asthma are given by which method?

A. Directly into the vein B. Through a gastrostomy tube C. Using a nebulizer D. Sprinkled onto the food Answer: C Rationale: Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a face mask) or a metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). Emergency medications are given intravenously. Most children do not have a gastrostomy tube, and medications sprinkled on foods are given with cystic fibrosis.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 751 2. In caring for the child with asthma, the nurse recognizes that bronchodilator medications are administered to children with asthma for which reason?

A. Relief of acute symptoms B. Management of chronic pain C. To stabilize the cell membranes D. Prevention of mild symptoms Answer: A Rationale: Bronchodilators are used for quick relief of acute exacerbations of asthma symptoms. Mast cell stabilizers help to stabilize the cell membrane by preventing mast cells from releasing the chemical mediators that cause bronchospasm and mucous membrane inflammation. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma. Bronchodilators are not effective for pain.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process

Reference: p. 751 3. The nurse has administered a medication to a child. When documenting the dosage given, the nurse realizes that an incorrect dose has been administered. The nurse has taken the child's vital signs, and they are within normal range. The child does not appear to be in any distress and is acting normally. Which of the following would be the next action for the nurse to take?

A. Give the correct dosage the next time the medication is given.

B. Monitor the child for any change in vital signs or behavior.

C. Follow the facility policy regarding medication errors.

D. Notify the next nurse who cares for this child that a dosage error has been made.

Answer: C Rationale: Medication errors can occur because nurses are human and not perfect.

To admit an error is often difficult, especially if there has been carelessness concerning the rules. A person may be strongly tempted to adopt a "wait and see" attitude, which is the gravest error of all. Nurses must accept responsibility for their own actions. Serious consequences for the child may be avoided if a mistake is disclosed promptly. Facility policies regarding medication errors should be followed.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 650 4. The nurse is caring for a child who weighs 75 lb. The medication ordered for the child has a therapeutic dosage range of 33 mg/kg per day to 48 mg/kg per day.

The medication ordered is to be given 4 times per day. Which dosages would be appropriate for the nurse to administer to this child in one dose?

A. 28.0 mg per dose B. 40.8 mg per dose C. 250 mg per dose D. 375 mg per dose Answer: D Rationale: One kilogram equals 2.2 lb.; therefore, a child weighing 75 lb weighs 34 kg. The low dose of this medication would be 34 X 33 = 1122 divided by 4 times a day equals 280.5 mg per dose. The high dose of this medication would be 34 X 48 = 1632 divided by 4 times a day equals 408 mg per dose. Therefore, a dose of 375 mg per dose would be appropriate.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

Integrated Process: Nursing Process Reference: p. 651 5. The nurse is caring for a child who weighs 31 kg. A medication is ordered for this child with a dosage range of 20 to 40 mg per kg of body weight per dose. Which dosage would be appropriate for the nurse to administer to this child in one dose?

A. 12.4 mg per dose B. 62.0 mg per dose C. 124.0 mg per dose D. 1,000 mg per dose Answer: D Rationale: If a dosage range of 20 to 40 mg per kg of body weight is a safe dosage range, and a child weighs 31 kg, the low dose of this medication would be 31 X 20 = 620. The high dose of this medication would be 31 X 40 = 1,240. Therefore, a dose of 1,000 mg per dose would be appropriate.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 651-653 6. Using the West nomogram scale, the nurse needs to calculate the safe dosage of a medication for a child. The child is 50 inches tall and weighs 76 lb. The normal dosage of the medication for an adult is 300 mg. Which of the following is the correct way to use the West nomogram scale?

A. Locate the child's height and weight on the scale, multiply those two numbers, and divide the adult dosage by the resulting number.

B. Use the scale to locate the child's height and weight. Use a straight edge to align these numbers with the scale indicating the surface area, divide that by the average adult body surface area, and multiply the resulting number by the adult dose.

C. Locate the child's height and weight on the nomogram. Use a straight edge to align these numbers with the scale indicating percentage of adult dosage and multiply the adult dosage by this number.

D. Use the "shortcut" scale because this child is average. This will show the nurse the percentage of the adult dosage appropriate for this child. Use this percentage to calculate the dosage.

Answer: B Rationale: The West nomogram, commonly used to calculate body surface area (BSA), is a graph with several scales arranged so that when two values are known, the third can be plotted by drawing a line with a straight edge. The child's weight is marked on the right scale, the height on the left scale. Use a straight edge to draw a line between the two marks. The point where the lines cross the column labeled

SA (surface area) is the child's BSA expressed in square meters. (A fourth scale on the nomogram is a "shortcut" scale that can be used for children of average proportions.) The average adult BSA is 1.73 square meters; thus, the way to calculate the appropriate dosage for a child is to divide the child's BSA by 1.73 and multiply the resulting number by the adult dose. Here, 1.15 divided by 1.73 equals 0.66. The result, 0.66, when multiplied by the adult dose (here, 300 mg), equals 198. Therefore, the correct dose for this child would be 198 mg.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 651-653 7. The nurse is administering an oral medication that comes in an elixir form. When giving the medication, the child begins to choke and sputter. The nurse confers with the pharmacist about alternate ways to give the medication to this child. The pharmacist might recommend that the nurse should: A. dilute the elixir so that the medication is not as hard to swallow.

B. ask the care provider to change the order to give a drug that comes in a suspension.

C. mix the medication with food so the medication will be easy to swallow.

D. give the medication in a glass of orange juice.

Answer: A Rationale: Elixirs contain alcohol and are apt to cause choking unless they are diluted. Syrups and suspensions are thick and may need dilution to ensure that the child gets the full dose. Always check with the pharmacist before diluting any medication. Do not use orange juice to give medication unless specifically ordered to do so; otherwise, the child may always associate the taste of orange juice with the unpleasant medicine. It is best not to mix medication in food in case the child refuses to eat the food.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 654 8. The nurse has an order to administer a rectal suppository to a 3-month-old child.

In addition to lubricating the suppository, which intervention will help assure appropriate administration of the medication?

A. Placing the child on the abdomen for insertion of the suppository B. Pre-warming the suppository in the hand for 10 to 20 seconds C. Using the index finger to insert the suppository into the rectum D. Holding the buttocks tightly together for 1 to 2 minutes after insertion

Answer: D Rationale: For the administration of rectal medications, the child is placed in a sidelying position and the nurse must wear gloves or a finger cot. The suppository is lubricated, then inserted into the rectum, followed by a finger, which is inserted up to the first knuckle joint. The little finger should be used for insertion in infants.

After the insertion of the suppository, the buttocks must be held tightly together for 1 to 2 minutes until the child's urge to expel the suppository passes. The suppository would begin to soften making it difficult to insert if warmed prior to insertion.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 656 9. The nurse has been caring for a 12-year-old boy during his 5-day hospitalization.

The child's IV has infiltrated, and the care provider is getting ready to change the intravenous line site. Which statement made by the nurse would be appropriate in supporting the child?

A. "I will be back after your IV is in place."

B. "Would you like me to stay with you or are you OK alone?"

C. "The client is left-handed and likes to draw; an IV site in his right arm would be best."

D. "The nurses on the unit know the client well, so maybe a nurse could start the IV." Answer: C Rationale: The staff nurse may serve as the child's advocate when the care provider comes to start an infusion. The staff nurse who has cared for the child has the child's confidence and knows the child's preferences.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 661 10. An order for an intramuscular medication has been ordered for a 4-year-old.

The nurse finds the child in the playroom with his caregiver. Which action by the nurse would be the best procedure to follow when administering this medication?

A. Move him to a spot in the room where no other children are playing and give the injection. Reward him with a lollipop or sticker if he cooperates. Complete all required documentation.

B. Take him back to his bed to give him his injection. Let him go back to the playroom if he doesn't cry. Complete all required documentation.

C. Take him to a separate treatment room to give him his injection. Praise his cooperation even if he cries. Take him back to the playroom. Complete all required documentation.

D. Ask the caregiver to let you know when he is finished playing and give him his injection in a treatment room at that time. Document the time you actually give the injection.

Answer: C Rationale: Whenever possible, give injections and do treatments in the treatment room. Keep the bed and playroom "safe" places for the child. Recording the administration of the medication, especially PRN medications, is critical to avoiding potential errors in medication administration. Documentation must be completed after the administration of any medication.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 656 11. The nurse is administering a PRN pain medication to a child. What is the highest priority for the nurse in this situation?

A. The nurse double-checks the medication calculation with another nurse.

B. The nurse checks the last time the medication was given.

C. The nurse asks the child to explain the pain the child is having.

D. The nurse documents the effect of the medication within 1 hour of administration.

Answer: B Rationale: When giving a PRN medication, always check the last time it was given and clarify how much has been given during the past 24 hours. The other choices are important but checking when and how much the child has had are the priorities.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 650 12. In understanding fluid and electrolyte balance, it is important for the nurse to recognize that fluid contained within the body cells is known as: A. intracellular B. interstitial C. extracellular D. intravascular

Answer: A Rationale: Intracellular fluid is contained within the body cells.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 659 13. After the RN has initiated intravenous (IV) therapy on the child in the pediatric unit, the newly licensed LPN is caring for the child. Which of the following is the LPN responsible for related to the IV therapy? Select all that apply.

A. The LPN monitors the IV site for redness.

B. The LPN monitors the IV site for pain.

C. The LPN administers IV medications.

D. The LPN monitors the IV flow rate.

E. The LPN changes the IV site as needed.

F. The LPN monitors the site for swelling Answer: A, B, D, F Rationale: The child and the IV infusion require monitoring as frequently as every hour. Check the IV site to see that it is intact and observe for redness, pain, induration (hardness), flow rate, moisture at the site, and swelling. Documentation is sometimes done on an IV flow sheet that lists the flow rate, the amount in the bottle, the amount in the burette, the amount infused, and the condition of the site.

Although in some states the LPN can be specially trained to do IV therapy, a newly licensed LPN is responsible for monitoring the child undergoing IV therapy but not licensed to start IV therapy or to administer IV medications.

Question format: Multiple Select Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 662 14. The nurse has brought a 3-year-old's oral medications into the room for administration. Upon approaching the child, the nurse said, "I have your medication. Would you rather have me hand it to you or Mommy?" In critiquing the nurse's actions, which is most accurate?

A. The nurse's behavior is correct. Children are afraid of the nurse.

B. The nurse's behavior is correct. The nurse provided the child a choice between two acceptable options with the outcome of taking the medication.

C. The nurse's behavior is incorrect. The nurse should have been firm in expecting the child to take the medication.

D. The nurse's behavior is incorrect. The mother did not prepare the medication and should not have administered the medication.

Answer: B Rationale: The nurse is correct to offer a choice to the preschooler and then for the mother to administer the medication, if chosen. This meets the developmental level of autonomy. The nurse prepared the medication and the medication remained with the nurse until handing it to the mother, who handed it to the child. The nurse witnessed the medication administration and documents it. The nurse firmly requires the medication to be taken but found a way for the child to take it that was acceptable to the child and accomplished the goal.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 652 15. The nurse is determining a pediatric dosage of medication using the West nomogram for estimating body surface area (BSA). Which two known factors are on the left and the right scales?

A. Use the height and milligrams of medication.

B. Use the weight and milliliters of medication.

C. Use the client's height and weight.

D. Use the milligrams and milliliters of medication.

Answer: C Rationale: The West nomogram for estimating body surface area uses the dimensions of the client to form a line that passes through a point determined as the body surface area. Following that determination, the particulars of the medication prescribed are used.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 651-653 16. The nurse is preparing an injection of ceftriaxone sodium 500 mg IM for a 9month-old client. When assessing the best site for injection, which landmarks are determined in preparation for injection?

A. trochanter and knee joint B. anterior superior iliac spine, iliac crest, and greater trochanter C. acromion process and armpit D. posterior superior iliac spine, greater trochanter, and gluteus maximus

Answer: A Rationale: When locating the trochanter and knee joint as landmarks, the nurse is using the vastus lateralis site—the main injection site for infants. The ventrogluteal site uses the anterior superior iliac spine, iliac crest, and greater trochanter. The deltoid site uses the acromion process and armpit. The dorsogluteal site, which is not recommended for the infant, uses the posterior superior iliac spine, greater trochanter, and gluteus maximus.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 657 17. The nurse is preparing an intravenous solution of D5 ¼ NS @ 20 ml/hour for a 6-month-old client. Which safety device will be added to protect against fluid overload?

A. a secondary line B. a volume control device C. a syringe pump D. pediatric IV tubing Answer: B Rationale: A volume control device (also called buretrol) is designed to deliver only the amount of medication placed in the chamber. The nurse places no more than 2 hours of fluid within the device. Should the pump fail, the client will receive only the fluid amount in the chamber, thus preventing fluid overload.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 662 18. What is a fundamental rationale for the administration of intravenous therapy?

Select all that apply.

A. It is minimally invasive.

B. to maintain fluid and electrolyte balance C. to have access to the intravenous route for testing D. It makes medication administration easier for the nurse.

E. Medications and nutrients can be infused through the line.

Answer: B, C, E

Rationale: Intravenous therapy is commonly administered to maintain fluid and electrolyte balance, to administer medications for therapeutic reasons and diagnostic testing, and for a primary medication administration and nutrient administration site. It is an invasive procedure that requires the advanced skill of the nurse. The rationale for intravenous therapy is not about convenience for the nurse.

Question format: Multiple Select Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Understand Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 659 19. The nurse is preparing an intravenous infusion for a 3-month-old client with dehydration secondary to gastroenteritis. Which condition or scenario puts this infant at greatest risk for a higher volume of fluid loss?

A. the decreased body surface area (BSA) to the body fluid volume B. greater fluid exchange caused by increased metabolic activity C. only taking sips of fluids when the infant does not feel well D. experiencing bouts of nausea throughout the day Answer: B Rationale: Infants are at high risk for fluid volume deficit due to greater fluid exchange caused by increased metabolic activity. The infant is in a period of rapid growth. The infant also has an increased BSA relative to the body fluid volume.

Because of this, larger quantities of fluid are lost through the skin. Taking sips of fluids places the infant at risk but not the highest risk. The child can be nauseated without fluid loss from vomiting.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 660 20. Which client does the nurse identify as in a state of alkalosis from hyperventilation?

A. the client with a pH of 6.

B. the client with a pH of 7.3 C. the client with a pH of 7.45 D. the client with a pH of 7.55 Answer: D

Rationale: It is important to monitor acid–base balance in children as it can change rapidly. The acidity of a solution is determined by hydrogen ions. Acid fluids are typically lower than 7 and can occur in conditions such as diabetes, kidney failure, and diarrhea. Normal pH is 7.35 to 7.45 and common with internal body fluids.

Alkalosis is pH >7.45 and exceeds normal limits in clients with hyperventilation.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 660 21. The nurse is caring for a pediatric client who requires vitamins, minerals, lipids and amino acids through the circulatory system instead of the gastrointestinal tract.

Which type of intravenous therapy is anticipated for long-term therapy?

A. peripheral venous catheter infusions B. intermittent fluids via a syringe pump C. central venous catheter infusions D. use of a short line catheter and volume control chamber Answer: C Rationale: Total parenteral nutrition (TPN) is the administration of dextrose, lipids, amino acids, electrolytes, vitamins, minerals and trace elements through the circulatory system. It is anticipated that long-term therapy will be completed via a central venous access device. Peripheral devices and short catheters are for shortterm therapy. Syringe pumps are for small amounts of fluid over a period of time.

The volume control chamber prevents fluid overload from pump malfunction.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs Pn: Physiological Integrity: Pharmacological Therapies Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 663 22. The caregivers of a 1-year-old tell the nurse they are frustrated because the medication their child requires daily comes in pill form, which they have been unable to get him to swallow. After clarifying with the pharmacist, what would be appropriate advice for the nurse to give these caregivers to help them make sure the child gets the full dose of medication each day?

A. Grind the tablet to a powder and give it to the child by spoon in the pureed peas he loves to eat.

B. Dissolve the tablet in a small amount of water sweetened with corn syrup; delivered by a syringe.

C. Hold him firmly on the caregiver's lap and insert the tablet beneath his tongue; hold his mouth firmly shut for a minute or so until his urge to expel the tablet passes.

D. Break the tablet into smaller pieces and put them beneath his tongue.

Remember that babies need to learn how to swallow, so if he thrusts the pill piece out of his mouth, simply push it back in.

Answer: B Rationale: It usually is best to give medicine in solution form to a small child.

Tablets, if used, must be dissolved in water. Do not use orange juice for a solvent unless specifically ordered to do so; otherwise, the child may always associate the taste of orange juice with the unpleasant medicine. If the medicine is bitter, corn syrup may disguise the taste. The child may develop a dislike for corn syrup, but that is not as problematic as would be developing a dislike for orange juice.

Medications should not be given in food because if the child does not consume the entire amount of food, the dosage of medication will not be accurate. In addition, if medication is given with food, the child may eventually associate the bad taste of the medication with food and may refuse to eat that food. There is little excuse for restraining a small child and forcing a medication down the child's throat. The child can always have the last word and bring it up again. Also there is a danger of aspiration. Of even greater importance are the antagonism and helplessness that build up in the child subjected to such a procedure. A child's sense of dignity must be respected as much as that of an adult.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 654 23. The nurse is administering oral medications to an 11-year-old child. Which intervention should the nurse implement to encourage the child to be medication adherent?

A. The nurse administers the oral medication using a syringe or dropper.

B. The nurse disguises the medication in a small amount of corn syrup.

C. The nurse involves the caregiver in the routine of administering the medications.

D. The nurse encourages the child to develop a chart of times when medications are due.

Answer: D Rationale: The child of this age is beginning to want more independence. They can tell time and want to be a participant in their care and in the daily schedule, such as in medication administration and other daily activities. Special interventions related to delivery of the medication (syringe and flavoring) are not required of a child this age. Involving the caregiver doesn't necessarily encourage adherence.

Question format: Multiple Choice

Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 655 24. The nurse is administering an intramuscular injection of an antibiotic to a 3month-old infant. Which would be the best site for the nurse to give this medication?

A. vastus lateralis muscle B. dorsogluteal muscle C. deltoid muscle D. ventrogluteal muscle Answer: A Rationale: The muscle preferred for intramuscular injections in the infant less than 7 months of age is the vastus lateralis, located on the thigh. The ventrogluteal and deltoid are used in older children to adults. The dorsogluteal is no longer considered suitable for an intramuscular injection due to the risk of injury to the sciatic nerve.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 657-658 25. The nurse is administering otic medication to a 22-month-old with a diagnosis of otitis media. Which nursing action ensures that the medication is distributed appropriately?

A. Place in a side-lying position B. Pull the pinna down and back C. Place a cotton ball in the outer ear D. Pull the pinna up and back Answer: B Rationale: By making sure that the ear canal is straight for the medication to progress to the tympanic membrane, the medication is distributed appropriately. It is also appropriate to place the child in a side-lying position. Some nurses place a cotton ball in the ear but that does not impact distribution of the medication. A child over 3 years of age needs the pinna pulled up and back.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 656

26. The pediatric nurse recognizes that what statement is true regarding medications administered via the intravenous route?

A. The medication is injected into the fatty tissue between the skin and the muscle.

B. Giving medications through the intravenous route is less traumatic than multiple injections.

C. The medications are absorbed more slowly by being given intravenously.

D. Administering medications intravenously is safer than by other routes.

Answer: B Rationale: Delivering medications intravenously is actually less traumatic than administering multiple injections. An injection into the fatty tissue between the skin and the muscle is a subcutaneous injection. Medication absorption is quickest via an IV route. When performed properly, all routes of medication administration are safe.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 659 27. A nurse has just performed the calculation to check the dosage of amoxicillin/potassium clavulanate prescribed for a child. The calculation indicates that the dosage is within the safe dosage range. Which action is appropriate for the nurse to do next?

A. Call the health care provider to confirm the dosage is correct.

B. Have another staff nurse confirm the calculation.

C. Prepare to administer the medication.

D. Call the pharmacy to confirm the dose.

Answer: B Rationale: After computing any dosage, the nurse should always have the computation checked by another staff person qualified to give medication or by someone in the department who is delegated for this purpose. Errors are easy to make and easy to overlook. A second person should do the computation separately; then both results should be compared. There is no need to call the health care provider or pharmacy unless the calculation determined that there was a problem with the dose. The dosage calculation needs to be confirmed by a second person before the medication is administered.

Question format: Multiple Choice Chapter 31: Medication Administration and Intravenous Therapy Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 650-653

Chapter 32 1. The nurse caring for chronically ill Jared notices that the relationship between his parents is quite strained. His father has been doing everything for him, while his mother has been expecting him to have the same capabilities as his healthy twin.

Which statement would accurately describe this situation?

A. They are both in denial about the child's condition and will not be helpful to their child unless they seek counseling.

B. Both parents are demonstrating normal responses, but they will be most helpful to Jared if they can find a middle ground.

C. Jared's mother needs to recognize and support Jared's more limited capabilities.

D. Jared's father needs to let Jared do everything he is possibly able to do himself so that he doesn't fall behind developmentally.

Answer: B Rationale: Caregivers who respond with gradual acceptance take a common-sense approach to the child's condition. They help the child to set realistic goals for selfcare and independence and encourage the child to achieve social and physical skills within his or her capability. Caregivers responding with overprotection try to protect the child at all costs: they hover – which prevents the child from learning new skills, they fail to use discipline, and they use any means to prevent the child from experiencing any frustration. Caregivers in denial behave as though the condition does not exist and they encourage the child to overcompensate for any disabilities.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 669-670 2. A pediatric nurse is caring for a group of 4-year-old clients with various diagnoses. The child being treated for which diagnosis will most need help understanding what is happening to him or her?

A. burns sustained in a fireworks accident B. broken bones sustained in a fall C. lung and spleen damage sustained in a car accident D. a rash suspected of being measles Answer: C Rationale: The perception of illness is subject to magical thinking for children until they are 7 or 8. They have more difficulty understanding illness when "what's wrong" is inside rather than outside.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem

Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 670 3. The caregivers of 8-year-old Alicia, diagnosed with a chronic illness, are talking with the nurse about how they plan to care for their child at home. In discussing the dietary aspects of her treatment, the caregivers tell the nurse that the entire family is going to follow her diet. In addition, time will be spent each day focusing on the child's growth and development, and tasks will be given to each of her siblings to help in the care of the ill child as well as to help the home run smoothly while the caregivers focus on Alicia. Which statement would be most appropriate for the nurse to respond to the caregivers?

A. "That's wonderful. She is lucky to have caregivers who are so willing to make whatever sacrifices necessary in caring for her."

B. "That sounds really effective. Is it necessary for all the family members to follow the same diet?"

C. "It sounds like you have a good plan. It is really great that her siblings will be picking up extra tasks as a way to support their sister."

D. "You are very devoted. Siblings often feel guilty or jealous; be sure that time is planned to spend with those children as well."

Answer: D Rationale: By overemphasizing the ill child's needs, some family members unknowingly create feelings of guilt in the healthy children. It is important for the caregivers to spend time with and do special activities with all of the children in the family. Explaining one sibling's chronic illness to the other siblings helps them to better understand the situation.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 671 4. The nurse is working with a 12-year-old who is hospitalized with a chronic illness. Which action by the nurse might help the chronically ill preteen thrive while hospitalized?

A. Encourage the client to wear his or her own clothes, talk to friends on the phone, and interact with other clients who have similar illnesses.

B. Make all treatment and care decisions; the preteen is too young to have any responsibility for his or her own care.

C. Create a clear list of behavioral rules to give the client when he or she arrives.

D. Encourage the client to keep his or her limitations foremost in mind when trying a new skill or task at which his or her peers have begun to excel.

Answer: A

Rationale: Family caregivers may become overprotective, which can prevent an ill child from exhibiting growth and development appropriate for his or her age and disability. Encourage the child to wear regular clothes, rather than stay in pajamas, to reduce feelings of being an invalid. Help the caregivers recognize the child's potential and set realistic growth and development goals. Set age-appropriate limits and enforce appropriate discipline. Accomplish this gradually by displaying a kind and caring attitude. Give the child choices within the limits of treatments and other aspects of required care. Introducing the child to other children with the same or a similar condition can help dispel feelings that he or she is the only person with such a condition. An older child or adolescent can benefit from social interaction with peers with and without disabilities.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 672 5. The parents of a newly admitted client on the pediatric unit are angry and upset about their child's diagnosis. The child has been diagnosed with a serious chronic illness. One parent is weeping, asking, "Are they sure?" The other is pounding his fist into his hand, saying over and over, "It's not fair. I love him too much. It's not fair." Which of the following would be an appropriate response for the nurse in this situation?

A. Stay in the room but say nothing.

B. Leave them alone for a while until they calm down.

C. Tell them that most children do fine for years with the illness and explain that they will adjust to the child's special needs.

D. Acknowledge their sadness and their anger and let them know that the staff is available for their support.

Answer: D Rationale: Denial is usually the first reaction that family caregivers have to the diagnosis. This is a time when they say, "How could this be?" or "Why my child?"

Let them express their emotions and respond in a nonjudgmental way. Staying with them and offering quiet, accepting support may be helpful. Statements such as "It will seem better in time" are inappropriate. Acknowledge the caregivers' feelings as acceptable and reasonable.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 674

6. The primary caregiver of Eddy, a 10-year-old child, is his single grandfather.

Over several months of inpatient and outpatient treatment, the nurse notices that the grandfather seems increasingly tired and stressed. Which statement would be most appropriate for the nurse to suggest to this grandfather as a possible course of action for himself and the child?

A. "When Eddy is feeling well enough, you and Eddy should go on a short vacation."

B. "You would probably benefit from some counseling from the hospital's clinical social worker."

C. "It is important for you to take a break from caring for Eddy. I can give you information about the hospital's respite care program."

D. "Going out with friends a few times a week might be beneficial in helping you cope with Eddy's condition."

Answer: C Rationale: A child who requires constant or frequent attention often can be exhausting for the family caregivers. The family with no close extended family and few close friends may find getting away for rest and relaxation, even for an evening, almost impossible. Help the family caregivers find resources for respite care. Any caregiver, no matter how devoted, needs to have a break from everyday cares and concerns.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 673 7. The nurse who regularly cares for chronically ill children will be most effective in helping the family adjust to the child's condition when they: A. have had experience with a chronically ill child in his or her own family.

B. understand the full scope of the medical issues involved with each illness.

C. understand the medication issues and the psychosocial implications of the illness on the child.

D. are aware of the implications of the disease and the resources available in the community for the child and family.

Answer: D Rationale: When a family member has a chronic illness, the entire family is affected in many ways. Chronic illness may affect the child's physical, psychosocial, and cognitive development. Because nurses are usually involved from the early stages of diagnosis, and because the child and family have ongoing and long-term needs, the nurse can play a vital role in helping the family adjust to the condition. It is important for the nurse to know the resources available for the child and family.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Understand

Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 674 8. Which is the best determination of the family's ability to manage a chronic condition?

A. financial stability B. outcome of condition C. family's coping ability D. knowledge base Answer: C Rationale: The effects of a chronic condition affect a family in a variety of ways.

How families cope depends on their support of each other. Families who have strong support systems usually are better able to meet the challenges of work, family and caring for a child with a chronic illness. Financial stability is nice to have but not the most important factor. Outcome of condition and knowledge base affects how the family feels and reacts but is not the best determination of the ability to manage the chronic condition.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 669 9. The nurse is caring for a mother and 12-year-old who is newly diagnosed with a chronic pediatric condition. When the nurse is instructing on the injection technique needed for care, the mother rises and takes the equipment stating, "I will care for him." Which behavior is recognized?

A. overprotection B. dominance C. age-appropriate parenting D. ensuring safe and appropriate care Answer: A Rationale: The nurse must consider the ability of the client to manage his/her care.

A 12-year-old should be able to manage care and is encouraged to do so.

Caregivers responding with overprotection try to protect the client at all times. They hover, prevent the child from learning new skills, and use any means to prevent the client from experiencing any frustration. Dominance is a controlling behavior. To assisting her child to be independent in an age-appropriate activity and to ensure safe care, the mother must be knowledgeable and oversee the injection process.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Understand

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 669 10. The nurse is volunteering at a respite care weekend camp for children with a chronic condition. This provides the caregivers with: A. financial strain due to the costliness of the programs.

B. time to enjoy family activities that the child cannot participate in.

C. a chance for rest and refreshment.

D. the opportunity to complete chores at home.

Answer: C Rationale: Respite care affords caregivers of chronically ill children a period of rest and refreshment. Respite care assists single caregivers and married parents who need to reconnect with others or reduce stress. The camps are typically affordable due to working with associations and having volunteers. It is not usual to send children away and then have a family activity. This would make the child feel excluded. It is nice to get "caught up" on activities but this is not the focus of respite care.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 670 11. Which action by the nurse is the helpful if the parents of a child with a chronic condition are experiencing financial difficulty? Select all that apply.

A. Provide information on state financial assistance.

B. Arrange a lunch tray to be sent for the parents.

C. Volunteer in a fundraiser for outstanding debts.

D. Ask the health care provider to decrease compensation costs.

E. Offer personal financial assistance to the family.

Answer: A, B, C Rationale: The nurse has many opportunities to assist clients and their families; however, the nurse must remember that this client is one of many. The nurse can provide information on local contacts for state assistance, provide tangible assistance immediately by arranging a lunch tray, and, if the nurse is able, volunteer in a fundraiser. It is not appropriate for the nurse to ask the health care provider to decrease his/her compensation or to offer personal financial assistance.

Question format: Multiple Select Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring

Reference: p. 674 12. Which does the nurse identify as the best indicator of how a child will react to the diagnosis of a chronic condition?

A. how the family reacts to the news B. how the health care provider explains the condition C. how much the child understands the condition D. how much medical intervention is needed Answer: A Rationale: The child looks to the parent for guidance in areas they do not understand; thus, how a parent reacts to the chronic condition influences how the child reacts—not how the health care provider explains the condition or how much the child understands or even understanding the medical intervention needed.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 670 13. Which scenario does the nurse anticipate for the life of an adolescent with a chronic condition who has deteriorating function?

A. feelings of being special due to decline B. independence in medication administration C. decrease in high school grades D. decline in involvement with peer activities Answer: D Rationale: Peers can be very supportive of the client with deteriorating function; however, at this stage of development, the adolescent is typically activity involved in sports and school activities. The adolescent with a chronic condition may not physically be able to be included in such activities, thus there is a decline in involvement. Special accommodations need to be made for the client but these typically do not make the client feel special. With a decrease in function, an independent adolescent may need assistance in medication administration. The adolescent with a chronic condition will focus on what he/she is able to do, which often includes focusing on schoolwork. Also, most conditions do not include a decrease in cognitive function.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 672

14. The nurse is interacting with a family of 3 (parent, school-aged child with a chronic illness, and preschool sibling) in a specialty clinic office. The parent is struggling with the sibling being disruptive when preparing the child with a chronic illness for the exam. Which nursing action is most helpful?

A. Remove the sibling from the room to a secure playroom area.

B. Support the parent by telling the sibling that the behavior is unacceptable.

C. Offer stickers and coloring books for the sibling to play with.

D. Encourage the sibling to assist in the preparation for the exam.

Answer: C Rationale: Some degree of sibling rivalry is found in all families. Anger, resentment and jealousy can occur due to the amount of time and attention that a child with a chronic condition requires. Having an age-appropriate activity, given to the child by the health care provider, provides positive attention to that child and allows focus on the exam. It is uncomfortable for a preschooler to be removed from the parent.

The nurse must acknowledge the behavior but not tell the sibling that the behavior is unacceptable. The child may not be interested in assisting in preparation for the exam.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 671 15. The nurse is completing a family assessment. Which behavior best highlights a positive interaction between the younger child with a chronic condition and an older sibling?

A. The older sibling allows the child to interact on the bus with friends.

B. The older sibling checks on the child before he attends basketball practice.

C. The older sibling organizes an outdoor game that all can participate in.

D. The older sibling acknowledges the child's struggles when talking with friends.

Answer: C Rationale: All interactions are supportive of the child with a chronic illness, but the best interaction is organizing an outdoor game which all can be involved in. This promotes acceptance of the child with a chronic condition and interaction with others. It also promotes sibling bonding and good psychosocial interaction.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 671

16. Which role of the nurse is the highest priority when a child is newly diagnosed with a chronic condition?

A. manager of diagnostic testing B. facilitator of coping skills C. educator of changes in lifestyle D. coordinator of health care appointments Answer: B Rationale: The highest priority is to help the child and family cope with the news of a newly diagnosed chronic illness. It is important to encourage the family to express their feelings and reactions to the situation. The nurse is to support by listening and formulating appropriate nursing interventions.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 671-672 17. The nurse is caring for a child with a chronic condition who has advanced skills and can perform activities of daily living independently. Which nursing goal is progressing?

A. The client will meet developmental milestones.

B. The client will adjust to THE ROLE OF THE NURSEonic condition.

C. The client will work with parents to accomplish needs.

D. The client will improve his/her self-esteem.

Answer: B Rationale: Major goals for the child are to accomplish growth and develop milestones, perform self-care tasks, decrease anxiety and improve social interaction. The nursing goal in progress is that the client is learning to adjust to living with a chronic condition by being able to complete tasks such as performing activities of daily living. The task of performing activities of daily living is not aligned with the outcomes of meeting developmental milestones, working with parents, or improving self-esteem.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Reference: p. 672 18. When caring for a preschooler with a chronic condition, which nursing action encourages client cooperation with daily tasks?

A. Explain tasks thoroughly.

B. Give the child a choice in participation.

C. Provide information with pictures.

D. Integrate play into tasks.

Answer: D Rationale: To obtain cooperation from a preschooler, it is best to incorporate play into the task. If the preschooler believes that the task is fun, he/she will participate willingly. The preschooler is unable to understand the need for medical tasks, so thorough explanations may scare the child. Some tasks must be completed, taking away the choice in participation. Pictures of the tasks can be helpful and used for client understanding.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 673 19. The nurse is assigned four clients in the pediatric unit. Which child with a chronic condition does the nurse anticipate having the nursing diagnosis, Impaired physical mobility?

A. the child with cystic fibrosis B. the child with sickle cell anemia C. the child with muscular dystrophy D. the child with hemophilia Answer: C Rationale: The child with muscular dystrophy experiences progressive muscle weakness and loss of muscle mass. Eventually, the child will have an impaired physical mobility. The child with cystic fibrosis would have a respiratory nursing diagnosis. The child with sickle cell anemia would have a pain nursing diagnosis.

The child with hemophilia would have a fluid volume deficiency nursing diagnosis.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 668-669 20. Which issue would a nurse likely identify as related to caregiving of a child with a chronic illness?

A. anxiety B. depression C. potential social isolation D. situational low self-esteem Answer: C

Rationale: Social isolation is a common occurrence because of the demands of parenting a child with a chronic condition. Having a child with a chronic condition requires constant attention, which can be exhausting. All caregivers need to have a break. Anxiety, depression and low self-esteem are not necessarily related to caregiving.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 673 21. The health care provider has advised respite care to assist the family of a child with a chronic condition. Which would be most appropriate for the nurse to facilitate?

A. an enterostomal therapist to visit the home B. a home health aide scheduled in the morning C. age- and activity-appropriate weekend camps D. nutritional support from a registered dietitian Answer: C Rationale: When the health care provider has advised respite care, it is most helpful for the nurse to facilitate an appropriate camp where the child can be well cared for and the parents are able to have some rest. Camps provide activities for socialization for the children as well as an opportunity for the parents to participate in normal activities.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 673-674 22. The parents and their child with a chronic illness have been seen by the nurse in the pediatrician's office since birth. Which situation is appropriate for instruction by the nurse?

A. diagnosis of secondary problems B. growth and development changes C. recent diagnostic testing and lab work D. consents for upcoming surgery Answer: B Rationale: Nursing instruction for a pediatric client is often focused on growth and development changes; that is no different in the child with a chronic condition.

Parents need to allow the child to develop and meet the milestones within the child's capabilities. The other options are for the health care provider.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 672 23. Which medical diagnosis does the nurse understand most often begins with an acute injury and then turns into a chronic condition?

A. a fractured arm B. low back pain C. pneumonia D. cerebral palsy Answer: B Rationale: Low back pain can begin with an acute episode (e.g., an accident) and then become a chronic condition due to damage or degeneration. A fractured arm, if fixed properly, is a self-limiting condition. Pneumonia is an acute condition that is resolved with antibiotics. Cerebral palsy is a chronic condition from the diagnosis.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 668-669 24. The nurse is working with a group of chronically ill school-aged children and their caregivers. Which strategy would be most effective in helping the children reach their self-care treatment goals?

A. Make a chart of self-care goals the child should do successfully; add a sticker to the chart each time a goal is reached.

B. The caregiver and child co-write a contract that identifies what reward will be earned when certain self-care treatment goals are mastered.

C. Frequently reinforce for the child why self-care goals are so important to their overall health.

D. Encourage the child to socialize with healthy peers every day so that he or she is motivated to become as independent as those peers.

Answer: B Rationale: Use a chart or other visual aid with listed tasks as a tool to help the younger child reach a desired goal. Stickers can also be used to record the younger child's progress. School-age children often respond well to contracts: for example, a special privilege or another incentive may be awarded when a set number of

stickers is earned. While the remaining options are appropriate actions, they are not as likely to encourage self-care as effectively as the reward system.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 673 25. An 8-year-old diagnosed with a chronic illness is returning home after an extended hospital stay. While the child tires easily, she is mobile and active when rested. Keeping in mind that the child is particularly interested in engaging in arts and crafts, which intervention should the nurse suggest to meet the child's development and socialization needs?

A. Finding a weekly children's group where there is a focus on arts and crafts projects and a willingness to address her energy needs.

B. Finding an art teacher who can come to the home, after the child's afternoon rest, to help nurture the child's interest in art.

C. Taking the child to the local library at least monthly to check out children's craft books to support the interest in arts and crafts.

D. Identifying for the caregiver the tools and supplies the child will need to best support her interest in arts and crafts when her energy level permits.

Answer: C Rationale: The chronically ill child may feel isolated from peers. Ask the child about his or her interests; these may give some clues about suitable after-school activities that will increase the child's interactions with peers. Make suggestions and confer with family caregivers to ensure that proposed plans are carried out.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 672 26. During a well-child checkup, a child shares being embarrassed when she is seen with her 7-year-old sister who wears an arm prosthesis after the limb was amputated. Which statement by the nurse most appropriately addresses the child's concerns?

A. "Your sister didn't want to lose her arm; you shouldn't feel embarrassed."

B. "That must be confusing, but it's important for your sister that you support her."

C. "That must be hard. I know you love your sister; it's normal for you to feel a little embarrassed."

D. "Your sister probably feels more embarrassed than you do."

Answer: C

Rationale: Siblings may feel stigma (embarrassment or shame) because of a brother or sister with a chronic illness, especially if the ill child has a physical disfigurement or apparent cognitive deficit. It is appropriate to acknowledge these feelings. The other options either minimize the child's concern or focus on the sibling's needs rather than the child's feelings of embarrassment.

Question format: Multiple Choice Chapter 32: The Child with a Chronic Health Problem Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 671

Chapter 33 1. A group of nurses is discussing child abuse (child maltreatment) and one nurse suggests that inadequate parenting skills may lead to child maltreatment. The nurse recognizes that sometimes child maltreatment occurs because the parent: A. is responding appropriately to the child's behavior.

B. believes the child is intentionally trying to make him or her angry.

C. may have unrealistic expectations of the child.

D. works hard to provide for the family and feels unappreciated.

Answer: C Rationale: Commonly, abusive parents have inadequate parenting skills; if they have unrealistic expectations of the child, they may not respond appropriately to the child's behavior.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 680 2. A caregiver who works in the hospital brings his 9-year-old son to the emergency room with a spiral fracture of the tibia. The caregiver reports that the injury occurred when the boy's 5-year-old sister hit him with wooden bat. The injury is inconsistent with an impact and with the sister's strength. Which of the following would be appropriate for the nurse to do in this situation?

A. Tell the caregiver that the story is not plausible and ask what really happened.

B. Leave the treatment area and call the police.

C. Leave the treatment area and call the social services department in the hospital.

D. Let the hospital administrator know so that the hospital can take any necessary action.

Answer: C Rationale: Abusive parents can be found at all socioeconomic levels. When a child is brought to a physician or hospital with abuse injuries, family caregivers may attribute the injury to an action of a sibling. Whenever the child's symptoms do not match the injury the caregiver describes, be alert for possible abuse. State laws require health care personnel to report suspected child abuse (child maltreatment).

This requirement overrides the concern for confidentiality. Laws have been enacted that protect the nurse who reports suspected child abuse from reprisal by a caregiver (e.g., being sued for slander) even if it is found that the child's situation is not a result of abuse. If the nurse does not report suspected child abuse, the penalty can be the loss of the nursing license. Do not accuse the caregiver before a complete investigation takes place.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Communication and Documentation Reference: p. 680 3. Which situation should the nurse explore for possible emotional abuse of the child by the caregiver?

A. The caregiver of a 13-year-old reports, "Amy is really frustrating me. I've been late for work every day this week because she hasn't been ready to leave for school on time."

B. The caregiver of a 16-year-old reports, "I couldn't believe that dinner wasn't ready when I got home from work last night. Jack knew it was his turn to cook."

C. The caregiver of a 12-year-old reports, "I'm sorry we missed Jamal's appointment last week, but he was supposed to remind me to come."

D. The caregiver of a 15-year-old reports, "Laia promised to earn the money to care for the dog if we got him, but she keeps turning down baby-sitting jobs to go out with her friends, and I have to add dog food to my already impossible budget."

Answer: C Rationale: Injury from emotional abuse can be just as serious and lasting as that from physical abuse, but it is much more difficult to identify. Several types of emotional abuse can occur, including role reversal in which the child must take on the role of parenting the parent and is blamed for the parent's problems.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 682 4. The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse (child maltreatment). Which finding might alert the nurse to this possibility that the child may have been abused?

A. The child has a fractured bone.

B. The child has bruises on the knees and elbows.

C. The child is hyperactive and angry.

D. The child has a burn that has not been treated.

Answer: D Rationale: Burns are a common type of injury seen in the abused child. Although burns may be accidental in young children, certain types of burns are highly suspicious. Cigarette burns, or burns from immersion of a hand in hot liquid, from a hot register (as evidenced by the grid pattern), from a steam iron, or from a curling iron are common abuse injuries. Caregivers have been known to immerse the

buttocks of a child in hot water if they thought the child was uncooperative in toilet training. Children often injure themselves and may have fractured bones or bruises on knees and elbows that are not from child abuse. Hyperactivity and anger are not physical signs of child abuse; they are emotional signs.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 680 5. The nurse is interviewing the caregiver of a 5-year-old child who has been admitted with bruises on the abdomen and thighs as well as additional bruises in various stages of healing. Which statement made by the caregiver might alert the health care team to the possibility of child abuse (child maltreatment)?

A. "His brother just plays too rough with him."

B. "My child goes to day care after school."

C. "He just learned to ride his bicycle."

D. "When he is in trouble I make him go to his room."

Answer: A Rationale: When a child is brought to a physician or hospital because of physical injuries, family caregivers may attribute the injury to some action of the child's that is not in keeping with the child's age or level of development. The caregiver may also attribute the injury to an action of a sibling. When the child's symptoms do not match the injury that the caregiver describes, be alert for possible abuse. The other statements might be normal situations for a 5-year-old and would not necessarily alert the nurse to a possibility of child abuse.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 680 6. In caring for a child who has been admitted after being sexually abused, which intervention would be included in the child's plan of care?

A. Observe for signs of anxiety.

B. Weigh on the same scale each day.

C. Encourage frequent family visits.

D. Test the urine for glucose upon admission.

Answer: A Rationale: The child who has been sexually abused may exhibit anxiety, acts of aggression or hostility, or have physical complaints regarding various aches and pains, gastrointestinal upsets, changes in bowel and bladder habits (including

enuresis), or nightmares. In cases of incest it is important that the perpetrator not be allowed to visit the child. Weighing the child and testing urine for glucose are not indicated for a child who has been sexually abused.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 684 7. The nurse is caring for a small child who has been admitted with a diagnosis of abusive head trauma (shaken baby syndrome). Which condition or concern often occurs with shaken baby syndrome?

A. edema to the arms and legs B. loss of vision and intellectual disability C. chronic infection and scarring D. reports of illness and nightmares Answer: B Rationale: When the child is shaken, a whiplash-type injury occurs to the neck. In addition, the child may have edema to the brain stem and retinal or brain hemorrhages. Loss of vision, intellectual disability, or even death may occur in children diagnosed with abusive head trauma (shaken baby syndrome). Reports of illness and nightmares may occur with children who are emotionally abused.

Peripheral edema, infection, and scarring are not concerns noted in children diagnosed with abusive head trauma (shaken baby syndrome).

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 681 8. A group of pediatric nurses is discussing the diagnosis of Munchausen syndrome by proxy. Which statement most accurately describes this disorder?

A. "It is seen when one person fabricates or induces illness in another to get attention."

B. "The disorder occurs when a child is shaken by the arms or shoulders in a repetitive manner."

C. "Children with this diagnosis often appear worried or fearful and have nightmares."

D. "It happens when there is sexual contact between a child and a caregiver."

Answer: A Rationale: In caregiver-fabricated illness (formerly Munchausen syndrome by proxy), one person either fabricates or induces illness in another to get attention.

When a caregiver has this syndrome, he or she frequently brings the child to a health care facility and reports symptoms of illness when the child is actually well.

Abusive head trauma (shaken baby syndrome) occurs when a child is shaken by the arms or shoulders in a repetitive manner. Children who are emotionally abused often appear worried and fearful, and have nightmares. When there is sexual contact between a child and a caregiver, it is classified as sexual abuse.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 681 9. The nurse is assessing an infant diagnosed with abusive head trauma (shaken baby syndrome). Clinical manifestations of shaken baby syndrome affect which body system the most?

A. musculoskeletal system B. cardiovascular system C. respiratory system D. nervous system Answer: D Rationale: The nervous system of the infant is most affected by abusive head trauma (shaken baby syndrome). When a caregiver shakes the infant, the brain is jarred in the skull. Clinical manifestations affecting the nervous system include irritability, lethargy, vomiting, and seizures. Bruising may be noted on the skin.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 681 10. The health care provider is unsure of physical symptoms and diagnosis of a pediatric client. The health care provider is prescribing diagnostic testing to determine possible poisoning by the parent. When the parent asks why laboratory work is being drawn, which response is best?

A. "Since we have not found the cause of the illness yet, the health care provider has ordered more blood tests."

B. "We are drawing laboratory work to rule out poison in the child's system."

C. "I am not really sure at this time. I just saw it on the prescription sheet."

D. "It is hospital policy to draw laboratory work daily to monitor the client status."

Answer: A Rationale: Informing the parent of the laboratory work prescribed is appropriate.

This response is telling the truth but does not alarm the parent. Telling the parent

that the tests are to rule out poison in the child's system could anger and alarm the parent. The other options either lie to the parent or do not answer the question.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 684 11. The nurse on a pediatric unit is caring for a client who has been physically and emotionally abused. Which adjustment in care is most appropriate?

A. Only draw laboratory work in the treatment room.

B. Allow the nonabusive caregiver to remain with the client.

C. Assign consistent nursing staff to the client when possible.

D. Provide play and distraction techniques to relieve stress.

Answer: C Rationale: All of the options are appropriate when caring for a client who has been physically and emotionally abused. The adjustment in care is assigning consistent nursing staff. This aids in establishing therapeutic communication and trust. All other options are standards of care on pediatric units.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 684 12. The school nurse observes an elementary school child arriving in the winter in shorts and a short sleeved shirt with no coat. The nurse would consider this as which type of abuse?

A. physical abuse B. emotional abuse C. sexual abuse D. neglect Answer: D Rationale: Not providing for the child's safety in winter conditions is an example of neglect. Neglect is comprised of the failure to provide adequate hygiene, health care, education, nutrition, love, nurturing, and supervision. Physical abuse includes physical harm. Emotional abuse includes demeaning verbal threats. Sexual abuse includes inappropriate contact between a child and caregiver.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity

Integrated Process: Nursing Process Reference: p. 685 13. Which statement made by a participant at a workshop on sexual abuse needs further clarification from the group leader?

A. "The difference between sexual abuse and sexual assault is the perpetrator."

B. "Sexual abuse by a person of trust is the most damaging type."

C. "Mostly low-income people commit sexual violence against children."

D. "In cases of incest, the child rarely tells anyone else."

Answer: C Rationale: Clarification is needed because the statement regarding socioeconomic status is incorrect. Sexual abuse of children exists in all age groups and cultures.

There is no socioeconomic, racial, religious, or ethnic boundaries. All of the other statements are true and need no clarification.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 683 14. A toddler is brought to the emergency department with burns on the feet and buttocks. The toddler is screaming in pain. The caregiver states that she did not know the bath water was so hot. What is the initial action completed by the nurse?

A. assessment of the toddler B. notifying a health care provider C. completing injury documentation D. calling law enforcement Answer: B Rationale: When a toddler is screaming in pain, the health care provider is notified at once. The nurse can assess the client with the health care provider. Verbal orders can be obtained and implemented. The documentation is completed after caring for the toddler. Law enforcement will be notified if needed. Most health care facilities have security on staff.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 684 15. The nurse is caring for a young child whose parents have been charged with physical abuse. Which child reaction is noted as a result of the parental behavior?

A. despondent and does not respond to questions

B. fretful and shrinks away when approached C. aggressive and kicks and fights during the assessment D. cries frequently and stares at the nurse Answer: B Rationale: Behaviors of the young child are intuitive. The child is fretful and shrinks away when approached. This is related to the conduct of the parents as they would punish the child. A young child may take time to trust the nurse. The nurse may provide crayons and paper for drawing to get the child to open up about fears and feelings. Otherwise, it may be difficult to communicate. Aggression can be common, including temper tantrums. Typically the child will not make eye contact with the nurse.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 684 16. The nurse is caring for a 4-year-old child with bruises on various areas of the body. Which parental statement does the nurse note as most suspicious?

A. "The child plays aggressively with the siblings in the house."

B. "The child plays tackle football at the local school. He has advanced skills."

C. "The child bruises easily but was checked for a bleeding disorder."

D. "The child is clumsy when running and playing with older siblings."

Answer: B Rationale: The most suspicious statement is related to playing tackle football at 4 years of age. Tackle football does not begin until the child is in school, not preschool. This would make the nurse concerned about the accuracy of the information. Education needs to be completed if the bruising is obtained from playing with siblings or taking part in various activities outside of the child's developmental level. The health care provider needs to be alerted to the various bleeding, particularly if previous testing for a bleeding disorder is within the medical record.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 680 17. Which type of abuse is reported most quickly to the police?

A. sexual assault B. incest C. neglect

D. emotional abuse Answer: A Rationale: Sexual assault is when sexual contact is by someone other than a caregiver. When the caregivers become aware, the assault is quickly reported.

Incest is rarely reported quickly as the child does not tell another person what is happening. Neglect and emotional abuse are more difficult to document and not as easy to differentiate.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 683 18. Which is the primary physical sign of a child who the nurse suspects as being emotionally abused?

A. poor hygiene B. fatigue C. delays in physical development D. inadequate medical care Answer: C Rationale: Failure to thrive and delays in physical development are the primary physical signs that the child is being emotionally abused. The nurse is correct to assess the interaction between the caregiver and child. Poor hygiene, fatigue and inadequate medical care indicate neglect.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 685 19. Which physical symptoms confirm that a child has been sexually abused or assaulted? Select all that apply.

A. stained and bloody underclothing B. The child states that someone touched the breasts.

C. inappropriate vaginal opening measurements D. suspicious actions of the caregiver E. sperm on body or clothes Answer: A, C, E Rationale: For confirmation that the child has been sexually abused or assaulted, there would be evidence such as stained and bloody underclothing, inappropriate

vaginal opening indicating intercourse, and the physical presence of sperm.

Suspicion of abuse includes the child's statement and suspicious actions.

Question format: Multiple Select Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 685 20. Which is essential in working with caregivers who have been affected by abuse?

A. knowing the legal system B. developing a therapeutic relationship C. providing details on social services in the community D. arranging family meetings to discuss issues Answer: B Rationale: The first step in assisting caregivers and families affected by abuse is developing a therapeutic relationship. This nonjudgmental relationship is essential in assisting the family to make decisions and, without it, the family will discount what the nurse is saying. Providing information on the legal system and social services in the community is enabled after the therapeutic relationship has begun.

The family is ultimately responsible for arranging family meetings but it can be suggested by the nurse.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 685-686 21. The nurse is admitting a pediatric client for a common pediatric surgical procedure. When completing the domestic violence screening, which statements require clarification? Select all that apply.

A. "My Dad yells a lot but never means it and doesn't hit anyone."

B. "We stay out of Mom's way when she is in a bad mood."

C. "I see my Dad drive by our new house to see who is here."

D. "I love my parents even though they are divorced."

E. "My Mom will hit my Dad when she is drunk but it doesn't hurt."

Answer: A, C, E Rationale: There are many types of domestic abuse such as physical violence, threats, emotional abuse, harassment, and stalking. Using this criteria of threats, the nurse requires clarification when the child states that Dad yells a lot and doesn't mean it. Driving by the new house could be harassment or stalking. The Mom hitting the Dad but not hurting him is physical abuse. The other statements do not imply domestic violence.

Question format: Multiple Select Chapter 33: Abuse in the Family and Community Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 686 22. Which adolescent behavior is most common if the parents have substance use problems?

A. staying away from the house B. taking on adult responsibilities C. being clingy to teachers at school D. telling everyone of the parental issues Answer: B Rationale: It is very common for the adolescent to take on parental roles in the home hoping that the parents will change their behavior. These children do not want negative attention to come to the family; thus, they keep to themselves and do not tell others of the difficulty at home.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 688 23. The nurse has identified the outcome of improving parenting and coping skills in a caregiver who has shown past poor judgement in caring for the children. Which action promotes a positive image of his or her abilities?

A. educating on positive parenting skills B. providing feedback on how to better cope with stressful situations C. providing a compliment when a caregiver does something well D. initiating a reward system when the parent accomplishes a goal Answer: C Rationale: It is best to compliment a caregiver on doing something well. This improves self-esteem and makes the parent feel worthy of parenting. Educating and providing feedback is the action of the nurse. The caregiver must have a desire to improve for the family and not for rewards.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 685-686

24. A mother brings a 23-month-old child for a well-child check. She apologizes, stating, "It's my allergies, not a cold, that is causing me to sniffle so much." The mother reports that the toddler seems "slower at doing things than my older children did." The nurse notices that the child sits in the mother's lap without fear or hesitation and responds to the her questions, but fails to looks at the mother's face when being spoken to. These behaviors are supportive of what additional assessment?

A. autistic behaviors demonstrated by the child B. attention deficit hyperactive disorder (ADHD) characteristics demonstrated by the child C. indications of physical abuse of the child by the caregiver D. evidence of cocaine abuse by the caregiver affecting the child Answer: D Rationale: Developmental delays occur in young children of substance abusers.

Infants of cocaine abusers avoid the caregiver's gaze, which contributes further to bonding delays. The children at greatest risk of becoming substance abusers are those who have families in which alcohol or drug abuse has been present; who suffer from abuse, neglect, or loss; or who have no close relationships as a result of a dysfunctional family.

Question format: Multiple Choice Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 687-688 25. A child is brought to the emergency department for evaluation. The caregiver states, "The child was running and tripped over the scooter on the sidewalk and landed on the left arm." The nurse assesses and records the findings (above). The nurse suspects child abuse (child mistreatment) and notifies the proper authorities.

Which finding(s) will the nurse use to support this suspicion? Select all that apply.

A. spiral fracture B. bruises on the knees C. bruises on the thighs D. abrasion on the left palm E. bruise on the upper back Answer: A, C, E Rationale: Bruises that occur accidentally to a child usually appear over bony areas such as the knees, elbows, shin, and forehead. Those that have been inflicted in an abusive manner may be found in soft tissue such as the buttocks, genitalia, thighs, back of the knees, upper back, and nose and eyes. In this case, findings suggesting child abuse (child mistreatment) include the spiral fracture and bruises on the thighs and upper back. The bruises on the knee and hand abrasion are likely accidental.

Question format: Multiple Select Chapter 33: Abuse in the Family and Community Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 680

Chapter 34 1. The nurse is working with a group of caregivers who have dying children. Which statement made by one of the caregivers indicates that this caregiver is in the depression stage of anticipatory grief?

A. "It is going to be hard for me when I can't hug my daughter anymore."

B. "I've got to go into my office for a meeting. I'm sure my son will be fine while I'm gone."

C. "I used to love playing board games with my son. Now that just makes me feel sad."

D. "I'll be able to handle my child's dying if she can just live until her next birthday."

Answer: C Rationale: Caring for a family that is facing the death of their child calls on all of the nurse's personal and professional skills. It includes offering sensitive, gentle, physical care and comfort measures for the child, as well as continuing emotional support for the child, the family caregivers, and the siblings. The diagnosis of a fatal illness initiates the grieving process in the child and the family: denial and isolation (she'll be fine without me), anger or bargaining (if only), depression (things that usually give pleasure no longer do) and acute grief, and finally, acceptance (I will be sad).

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 696-698 2. A 3-year-old who has been attending preschool has been diagnosed with leukemia. The caregivers of this child ask the nurse what they can do to help their child feel secure. Which recommendation could the nurse make to these caregivers that would be helpful in making the child feel secure?

A. "Let your child continue to attend preschool as much as possible."

B. "Keep your child at home and spend as much one-on-one time with her as possible."

C. "Keep your child out of school but invite some friends over for play dates."

D. "Plan special outings with just the family during the time the child would normally have been at school."

Answer: A Rationale: Maintaining routine as much as possible helps to give the ill or dying toddler a greater sense of security.

Question format: Multiple Choice

Chapter 34: The Dying Child Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 694 3. The nurse is caring for a child who has been a client in the pediatric unit for several weeks. The child has a terminal illness and is dying. The caregivers and the nurse are in the room when the child takes the last breath and dies. Which action by the nurse would be considered appropriate at this time?

A. The nurse walks out of the room and calls the nursing supervisor and chaplain.

B. The nurse tells the family that they share in the family's sadness and cries with them.

C. The nurse maintains their professional demeanor and tells the caregivers that a staff person will be in to take the body soon.

D. The nurse consoles the family members by hugging or rubbing their backs and then moves to a corner of the room to cry.

Answer: B Rationale: When death comes, it is perfectly appropriate to share the family's grief, crying with them and then giving them privacy to express their sorrow. The nurse can stay with the family for awhile, remaining quietly supportive with an attitude of a comforting listener. An appropriate comment may be, "I am so sorry" or "This is a very sad time." The nurse needs to keep the focus on the family's grief and what the nurse can do to support them.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 698 4. In interacting for several days with a dying child, the nurse realizes that the child has not mentioned death. There are some dead flowers in a vase on the child's windowsill. The child looks at the flowers and says, "Did they die?" Which statement would be most appropriate for the nurse to make to give the child an opportunity to open up and talk about dying?

A. "These flowers don't seem to be alive anymore. I'll take them away."

B. "These flowers are dead now. What do you think it would be like to die?"

C. "I'm going to throw these flowers in the trash, okay?"

D. "Well, these flowers aren't very cheerful anymore. I'll get rid of them."

Answer: B Rationale: Although the dying child may be unable to understand death, the emotions of family caregivers and others alert the child that something is threatening his or her secure world. Dealing with the child's anxieties with openness

and honesty restores the child's trust and comfort. The nurse can talk about death regarding less emotional situations such as dead flowers, trees, insects, or birds.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 693 5. The nurse has recently started caring for a dying child. The nurse has not yet had a chance to discuss the family's beliefs with the child's caregivers. In the middle of the night, the child awakens and is frightened. She asks the nurse what the nurse's religious beliefs are about death. Which response would be appropriate?

A. "I believe that good people, like you, go to heaven."

B. "I don't have any religion but I don't think you should be scared of dying."

C. "I like to keep my beliefs to myself. Are you having trouble sleeping?"

D. "Most religions seem to believe that spirits live on after the body dies. What are you thinking about?"

Answer: D Rationale: Nighttime is especially frightening for children because they often think they will die at night. Provide company and comfort. Be alert for periods of wakefulness when the child may need someone to talk to. Be honest and straightforward; avoid injecting your beliefs into the conversation.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 703 6. The father of a 10-year-old who has recently been diagnosed with a terminal illness tells the nurse that his family had been working together for the previous year trying to get the 10-year-old and his 6-year-old sister to play better together and to share with each other. Which statement would be most appropriate for the nurse to tell the father regarding children and the diagnosis of an illness?

A. "The younger child might believe that her anger at her brother caused his illness; she will need reassurance that she does not have that power."

B. "The older child might believe that his sister's anger caused his illness; he will need reassurance that his sister does not have that power."

C. "It will be important that the children learn to play well together while the older child is alive so that the younger child will have positive memories of the older child."

D. "Both children are likely to be more cooperative and pleasant with each other as they deal with this crisis."

Answer: A

Rationale: When a child dies, young siblings who are still prone to magical thinking may feel guilty, particularly if a strong degree of rivalry existed before the illness.

These children need continued reassurance that they did not cause nor help to cause their sibling's death. Reactions to the illness and its accompanying stresses can cause classroom problems for school-aged siblings; these may be incorrectly labeled as learning disabilities or behavioral disorders unless school personnel are aware of the family situation.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 700 7. A young nurse has had no experiences of death in her own life. As a staff nurse, she finds herself dealing with young children who are terminally ill. She feels extremely uncomfortable facing these children and their caregivers. What is the best approach for the nurse to take in caring for these families?

A. Focus on the physical needs of the client; the nurse's job is to care for those aspects of the child's needs.

B. Ask another nurse to perform those tasks that involve discussions with the clients and their caregivers.

C. Ask her supervisor to allow her to attend a seminar on dealing with the terminally ill and to recommend books and articles that will help her understand death better.

D. Recognize that the bad thing is not happening to her, and face her responsibility to care for all of the needs of the client.

Answer: C Rationale: Health care workers often are uncomfortable with dying clients, so they avoid them and are afraid that the clients will ask questions that they cannot or should not answer. These caregivers signal by their behavior that the client should avoid the fact of his or her impending death and should keep up a show of bravery.

In effect, they are asking the client to meet their needs instead of trying to meet the client's needs. A workshop, conference, or seminar in which one's own feelings about life and death are explored is useful in preparing the nurse to care for the dying child and family.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 693

8. A child who is dying becomes restless and fidgety, then becomes calm and peaceful. The caregivers feel hopeful that the child seems "better." Which statement would be the best for the nurse to tell the caregivers about this pattern?

A. "This pattern is part of dying; the child's death is imminent."

B. "This pattern is not unusual in a dying child and might happen over and over again."

C. "This pattern suggests that the child is feeling more comfortable and has less distress from the illness."

D. "This pattern is consistent with medication cycles; the fidgeting is caused by pain, and the calmness is a sign that the pain has been controlled with medicine."

Answer: A Rationale: Just before death, the child who has remained conscious may go through a period of restlessness, followed by a period of peace and calm. The nurse and family members should be aware of these reactions and know that death is near.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 699-700 9. The caregivers of a dying 9-year-old boy are in his hospital room. Death is near and the child has drifted in and out of consciousness for several days. The caregivers are at two different stages of anticipatory grief and are arguing in whispers in the room. The best response in this situation would be for the nurse to: A. recognize that their differences are normal and leave them to their argument.

B. interrupt their conversation, acknowledge that their feelings are valid, and let them know that the child can hear them and might be upset by their discord.

C. interrupt their conversation, acknowledge that their feelings are valid, and ask them to leave the room.

D. call a chaplain to come and speak with them.

Answer: B Rationale: Even though the dying child may have a decreased level of consciousness, his or her hearing remains intact. Family members at the bedside as well as health care personnel may need to be reminded to avoid saying anything that would not be said if the child were fully conscious. Discourage whispered conversations in the room. Emotions and fears must be acknowledged, and caregivers should be reassured that their reactions are normal. The support of a member of the clergy may be helpful during this time. Help family members contact their own spiritual counselor or offer to contact the hospital chaplain if the family desires.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply

Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 699-700 10. A single parent of a dying child has told the nurse she would like to take care of her daughter at home. What would be best for the nurse to do to help the mother reach a decision that will be good for both the mother and the child? The nurse should: A. Put the mother in touch with the department of a hospital that can help her sort out the availability of home nursing care, insurance coverage, and respite care.

B. Remind the mother that the number of staff people caring for the child in the hospital is unlikely to be duplicated at home, making the hospital a better choice.

C. Validate her courageous idea and say that the staff at the hospital will always be available to answer her questions.

D. Suggest that she look into a hospice residence, which is often a good alternative to caring for the child alone at home or having the child remain in the hospital.

Answer: A Rationale: The home can be a more loving and caring environment but this choice must be considered carefully in terms of financial, health care, and caregiver health concerns. This is an extremely difficult decision for a family. Family members need support and guidance from health care personnel while they are trying to make the decision, after the decision is made, and even after the child dies.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 701 11. When mentoring a graduate practical nurse (PN), which behavior would the registered nurse (RN) address if demonstrated by the PN in the care of a dying child?

A. agreeing to pray with the client and family B. checking on the client and family once every shift C. assessing comfort measures needed by the client every hour D. providing bedding for the family to remain close to the client Answer: B Rationale: Graduate nurses frequently have a difficult time interacting with dying clients and their families. When unsure of care or uncomfortable with the situation, nurses tend to avoid the client and family. Checking on the client and family just one time every shift demonstrates practicing avoidance behavior. Taking care measures to ensure client comfort and support for the family requires frequent assessment and nursing care. Praying with the client and family when asked is often welcomed and demonstrates spiritual support. Providing comfort measures for

the dying child is a priority nursing action. Caring for the family by providing opportunities for rest while remaining close to the client encourages family support for the client.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 693 12. A toddler's older sibling has died. Which nursing response best addresses a toddler's concern about, "Where has my brother gone?"

A. "Your brother is gone but is in a special place. We can think about him and remember the fun times."

B. "Your brother has fallen asleep and is safe where he has gone. We look forward to seeing him again someday."

C. "We do not know or understand where your brother has gone as we have never gone there. Many people say it is a wonderful place."

D. "It is best to ask your Mommy where he is. She will explain it to you."

Answer: A Rationale: Questions are best answered simply and honestly when explaining the death of a loved one to a toddler. The toddler must know that the brother is not returning, but we can remember him. Also, many toddlers want to know that the brother is not sick anymore or hurting. The nurse would not relate death to sleeping, because the toddler may become afraid to fall asleep. Stating that we do not understand where the brother is can also be scary for the toddler, because he may think that the brother is lost. Deflecting the toddler's question is not helpful to the toddler and is a block to communication.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 693 13. Which action by the nurse providing end-of-life care to a preschool-aged client best promotes comfort?

A. positioning a favorite toy by the client's hand B. allowing a pet to visit and sit on the client's lap C. providing a warm bath and back massage before bed D. arranging for a bed to allow the parent to lie with the child Answer: D Rationale: The main fear of preschoolers is to be separated from the parents.

Allowing the parents to lie closely with the child soothes the child and promotes

comfort, especially at the end of life. The other options are good client-specific nursing interventions.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 694 14. The nurse is providing client-centered support to an adolescent diagnosed with a terminal illness. Keeping the client's developmental stage in mind, which nursing intervention will best meet the client's needs?

A. rearranging the medication schedule so the client can see a favorite sports team B. changing the client's room so the client can watch the busy outdoors C. limiting visits from friends at school to the client's birthday D. encouraging siblings to participate with client in hospital activities Answer: A Rationale: The nurse must consider the developmental stage of the client.

Adolescents try to live their lives to the fullest while they are able. Adolescents understand their impending death. For the nurse, the best action is to assist, if possible, participation in activities important to the client. Having the client watch the world from the inside is not considering his/her desire to participate in activities. Peers are very important to the adolescent and should be allowed to visit more than on the client's birthday. Hospital activities are not selected by the client.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 695 15. When considering a school-aged child, the nurse should anticipate which factor as playing an influential role in the development of the concept of death?

A. social media B. video games C. family D. friends Answer: C Rationale: Past experiences with death affect the client's attitude and interpretation of death. Family members are role models who have the most influence on the child. Friends and social media have strong influences on the adolescent. Video games are not a typical influence.

Question format: Multiple Choice Chapter 34: The Dying Child

Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 694 16. When caring for a child who is dying, which statement by the child leads the nurse to believe that the topic of death needs to be discussed further?

A. "I am going to a better place."

B. "I do not want to leave my parents."

C. "The bogeyman is going to come and fly me away."

D. "I want to make a picture so my sister remembers me."

Answer: C Rationale: Misconceptions by the child, such as the bogeyman statement, often indicate that no one has prepared the child for death, thus leaving the child to imagine what may happen. The other statements are common for a child who is understands that he or she has a terminal diagnosis.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 695 17. The parents of a terminally ill child ask the nurse how to have a conversation about illness. Which is the most appropriate concept for the nurse to base the response?

A. Be direct, using age-appropriate language the child can understand.

B. Use metaphors that the child has heard from past stories.

C. Relate to a favorite family member who has died.

D. Use broad terms and general statements.

Answer: A Rationale: Children know when they are dying and want to be able to understand what is happening. Being truthful and direct evokes trust and security. Always use age-appropriate language to enhance therapeutic communication. Using metaphors is commonly not realistic and thus can be confusing to the child. Relating to a family member is not about the client. Using broad terms does not thoroughly answer the child's questions and may be a block to communication.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 696

18. Which technique will best foster the initial communication between the nurse and a school-aged child recently told of a cancer diagnosis?

A. Provide supplies for the child to draw a picture.

B. Begin a conversation about the diagnosis with the parent.

C. Sit quietly at the bedside until the child is ready to communicate.

D. Offer age-appropriate board games, movies, or video games.

Answer: A Rationale: Drawing, poetry, or writing lyrics are ways that a school-aged child can express his or her emotions. Upon viewing, the nurse is able to comment, which opens communication. Talking with the parent excludes communication with the child. Sitting quietly is ineffective if the child does not know how to verbalize emotions. Offering board games can be fun and divert the child's attention from the cancer, but this does not help the child communicate feelings.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 699-700 19. A graduate nurse has provided care for a pediatric client who has died. Which statement to the family would require further discussion between the graduate nurse and the registered nurse (RN) mentor?

A. "It is so hard to see you cry."

B. "This reminds me of the time my aunt died."

C. "I am very sorry of your loss. He was a great kid."

D. "Please let me know if there is something I can do for you."

Answer: B Rationale: At the time when the client has died, the focus is on the family and their grief. The nurse would not mention personal experiences. Acknowledging family feelings, validating the life of the child, and letting the family know that nursing staff are there for them are appropriate nursing statements.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Caring Reference: p. 698 20. The emergency room nurse is caring for a family who lost an adolescent in a violent car accident. Which initial nursing action best helps the family's grieving process?

A. notifying the family's religious leader of the tragedy B. cleaning and making the deceased presentable to the family

C. calling the funeral home to make arrangements for the body transfer D. presenting the family with the deceased's personal belongings Answer: B Rationale: The death of a child unexpectedly produces acute grief. Even if the child has a traumatic death with disfigurement, the family must be given the opportunity to see the adolescent to help with closure. The nurse can best aid in the grieving process by cleaning and preparing the body for viewing. The other options are appropriate measures for the nurse to complete, but not most helpful with the grieving process.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 699 21. The nurse is discussing the principles of hospice care to the family of a terminally ill pediatric client. Which parental statement would the nurse clarify as a misconception?

A. "My son will be assessed for pain relief."

B. "We can participate in our religious practices."

C. "My son will still receive aggressive treatments for a cure."

D. "My son will have holistic nursing care meeting his needs."

Answer: C Rationale: The client who is in hospice care will not receive heroic lifesaving measures. Families must understand that hospice services emphasize sensitive, humane care for the dying. Hospice care provides pain relief and holistic care through the dying process. Families are encouraged to practice their faith.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 700 22. When evaluating a terminally ill client for pain relief following medication administration, which nursing assessments would be documented to support that the medication was effective? Select all that apply.

A. Heart rate and respirations are within normal limits.

B. The client is lying in a flexed position on the bed.

C. The client is quietly sleeping on the parent's lap.

D. The child is withdrawing from the environment.

E. The client verbalizes a 1 on the analog pain scale.

Answer: A, C, E Rationale: When the nurse is assessing the client for pain relief following medication administration, vital signs within normal limits support that pain relief has occurred.

Blood pressure and heart and respiration rates are elevated in clients who are in pain. Typically clients who are able to relax and sleep have pain relief. On the analog pain scale, a low score of 0 to 1 documents pain relief. Clients who are flexed or withdrawn display signs of unrelieved pain.

Question format: Multiple Select Chapter 34: The Dying Child Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 702 23. Which factor associated with the caring of a dying pediatric client is most often cited by nurses as presenting the greatest degree of difficulty?

A. realizing that the clients have not lived much of their life B. caring for such families takes a high emotional toll C. being constantly reminded of their personal mortality D. addressing cultural difference in beliefs and practices Answer: C Rationale: Death reminds all people of their own mortality, thus is uncomfortable and must be personally confronted. Having a personal impact is most difficult when caring for clients who are dying. The other options are correct statements, but not as frequently noted.

Question format: Multiple Choice Chapter 34: The Dying Child Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 693 24. The nurse is attempting to include family in the care of a hospitalized, terminally ill adolescent. Which interventions can be appropriately delegated to family members? Select all that apply.

A. Provide mouth swabs for the family to moisten lips.

B. Discuss the client's status with care options at the beside.

C. Provide pillows to facilitate the repositioning for comfort.

D. Keep a blood pressure cuff and stethoscope available at bedside.

E. Supply sufficient disposable pads to be placed under the client as needed.

Answer: A, C, E Rationale: The family is able to provide comfort measures to the dying child. This provides the family with a sense of control and the feeling that they are able to care

for the child in the final days. The family is able to moisten the lips, position the client for comfort, or change pads under or around the child. Discussing the client's status is inappropriate at the bedside because the child may be able to hear the conversation. Nursing measures, such as taking blood pressure, are assigned to the nurse.

Question format: Multiple Select Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 703 25. Which communication strategies are appropriate when discussing the topic of death and dying with a terminally ill school-aged child? Select all that apply.

A. Use the terms death and dying in the conversation.

B. Listen to the child and accept the child's feelings.

C. Tell the client that you know how hard this is.

D. Consider the developmental level of the child.

E. Say "I do not know" when unsure of an answer.

F. Allow the health care provider to answer all questions.

Answer: A, B, D, E Rationale: The nurse should encourage communication with the client and observe for clues that the client is willing to express feelings. Once communication is established, the nurse uses appropriate terms in conversation and listens and accepts the client's feelings. Nurses should always say "I do not know" when unsure of an answer. The nurse must consider the developmental age of the child when interacting with a child. Telling the client that you know it is difficult is a cliché and inappropriate. Nurses, as well as health care providers, may answer the client's questions.

Question format: Multiple Select Chapter 34: The Dying Child Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Reference: p. 695

Chapter 35 1. When caring for an infant who is hospitalized with Haemophilus influenzae meningitis, an important nursing intervention for the child would be for the nurse to: A. restrain the child before and during a seizure.

B. place the child in a side-lying position and keep the position using pillows.

C. monitor intake and output and increase fluid intake every 4 hours.

D. check the child's neurologic status every 2 hours.

Answer: D Rationale: The nursing interventions for the child with meningitis are related to the goals for this child, which include monitoring for complications related to neurologic compromise, preventing aspiration, keeping the child safe from injury during a seizure, and monitoring fluid balance. During a seizure, stay with the child, protect the child from injury, but do not restrain him or her. To prevent aspiration, position the child in a side-lying position, watch for and remove excessive mucus as much as possible, and use suction sparingly. Every 2 hours, observe the child for seizure activity, vital signs, neurologic changes, and change in level of consciousness. The child is placed on fluid restrictions if he or she has decreased urinary output, hyponatremia, increased weight, nausea, and irritability.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 724 2. The caregiver of a 2-year-old calls the clinic concerned that her child may have pushed paper into her ears, and she asks the nurse what to do. The mother found the child pushing on her ears with torn paper on the floor in front of her. What would be the appropriate response by the nurse?

A. "Wait for a day or two to see if the child's ears seem irritated. If they do, bring her in."

B. "Sterilize a pair of narrow tweezers. While someone else holds the child's head still, carefully insert the tweezers and remove the paper if there is any."

C. "The child should be seen by a care provider. Don't put anything in her ear and bring her in right away."

D. "Wash her ear out using warm water and an ear syringe then the paper will flush out with the water."

Answer: C Rationale: Irrigation of the ear may remove small objects except paper, which becomes impacted as it absorbs moisture. The physician generally uses small

forceps to remove objects not dislodged by irrigation. The caregiver should not insert anything into the child's ear.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 717 3. The nurse caring for a deaf child is preparing to give the child an intramuscular injection in the child's upper arm. The child's attention is focused on the caregiver on the opposite side of the bed. Before administering the injection, it would be most important for the nurse to do which of the following?

A. Pat the child gently on the shoulder to get his attention and point to her own arm so he knows she is giving him the injection.

B. Ask his caregiver to point out that the nurse is there.

C. Move around the bed and make eye contact, then show the child the syringe and indicate that the shot is going to be given.

D. Ask the caregiver to keep the child's attention focused on her.

Answer: C Rationale: When speaking to the deaf child, stand or sit face-to-face on the child's level. Be certain that a deaf child can see you before you touch him or her.

Demonstrate each procedure before it is performed, showing the child the equipment or pictures of the equipment to be used.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 716 4. A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse?

A. "This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."

B. "This is a serious problem. Aspirin is likely to cause Reye syndrome, and she should be admitted to the hospital for observation as a precaution."

C. "This is unlikely to be a problem. Half an aspirin is not enough to cause harm.

Reye syndrome generally only develops from prolonged use of aspirin in connection with a virus."

D. "This might or might not be a problem. Watch your daughter for signs of nasal discharge, sneezing, itching of the nose, or dark circles under the eyes. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome."

Answer: A Rationale: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 717 5. The caregivers of a child who has had difficulty learning to walk notice that when the child attempts to pull himself up to stand, he can't seem to get his legs uncrossed and beside each other. When he is in a standing position, he stays up on his toes. This is different from what they saw with their older children and they are concerned. Further diagnostic tests indicate the child has cerebral palsy. When instructing on the types of cerebral palsy, which type will the nurse present?

A. ataxic cerebral palsy B. athetoid cerebral palsy C. rigidity cerebral palsy D. spastic cerebral palsy Answer: D Rationale: Among other things, spastic cerebral palsy is characterized by scissoring caused by severe hip adduction. When scissoring is present, the child's legs are crossed and the toes are pointed down. When standing, the child is on his or her toes. It is difficult for this child to walk on the heels or run. Ataxic cerebral palsy is essentially a lack of coordination caused by disturbances in the kinesthetic and balance senses; it is characterized by an awkward and wide-based gait. Athetoid cerebral palsy is marked by involuntary, uncoordinated motion with varying degrees of muscle tension. Children with this disorder are constantly in motion; the whole body is in a state of slow, writhing muscle contractions whenever voluntary movement is attempted. Rigidity cerebral palsy is uncommon and is characterized by rigid postures and lack of active movement.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 727 6. The nurse is discussing discipline issues with a group of caregivers of preschoolaged children who have a cognitive impairment. One father tells the group that after he tells his child to stop doing something, the child just continues. Parents in the group make the following statements. Which statement indicates an understanding of disciplining the cognitively impaired child?

A. "We hold a family meeting to explain to our other children that she gets away with things they will not get away with because of her impairment."

B. "We wait until a behavior happens a second time and immediately put our child in time-out."

C. "We always take away a privilege our child has been looking forward to, such as going to a movie next weekend."

D. "My wife and I just ignore the behavior and if there is a mess, clean up the mess. He doesn't understand that he has an impairment."

Answer: B Rationale: If discipline is needed, be certain it follows the misdeed immediately so that the cause-and-effect relationship is clear. Obedience is an important part of discipline, especially for the child with faulty reasoning ability, but the objectives of discipline should be much broader than simply obedience. The child needs to know what to expect and finds security and support in routines and consistency. Use kindness, love, understanding, and physical comforting as a major part of discipline.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 731 7. The mother of a child newly diagnosed with an intellectual disability tells the nurse that her partner disagrees with the diagnosis and believes that the child is perfectly normal. The mother shares with the nurse that she finds this reaction frustrating and confusing. Which action by the nurse would be appropriate in supporting this mother?

A. Reassure the mother that her partner's reaction is a normal stage in the grieving process.

B. Offer to speak with the partner to explain how the diagnosis was reached.

C. Suggest that the couple get a second opinion about the child's condition.

D. Recommend that the couple consider placing the child in foster care until they adjust to the diagnosis.

Answer: A

Rationale: The family's first reaction to learning that the child may have cognitive impairment is grief because this is not the perfect child of their dreams. A parent may feel shame, assuming that he or she cannot produce a perfect child. Some rejection of the child is almost inevitable at least in the initial stages, but this must be worked through for the family to cope.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 733 8. What information is most correct regarding the nervous system of the child?

A. The child's nervous system is fully developed at birth.

B. As the child grows, the gross and fine motor skills increase.

C. The child has underdeveloped fine motor skills and well-developed gross motor skills.

D. The child has underdeveloped gross motor skills and well-developed fine motor skills.

Answer: B Rationale: As the child grows, the quality of the nerve impulses sent through the nervous system develops and matures. As these nerve impulses become more mature, the child's gross and fine motor skills increase in complexity. The child becomes more coordinated and able to develop motor skills.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 709 9. The nurse recognizes that if the infant is following normal development, the infant will be able to focus and follow an object with the eyes by what age?

A. 7 days of age B. 21 days of age C. 1 month of age D. 2 months of age Answer: D Rationale: Newborns are born nearsighted. They prefer the human face to other objects. At 1 month they can recognize by site the people they know. By 2 months of age, the infant can focus and follow an object with the eyes. Binocularity develops at 6 months and color vision follows at 7 months.

Question format: Multiple Choice

Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 709 10. The nurse is discussing the ears and hearing in a child with a group of peers.

Which statement is most accurate related to this topic?

A. The eustachian tube in the infant is straighter and wider than in the adult.

B. The infant usually responds to sounds around the age of 6 months.

C. The eardrum is located between the middle and the internal ear.

D. Most children do not have acutely developed hearing until the age of 5 years.

Answer: A Rationale: In infants and young children, the eustachian tube is straighter, shorter, and wider than in the older child and adult. Hearing in children is acute, and the infant will respond to sounds within the first month of life.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 716 11. The nurse is teaching a group of parents about eyes and eye concerns. The nurse tells these caregivers about a condition that occurs when unequal curvatures in the cornea bend the light rays in different directions and this causes images to be blurred. The condition the nurse is referring to is: A. Refraction B. Myopia C. Astigmatism D. Hyperopia Answer: C Rationale: Astigmatism is caused by unequal curvatures in the cornea that bend the light rays in different directions and produce a blurred image. Refraction is the way light rays bend as they pass through the lens to the retina. Myopia is nearsightedness; hyperopia is farsightedness.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 710

12. The caregiver of a 2-year-old child tells the nurse, "They told me my daughter has an eye disorder called hyperopia." Which statement made by the mother indicates she has an understanding of this child's current condition?

A. "She can see better close up than at a distance."

B. "Now I know why when she is working on puzzles she says her eye is sleepy."

C. "She has to have glasses right away."

D. "At least by the time she gets married maybe she can have contacts."

Answer: B Rationale: Hyperopia is farsightedness in which a person sees objects better at a distance than close up. Considerable eye fatigue may result from efforts at accommodation for close work. It is common in young children and often persists into the first grade or even later. Usually correction is not needed in a preschooler.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 709 13. The nurse is caring for an 8-year-old hospitalized child who is visually impaired.

Which nursing intervention would be the highest priority in helping this child reduce anxiety related to hospitalization?

A. The nurse takes the child to the playroom and lets her touch the toys.

B. The nurse talks to the child when entering and leaving the room.

C. The nurse encourages the child to call her friends on the telephone.

D. The nurse stays with the child during meals and helps her eat.

Answer: B Rationale: The highest priority is for the nurse to identify herself to the child when entering or leaving the room. This helps reduce fear and anxiety and the possibility of being startled by an unexpected touch. It is important for the child to have activities related to normal growth and development, such as touching and playing with the toys in the playroom, talking on the telephone, and having the nurse spend time with the child, but these are not the highest priorities.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Caring Reference: p. 712 14. The nurse is observing a child following an eye injury. Which symptom should alert the nurse to the possibility that the child's uninjured eye may be exhibiting signs of an inflammatory reaction?

A. swelling or dryness

B. brightness of vision C. discharge of purulent drainage D. an intolerance to light Answer: D Rationale: Sympathetic ophthalmia, an inflammatory reaction of the uninjured eye, may follow perforation wounds of the eye. Sympathetic ophthalmia often includes photophobia (intolerance to light), lacrimation (secretion of tears), pain, and some dimness of vision. Symptoms of eye infections include swelling discharge of purulent material.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 713 15. The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with otitis media. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of otitis media?

A. "When you look at the ear of the infant, pull the ear up and back."

B. "They usually are fussy, but they rarely have a fever."

C. "After the eardrum ruptures, the child's pain is relieved."

D. "Antibiotics don't have much effect, so they aren't used for treatment."

Answer: C Rationale: Spontaneous rupture of the eardrum may occur, in which case there will be purulent drainage, and the pain caused by the pressure buildup in the ear will be relieved. The ear in the infant is examined with an otoscope by pulling the ear down and back to straighten the ear canal. In the older child, the ear is pulled up and back. Symptoms may include fever, irritability, and hearing impairment. Antibiotics are used during the period of infection and for several days after to prevent mastoiditis or chronic infection.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 716 16. In children with otitis media, a procedure known as a myringotomy may be performed. Which statement is most accurate regarding this procedure?

A. During this procedure, small tubes are inserted into the tympanic membrane.

B. This procedure is performed as soon as otitis media is diagnosed.

C. A small incision is made in the earlobe during this procedure.

D. The purpose of this procedure is to decrease or stop the drainage.

Answer: A Rationale: Myringotomy (incision of the eardrum) may be performed to establish drainage and to insert tiny tubes into the tympanic membrane to facilitate drainage.

The procedure is done for children with chronic otitis media, not as soon as the child is diagnosed.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 716 17. The nurse is collecting data on an 18-month-old child admitted with a diagnosis of possible seizures. When interviewing the caregivers, which questions would be most important for the nurse to ask?

A. "Is your child up to date on his immunizations?"

B. "Has anyone in your family been sick recently" C. "What type of activities was your child doing today?"

D. "Have you checked your child's temperature?"

Answer: D Rationale: In children between the ages of 6 months and 3 years, febrile seizures (seizures resulting from fever) are the most common. Febrile seizures usually occur in the form of a generalized seizure early in the course of a fever. Although an illness in another member of the family might indicate the possibility of an infection or other illness, this would not be the priority question to ask. If the child has had an immunization recently, the child could develop a fever, but asking if the immunizations are up-to-date is not asking about recent immunizations. The child's daily activities would not likely promote seizure activity.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 718 18. The nurse is caring for a child admitted with focal onset impaired awareness seizure (complex partial seizure). Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. The child had jerking movements and then the extremities stiffened.

B. The child had shaking movements on one side of the body.

C. The child was rubbing the hands and smacking the lips.

D. The child was dizzy and had decreased coordination.

Answer: C Rationale: With the focal onset impaired awareness seizure, formerly called complex partial seizure, the child is confused or their awareness is affected during the seizure. The seizure begins in a small area of the brain and changes or alters consciousness. These seizures can have motor and non-motor symptoms. They cause memory loss and staring and nonpurposeful movements, such as hand rubbing, lip smacking, arm dropping, and swallowing. In the tonic phase of tonic– clonic seizures, the child's muscles contract, the child may fall, and the child's extremities may stiffen. During the prodromal period of the tonic–clonic seizure, the child might have a lack of coordination.Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 718 19. The nurse is collecting data from the caregivers of a child admitted with seizures. Which statement indicates the child most likely had an absence seizure?

A. "His arms had jerking movements in his legs and face."

B. "He was just staring into space and was totally unaware."

C. "He kept smacking his lips and rubbing his hands."

D. "He usually is very coordinated, but he couldn't even walk without falling."

Answer: B Rationale: Absence seizures rarely last longer than 20 seconds. The child loses awareness and stares straight ahead but does not fall. Myoclonic seizures are characterized by a sudden jerking of a muscle or group of muscles, often in the arms or legs, without loss of consciousness.. Focal onset impaired awareness seizures (formerly called complex partial seizure) cause nonpurposeful movements, such as hand rubbing and lip smacking. During the prodromal period of the tonicclonic seizure, the child might have a lack of coordination.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 719 20. The nurse is caring for a child admitted with focal onset motor seizures (simple partial motor seizures). Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. The child had jerking movements in the legs and facial muscles.

B. The child had shaking movements on one side of the body.

C. The child was rubbing the hands and smacking the lips.

D. The child was dizzy and had decreased coordination.

Answer: B Rationale: Focal onset aware seizures (formerly called simple partial seizures) can either have motor or sensory symptoms. A focal onset motor seizure causes a localized motor activity such as shaking of an arm, leg, or other body part. A focal onset sensory seizure may include sensory symptoms called an aura, which signals an impending attack. Myoclonic seizures are characterized by a sudden jerking of a muscle or group of muscles, often in the arms or legs, without loss of consciousness. Complex partial seizures may cause nonpurposeful movements, such as hand rubbing and lip smacking. During the prodromal period of the tonicclonic seizure, the child might have a lack of coordination.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 718 21. The nurse is interviewing the caregivers of a child brought to the emergency unit. The caregiver states, "She has a history of seizures but this time it lasted more than 30 minutes and she just keeps having them." The most accurate description of this child's condition would be: A. The child is in status epilepticus.

B. The child is having generalized seizures.

C. The child's history indicates she has infantile seizures.

D. The child may begin to have absence seizures every day.

Answer: A Rationale: Status epilepticus is the term used to describe a seizure that lasts longer than 30 minutes, or a series of seizures in which the child does not return to his or her previous normal level of consciousness. The child likely is having generalized seizures, but the most accurate description of what is happening is status epilepticus. With infantile spasms, muscle contractions are sudden, brief, symmetrical, and accompanied by rolling eyes. With absence seizures the child loses awareness and stares straight ahead but does not fall.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 719

22. The caregiver of a child who has a history of seizures reports that her child was complaining of being dizzy, and the caregiver noted the child seemed drowsy and was clumsy. The nurse recognizes that the description of the child's behavior was most likely which stage of a tonic-clonic seizure?

A. aura B. clonic C. postictal D. prodromal Answer: D Rationale: During the prodromal period of a seizure, the child might be drowsy, dizzy, or have a lack of coordination. The aura is a warning immediately before the seizure and may relate to sensory signs. There are generalized jerking muscle movements in the clonic phase. During the postictal period, the child may sleep soundly and may have a period of confusion or stupor.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 719 23. The nurse caring for a 3-year-old child with a history of seizures observes the child having a seizure. What information should the nurse document concerning the event? Select all that apply.

A. Time the seizure started B. Factors present before seizure started C. Persons in attendance during seizure D. Number of seizures child has had in the last 48 hours E. Eye position and movement F. Incontinence of urine or stool Answer: A, B, E, F Rationale: Following a seizure, the nurse documents the following: time the seizure started; what the child was doing when the seizure began; any factor present just before the seizure (bright light, noise); part of the body where seizure activity began; movement and parts of the body involved; any cyanosis; eye position and movement; incontinence of urine or stool; time seizure ended; and child's activity after the seizure. Who was with the child or the number of seizures the child has had are not relevant to document regarding observation of this seizure.

Question format: Multiple Select Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Communication and Documentation Reference: p. 722

24. The nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client?

A. The caregivers will be prepared to care for the child at home.

B. The child will have an understanding of the disorder.

C. The family will understand seizure precautions.

D. The child will remain free from injury during a seizure.

Answer: D Rationale: Keeping the child free from injury is the priority goal. The other choices are important, but keeping the child safe is higher than preparing for home care or knowledge deficit concerns. The physical concerns are always priority over the psychological concerns when caring for clients.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Analyze Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 722 25. A symptom often seen in the child diagnosed with Haemophilus influenza meningitis occurs when the child has a stiff neck. This symptom is referred to as which of the following?

A. opisthotonos B. nuchal rigidity C. encephalopathy D. purpuric rash Answer: B Rationale: Nuchal rigidity (stiff neck) is a symptom seen in Haemophilus influenzae meningitis that may progress to opisthotonos (arching of the back). Encephalopathy is an abnormal condition of the brain tissues. Bleeding under the skin causes a purpuric rash.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 723 26. In caring for the child with meningitis, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care?

A. Delayed growth and development related to physical restrictions B. Risk for injury related to seizure activity C. Risk for acute pain related to surgical procedure D. Ineffective airway clearance related to history of seizures

Answer: B Rationale: The child's risk for injury would be an appropriate nursing diagnosis.

Surgery is not indicated for the child with meningitis, and if the child has a history of seizures, it would specifically impact airway clearance. Growth and development issues are a concern but not likely delayed due to this diagnosis.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 724 27. Haemophilus influenzae meningitis is usually spread by which method of transmission?

A. intravenous B. fecal C. droplet D. contact Answer: C Rationale: Transmission of H. influenzae meningitis is by means of droplet infection from an infected person; other forms of meningitis are contracted by an invasion of the meninges via the bloodstream from an infection elsewhere. Fecal and contact transmission is not how H. influenzae meningitis is spread or transmitted.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 723 28. The nurse is observing a group of children diagnosed with various types of cerebral palsy. One of the children has an awkward and wide-based gait. The nurse recognizes this characteristic as common in which type of cerebral palsy?

A. ataxic cerebral palsy B. athetoid cerebral palsy C. rigidity cerebral palsy D. spastic cerebral palsy Answer: A Rationale: Ataxic cerebral palsy is essentially a lack of coordination caused by disturbances in the kinesthetic and balance senses; it is characterized by an awkward and wide-based gait. Athetoid cerebral palsy is marked by involuntary, uncoordinated motion with varying degrees of muscle tension. Children with this

disorder are constantly in motion; the whole body is in a state of slow, writhing muscle contractions whenever voluntary movement is attempted. Rigidity cerebral palsy is uncommon and is characterized by rigid postures and lack of active movement. Spastic cerebral palsy is characterized by scissoring caused by severe hip adduction.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 727 29. The nurse is reinforcing teaching with the caregivers of a child who has had a head injury and is being discharged. Which statement made by the caregiver indicates an accurate understanding of the follow-up care for this child?

A. "If he falls asleep, we will wake him up every 15 minutes."

B. "We can give him acetaminophen for a headache, but no aspirin."

C. "Even if the flashlight bothers him, we will check his eyes."

D. "If he vomits again, we will bring him back immediately."

Answer: C Rationale: The child's pupils are checked for reaction to light every 4 hours for 48 hours. If the child falls asleep, he or she should be awakened every 1 to 2 hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The caregiver should observe the child for at least 6 hours for vomiting or a change in the child's level of consciousness. The caregiver should notify the health care provider immediately if the child vomits more than three times, but if the child vomits once, returning to the care provider immediately is not needed.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 735 30. A child is home with the caregivers following a treatment for a head injury. The caregiver should contact the care provider if the child makes which statement?

A. "You look funny. Well, both of you do. I see two of you."

B. "My stomach is upset. I feel like I might throw up."

C. "I am glad that my headache is getting better."

D. "It will be nice when you will let me take a long nap. I am sleepy."

Answer: A Rationale: The caregiver should notify the health care provider immediately if the child vomits more than three times, has pupillary changes, has double or blurred

vision, has a change in level of consciousness, acts strange or confused, has trouble walking, or has a headache that becomes more severe or wakes him or her from sleep. These instructions should be provided in written form to the caregiver. Just feeling nauseated is not a reason to notify the provider.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 735 31. Which of these age groups has the highest actual rate of death from drowning?

A. infants B. toddlers C. preschool children D. school-aged children Answer: B Rationale: Toddlers and older adolescents have the highest actual rate of death from drowning.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 735 32. The nurse is talking with the mother of a 4-year-old boy who will soon be going to a pre-kindergarten program. The child has had the Snellen vision test done at home, and he was unable to distinguish the pictures at the distance that would indicate his vision is normal. The child's mother asks the nurse if he will need glasses. Which statement made by the nurse would be most appropriate regarding the child's vision?

A. "He might be suffering from hyperopia and probably will need glasses now."

B. "A child's vision is not completely developed by this age. Your child might outgrow this nearsightedness."

C. "He is likely to have a slight astigmatism, which almost always needs to be corrected by glasses."

D. "His vision problem will get in the way of his learning, so he will probably have to have glasses before he starts school."

Answer: B Rationale: Visual acuity of children gradually increases from birth, when the visual acuity is usually between 20/100 and 20/400, until about 5 years of age, when most children have 20/20 vision. Hyperopia (farsightedness) is a refractive condition in which the person can see objects better at a distance than close up.

Astigmatism is caused by unequal curvatures in the cornea that bend the light rays in different directions.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 709 33. The health care provider orders amoxicillin 35 mg/kg/day in three divided doses for a child with otitis media. The child weighs 44 lb and the medication is available in a suspension of 50 mg/ml. What is the total daily dosage in ml for this child?

A. 0.4 ml B. 1.4 ml C. 14.0 ml D. 140 ml Answer: C Rationale: The child weighs 20 kg. The total daily dose would be 700 mg of medication or a total of 14 ml of medication for the total daily dosage.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 716 34. When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply.

A. The nurse pads the crib or side rails before a seizure.

B. The nurse positions the child on the side during a seizure.

C. The nurse places a washcloth in the mouth to prevent injury during seizure.

D. The nurse stays with the child and calls for help when a seizure begins.

E. The nurse has oxygen available to use during a seizure.

F. The nurse teaches the caregivers regarding seizure precautions.

Answer: A, B, D, E, F Rationale: The nurse should pad the crib sides and keep sharp or hard items out of the crib. The nurse should also position the child to one side to prevent aspiration of saliva or vomitus and have oxygen and suction equipment readily available for emergency use. The nurse should teach family caregivers seizure precautions so they can handle a seizure that occurs at home. The nurse should not put anything in the child's mouth; doing so could cause injury to the child or to the nurse. It is important for the nurse to promptly inform other members of the care team when a child is experiencing seizure activity, but leaving the bedside to do so would be unsafe.

Question format: Multiple Select Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 722 35. The nurse asks the caregivers of a child diagnosed with cerebral palsy whether the child "seems to be in a state of constant motion." The question is designed to identify what form of cerebral palsy?

A. ataxic B. athetoid C. rigidity D. spastic Answer: B Rationale: Athetoid cerebral palsy is marked by involuntary, uncoordinated motion with varying degrees of muscle tension. Children with this disorder are constantly in motion; the whole body is in a state of slow, writhing muscle contractions whenever voluntary movement is attempted. Ataxic cerebral palsy is essentially a lack of coordination caused by disturbances in the kinesthetic and balance senses; it is characterized by an awkward and wide-based gait. Rigidity cerebral palsy is uncommon and is characterized by rigid postures and lack of active movement.

Spastic cerebral palsy is characterized by scissoring caused by severe hip adduction. When scissoring is present, the child's legs are crossed and the toes are pointed down. When standing, the child is on her or his toes. It is difficult for this child to walk on the heels or run.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 727 36. The nurse is providing education to the caregivers of a child recently diagnosed with tonic-clonic seizure disorder. What instructions should the nurse provide related to the tonic stage of this type of seizure?

A. Be prepared for the child to report being dizzy.

B. Ask the child whether he or she is experiencing any unusual sensory sensations.

C. Monitor the child's breathing closely.

D. Be prepared for the child to be temporarily confused.

Answer: C Rationale: Tonic–clonic seizures consist of four stages: the prodromal period, when the child may be drowsy or dizzy; the aura, which is sensory event that serves as a warning immediately before the seizure; the tonic–clonic movements, when the

child's muscles contract, the child may fall, and the child's extremities may stiffen.

The contraction of respiratory muscles during the tonic phase may cause the child to become cyanotic and appear briefly to have respiratory arrest. During the postictal period, the child may sleep soundly and may have a period of confusion or stupor.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 719 37. The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client?

A. frequent temperature assessment B. use of anticonvulsant medications C. ketogenic diet D. vagus nerve stimulation Answer: B Rationale: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.

Question format: Multiple Choice Chapter 35: The Child with a Sensory/Neurologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 720

Chapter 36 1. A female nurse of childbearing ages caring for a 2-year-old child diagnosed with bacterial pneumonia. The child has been placed in a mist tent. In caring for the child, it is important for the nurse to: A. monitor the child regularly for signs of cyanosis.

B. avoid contact with the mist.

C. use contact transmission precautions.

D. check for hyperthermia related to enclosure in the tent.

Answer: A Rationale: In some treatment of bacterial pneumonia a croupette or mist tent is used. When a child is in a mist tent, the nurse must be constantly observed for cyanosis. Studies how that children have become cyanotic in mist tents and have suffer subsequent arrest, due to the lack of visibility while in the tent. Treatments for bacterial pneumonia do not carry risk for teratogenicity. Ribavirin is an antiviral drug that may be used to treat certain children with respiratory syncytial virus. It is administered as an inhalant by hood, mask, or tent and has a high risk for teratogenicity. In treating a client with bacterial pneumonia, the client may need to be placed on infection control precautions according to the policy of the health care facility; in most facilities, these will be droplet precautions. Although the nurse should look for hyperthermia related to the infection process, there is no risk for hyperthermia related to the child being enclosed in the tent.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process 0 p. 757 2. The caregivers of a child who was diagnosed with cystic fibrosis 5 months ago report that they have been following all of the suggested guidelines for nutrition, fluid intake, and exercise, but the child has been having bouts of constipation and diarrhea. The nurse tells the caregiver to increase the amount of which substance in the child's diet?

A. Iodized salt B. Saturated fat C. Pancreatic enzymes D. Calories from protein Answer: C Rationale: Adequate nutrition helps the child resist infections. Pancreatic enzymes must be administered with all meals and snacks. If the child has bouts of diarrhea or constipation, the dosage of enzymes may need to be adjusted. The child's diet

should be high in carbohydrates and protein with no restriction of fats. The child may need 1.5 to 2 times the normal caloric intake to promote growth. Low-fat products can be selected if desired. The child also may require additional salt in the diet. Increased caloric intake compensates for impaired absorption.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 760 3. The nurse is teaching the caregivers of a child with cystic fibrosis. What is most important for the nurse to teach this family?

A. Be sure the child exercises daily.

B. Watch out for signs that family members are overly stressed.

C. Avoid overprotecting the child.

D. Encourage everyone in the family to use good handwashing techniques.

Answer: D Rationale: The child with cystic fibrosis has low resistance, especially to respiratory infections. For this reason, take care to protect the child from any exposure to infectious organisms. Good handwashing techniques should be practiced by the whole family; teach the child and family the importance of this first line of defense.

Practice and teach other good hygiene habits.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 764 4. The nurse is doing discharge teaching for a child who has had a tonsillectomy.

The nurse tells the client and family that the child should have plenty of fluids. In addition, the nurse would explain to the child's caregiver that the child may: A. have a painful earache around the third day postoperatively, but the earache will be gone by the fourth day.

B. vomit dark, old blood, but the caregiver should call the clinic if the child has bleeding between the fifth and seventh days postoperatively.

C. be given ice cream and milk the first postoperative day because these foods make swallowing easier.

D. have severe throat pain for up to 2 weeks postoperatively; this is not a concern.

Answer: B Rationale: Bleeding is most often a concern within the first 24 hours following surgery and between the fifth to seventh days postoperatively. Bright, red-flecked emesis or oozing indicates fresh bleeding. If at any time following the surgery there

is bright red bleeding, frequent swallowing, or restlessness, the care provider should be notified. A mild earache may be expected around the third day.

Encourage fluid intake but avoid irritating liquids such as orange juice. Be aware that milk and ice cream products tend to cling to the surgical site and make swallowing more difficult; thus they are poor choices despite the old tradition of offering ice cream after a tonsillectomy.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 746 5. The caregivers of an 8-year-old bring their child to the pediatrician and report that the child has not had breathing problems before, but since taking up lacrosse the child has been coughing and wheezing at the end of every practice and game.

Their friend's child has often been hospitalized for asthma; they are concerned that their child has a similar illness. The nurse knows that because the problems seem to be directly related to exercise, it is likely that the child will be able to be treated with: A. decreased activity and increased fluids.

B. corticosteroids and leukotriene inhibitors.

C. removal of allergens in the home and school.

D. a bronchodilator and mast cell stabilizers.

Answer: D Rationale: Mast cell stabilizers are used to help decrease wheezing and exerciseinduced asthma attacks. A bronchodilator often is given to open up the airways just before the mast cell stabilizer is used. Corticosteroids are anti-inflammatory drugs used to control severe or chronic cases of asthma. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 749 6. The nurse is doing an in-service training with nurses working with families who may be in situations that create high-risk health situations for their children. The nurse explains that children of caregivers with which situation should be tested annually for tuberculosis?

A. a caregiver with a diagnosis of HIV B. a caregiver who has been serving in the military in the Middle East C. a caregiver whose family is homeless D. a caregiver who immigrated from Africa before her child was born

Answer: C Rationale: Tuberculosis screening is recommended annually for children in high-risk situations or communities, including the following: a family in which there is an active case of TB; Native American children; and children who recently immigrated from Central or South America, the Caribbean, Africa, Asia, or the Middle East.

Other high-risk children are those infected with HIV, those who are homeless or live in overcrowded conditions, and those immunosuppressed from any cause.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 766 7. The caregiver of a 6-month-old boy calls the nurse concerned about her child.

The child has been irritable, fussy, and is sneezing. The child's temperature is 100oF (37.8oC). The nurse suspects that the cause of the symptoms is: A. pneumonia.

B. a pollen-based allergy.

C. cystic fibrosis.

D. a common cold.

Answer: D Rationale: The child with a common cold sneezes and becomes irritable, fussy and restless. The congested nasal passages can interfere with nursing, increasing the infant's irritability. Because an older child can mouth breathe, nasal congestion is not as great a concern as it is in the infant. The infant usually develops fever early in the course of the infection, often as high as 102°F to 104°F (38.9°C to 40°C), The child with an allergy woulld have more symptoms and will not likely have an elevated temperature The infant with pneumonia will most likely have a rapid and abrupt temperature increase, possibly to 103°F to 105°F (39.4°C to 40.6°C) and marked respiratory distress with obvious air hunger, flaring of the nostrils, circumoral (around the mouth) cyanosis, and chest retractions. The child with cystic fibrosis will have a hard, nonproductive chronic cough, a barrel chest, and clubbing of fingers. The abdomen becomes distended, and body muscles become flabby.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 743-744 8. The nurse is bottle feeding an infant diagnosed with pneumonia. An important action for the nurse to take is clearing the infant's nose, and then the nurse should feed the infant using:

A. a large-holed nipple so that the infant doesn't have to work too hard.

B. the smallest-holed nipple available so that the infant can exercise the muscles.

C. a nipple that is small enough so that the baby doesn't choke, but not so small that they have to work too hard to eat.

D. a nipple specially designed to fit an infant's mouth.

Answer: C Rationale: For the infant with pneumonia, use the smallest nipple so that he or she does not choke, but also does not have to work too hard. A large-holed nipple would allow the fluids to flow too quickly and likely choke the infant. Working too hard with a small-holed nipple would wear the infant out and require the use of excessive energy. There is no need for a special nipple.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 757 9. What statement is the most accurate regarding the structure and function of the newborn's respiratory system?

A. The diameter of the child's trachea is the same as that of adults.

B. Most infants are nasal breathers rather than mouth breathers.

C. The respiratory tract in the child is fully developed by age 2.

D. Infants and young children have smaller tongues in proportion to their mouths.

Answer: B Rationale: Newborns are obligatory nose breathers until at least 4 weeks of age.

The diameter of the infant and child's trachea is about the size of the child's little finger. The respiratory tract grows and changes until the child is about 12 years of age. During the first 5 years of life, infants and young children have larger tongues in proportion to their mouths.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 743 10. The nurse is working with a group of caregivers of small children discussing various disorders seen in children. One of the caregivers makes the statement that her children always seem to have a common cold. After discussing this condition, the caregivers make the following statements. Which statement indicates the most accurate understanding of a complication related to the common cold?

A. "When my 6-month-old gets a cold, I know her temperature will be high."

B. "At least with a cold they only have diarrhea for a few days."

C. "Next time he has a cold, I will watch closely to see if my 1-year-old pulls at his ears."

D. "Last week my son came home from school with a cold and I gave him Tylenol for the pain."

Answer: C Rationale: The most common complication of a common cold is otitis media. If the symptoms persist for several days, the child must be seen by a physician to rule out complications such as otitis media. Most young children do not have a fever with a common cold. The child may have mild diarrhea caused by mucus drainage into the digestive system, but this is not a major complication seen with the condition. The school-age child can be given acetaminophen, but pain is not a complication associated with the common cold.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 744 11. The caregivers of a child report that their child had a cold and complained of a sore throat. When interviewed further they report that the child has a high fever, is very anxious, and is breathing by sitting up and leaning forward with the mouth open and the tongue out. The nurse recognizes these symptoms as those seen with which disorder?

A. Spasmodic laryngitis B. Tonsillitis C. Laryngotracheobronchitis D. Epiglottitis Answer: D Rationale: The child with epiglottitis may have had a mild upper respiratory infection before the development of a sore throat, and then became anxious and prefers to breathe by sitting up and leaning forward with the mouth open and the tongue out. The child with tonsillitis may have a fever, sore throat, difficulty swallowing, hypertrophied tonsils, and erythema of the soft palate. Exudate may be visible on the tonsils. The child with acute laryngotracheobronchitis develops hoarseness and a barking cough with a fever, cyanosis, heart failure; acute respiratory embarrassment can also result.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 748

12. The nurse is assigned four pediatric clients with diagnoses of acute bronchiolitis and acute interstitial pneumonia. When discussing the history of the disorder, the nurse anticipates which for the age of onset?

A. "It is most often seen in premature newborns right after they are born."

B. "Most children who have this are about 6 months old."

C. "It usually occurs when children start school, around the age of 5."

D. "Most children with this disorder are in their teens."

Answer: B Rationale: Acute bronchiolitis (acute interstitial pneumonia) is most common during the first 6 months of life and is rarely seen after the age of 2 years.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 748 13. The nurse is working with a group of caregivers of children diagnosed with asthma. Which statement made by a caregiver is most accurate regarding the triggers that may cause an asthma attack?

A. "My neighbor told me that asthma attacks are caused by hot weather."

B. "I always thought that a lack of exercise caused my child's asthma."

C. "My sister and her family love animals, and when we go to their house my daughter always has an asthma attack."

D. "One person told me that asthma is caused by using antibiotics for infection."

Answer: C Rationale: Asthma may be a response to certain foods, or may be triggered by exercise or exposure to cold weather. Irritants such as wood-burning stoves, cigarette smoke, dust, pet dander, and foods such as chocolate, milk, eggs, nuts, and grains may also aggravate the condition. Additionally, infections such as bronchitis and upper respiratory infection can provoke asthma attacks. Using antibiotics to treat infections does not cause an asthma attack.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 749 14. The nurse is caring for a child admitted with asthma. Which clinical manifestations would likely have been noted in the child with this diagnosis?

A. Elevated temperature B. Wheezing C. Circumoral cyanosis

D. Clubbed fingers Answer: B Rationale: Symptoms of asthma include dry hacking cough, wheezing (the sound of expired air being pushed through obstructed bronchioles), and difficulty breathing.

Elevated temperature is not usually seen. Circumoral cyanosis is seen with a diagnosis of pneumonia, and clubbing of the fingers is seen in cystic fibrosis.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 749 15. The nurse is caring for a child who has been admitted with a diagnosis of asthma. What laboratory/diagnostic tool would likely have been used for this child?

A. Purified protein derivative test B. Sweat sodium chloride test C. Blood culture and sensitivity D. Pulmonary functions test Answer: D Rationale: Pulmonary function tests are valuable diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs. Purified protein derivative tests are used to detect TB. Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 750 16. The nurse is caring for a child who has been admitted with a possible diagnosis of cystic fibrosis. Which laboratory/diagnostic tools would most likely be used to help determine the diagnosis of this child?

A. Purified protein derivative test B. Sweat sodium chloride test C. Blood culture and sensitivity D. Pulmonary functions test Answer: B

Rationale: Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Purified protein derivative tests are used to detect TB. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection. Pulmonary function tests are diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 760 17. The nurse is caring for a child who has been admitted with a possible diagnosis of tuberculosis. Which laboratory/diagnostic tools would most likely be used to help diagnose this child?

A. Purified protein derivative test B. Sweat sodium chloride test C. Blood culture and sensitivity D. Pulmonary functions test Answer: A Rationale: Purified protein derivative tests are used to detect TB. Sweat sodium chloride tests are used for determining the diagnosis of cystic fibrosis. Blood culture and sensitivity is done to determine the causative agent as well as the anti-infective needed to treat an infection. Pulmonary function tests are diagnostic tools for the child with asthma and indicate the amount of obstruction in the bronchial airways, especially in the smallest airways of the lungs.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 766 18. The LPN is working with the RN to develop a plan of care for a child with asthma. Which would be appropriate goals of treatment for this child? Select all that apply.

A. preventing symptoms B. decreasing activity levels C. preventing recurrence D. decreasing fluid intake E. relieving pain Answer: A, C

Rationale: The goals of asthma treatment includes preventing symptoms, maintaining near-normal lung function and activity levels, preventing recurring exacerbations and hospitalizations, and providing the best medication treatment with the fewest adverse effects. Pain is not a major concern for the child with asthma.

Question format: Multiple Select Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 751 19. The nurse is reinforcing teaching with a group of caregivers of children diagnosed with asthma. Which statement best indicates an understanding of the management and treatment for this diagnosis?

A. "We have taken the carpet out of our house and let my mom take our dog."

B. "He knows how and even when he needs to use his peak flow meter."

C. "Even the babysitter helps us keep up the diary with her symptoms."

D. "The medications she takes are all in one place, ready for her to take at any time."

Answer: A Rationale: Families must make every effort to eliminate any possible allergens from the home. Prevention is the most important aspect in the treatment of asthma.

Learning how to use a peak flow meter, using a peak flow and symptom diary, and having the medications available are important aspects of treatment, but prevention is the best.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 750 20. The nurse at a camp for children with asthma is teaching these children about the medications they are taking and how to properly take them. The nurse recognizes that many medications used on a daily basis for the treatment of asthma are given by which method?

A. Directly into the vein B. Through a gastrostomy tube C. Using a nebulizer D. Sprinkled onto the food Answer: C Rationale: Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a

face mask) or a metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). Emergency medications are given intravenously. Most children do not have a gastrostomy tube, and medications sprinkled on foods are given with cystic fibrosis.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 751 21. The nurse is reinforcing teaching about medications with the parents of a 2year-old who has cystic fibrosis. The nurse suggests that pancreatic enzymes may be given by which method?

A. Directly into the vein B. Through a gastrostomy tube C. Using a nebulizer D. Sprinkled onto the food Answer: D Rationale: Pancreatic enzymes are used in the treatment of cystic fibrosis and are given by opening the capsule and sprinkling the medication on the child's food. If the child with cystic fibrosis has an infection, IV medications may be given, but this is not on a daily basis. Most children do not have a gastrostomy tube. Many of these drugs used in the treatment of asthma can be given either by a nebulizer (tube attached to a wall unit or cylinder that delivers moist air via a face mask) or a metered-dose inhaler [MDI], which is a hand-held plastic device that delivers a premeasured dose.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 760 22. During a class for caregivers of children with asthma, a caregiver asks the nurse the following question when medications are being discussed. "They told me about a plastic device my child can hold in his a hand which will give him a premeasured and exact amount of his corticosteroid." The nurse recognizes that the caregiver is most likely referring to which device?

A. Medication cup B. Metered-dose inhaler C. Nebulizer D. Needleless syringe Answer: B

Rationale: In the treatment of asthma, corticosteroids are most often delivered by metered-dose inhaler ([MDI], which is a hand-held plastic device that delivers a premeasured dose). The medication cup and needleless syringe may deliver PO medications, but most often corticosteroids are not given PO in the treatment of asthma, and those would not be premeasured and an exact dosage like a metereddose inhaler would be. Corticosteroids are not administered by nebulizer.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 751 23. In caring for the child with asthma, the nurse recognizes that bronchodilator medications are administered to children with asthma for which reason?

A. Relief of acute symptoms B. Management of chronic pain C. To stabilize the cell membranes D. Prevention of mild symptoms Answer: A Rationale: Bronchodilators are used for quick relief of acute exacerbations of asthma symptoms. Mast cell stabilizers help to stabilize the cell membrane by preventing mast cells from releasing the chemical mediators that cause bronchospasm and mucous membrane inflammation. Leukotriene inhibitors are given by mouth along with other asthma medications for long-term control and prevention of mild, persistent asthma. Bronchodilators are not effective for pain.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 751 24. In caring for the child with asthma, the nurse recognizes that which nursing diagnosis would be the highest priority in this child's plan of care?

A. Delayed growth and development related to physical restrictions B. Risk for fluid volume excess related to medications C. Risk for infection related to anatomic structures of involved body system D. Ineffective airway clearance related to the diagnosis Answer: D Rationale: The highest priority for the child with asthma is to keep the airway clear because of the bronchospasms and increased pulmonary secretions the child may have. The child is more likely to have deficient fluid volume related to tachypnea and diaphoresis. Infections can occur, but they are less of a concern than the

airway clearance. Growth and development issues can occur because the child may have to limit activities, but these issues are not the priority.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 753 25. The nurse caring for the child with asthma weighs the child daily. What is the most important reason for doing a daily weight on this child?

A. To determine medication dosages B. To monitor the child's growth pattern C. To ensure that the child's food intake is adequate D. To determine fluid losses Answer: D Rationale: During an acute asthma attack the child may lose a great quantity of fluid through the respiratory tract and may have poor oral intake because of coughing and vomiting. Theophylline administration also has a diuretic effect, which compounds the problem. Weigh the child daily to help determine fluid losses. The child's weight is used to determine medication dosages, to ensure that the child is appropriately gaining weight and growing, and that the intake is adequate.

However, the most important reason for a daily weight is to determine fluid loss.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 753 26. A group of nurses is reviewing the diagnosis of cystic fibrosis. With regard to the effect of this disease on the body, which parts of the body (besides the lungs) are most affected by this disease?

A. Brain and spinal cord B. Pancreas and liver C. Heart and blood vessels D. Kidney and bladder Answer: B Rationale: The major organs affected are the lungs, pancreas, and liver. The brain, spinal cord, heart, blood vessels, kidney and bladder are not the most affected organs.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Remember

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 759 27. The student nurse is collecting data on a child diagnosed with cystic fibrosis and notes the child has a barrel chest and clubbing of the fingers. In explaining this manifestation of the disease, the staff nurse explains the cause of this symptom to be: A. impaired digestive activity.

B. high sodium chloride concentration in the sweat.

C. chronic lack of oxygen.

D. decreased respiratory capacity.

Answer: C Rationale: In the child with cystic fibrosis the development of a barrel chest and clubbing of fingers indicate chronic lack of oxygen. Impaired digestive activity may occur due to a lack of pancreatic enzymes. The high sodium concentration makes the child taste salty, but is not related to the barrel chest and clubbing of the fingers. Respiratory issues are a concern, but the barrel chest and clubbing of the fingers are not because of the child's respiratory capacity.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 759 28. The nurse is reinforcing teaching with the family caregivers of a child diagnosed with tuberculosis who is being treated with the drug rifampin. Which statement made by the caregivers indicates an understanding of this medication?

A. "My son will have to take this medication the rest of his life."

B. "While she is taking this medication, I won't worry if her tears look orange."

C. "This medication may cause slight bleeding when she urinates."

D. "He will not be able to attend school for the first few months that he is on this medication."

Answer: B Rationale: Rifampin is tolerated well by children, but causes body fluids such as urine, sweat, tears, and feces to turn orange-red. Drug therapy is continued for 9 to 18 months. After drug therapy has begun, the child or adolescent may return to school and normal activities. Although the urine may be orange-red, this does not indicate bleeding. If bleeding with urination presents, then it should be reported and followed up on.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Analyze

Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 766 29. The nurse is collecting data on a child with a diagnosis of tonsillitis. Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. bark-like cough B. hoarseness C. erythema of the pharynx D. inability to make audible voice sounds Answer: C Rationale: The child with tonsillitis may have a fever of 101°F (38.4°C) or higher, a sore throat, often with dysphagia (difficulty swallowing), hypertrophied tonsils, and erythema of the pharynx. The child with spasmodic laryngitis has a bark-like cough, hoarseness, and an inability to make audible voice sounds.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 744 30. When caring for a child with acute bronchiolitis, which nursing interventions should be included in the plan of care? Select all that apply.

A. Encourage fluids.

B. Administer oxygen.

C. Suction the nose.

D. Administer antibiotics.

E. Follow contact precautions.

F. Encourage activity.

Answer: A, B, C, E Rationale: The child is treated with nasal suctioning, rest, and increased fluids.

Humidified oxygen may be administered via a nasal cannula, face mask, or an oxyhood (a clear plastic hood placed over the infant's head) if needed. Antibiotics are not prescribed because the causative organism is a virus. IV fluids often are administered to ensure an adequate intake and to permit the infant to rest. The hospitalized child is placed on contact transmission precautions to prevent the spread of infection.

Question format: Multiple Select Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 748

31. The nurse makes the statement that if an older child inhales a foreign body, the inhaled object is more likely to be drawn into the right bronchus rather than the left. What is the basis for this statement?

A. The left bronchus is shorter and wider than the right.

B. The right bronchus is shorter and wider than the left.

C. Both bronchi are the same size, but the left is more vertical than the right.

D. The left bronchus is more vertical than the right.

Answer: B Rationale: In children older than 2 years, the right bronchus is shorter, wider, and more vertical than the left. If the child inhales a foreign body, it is more likely to be drawn into the right bronchus rather than the left.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 743 32. When assessing a child for the probable cause of acute bronchiolitis, the nurse focuses on which factor?

A. Bacterial infections B. Environmental allergies C. Prenatal complications D. Viral infections Answer: D Rationale: Acute bronchiolitis is caused by a viral not bacterial infection. Neither allergies nor prenatal complications contribute to the development of this disorder.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 743 33. The caregivers bring a 2-year-old child to the emergency care center after becoming concerned when the child woke up in the middle of the night with a barklike cough and labored breathing. Which assessment question related to the child's condition earlier in the day would the nurse ask to rule out the possibility of spasmodic laryngitis?

A. "Did the child have a runny nose?"

B. "Was there any reason to think the child had difficulty swallowing?"

C. "Did you notice the child drooling?"

D. "Did the child breathe through the mouth rather than the nose?"

Answer: A Rationale: The child with spasmodic laryngitis often presents with a runny nose prior to the respiratory event. The child with spasmodic laryngitis often awakens after a few hours of sleep with a bark-like cough and increasing respiratory difficulty. The child with epiglottitis may have a sore throat, often with dysphagia (difficulty swallowing and resulting drooling) and demonstrates mouth breathing with the tongue protruding out of the mouth.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 747 34. The caregiver of a child diagnosed with allergic rhinitis asks the nurse working in the allergy clinic why her child frequently pushes his nose upward and backward.

Which response accurately explains this action?

A. The child is attempting to draw attention to his/her nose.

B. The child has a nasal discharge and he is trying to keep his nose from running.

C. The child is concerned that he is going to sneeze and is trying to stop the sneeze.

D. The child is trying to relieve the itching and open the air passages.

Answer: D Rationale: The "allergic salute" is an action in which the child pushes his or her nose upward and backward to relieve itching and open the air passages in the nose.

The child with allergic rhinitis may have a nasal discharge and frequently sneeze, but this action does not have any relevance to these symptoms.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 744 35. A 4-week-old infant is diagnosed with acute bronchiolitis. The parent states, "I do not know how the baby got this!" How should the nurse respond?

A. "Do you have allergies in the family?"

B. "Do any family members have history of asthma?"

C. "Do you have air conditioning in your house?"

D. "Has your infant been around any crowds?"

Answer: D

Rationale: Acute bronchiolitis is caused by a viral infection, most often, respiratory syncytial virus. Viruses are often spread between groups of people in close contact.

Hereditary and environmental complications do not relate to this disorder.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 743 36. A 2-year-old child has had a common cold for 4 days. The caregiver calls the nurse in the emergency department at 2 a.m. on a cold winter night to say that the child has awakened with a barking cough and an elevated temperature; the child seems blue around the mouth. The nurse would appropriately recommend what action to the caregiver?

A. "Put a cool mist humidifier or vaporizer in the room to see if that relieves the cough. Call back if there is no relief in an hour."

B. "Bundle the child up and take the child out into the cold for a few minutes. Call back if the exposure to the cold air does not provide relief."

C. "Bring the child to the emergency room immediately."

D. "Turn on all of the hot water taps in the bathroom and close the door. Take the child into the steam-filled room for 15 minutes. If there is no relief, bring the child to the emergency room."

Answer: C Rationale: Acute laryngotracheobronchitis generally occurs after an upper respiratory infection with fairly mild rhinitis and pharyngitis. The child develops hoarseness and a barking cough with a fever that may reach 104° F (40° C) to 105° F (40.6° C). As the disease progresses, marked laryngeal edema occurs and the child's breathing becomes difficult; the pulse is rapid and cyanosis may appear.

Heart failure and acute respiratory distress can result. The child needs to be treated immediately. Humidified air is helpful in reducing laryngospasm; humidifiers may be used in the child's bedroom to provide high humidity. Cool humidifiers are recommended, but vaporizers also may be used. Taking the child into the bathroom and opening the hot water taps with the door closed is a quick method for providing moist air, if the water runs hot enough. Sometimes the spasm is relieved by exposure to cold air: for instance, when the child is taken out into the night to go to the emergency department or to see the physician.

Question format: Multiple Choice Chapter 36: The Child with a Respiratory Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 747

Chapter 37 1. A nurse admits an infant with a possible diagnosis of congestive heart failure.

Which signs or symptoms would the infant most likely be exhibiting?

A. Feeding problems B. Bradypnea C. Bradycardia D. Yellowish color Answer: A Rationale: The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. In a child with CHF, tachypnea would be seen, not bradypnea.

The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 772 2. In discussing the causes of iron-deficiency anemia in children with a group of nurses, the following statements are made. Which of these statements is a misconception related to iron-deficiency anemia?

A. "A family's economic problems are often a cause of malnutrition."

B. "Milk is a perfect food, and babies should be able to have all the milk they want."

C. "Caregivers sometimes don't understand the importance of iron and proper nutrition."

D. "Children have a hard time getting enough iron from food during their first few years."

Answer: B Rationale: Babies with an inordinate fondness for milk can take in an astonishing amount and, with their appetites satisfied, may show little interest in solid foods.

These babies are prime candidates for iron-deficiency anemia. Many children with iron-deficiency anemia, however, are undernourished because of the family's economic problems. A caregiver's knowledge deficit about nutrition is often present.

Because only 10 percent of dietary iron is absorbed, a diet containing 8 to 10 mg of iron is needed for good health. During the first years of life, obtaining this quantity of iron from food is often difficult for a child. If the diet is inadequate, anemia quickly results.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 778 3. The nurse is caring for a child diagnosed with hemophilia. The child is crying because of the pain. Which nursing action would be appropriate for the nurse to do to relieve the child's pain?

A. Give aspirin as ordered.

B. Immobilize the affected extremity.

C. Distract the child with an age-appropriate activity.

D. Have the child perform range-of-motion exercises.

Answer: B Rationale: The involved extremity should be promptly immobilized to prevent contractures of soft tissues, to decrease bleeding, and to relieve pain. Aspirin and drugs containing aspirin should not be given to children with hemophilia because it may prolong bleeding. (Ibuprofen, however, has been proven safe for these children.) While diversionary activities can help the child deal with pain, they will not relieve it. Range-of-motion exercises should not be done during or right after an acute episode because stretching of the joint capsule may cause additional bleeding.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 785 4. A nurse admits a child with a diagnosis of acute lymphoblastic leukemia (ALL).

During the each phase of treatment, which would most likely be seen periodically?

A. a relapse B. a complete remission C. a bone marrow transplant D. methotrexate injection into cerebrospinal fluid Answer: D Rationale: Intensive chemotherapy is initially divided into three phases: induction therapy—geared to achieving a complete remission with no leukemia cells; consolidation Therapy—given to prevent the regrowth of leukemic cells; and maintenance Therapy—maintaining the remission. Given periodically throughout each of the phases of treatment is CNS Preventive Therapy—preventing invasion of the central nervous system by leukemia cells. During CNS Preventive Therapy, intrathecal administration (drugs injected into the cerebrospinal fluid by lumbar

puncture) of methotrexate is used to eradicate leukemia cells in the central nervous system.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 788 5. In developing a plan of care for the child diagnosed with rheumatic fever, the nursing intervention that takes highest priority for this child is to: A. position the child to relieve joint pain.

B. monitor the C-reactive protein and erythrocyte sedimentation rate (ESR) levels.

C. provide age-appropriate diversional activities.

D. promote rest periods and bed rest.

Answer: D Rationale: As long as the rheumatic process is active, progressive heart damage is possible. To prevent heart damage, bed rest is essential to reduce the heart's workload. Laboratory tests for ESR and C-reactive protein can be used to evaluate disease activity and guide treatment, but they do not improve the child's health.

The child's comfort is important, so it is essential to relieve joint pain and prevent injury with padded bed rails. But these measures are less important than rest when it comes to preventing long-term complications such as residual heart disease.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 775 6. The caregiver of a child with sickle cell disease asks the nurse how much fluid her child should have each day after the child goes home. In response to the caregiver's question, the nurse would explain that for the child with sickle cell disease, it is best that the child have: A. 300 to 800 ml of fluid per day.

B. 1,000 to 1,200 ml of fluid per day.

C. 1,500 to 2,000 ml of fluid per day.

D. 2,500 to 3,200 ml of fluid per day.

Answer: C Rationale: Prevention of crises is the goal between episodes. Adequate hydration is vital; fluid intake of 1,500 to 2,000 ml daily is desirable for a child weighing 20 kg and should be increased to 3,000 ml during the crisis.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder

Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 780 7. The nurse is preparing a child for discharge following a sickle cell crisis. Which statement by the mother indicates a need for further teaching?

A. "She loves popsicles, so I'll let her have them as a snack or for dessert."

B. "I bought the medication to give to her when she says she is in pain."

C. "She has been down, but playing in soccer camp will cheer her up."

D. "I put her legs up on pillows when her knees start to hurt."

Answer: C Rationale: Following a sickle cell crisis, the child should avoid extremely strenuous activities that may cause oxygen depletion. Fluids are encouraged, pain management will be needed, and the child's legs may be elevated to relieve discomfort, so these are all statements that indicate an understanding of caring for the child who has had a sickle cell crisis.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 780 8. The nurse is talking with a 9-year-old child diagnosed with acute leukemia who will soon begin chemotherapy. The child expresses worry that when her hair falls out friends won't like her or want to play with her anymore. Which response by the nurse would be best?

A. Reassure the child that her hair will grow back in 3 to 6 months.

B. Tell the child that having chemotherapy is the only way she'll get better.

C. Talk with her and her family about wearing a wig, cap, or scarf.

D. Distract the child with a book or educational computer games.

Answer: C Rationale: The child undergoing chemotherapy may want to wear a wig, especially when returning to school. Encourage the family to choose the wig before chemotherapy is started so that it matches the child's hair and the child has time to get used to it. A cap or scarf often is appealing to a child, particularly if it carries a special meaning for him or her. The hair will most likely grow back, chemotherapy is necessary, and distraction can decrease the anxiety, but these are not the best responses for this child.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity

Integrated Process: Caring Reference: p. 790 9. A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed.

This child most likely has a deficiency of which blood factor?

A. Factor V B. Factor VIII C. Factor X D. Factor XIII Answer: B Rationale: The most common types of hemophilia are factor VIII deficiency and factor IX deficiency, which are inherited as sex-linked recessive traits, with transmission to male offspring by carrier females.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 783 10. A group of nurses is reviewing the cardiovascular system and its function.

Which statement by one of the nurses demonstrates an understanding of a child's cardiovascular system?

A. "At birth, the infant's right and left ventricle are about the same size."

B. "Between the ages of 5 and 6, the child's left ventricle grows to about two times the size of the right."

C. "The heart rate of the child decreases whenever the child experiences a fever."

D. "The child's heart doesn't mature and function like an adult's until between 8 and 10 years of age."

Answer: A Rationale: At birth, both the right and left ventricles are about the same size, but by a few months of age, the left ventricle is about two times the size of the right. If the infant has a fever, respiratory distress, or any increased need for oxygen, the pulse rate goes up to increase the cardiac output. Although the size of the heart is smaller, by the time the child is 5 years old, the heart has matured, developed, and functions just as the adult's heart.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 771 11. The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason?

A. To decrease the pain to a tolerable level B. To increase the heart rate C. To establish a maintenance dose of the drug D. To build the blood levels to a therapeutic level Answer: D Rationale: The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 772 12. The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with rheumatic fever. The nurses in the group make the following statements. Which statement is most accurate regarding the diagnosis of rheumatic fever?

A. "This disorder is caused by genetic factors."

B. "Children who have this diagnosis may have had strep throat."

C. "Being up-to-date on immunizations is the best way to prevent this disorder."

D. "The onset and progression of this disorder is rapid."

Answer: B Rationale: Rheumatic fever is precipitated by a streptococcal infection, such as strep throat, tonsillitis, scarlet fever, or pharyngitis, which may be undiagnosed or untreated. Rheumatic fever is a chronic disease of childhood, affecting the connective tissue of the heart, joints, lungs, and brain. There is no immunization to prevent rheumatic fever. The onset of rheumatic fever is often slow and subtle.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 774

13. The nurse is caring for a child with rheumatic fever who has polyarthritis. Which lab result would the nurse most anticipate with this child's diagnosis and symptoms?

A. increased clotting time B. decreased white blood cell count (WBC) C. increased erythrocyte sedimentation rate (ESR) D. decreased leukocyte count Answer: C Rationale: In a child with rheumatic fever who has polyarthritis, the erythrocyte sedimentation rate (ESR) is increased. Although the clotting time may be altered with the use of aspirin, this is not anticipated with the treatment. The white blood cell and leukocyte counts would be elevated.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 774 14. The nurse is reinforcing teaching with the caregivers of a child with rheumatic fever. Which statement made by the caregivers best indicates an understanding of the treatment regimen?

A. "She will be on a high sodium diet until the symptoms go away."

B. "Keeping her involved in her regular sports activities will be important."

C. "She'll be so happy about watching a movie while on bed rest."

D. "If she cuts herself, we know to keep that part of her body elevated above the heart."

Answer: C Rationale: The chief concern in caring for a child with rheumatic fever is the prevention of residual heart disease. Bed rest is important and the length of bed rest is determined by the degree of carditis present. Residual heart disease is treated in accordance with its severity and its type with digitalis, restricted activities, diuretics, and a low-sodium diet as indicated. Bleeding is not a concern with rheumatic fever.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 775 15. In caring for the child with rheumatic fever, the nurse recognizes that which nursing diagnosis would be most important to include in this child's plan of care?

A. Delayed growth and development

B. Risk for aspiration C. Risk for acute pain D. Disturbed body image Answer: C Rationale: Acute pain related to joint pain when extremities are touched or moved is a concern for the child with rheumatic fever. Diversional activities are important, but growth and development is not likely to be delayed. Chorea may be frustrating to the child but body image is not altered. Respiratory issues are not noted with rheumatic fever.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 776 16. The nurse is collecting data from a caregiver, and the caregiver states that the child has had a "strawberry-colored tongue." The nurse recognizes this as a manifestation of which disorder?

A. congestive heart failure B. rheumatic fever C. Kawasaki disease D. hemophilia Answer: C Rationale: A strawberry-colored tongue is a symptom seen in the child with Kawasaki disease. This symptom is not seen in congestive heart failure, rheumatic fever, nor hemophilia.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 778 17. The nurse is discussing the stages of Kawasaki disease with a group of peers.

The nurse states that the child is at the greatest risk for having an aneurysm during: A. the acute stage.

B. the subacute stage.

C. the convalescent stage.

D. the chronic stage.

Answer: B

Rationale: Kawasaki disease occurs in three stages: Acute-high fever that does not respond to antibiotics or antipyretics; child is irritable. Subacute-fever resolves, irritability continues; greatest risk for aneurysms. Convalescent-symptoms are gone; phase continues until lab values are normal and child's energy, appetite, and temperament have returned. The chronic stage is not one of the identified stages of the disorder.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 778 18. The most serious concern for the child diagnosed with Kawasaki disease is the effect on which of the following body organs?

A. brain B. lungs C. heart D. kidneys Answer: C Rationale: In the child with Kawasaki disease, inflammation of the arteries, veins, and capillaries occurs, and this inflammation can lead to serious cardiac concerns.

The other organs are not at as great a risk for complications in the child with Kawasaki disease.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 778 19. For the child with Kawasaki disease who is treated with immunoglobulin, it is most important to delay the administration of which of the following immunizations for 3 to 6 months following the treatment?

A. DTaP (diphtheria, tetanus, acellular pertussis) B. hepatitis B C. inactivated poliovirus D. MMR (measles, mumps, rubella) Answer: D Rationale: Following treatment of Kawasaki disease with immunoglobulins, live vaccines such as MMR (measles, mumps, and rubella) should not be given for 3 to 6 months to a child who has been treated with immunoglobulin (IG). The IG prevents the body from building antibodies, so the vaccine will likely be ineffective

in preventing the disease that it is being given to prevent. Although immunizations, in general, are not given, in particular the MMR should not be given.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 778 20. The nurse is reinforcing teaching with a group of caregivers of children diagnosed with iron-deficiency anemia. One of the caregivers tells the group, "I give my child ferrous sulfate." Which statement made by the caregivers is correct regarding giving ferrous sulfate?

A. "When I give my son ferrous sulfate I know he also needs potassium supplements."

B. "I always give the ferrous sulfate with meals."

C. "My husband gives our daughter orange juice when she takes her ferrous sulfate, so she gets Vitamin C." D. "We watch closely for any diarrhea since that usually happens when he takes ferrous sulfate."

Answer: C Rationale: When ferrous sulfate is administered, it should be given between meals with juice (preferably orange juice, because vitamin C aids in iron absorption). For best results, iron should not be given with meals. Ferrous sulfate can cause constipation or turn the child's stools black.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Teaching/Learning Reference: p. 779 21. The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with sickle cell disease. The nurses in the group make the following statements. Which statement is most accurate regarding this condition?

A. "The trait or the disease is seen in one generation and skips the next generation."

B. "If the trait is inherited from both parents the child will have the disease."

C. "The disease is most often seen in individuals of Asian decent."

D. "Males are much more likely to have the disease than females."

Answer: B Rationale: When the trait is inherited from both parents (homozygous state), the child has sickle cell disease, and anemia develops. The trait does not skip

generations. The trait occurs most commonly in black clients. Either sex can have the trait and disease.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 779 22. In caring for a child with sickle cell disease, the highest priority goal is: A. the caregiver's anxiety will be reduced.

B. the child's skin integrity will be maintained.

C. the family will verbalize understanding of the disease crisis.

D. The child's fluid intake will improve.

Answer: D Rationale: The highest priority goals for this child are maintaining comfort and relieving pain. The child is prone to dehydration because of the kidneys' inability to concentrate urine, so increasing fluid intake is the next highest priority. Other goals include improving physical mobility, maintaining skin integrity, reducing the caregiver's anxiety, and increasing the caregiver's knowledge about the causes of crisis episodes — but these goals are not the highest priority.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 781 23. The nurse is collecting data from the caregivers of a child brought to the clinic setting. The parents tell the nurse that the child's skin seems to be an unusual color. The nurse notes that the child's skin appears bronze-colored and jaundiced.

This observation alerts the nurse to the likelihood that this child has which disorder?

A. Hemophilia B. Sickle cell disease C. Kawasaki disease D. Thalassemia Answer: D Rationale: In the child with thalassemia the skin may appear bronze-colored or jaundiced. The child with hemophilia may have bruised areas on the skin. The skin color in children with sickle cell disease may be pale in color, and with Kawasaki disease the child may have a rash on the trunk and extremities.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder

Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 783 24. The child with thalassemia may be given which classification of medication to prevent one of the complications frequently seen with the treatment of this disorder?

A. Vitamin supplements B. Iron-chelating drugs C. Factor VIII preparations D. Potassium supplements Answer: B Rationale: Frequent transfusions can lead to complications and additional concerns for the child, including the possibility of iron overload. For these children, ironchelating drugs such as deferoxamine mesylate may be given. Vitamin and potassium supplements would not be given to treat the iron overload. Factor VIII preparations are given to the child with hemophilia.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 783 25. A child diagnosed with hemophilia presents with warm, swollen, painful joints.

Which action will the nurse take first?

A. Document the presence of hemarthrosis in the client's chart B. Notify the client's primary health care provider C. Assess the client's urine and stool for blood D. Prepare to administer factor replacement medication Answer: D Rationale: Many clients with hemophilia have repeated episodes of hemarthrosis or bleeding into the joints, and develop functional impairment of the joints, despite careful treatment. To assist in limiting impairment, the nurse would prepare to administer factor replacement medications, such as plasma, recombinant clotting factor VIII, or a clotting promotor medication. The nurse would document the finding, notify the health care provider, and assess the client for additional symptoms after limiting the amount of blood loss.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process

Reference: p. 785 26. The nurse is caring for a child admitted with suspected leukemia. The nurse has taken the child's history and performed an assessment. The nurse will plan to prepare the child for which additional diagnostic test first?

A. urinalysis B. complete blood cell count (CBC) C. bone marrow aspiration D. magnetic resonance imaging (MRI) Answer: B Rationale: After obtaining the child's history and symptoms, the nurse would prepare the child for laboratory blood studies to assess the child's white blood cell (WBC) count. A complete blood cell (CBC) count will provide data on the child's WBC level. A bone marrow aspiration would be scheduled based on the results of the CBC as it is required to confirm the diagnosis of leukemia. A urinalysis is done for many disorders. In regard to childhood cancers, it is done to assist assessment for neuroblastoma. MRIs can also be done for many disorders. Brain tumors are common childhood cancers where MRIs are used.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 788 27. Which site is most frequently used to perform a bone marrow aspiration?

A. Humerus B. Iliac crest C. Rib cage D. Femur Answer: B Rationale: The preferred site for bone marrow aspiration in children is the iliac crest. The other sites are not used for a bone marrow aspiration.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 788 28. The nurse is caring for a child with leukemia. Which nursing intervention would be the highest priority for this child?

A. encouraging the child to share feelings B. grouping nursing care

C. following guidelines for reverse isolation D. providing age-appropriate activities Answer: C Rationale: The child with leukemia is susceptible to infection, especially during chemotherapy. Infections such as meningitis, septicemia, and pneumonia are the most common causes of death. To protect the child from infectious organisms, follow standard guidelines for reverse isolation. Grouping nursing care to provide rest is important, but not the highest priority. Encouraging the child to share feelings and providing age-appropriate activities are important, but psychological issues are a lower priority than physical.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 789 29. Which nursing interventions would be appropriate for the plan of care designed for a child diagnosed with hemophilia who is experiencing an episode of active bleeding? Select all that apply.

A. Performing passive range-of-motion exercises B. Administer ibuprofen as prescribed for pain C. Applying splints to extremities D. Schedule physical therapy E. Schedule regular active range-of-motion exercises Answer: B, C, E Rationale: Passive range-of-motion exercises help prevent the development of joint contractures. Do not use them, however, after an acute episode because stretching of the joint capsule may cause bleeding. Encourage the child to do active range-ofmotion exercises because he or she can recognize his or her own pain tolerance.

Many clients who have had repeated episodes of hemarthrosis (bleeding into the joints) develop functional impairment of the joints, despite careful treatment. Use splints and devices to position the limb in a functional position. Physical therapy is helpful after the bleeding episode is under control. Ibuprofen has been proven safe for the management of related joint pain experienced by these children.

Question format: Multiple Select Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 778 30. A group of nursing students is discussing the diagnosis of iron deficiency anemia. The students demonstrate an understanding of the need for dietary iron

when suggesting the inclusion of what foods into the diet of a 4-year-old diagnosed with this form of anemia? Select all that apply.

A. Egg yolks B. Egg whites C. Raisins D. Peanut butter E. Cheese F. Oatmeal Answer: A, C, D, F Rationale: Egg yolks, raisins, peanut butter and oatmeal are food sources high in iron. Cheese is not as high in iron. Avoid egg whites for young children because of allergies.

Question format: Multiple Select Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 779 31. The nurse is collecting data on a 5-year-old child admitted with the diagnosis of congestive heart failure. Which clinical manifestation observed during the physical assessment would be consistent with this diagnosis?

A. Jerking movements of the arms and legs B. Scissoring of the legs with toes pointed down C. Failure to gain weight D. Spooning of the finger nails Answer: C Rationale: In infants and older children, one of the first signs of CHF is tachycardia.

Other signs of CHF often seen in the older child include failure to gain weight; weakness; fatigue; restlessness; irritability; and a pale, mottled, or cyanotic color.

Rapid respirations or tachypnea, dyspnea, and coughing with bloody sputum also are seen. Edema and enlargement of the liver and heart may be present. Jerking movements indicate seizure activity. Scissoring of the legs is seen in cerebral palsy, and spooning of the fingernails is seen in iron-deficiency anemia.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 772 32. The child is prescribed liquid ferrous sulfate. The nurse should encourage the child to take which action immediately after each dose to best eliminate possible side effects?

A. Drink a glass of milk B. Brush his or her teeth C. Remain in an upright position for at least 15 minutes D. Not eat or drink for one hour Answer: B Rationale: To prevent staining of the teeth, the child should brush the teeth after administration of iron preparations such as ferrous sulfate. There is no need to remain upright, drink milk or to refrain from eating or drinking for one hour.

Question format: Multiple Choice Chapter 37: The Child with a Cardiovascular/Hematologic Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 779

Chapter 38 1. The nurse has admitted a child with a diagnosis of severe gastroenteritis. To help prevent the risk of transmitting infection to other clients, the nurse should: A. wear a mask when handling articles contaminated with feces.

B. follow standard precautions.

C. discourage anyone from visiting.

D. sterilize thermometers between clients.

Answer: B Rationale: To prevent the spread of possibly infectious organisms to other pediatric patients, follow standard precautions issued by the Centers for Disease Control and Prevention. Gloves should be worn when handling items contaminated with feces, but masks are not necessary. Visitors should be limited to family only. Take the temperature with a thermometer that is used only for that child.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 804 2. The nurse is caring for an infant immediately after pyloromyotomy surgery has been performed to treat pyloric stenosis. The infant's parents are understandably anxious about their child. Given the situation, what is the most appropriate way for the nurse to position the infant during the anesthesia recovery period?

A. Allow the parents to hold their infant B. Place the infant on the back.

C. Lay the infant on their stomach.

D. Support the infant and place them on their side.

Answer: D Rationale: Postoperatively, the child should be placed on his side to prevent aspiration of mucus or vomitus, especially during the anesthesia recovery period.

After fully waking from the surgery, he can be held by a family caregiver in a position that does not interfere with IV infusions and is comforting to both caregiver and child.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 809

3. A nurse notices a child chewing several pieces of something white. The child is also drooling and crying. A container that looks like an empty pill bottle is on the floor. The first action by the nurse would be to: A. call 911 for emergency help.

B. ask the poison control center about an antidote.

C. give the child syrup of ipecac to induce vomiting.

D. remove the substance from the child's mouth.

Answer: D Rationale: Treatment steps in order of importance for poisoning: Remove the obvious remnants of the poison. Call 911 for emergency help if the child has collapsed or stopped breathing. If the child is conscious and alert, call the poison control center and follow their instructions. Administer the appropriate antidote if recommended. Administer general supportive and symptomatic care. The American Academy of Pediatrics (AAP) no longer recommends administering syrup of ipecac because it hasn't been proven that inducing vomiting prevents poisoning. Because of the potential for misuse, the AAP also recommends safely disposing of any syrup of ipecac already in the home. In an emergency care setting, gastric lavage may be used to empty the stomach of toxic substances.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 820 4. A young child has been admitted with a diagnosis of enterobiasis (pinworm infection). This child will most likely have a history of: A. bedwetting.

B. restlessness.

C. perianal itching.

D. malnutrition.

Answer: C Rationale: Intense perianal itching is the primary symptom of pinworm infection, enterobiasis. Young children who cannot clearly verbalize their feelings may be restless, sleep poorly, or have episodes of bedwetting. Pinworm infestation is as common as an infection or cold, making a history of malnutrition less likely. Chronic hookworm infestation can cause malnutrition, however.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 817

5. The nurse is caring for a 7-year-old diagnosed with pinworms. The nurse talks with the child's caregiver about proper treatment and prevention of future infections. Which statement made by the caregiver indicates a need for further teaching?

A. "I always have to remind him to wash his hands before eating."

B. "We just bought a washer and dryer, and the hot water works well."

C. "Thank goodness my other children and I are not sick too."

D. "He hates having his nails trimmed but I will insist they are kept short."

Answer: C Rationale: The life cycle of pinworms is 6 to 8 weeks. Clothing, bedding, food, toilet seats, and other articles become infected, and the infestation spreads to other members of the family. Pinworm eggs also can float in the air and be inhaled.

Family members may be infected and not realize it. Because pinworms are so easily transmitted, the nurse should encourage all family members to be treated as well.

Washing hands before eating and after using the toilet, frequent laundering of bedding and underclothes in hot water, and short, clean fingernails are all ways to prevent subsequent infections.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 817 6. The caregivers of a child just diagnosed with diabetes express concern that they won't remember the different signs and symptoms of hyperglycemia and hypoglycemia. As a result, they are afraid they won't handle an emergency correctly. What is the best initial response by the nurse to help ensure the child's safety?

A. Instruct them to treat the reaction as if it's hypoglycemia, which is more likely.

B. Repeat the signs and symptoms over and over until they seem to understand.

C. Suggest that the child wear an insulin pump for continuous insulin administration.

D. Give the caregivers educational pamphlets and videos about diabetes.

Answer: A Rationale: Hypoglycemia is much more likely to occur than hyperglycemia; if there is any doubt as to whether the child is having a hypoglycemic or hyperglycemic reaction, it should be treated as hypoglycemia. While the pump may offer continuous insulin, it does not sense blood glucose level; insulin reactions can still occur. Careful monitoring of blood glucose is still needed. While repeating signs and symptoms may be helpful, caregivers of a recently diagnosed child have lots of information to absorb and the repetition may create more anxiety. Assuming that the caregivers can read and understand them, written materials and videos may be

helpful but they should not take the place of an initial teaching session with a nurse.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Caring Reference: p. 830 7. The nurse is working with the mother of a newborn. The mother asks why a baby needs small feedings at frequent intervals. The nurse explains to the mother that this is necessary because in the infant: A. the enzymes secreted by the liver and pancreas are reduced.

B. food moves more slowly through the GI tract.

C. the pylorus has not been fully formed.

D. peristaltic action is absent in the lower portion of the bowel.

Answer: A Rationale: In the newborn, the enzymes secreted by the liver and pancreas are reduced. Thus, the infant cannot break down and use complex carbohydrates. As a result, the newborn diet must be adjusted to allow for this immaturity. By the age of 4 to 6 months, the needed enzymes are usually sufficient in amount. The smaller capacity of the infant's stomach and the increased speed at which food moves through the GI tract requires feeding smaller amounts at more frequent intervals.

In addition, the small capacity of the colon leads to a bowel movement after each feeding. The pyloric sphincter is formed, but is lax and does not have bearing on the frequency of feeding.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 796 8. The nurse admits an infant who is nutritionally deprived. The infant is weak and seems somewhat uninterested in food. In developing the infant's plan of care, how often will the nurse most likely plan to feed this infant?

A. every hour B. every 2 or 3 hours C. every 4 hours D. on demand Answer: B Rationale: For the child who is nutritionally deprived, scheduling feedings every 2 or 3 hours is best because most weak babies can handle frequent, small feedings

better than feedings every 4 hours. Feeding every hour would not give the weak child an adequate amount of time to rest and sleep between feedings.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 799 9. The teeth, tongue, gallbladder, appendix, salivary glands, liver, and pancreas are referred to as accessory organs, and the purpose of these is: A. to secrete liquids that help the food to be tasted as a person eats.

B. to aid in the digestive process and to produce substances that aid in the digestive process.

C. to cushion and protect the digestive organs.

D. to decrease the secretion of acids in the digestive organs.

Answer: B Rationale: Other organs, called accessory organs, include structures that aid in the digestive process, as well as glands that secrete substances that further aid in digestion. These accessory organs include the teeth, tongue, gallbladder, appendix, salivary glands, liver, and pancreas. These organs do not affect the taste of food.

Cerebrospinal fluid cushions and protects the nerve cells. These organs do not decrease the secretion of acids.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 796 10. Which of the following is most correct regarding the gastrointestinal system of the child?

A. The child's gastrointestinal system is fully matured when the child is born.

B. The enzymes secreted by the child's liver and pancreas are much greater in amount than in the adult.

C. The child cannot break down and use complex carbohydrates in the same way the adult can.

D. The speed with which food passes through the gastrointestinal tract in the child is much slower than in the adult.

Answer: C Rationale: In the GI tract of the newborn, the enzymes secreted by the liver and pancreas are reduced. Thus, the infant cannot break down and use complex carbohydrates. In the infant, food moves through the GI tract with increased speed.

The GI tract matures and the capacity of the GI tract increases as the child gets older.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 796 11. The school nurse is working with a group of teachers who instruct children who are nutritionally deprived. As the teachers are talking with the nurse they make the following statements. Which statement most indicates a problem related to decreased nutrition?

A. "One of my students is taller than several of the other children in the class."

B. "I am really glad that during this quarter the absence rate in my classroom has dropped."

C. "Several of the children in my class have such a hard time concentrating."

D. "The grades of the children in my class are higher than in the classroom next to me."

Answer: C Rationale: Malnourished children grow at a slower rate, have a higher rate of illness and infection, and have more difficulty concentrating and achieving in school.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 797 12. The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with Kwashiorkor. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of Kwashiorkor?

A. "These children have a severe deficiency of vitamin D." B. "It is important to increase the intake of protein for these children."

C. "The highest incidence of this disease is seen in children who are adolescents."

D. "The cause of this disease can be treated very simply."

Answer: B Rationale: Kwashiorkor results from severe deficiency of protein with an adequate caloric intake. It accounts for most of the malnutrition in the world's children today.

The highest incidence is in children 4 months to 5 years of age. Although strenuous efforts are being made around the world to prevent this condition, its causes are complex.

Question format: Multiple Choice

Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 797 13. In understanding the disease of marasmus when seen in children, the nurse recognizes that the disease is caused because of which of the following?

A. deficiency of vitamin C and iron B. excess of vitamin C and iron C. deficiency of protein and calories D. excess of protein and calories Answer: C Rationale: Marasmus is a deficiency in calories as well as protein. Scurvy is caused by inadequate intake of vitamin C, and anemia is caused by lack of iron. Excess calories add to the concern of obesity in children. Excess vitamin C is excreted, and it is unusual to have an excess of iron or protein in the diet of children; those nutrients are more often inadequate in children's diets.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 797 14. The nurse recognizes that in the disorder referred to as rickets, the child has a lack of vitamin D. Because of the lack of vitamin D, the absorption of which of the following is decreased?

A. calcium and phosphorus B. vitamin C and thiamine C. riboflavin and niacin D. iron and potassium Answer: A Rationale: Rickets, a disease affecting the growth and calcification of bones, is caused by a lack of vitamin D. The absorption of calcium and phosphorus is diminished because of the lack of vitamin D, which is needed to regulate the use of these minerals. The absorption of the other nutrients is not affected by the lack of vitamin D. Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 797

15. The incidence of vitamin D deficiency in the United States is less than in many countries. What is the most likely reason for this?

A. Many children in the U.S. take daily vitamin supplements.

B. The water in many towns and cities in the U.S. has vitamin D added.

C. Some foods in the U.S. have been fortified with vitamin D. D. The amount of ultraviolet sunlight each day in the U.S. is adequate to provide needed vitamin D. Answer: C Rationale: Whole milk and evaporated milk fortified with 400 U of vitamin D per quart are available throughout the United States, which decreases the vitamin D deficiency of children in the U.S. Vitamin D can be administered orally in the form of fish liver oil or synthetic vitamin, but this is not common for children in the U.S. Water is not fortified with vitamin D, and some communities in the U.S. do not get adequate sunshine to meet vitamin D needs.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 797 16. A group of nursing students is discussing the diagnosis of vitamin C deficiency.

The students have an appropriate understanding of the need for appropriate dietary intake when they identify which vitamin C rich foods? Select all that apply.

A. strawberries B. potatoes C. peas D. fish sticks E. cottage cheese F. bagels Answer: A, B, C Rationale: A variety of fresh vegetables and fruits supplies vitamin C for the older infant and child. Strawberries, potatoes, and peas are high in vitamin C content.

Meat, dairy, and grain foods have little vitamin C content.

Question format: Multiple Select Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 797 17. The nurse is collecting data on a child who has been nutritionally deprived. The nurse notes that the child is irritable and listless. The foster caregiver reports that

the child says she is not hungry and has been vomiting. It is discovered that the child has beriberi. This disease is due to a deficiency in which of the following?

A. thiamine B. vitamin C C. niacin D. iron Answer: A Rationale: Children whose diets are deficient in thiamine exhibit irritability, listlessness, loss of appetite, and vomiting. A severe lack of thiamine in the diet causes beriberi, a disease characterized by cardiac and neurologic symptoms.

Beriberi does not occur when balanced diets that include whole grains are eaten.

Lack of vitamin C causes scurvy, lack of niacin causes pellagra, and lack of iron causes anemia.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 798 18. The nurse is discussing the disease known as pellagra. This disease is due to a deficiency in which of the following?

A. thiamine B. vitamin C C. niacin D. iron Answer: C Rationale: Niacin insufficiency in the diet causes a disease known as pellagra, which presents with GI and neurologic symptoms. A diet deficient in thiamine causes beriberi. Lack of vitamin C causes scurvy, and lack of iron causes anemia.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 798 19. The child is diagnosed with hypocalcemia. The nurse should assess the child for which possible complication?

A. cardiac arrhythmias B. neurologic deficiencies C. kidney failure D. urinary tract disorders

Answer: B Rationale: Hypocalcemia (insufficient calcium) causes neurologic damage, including intellectual disability. Calcium is necessary for bone and tooth formation and is also needed for proper nerve and muscle function. Hypokalemia can cause cardiac issues. Kidney and urinary disorders are not likely to be caused by insufficiencies in the diet.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 798 20. The nurse is collecting data from the caregivers of a child who is suspected of having a food allergy. Which clinical manifestation would likely have been noted in this child?

A. restlessness and irritability B. blinking and twitching of the mouth C. nasal discharge and sneezing D. urticaria and pruritus Answer: D Rationale: Common symptoms are urticaria (hives), pruritus (itching), stomach pains, and respiratory symptoms. Some of the symptoms may appear quickly after the child has eaten the offending food, but other foods may cause a delayed reaction. Restlessness and irritability may be seen in children with seizure disorders, blinking, and twitching of the mouth are seen with absence seizures, and nasal discharge and sneezing are seen with allergic rhinitis.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 798 21. The nurse is educating the caregivers of a child suspected of having developed a food allergy. Which foods will the nurse identify for elimination from the child's diet? Select all that apply.

A. eggs B. broccoli C. corn D. oranges E. grapes F. soybeans Answer: A, C, D, F

Rationale: Among the foods most likely to cause allergic reactions are milk, eggs, wheat, corn, legumes (including peanuts and soybeans), oranges, strawberries, and chocolate. Vegetables other than corn are less likely to cause allergies. Citric fruits are more often the cause of allergies.

Question format: Multiple Select Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: 22. The nurse is caring for a pediatric client with idiopathic celiac disease. Which meal will the nurse select for this client?

A. Ham and cheese sandwich, orange slices, chips, and whole milk B. Whole wheat pasta, meatballs, carrot sticks, apple, and water C. Baked salmon, potato slices, vanilla ice cream, and apple juice D. Meatloaf, green beans, peanut butter cookie, and fat-free milk Answer: C Rationale: Celiac disease is an autoimmune condition where contact with gluten causes a reaction from the body's immune system. Clients with celiac disease should be educated to eat a gluten-free diet to decrease symptoms and limit small intestine irritation. Gluten is a protein found in wheat, barley, and rye. Most commercially used flour contains wheat and should be avoided. The nurse would select foods such as meats/fish (salmon), fruits, vegetables (potatoes), and rice.

Single flavor ice creams, such as chocolate, vanilla, and strawberry are gluten free, while cookies contain flour and should be avoided. Fruit juices, water, and milk are all gluten free. Meatloaf may contain oats; however, studies suggest oats are fine to consume, as long as the oats did not come into contact with wheat during processing. Reading the label would indicate if wheat was contacted. Sandwich bread and pastas contain gluten unless special gluten-free products are purchased or it is homemade. The nurse would not assume those items were gluten-free.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 801 23. The nurse is reinforcing dietary teaching with the caregiver of a child diagnosed with celiac disease. The caregivers make the following statements. Which statement indicates a need for further teaching regarding the dietary restrictions for the child with celiac disease?

A. "The soup we eat at our house is all made from scratch."

B. "She loves hot dogs, and we always cut hers up into small pieces."

C. "I have learned to make my own bread with no gluten."

D. "Even though milk and pudding are good for her, we don't give her those foods."

Answer: B Rationale: Commercially canned creamed soups, cold cuts, frankfurters, and pudding mixes generally contain wheat products and should not be included in the diet of the child with celiac syndrome. This caregiver needs further teaching regarding giving her child hot dogs, even if they are cut into small pieces. The other choices show an understanding of the dietary restrictions.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 801 24. The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements.

Which statement is most accurate related to the diagnosis of congenital aganglionic megacolon?

A. A partial or complete intestinal obstruction occurs.

B. A thickened, elongated muscle causes an obstruction at the end of the stomach.

C. There are recurrent paroxysmal bouts of abdominal pain.

D. In this disorder the sphincter that leads into the stomach is relaxed.

Answer: A Rationale: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach. Colic consists of recurrent paroxysmal bouts of abdominal pain.

Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 810 25. The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements.

Which statement is most accurately related to the diagnosis of pyloric stenosis?

A. A partial or complete intestinal obstruction occurs.

B. A thickened, elongated muscle causes an obstruction at the end of the stomach.

C. There are recurrent paroxysmal bouts of abdominal pain.

D. In this disorder the sphincter that leads into the stomach is relaxed.

Answer: B Rationale: Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, with a severe narrowing of its lumen. The pylorus is thickened to as much as twice its size, is elongated, and has a consistency resembling cartilage. As a result of this obstruction at the distal end of the stomach, the stomach becomes dilated. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain.

Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 807 26. The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements.

Which statement is most accurately related to the diagnosis of colic?

A. A partial or complete intestinal obstruction occurs.

B. A thickened, elongated muscle causes an obstruction at the end of the stomach.

C. There are recurrent paroxysmal bouts of abdominal pain.

D. In this disorder the sphincter that leads into the stomach is relaxed.

Answer: C Rationale: Colic is described as episodes of crying in the infant, lasting up to several hours a day and recurring several times a week for several weeks. These episodes are often associated with recurrent gastrointestinal disturbances and are fairly common in young infants. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach. Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus is relaxed and allows gastric contents to be regurgitated back into the esophagus.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 802

27. The nurse is caring for a child admitted with pyloric stenosis. Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. Explosive diarrhea B. Projectile vomiting C. Severe abdominal pain D. Frequent urination Answer: B Rationale: During the first weeks of life, the infant with pyloric stenosis often eats well and gains weight and then starts vomiting occasionally after meals. Within a few days the vomiting increases in frequency and force, becoming projectile. The child may have constipation, and peristaltic waves may be seen in the abdomen, but the child does not appear in severe pain. Urine output is decreased and urination is infrequent.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 807 28. The nurse is caring for a child with a diagnosis of pyloric stenosis during the preoperative phase of the child's treatment. What is the highest priority at this time?

A. Preparing family for home care B. Promoting comfort C. Maintaining skin integrity D. Improving hydration Answer: D Rationale: Preoperatively, the highest priority for the child with pyloric stenosis is to improve nutrition and hydration. Maintaining mouth and skin integrity, and relieving family anxiety are important, but these are not the priority. The child will not likely have intense pain. Preparing the family for home care would be a postoperative goal.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 808 29. The nurse is caring for a child admitted with congenital aganglionic megacolon.

Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. Prolonged bleeding

B. Chronic cough C. Persistent constipation D. Irregular breathing Answer: C Rationale: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Prolonged bleeding is a manifestation of hemophilia. A chronic cough is noted in the child with cystic fibrosis. Irregular breathing occurs in children with seizures.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 810 30. The nurse is discussing the treatment of congenital aganglionic megacolon with the caregivers of a child diagnosed with this disorder. Which statement is the best explanation of the treatment for this diagnosis?

A. "The treatment for the disorder will be a surgical procedure."

B. "Your child will be treated with oral iron preparations to correct the anemia."

C. "We will give enemas until clear and then teach you how to do these at home."

D. "Your child will receive counseling so the underlying concerns will be addressed."

Answer: A Rationale: Treatment of congenital aganglionic megacolon involves surgery with the ultimate resection of the aganglionic portion of the bowel. Chronic anemia may be present, but iron will not correct the disorder. Enemas may be given to initially achieve bowel elimination, but they will not treat the disorder. Differentiation must be made between this condition and psychogenic megacolon because of coercive toileting or other emotional problems. The child with aganglionic megacolon does not withhold stools or defecate in inappropriate places, and no soiling occurs.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 811 31. The nurse is caring for a child admitted with acute appendicitis. Prior to the child going to the operating room for emergency surgery, which nursing intervention would the nurse most likely perform?

A. The nurse gives the child laxatives to evacuate the colon.

B. The nurse encourages the child and family to express their fears.

C. The nurse administers oral fluids to prevent dehydration.

D. The nurse applies a heating pad to the abdomen to manage pain.

Answer: B Rationale: The child facing an emergency surgery may be extremely frightened and also may be in considerable pain. The family caregiver may be apprehensive about impending surgery. Explain to the child and the family what is happening and why, and encourage them to express their fears. Laxatives and enemas are contraindicated because they increase peristalsis, which increases the possibility of rupturing an inflamed appendix. Oral fluids are withheld and the child is NPO before surgery. A heating pad is contraindicated because of the danger of rupture of the appendix.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 816 32. The treatment for children with a pinworm infection is to administer which classification of medication?

A. anticoagulants B. anticonvulsants C. anthelmintics D. antipyretics Answer: C Rationale: Treatment consists of the use of an anthelmintic (or vermifugal, a medication that expels intestinal worms). Anticoagulants are used to prevent clot formation and extension. Anticonvulsants are used for seizure disorders.

Antipyretics are used to treat elevated temperatures.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 817 33. The most common source of lead poisoning in children comes from which of the following sources?

A. paint used in older homes B. juice stored in glass jars C. water purchased in plastic jugs D. toys painted with spray paint Answer: A

Rationale: Lead poisoning has other causes, but the most common cause has been the lead in paint, especially paint used on the outside or the inside of older houses.

Other sources of lead are toys painted with lead-containing paint, drinking water contaminated by lead pipes or copper pipes with lead-soldered joints, and fruit juices or other food improperly stored in glazed earthenware.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 820 34. In caring for a child with lead poisoning, which method of treatment is used to remove the lead from the child's system?

A. diuretics B. chelating agents C. laxatives D. emetics Answer: B Rationale: The use of a chelating agent (an agent that binds with metal) increases the urinary excretion of lead. Diuretics, laxatives, and emetics are not used in the treatment of lead poisoning.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 821 35. The nurse is interviewing the caregivers of a child admitted with a diagnosis of type 1 diabetes mellitus. The caregiver states, "She is hungry all the time and eats everything, but she is losing weight." The caregiver's statement indicates the child most likely has: A. Polyuria B. Pica C. Polyphagia D. Polydipsia Answer: C Rationale: Symptoms of type 1 diabetes mellitus include polyphagia (increased hunger and food consumption), polyuria (dramatic increase in urinary output, probably with enuresis) and polydipsia (increased thirst). Pica is eating nonfood substances.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder

Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 824 36. The nurse is interviewing the caregivers of a child admitted with a diagnosis of type 1 diabetes mellitus. The caregiver states, "The teacher tells us that our child has to use the restroom many more times a day than other students do." The caregiver's statement indicates the child most likely has: A. Polyuria B. Pica C. Polyphagia D. Polydipsia Answer: A Rationale: Symptoms of type 1 diabetes mellitus include polyuria (dramatic increase in urinary output, probably with enuresis), polydipsia (increased thirst), and polyphagia (increased hunger and food consumption). Pica is eating nonfood substances.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 824 37. The nurse is caring for a child admitted to the emergency center in diabetic ketoacidosis. Which clinical manifestations would the nurse most likely note in this child?

A. Pale and moist skin B. Drowsiness and fruity odor to breath C. Hyperactive and restless behavior D. Slow pulse and elevated blood pressure Answer: B Rationale: Diabetic ketoacidosis is characterized by drowsiness, decreased skin turgor, acetone breath with a fruity smell, and Kussmaul breathing (abnormal increase in the depth and rate of the respiratory movements). Nausea and vomiting may occur. If untreated, the child lapses into coma and exhibits dehydration, electrolyte imbalance, rapid pulse, and subnormal temperature and blood pressure.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 824

38. When collecting data on a child diagnosed with diabetes mellitus, the nurse notes that the child has had weight loss and other symptoms of the disease. The nurse would anticipate which finding in the child's fasting glucose levels?

A. 60 mg/dl B. 100 mg/dl C. 140 mg/dl D. 220 mg/dl Answer: D Rationale: A fasting blood sugar result of 200 mg/dL or more almost certainly is diagnostic for diabetes when other signs, such as polyuria and weight loss despite polyphagia, are present.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 824 39. The nurse is caring for a 3-year-old diagnosed with diabetes mellitus. The child's eating patterns are unpredictable. One day the child will eat almost nothing, the next day the child eats everything on her tray. The nurse recognizes that this type of insulin would most likely be used in treating this child?

A. Long-acting insulin B. Regular insulin C. Rapid-acting insulin D. Intermediate-acting insulin Answer: C Rationale: The introduction of rapid-acting insulin, such as lispro, has greatly changed insulin administration in children. The onset of action of rapid-acting insulin is less than 15 minutes. Rapid-acting insulin can even be used after a meal in children with unpredictable eating habits. Regular, intermediate, and long-acting insulin all have a longer onset, peak, and duration than rapid-acting insulin, and are more difficult to regulate in the child with unpredictable eating patterns.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 825 40. The school nurse notes that a child diagnosed with diabetes mellitus is experiencing an insulin reaction and is unable to eat or drink. Which action would be the most appropriate for the school nurse to take?

A. Request that someone call 911.

B. Administer subcutaneous glucagon.

C. Anticipate that the child will need intravenous glucose.

D. Dissolve a piece of candy in the child's mouth.

Answer: B Rationale: If the child having an insulin reaction cannot take a sugar source orally, glucagon should be administered subcutaneously to bring about a prompt increase in the blood glucose level. This treatment prevents the long delay while waiting for a physician to administer IV glucose or for an ambulance to reach the child.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 825 41. The nurse is collecting data for a child who is having a routine checkup. The caregiver tells the nurse that her child eats things such as laundry starch, clay, paper, and paint. The nurse recognizes that the child's behavior indicates that the child likely has which disorder?

A. pica B. invagination C. steatorrhea D. polyuria Answer: A Rationale: Pica is the ingestion of nonfood substances, such as laundry starch, clay, paper, and paint. Invagination is the telescoping of a portion of the bowel.

Steatorrhea (fatty stools) is a condition seen in idiopathic celiac disease, and polyuria is a dramatic increase in the urinary output.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 820 42. The nurse is collecting data on a 2-year-old child admitted with a diagnosis of gastroenteritis. When interviewing the caregivers, which question is most important for the nurse to ask?

A. "How many times a day does your child urinate?"

B. "How long has your child been toilet trained?"

C. "Tell me about the types of stools your child has been having."

D. "What foods has your child eaten during the last few days?"

Answer: C Rationale: For the child with gastroenteritis, the interview with the family caregiver must include specific information about the history of bowel patterns and the onset of diarrheal stools, with details on the number and type of stools per day. Recent eating patterns, determining if the child is toilet trained, and how many times a day the child urinates are important questions, but the highest priority is gathering data regarding the stools and stool pattern.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 804 43. The nurse is teaching an in-service program to a group of nurses on the topic of gastrointestinal disorders. The nurses in the group make the following statements.

Which statement is most accurate related to the diagnosis of gastroesophageal reflux?

A. A partial or complete intestinal obstruction occurs.

B. A thickened, elongated muscle causes an obstruction at the end of the stomach.

C. There are recurrent paroxysmal bouts of abdominal pain.

D. In this disorder the sphincter that leads into the stomach is relaxed.

Answer: D Rationale: Gastroesophageal reflux (GER) occurs when the sphincter in the lower portion of the esophagus, which leads into the stomach, is relaxed and allows gastric contents to be regurgitated back into the esophagus. Congenital aganglionic megacolon is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. Colic consists of recurrent paroxysmal bouts of abdominal pain. Pyloric stenosis is characterized by hypertrophy of the circular muscle fibers of the pylorus, which leads to an obstruction at the distal end of the stomach.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 801 44. The nurse is doing teaching with the caregivers of toddler and preschool agedchildren. One of the caregivers tells the group that her child had diarrhea and she was told that it was caused by giardiasis. Which statement made by the caregiver indicates the most likely situation in which the child contacted the disorder?

A. "My son spent time with a neighbor who was diagnosed with pinworms."

B. "He attends a day care center four days a week while I am at work."

C. "I won't let his sister take bubble baths but I do let him take one a few times a week."

D. "My mother is in a nursing home but I always make the kids wash their hands before we leave her."

Answer: B Rationale: Giardiasis is caused by the protozoan parasite Giardia lamblia. It is a common cause of diarrhea and is prevalent in children who attend day care centers and other types of residential facilities; it may be found in contaminated mountain streams or pools frequented by diapered infants. Bubble baths can lead to urinary tract infections, but are not the cause of Giardiasis infestations. It is not related to either C. Diff or pinworms.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 818 45. The nurse is educating the parents of a client newly diagnosed with type 1 diabetes. Which statement by the parents indicates additional teaching is needed?

A. "When our child is sick, we may need to check glucose levels more frequently."

B. "Our child should eat three meals and midafternoon and bedtime snacks each day."

C. "We and our child need to learn to identify carbohydrate, protein, and fat foods."

D. "Our child should not participate in sports or physical activity."

Answer: D Rationale: The nurse would provide additional education if the parents state the child should not participate in sports or physical activity. The child with diabetes can, and should, be physically active to maintain proper health and facilitate efficient insulin usage by the body. Glucose levels should be checked more frequently during times of sickness, as well as assessing the urine for ketones.

Consistency of intake can help prevent complications and maintain near-normal blood glucose levels. The parents and child should know how to identify foods to adequately monitor the child's nutritional intake. A dietitian with expertise in diabetes education should be consulted for referral as needed.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 828 46. The nurse is teaching a group of caregivers of children diagnosed with diabetes mellitus. The nurse is explaining insulin shock and the caregivers make the

following statements. Which statement indicates the best understanding of a reason an insulin reaction might occur?

A. "If my child eats as much as their older brother eats they could have an insulin reaction."

B. "My child measures their own medication but sometimes doesn't administer the correct amount."

C. "My child monitors their glucose levels to keep them from going too high."

D. "On the weekends we encourage our child to participate in lots of sports activities and stay busy so they don't have an insulin reaction."

Answer: B Rationale: Insulin reaction (insulin shock, hypoglycemia) is caused by insulin overload, resulting in too-rapid metabolism of the body's glucose. This may be attributable to a change in the body's requirement, carelessness in diet (such as failure to eat proper amounts of food), an error in insulin measurement, or excessive exercise.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 825 47. The nurse is doing dietary teaching with the caregivers of a child diagnosed with idiopathic celiac disease. What food will the nurse recommend as an appropriate diet choice?

A. Bananas B. Toast C. Oatmeal D. Canned soup Answer: A Rationale: People with idiopathic celiac disease will need to avoid gluten in the diet.

Of the foods listed, the nurse should recommend the child eat bananas, which do not contain gluten and are usually well tolerated. Products that contain wheat, rye, or oats should be excluded. The nurse should teach the family that gluten is often hidden in processed or canned food, for example, many canned soups contain hidden gluten.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 801

48. The parent of a child diagnosed with intussusception asks the nurse why the child's stool looks so strange. How should the nurse reply?

A. "Your child's stool is mixed with blood and mucus, so it looks very different."

B. "Your child's stool looks like that because the intestine is inflamed."

C. "The stool looks like that from the barium used to reduce the intussusception."

D. "I know it concerns you, but the stool is normal for the problem your child is having."

Answer: A Rationale: In the child with intussusception, the stools consist of blood and mucus, thereby earning the name currant jelly stool. There is a telescoping of the upper portion of the bowel slipping over the lower portion. The condition occurs more often in boys than in girls and the highest incidence occurs in infants between the ages of 4 and 10 months. The infant who previously appeared healthy and happy suddenly becomes pale, cries out sharply, and draws up the legs in a severe, colicky spasm of pain. This spasm may last for several minutes, after which the infant relaxes and appears well until the next episode, which may occur 5, 10, or 20 minutes later. The stool does not have the appearance because of infection or inflammation. It is because of the stricture caused by the telescoping of the bowel.

Making these statements gives the parent false information. Stating "I know it concerns you" might be true but the remainder of the sentence telling the parent the stool is normal is not true and is not reassuring to the parent. Barium or air may be used to reduce the intussusception, but it's not the reason for the color and consistency of the stool.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 814 49. The nurse working with the child diagnosed with type 2 diabetes mellitus recognizes the disorder can be managed by: A. taking oral hypoglycemic agents.

B. increasing carbohydrates in the diet, especially in the evening.

C. conserving energy with rest periods during the day.

D. decreasing amounts of daily insulin.

Answer: A Rationale: Oral hypoglycemic agents, such as metformin, are often effective for controlling blood glucose levels in children diagnosed with type 2 diabetes mellitus.

Insulin may be used for a child with type 2 diabetes if oral hypoglycemic agents alone are not effective, but "decreasing" the daily insulin would not help treat this disorder. Lifestyle changes such as increased exercise (not conserving energy by resting during the day), and limiting large amounts of carbohydrates are important aspects of treatment for the child.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 833 50. The nurse admits a 7-year-old child who reports pain in the lower right quadrant of the abdomen, nausea, and constipation. An assessment shows that the child has a fever of 101℉ (38.3℃). Which nursing intervention should the nurse implement to safely address the child's reported pain?

A. Request a prescription for a laxative.

B. Place a heating pad or hot water bottle on the abdomen.

C. Help the child find a comfortable position.

D. Give the child an analgesic such as acetaminophen.

Answer: C Rationale: The child's symptoms indicate possible appendicitis. When appendicitis is suspected, laxatives and enemas are contraindicated because they increase peristalsis, which increases the possibility of rupturing an inflamed appendix. Heat to the abdomen is also contraindicated because of the danger of rupture of the appendix. Medicating with analgesics is inappropriate, because medication may conceal signs of tenderness that are important for diagnosis. Comfort can be provided through positioning.

Question format: Multiple Choice Chapter 38: The Child with a Gastrointestinal/Endocrine Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 815

Chapter 39 1. The nurse is caring for a child who is being evaluated for a possible nephroblastoma. Which nursing intervention would be important for this child?

A. Monitor for protein in the urine at each voiding.

B. Protect the child from having the abdomen palpated.

C. Check blood pressure every 2 hours.

D. Measure the child's intake and output every hour.

Answer: B Rationale: When the child is being evaluated and treated, abdominal palpation should be avoided because cells may break loose and spread the tumor.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 846 2. The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also has a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100 ℉ (37.8 ℃). The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have: A. a urinary tract infection.

B. lipoid nephrosis (idiopathic nephrotic syndrome).

C. acute glomerulonephritis.

D. rheumatic fever.

Answer: C Rationale: Acute glomerulonephritis is a condition that appears to be an allergic reaction to specific infections, most often group A beta-hemolytic streptococcal infections such as rheumatic fever. Presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection such as strep throat, otitis media, tonsillitis, or impetigo. Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103 ℉ to 104 ℉ (39.4 ℃ to 40 ℃) at the onset, but decreases in a few days to about 100 ℉ (37.8 ℃).

Slight headache and malaise are usual, and vomiting may occur.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

Reference: p. 841 3. A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?

A. The child has a urinary tract infection due to not bathing while on the fishing trip.

B. The child is out of the habit of waking himself up during the night to void.

C. The child did not want to go on the fishing trip and is now retaliating against being made to go.

D. The child has been sexually abused, maybe on the fishing trip.

Answer: D Rationale: Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse (child mistreatment) and should be further explored.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 840 4. A 12-year-old girl who has not yet reached menarche comes to the pediatrician's office for her annual well-child check. As the nurse is weighing and measuring her, the child says emphatically that she does not want to get her period. Which response would be most appropriate for the nurse to make to this child?

A. "What have you heard about it that makes you worried?"

B. "But it's a good thing, having a period is a part of growing up."

C. "Are you afraid of getting pregnant?"

D. "Do you think it will hurt?"

Answer: A Rationale: The beginning of menstruation, called menarche, normally occurs between the ages of 12 and 13 years. For many girls this is a joyous affirmation of their womanhood, but others may have negative feelings about the event depending on how they have been prepared for menarche and for their roles as

women. The nurse would need to explore the child's understanding of the implications of menarche.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 846 5. A single male caregiver of a 14-year-old girl accompanies his daughter to her pre-high school physical. In the course of discussion about how his daughter is developing, he remarks, "She's terrific most of the time. Of course when she gets her period, she's miserable and mean, but I tell her that's just what it's like to be a woman." What would be the most appropriate response by the nurse?

A. "PMS is a problem for a lot of women, but sometimes it's worse in the beginning.

She might outgrow it."

B. "There are nutritional and medical things she can do to lessen the symptoms; I'll give both of you information about some strategies and we'll track her for a few months."

C. "That must be hard on you, especially because you are raising her by yourself."

D. "That doesn't make being a woman sound very good. It would probably be easier for her if you could be more supportive."

Answer: B Rationale: Women of all ages are subject to the discomfort of premenstrual syndrome (PMS), but the symptoms may be alarming to the adolescent. Symptoms include edema (resulting in weight gain), headache, increased anxiety, mild depression, and mood swings. Generally the discomforts of PMS are minor and can be relieved by reducing salt intake during the week before menstruation, taking mild analgesics, and applying local heat. When symptoms are more severe, the physician may prescribe a mild diuretic to be taken the week before menstruation to relieve edema; occasionally, oral contraceptive pills are prescribed to prevent ovulation.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 846 6. The nurse is reinforcing teaching with the caregiver of 5-year-old twins regarding urinary tract infections (UTIs). The caregiver is puzzled about why her daughter has had three urinary tract infections but her son has had none. She reports that their diets and fluid intake is similar. Which statement would be accurate for the nurse to tell this mother?

A. "A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily."

B. "Girls tend to urinate less frequently than boys, making them more susceptible to UTI's."

C. "Girls need more vitamin C than boys to keep their urinary tract healthy, so your daughter may be deficient in vitamin C." D. "It is unlikely that your daughter is practicing good cleaning habits after she voids."

Answer: A Rationale: Many different bacteria may infect the urinary tract, and intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. The female urethra is shorter and straighter than the male urethra, so it is more easily contaminated with feces.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 837-838 7. A child who has been diagnosed with minimal change nephrotic syndrome (MCNS) is being discharged after a 3-week hospitalization. Her edema has been greatly reduced and her appetite is beginning to return. Her caregivers have promised to have a family party to celebrate her return. The child has requested the following foods for the party. Which of these foods would the nurse suggest is appropriate for this child's diet?

A. banana splits B. popcorn C. potato chips D. orange soda Answer: A Rationale: For the child with nephrotic syndrome, the addition of salt is discouraged, and sometimes the child is put on a low sodium diet. In addition, the child may be placed on a high protein diet. Popcorn, potato chips, and orange soda all have higher sodium content than a banana split. The banana split would also have higher protein content.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 843 8. The caregiver of a child being treated at home for acute glomerulonephritis calls the nurse reporting that her daughter has just had a convulsion. The child is resting

comfortably but the caregiver would like to know what to do. The nurse would instruct the caregiver to take which action?

A. Weigh the child in the same clothes she had been weighed in the day before and report the two weights to the nurse while the nurse is on the phone.

B. Take the child's blood pressure and report the findings to the nurse while the nurse is still on the phone.

C. Give the child a diuretic and report back to the nurse in a few hours.

D. Give the child fluids and report back to the nurse in a few hours.

Answer: B Rationale: Blood pressure should be monitored regularly using the same arm and a properly fitting cuff. If hypertension develops, a diuretic may help reduce the blood pressure to normal levels. An antihypertensive drug may be added if the diastolic pressure is 90 mm Hg or higher. The concern is immediate so reporting the findings in a few hours could delay needed treatment. The child should be weighed daily in the same clothes and using the same scale, but the blood pressure is the priority in this situation.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 841 9. If the newborn is following a normal development process, the child will most likely void when which amount of urine is in the bladder?

A. 3 ml B. 6 ml C. 15 ml D. 25 ml Answer: C Rationale: In the newborn, the bladder empties when about 15 ml of urine is present.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 837-838 10. The location of the kidneys in the child in relationship to the location of the kidneys in the adult makes which fact a greater likelihood in the child?

A. The adult has less fat to cushion the kidney.

B. The child has a greater risk for trauma to the kidney.

C. The child has more frequent urges to empty the bladder.

D. The adult has a greater chance of retaining fluids than the child.

Answer: B Rationale: The kidneys in children are located lower in relationship to the ribs than in adults. This placement and the fact that the child has less of a fat cushion around the kidneys cause the child to be at greater risk for trauma to the kidneys. The location of the kidneys does not affect the urges to empty the bladder nor the retaining of fluids.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 837-838 11. If the child follows a normal development process, the child's kidneys will most likely have reached their full size and function by which age?

A. 5 years of age B. 8 years of age C. 12 years of age D. 20 years of age Answer: C Rationale: The kidneys reach their full size and function by the time the child is an adolescent.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 837-838 12. The nurse is discussing urinary tract infections (UTI's) in children with a group of peers. Which fact is the most accurate regarding urinary tract infection seen in children?

A. Urinary tract infections are rarely seen after toilet training.

B. The most common age for UTIs in children is 2 to 6 years of age.

C. Males between the ages of 10 to 12 years of age commonly get UTIs. D. Girls who have gone through puberty most commonly get UTIs. Answer: B Rationale: Urinary tract infections (UTIs) are fairly common in the "diaper age," in infancy, and again between the ages of 2 and 6 years. Older school-aged and adolescent girls are not as prone to UTIs. Question format: Multiple Choice

Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 838-839 13. Most urinary tract infections seen in children are caused by: A. hereditary causes.

B. fungal infections.

C. intestinal bacteria.

D. dietary insufficiencies.

Answer: C Rationale: Although many different bacteria may infect the urinary tract, intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes.

Hereditary and dietary concerns are not causes of urinary tract infections.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 838 14. The nurse is teaching a group of nursing students about genitourinary conditions. The nurse tells these students about a condition that occurs when there is an inflammation of the kidney and renal pelvis. The condition the nurse is referring to is: A. oliguria.

B. amenorrhea.

C. pyelonephritis.

D. ascites.

Answer: C Rationale: Pyelonephritis is an inflammation of the kidney and renal pelvis. Oliguria is a subnormal volume of urine. Amenorrhea is the absence of menstruation.

Ascites is edema in the peritoneal cavity.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 838-839 15. The nurse is discussing genitourinary conditions with a group of 16-year-old girls. One of the girls says she has heard about girls who have stopped taking birth control pills and now don't have periods. The condition the girl is referring to is:

A. oliguria.

B. amenorrhea.

C. pyelonephritis.

D. ascites.

Answer: B Rationale: Amenorrhea is the absence of menstruation. Pyelonephritis is an inflammation of the kidney and renal pelvis. Oliguria is a subnormal volume of urine. Ascites is edema in the peritoneal cavity.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 847 16. The first method of choice for obtaining a urine specimen from a 3-year-old child with a possible urinary tract infection is: A. performing a suprapubic aspiration.

B. placing a cotton ball in the underwear to catch urine.

C. placing an indwelling urinary catheter.

D. obtaining a clean catch voided urine.

Answer: D Rationale: In the cooperative, toilet-trained child, a clean midstream urine may be used successfully to obtain a "clean catch" voided urine. If a culture is needed, the child may be catheterized, but this is usually avoided if possible. A suprapubic aspiration also may be done to obtain a sterile specimen. In the toilet-trained child, using a cotton ball to collect the urine would not be appropriate.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 839 17. Urinary tract infections are usually successfully treated by what means?

A. Increasing fluids, such as cranberry juice B. Administering antibiotics C. Performing bladder irrigations D. Administering diuretics Answer: B Rationale: UTIs may be treated with antibiotics (usually sulfamethoxazole or ampicillin) at home. Fluids are encouraged, but they do not treat the infection.

Bladder irrigations and diuretics are not used in the treatment of urinary tract infections.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 838-839 18. The nurse is collecting data on a 2-year-old child admitted with a diagnosis of urinary tract infection. When interviewing the caregivers, which question would be most important for the nurse to ask?

A. "Is your child potty trained?"

B. "Has your child complained of pain?"

C. "How often do you bathe your child?"

D. "Do any of your other children have a temperature?"

Answer: B Rationale: Gather information about the current illness: when the fever started and its course thus far; signs of pain or discomfort on voiding; recent change in feeding pattern; presence of vomiting or diarrhea; irritability; lethargy; abdominal pain; unusual odor to urine; chronic diaper rash; and signs of febrile convulsions. Toilet training and bathing habits would be of importance, but they are not the most important to ask. Temperatures in other children in the family would not be related to this child's current situation.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 838-839 19. The nurse is collecting data on a 6-year-old child admitted with a possible urinary tract infection. Which vital sign might indicate the possibility of an infection?

A. pulse rate 135 bpm B. pulse oximetry 93% on room air C. respirations 22 per minute D. blood Pressure 100/70 Answer: A Rationale: Data to collect regarding the child includes temperature, pulse (be alert for tachycardia) and respiration rates; normal vital signs for a 6-year-old would be a pulse rate of 70 to 115 beats per minute, so this rate shows tachycardia. The other vital signs are all within normal limits for a child this age.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder

Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 839 20. When caring for a child who has a urinary tract infection, which nursing interventions would be most appropriate. Select all that apply.

A. The nurse encourages the child to void every 30 minutes.

B. The nurse positions the child on a bedpan rather than on the toilet.

C. The nurse observes for signs of pain or burning on urination.

D. The nurse monitors intake and output.

E. The nurse administers pain medications each time the child voids.

F. The nurse administers antipyretics as needed.

Answer: C, D, F Rationale: Because of pain and burning on urination, the toilet-trained child may try to hold urine and not void. Encourage the child to void every 3 or 4 hours to prevent recurrent infection. Observe the child for signs of burning and pain when he or she is urinating. Monitor and measure urine output. Antipyretic medications may be ordered to reduce body temperature. A bedpan would not be necessary in most children with a UTI. Pain medications following each voiding would not be indicated.

Question format: Multiple Select Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 839 21. The nurse recognizes that what would be a likely physiologic cause for a child to have enuresis?

A. Regression to get attention B. Stress and stressful situations C. Sexual abuse D. Sleeping too soundly Answer: D Rationale: Physiologic causes may include a small bladder capacity, urinary tract infection, and lack of awareness of the signal to empty the bladder because of sleeping too soundly. Psychological causes might include rigorous toilet training, resentment toward family caregivers, a desire to regress to an earlier level of development to receive more care and attention, or emotional stress and stressful situations. Enuresis can be a symptom of sexual abuse.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort

Integrated Process: Nursing Process Reference: p. 840 22. The nurse is teaching an in-service program to a group of colleagues on the topic of children diagnosed with acute glomerulonephritis. In which age range is the peak incidence of this disorder noted?

A. 2 to 4 years of age B. 6 to 7 years of age C. 12 to 13 years of age D. 15 to 17 years of age Answer: B Rationale: Acute glomerulonephritis has a peak incidence in children 6 to 7 years of age and occurs twice as often in boys.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 841 23. The nurse is collecting data for a child diagnosed with acute glomerulonephritis.

What would the nurse likely find in this child's history?

A. The child has a sibling with the same diagnosis.

B. The child had a congenital heart defect.

C. The child recently had an ear infection.

D. The child is being treated for asthma.

Answer: C Rationale: In the child with acute glomerulonephritis, presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection, such as strep throat, otitis media, tonsillitis, or impetigo. There is not a family history of the disorder, a history of congenital concerns or defects, nor asthma in children with acute glomerulonephritis.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 841 24. The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. Loose, dark stools B. Tea-colored urine C. Strawberry-red tongue

D. Jaundiced skin Answer: B Rationale: The presenting symptom in acute glomerulonephritis is grossly bloody urine. The caregiver may describe the urine as tea- or cola-colored. Periorbital edema may accompany or precede hematuria. Loose stools are seen in diarrhea. A strawberry-colored tongue is a symptom seen in the child with Kawasaki disease.

Jaundiced skin is noted in hepatitis.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 841 25. A symptom often seen in acute glomerulonephritis is edema. The most common site the edema is first noted is in which area of the body?

A. Ankles B. Hands C. Eyes D. Sacrum Answer: C Rationale: Periorbital edema may accompany or precede hematuria in children with acute glomerulonephritis. Edema in the ankles, hands, and sacrum are not noted in acute glomerulonephritis.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 841 26. The nurse is collecting data on a 6-year-old child admitted with acute glomerulonephritis. Which vital sign would the nurse anticipate with this child's diagnosis?

A. Pulse rate 112 bpm B. Pulse oximetry 93% on room air C. Respirations 24 per minute D. Blood pressure 136/84 Answer: D Rationale: Hypertension appears in 60% to 70% of clients during the first 4 or 5 days with a diagnosis of acute glomerulonephritis. The pulse of 112 would be a little

high for a child this age, but not a concern with this diagnosis. The other vital signs are within normal limits for a child of this age.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 841 27. When caring for a child who has a diagnosis of acute glomerulonephritis, which nursing interventions would most likely be included in the child's plan of care?

Select all that apply.

A. The nurse encourages ambulation several times a day.

B. The nurse promotes increased fluid intake.

C. The nurse administers diuretics.

D. The nurse administers antihypertensives.

E. The nurse weighs the child every day using the same scale.

F. The nurse dipsticks the child's urine to test for protein.

Answer: C, D, E, F Rationale: Fluid intake and urinary output should be carefully monitored and recorded. Special attention is needed to keep the intake within prescribed limits.

The amount of fluid the child is allowed may be based on output, as well as on evidence of continued hypertension and oliguria. If hypertension develops, a diuretic may help reduce the blood pressure to normal levels. An antihypertensive drug may be added if the diastolic pressure is 90 mm Hg or higher. Weigh the child daily, at the same time, on the same scale, and in the same clothes. The urine must be tested regularly for protein and hematuria using dipstick tests. Bed rest should be maintained until acute symptoms and gross hematuria disappear.

Question format: Multiple Select Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 841-842 28. The nurse is teaching an in-service program on children diagnosed with nephrotic syndrome. Which statement made by the nurse accurately reflects information on the disease process?

A. "These children have such a big appetite and are always hungry."

B. "The child may look chubby, but he is really malnourished."

C. "When you look at the urine of these children it is smoky and bloody."

D. "Their lab work shows a decreased level of cholesterol."

Answer: B

Rationale: In children with nephrotic syndrome, malnutrition may become severe.

The generalized edema masks the loss of body tissue, causing the child to present a chubby appearance and to double his or her weight. After diuresis, the malnutrition becomes quite apparent. Anorexia, irritability, and loss of appetite develop.

Hematuria is not usually present, although a few red blood cells may appear in the urine. There is an increase in the level of cholesterol in the blood.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 842 29. The LPN is working with the RN to develop a plan of care for a child with nephrotic syndrome. Which of the following would be appropriate goals of treatment for this child? Select all that apply.

A. conserving energy B. encouraging a high-salt diet C. preventing infection D. restricting protein intake E. promoting coping Answer: A, C, E Rationale: The major goals for the child with nephrotic syndrome are relieving edema, improving nutritional status, maintaining skin integrity, conserving energy, and preventing infection. The family goals include learning about the disease and treatments, as well as learning ways to cope with the child's long-term care. The child may be on a no-added-salt or low-salt diet, but there are usually no food restrictions.

Question format: Multiple Select Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 843 30. The nurse is caring for an 8-year-old child hospitalized with nephrotic syndrome. Which nursing intervention would be appropriate for this child?

A. Measure the abdominal girth daily.

B. Weigh the child once a week.

C. Test the urine for ketones twice a day.

D. Administer antipyretics as needed.

Answer: A Rationale: Measure the child's abdomen daily at the level of the umbilicus, and make certain that all staff personnel measure at the same level. Weigh the child at

the same time every day on the same scale in the same clothing. Test the urine regularly for albumin and specific gravity. Elevated temperature is not an issue with nephrotic syndrome.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 843 31. A group of nursing students is discussing terminology related to the genitourinary system during a post-conference setting. One of the students asks what mittelschmerz is or what it means. A classmate of this student correctly answers that mittelschmerz is: A. a symptom of premenstrual syndrome.

B. the beginning of menstruation.

C. a dull, aching abdominal pain at ovulation.

D. a medication given to treat dysmenorrhea.

Answer: C Rationale: Mittelschmerz is a dull, aching abdominal pain at the time of ovulation (hence the name, which means "midcycle"). The beginning of menstruation is called menarche. Symptoms include edema (resulting in weight gain), headache, increased anxiety, mild depression, and mood swings. Nonsteroidal antiinflammatory drugs (NSAIDs) such as ibuprofen (Advil, Motrin) inhibit prostaglandins and are the treatment of choice for primary dysmenorrhea, which is painful menstruation.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 846 32. The nurse is doing a presentation for a group of nursing students about the topic of menstrual disorders. After discussing the disorder secondary amenorrhea, the students make the following statements. Which statement made by the nursing students is the most accurate regarding the cause of secondary amenorrhea?

A. "It is caused from taking birth control pills when a girl is younger than 13 years old."

B. "This disorder is usually seen after a girl has had a spontaneous abortion (miscarriage)."

C. "Emotional stress can be a cause of this disorder."

D. "This is what happens if a 16-year-old girl has never had any periods at all."

Answer: C

Rationale: Secondary amenorrhea can be the result of discontinuing contraceptives, a sign of pregnancy, the result of physical or emotional stress, or a symptom of an underlying medical condition. A complete physical examination, including gynecologic screening, is necessary to help determine the cause. Primary amenorrhea occurs when a girl has had no previous menstruation. A spontaneous abortion (miscarriage) does not cause secondary amenorrhea.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 847 33. A child is hospitalized with nephrotic syndrome. Which measurement is best for the nurse to determine the child's edema?

A. weight, daily B. urine output, every shift C. amount of protein in the urine D. abdominal circumference Answer: A Rationale: The classic sign of nephrotic syndrome is edema. It is usually generalized, but may be manifested as ascites or be periorbital depending on the seriousness of the disease. The easiest way to determine edema is by weighing the child. The child should be weighed on the same scale, at the same time daily, and with the same amount of clothing. The abdomen would only need to be measured if ascites was suspected or known. Measuring urine output will not determine edema, although it should be done to determine if urine is being produced in adequate amounts. Measuring the amount of protein in the urine will also not determine edema. The measurement is important to determine the progress of the disease, however.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 842-843 34. A school-aged child has come to the clinic with symptoms of a urinary tract infection. The child reports dysuria, frequency and hesitancy. What nursing assessment is most important for the nurse to complete?

A. Assess for bladder distention.

B. Measure the urine output.

C. Monitor the temperature.

D. Assess for flank pain.

Answer: A

Rationale: In school-aged and older children, a urinary tract infection can be manifested by fever, vomiting, dysuria, frequency, hesitancy, urgency, flank pain and poor appetite. Because there are dysuria and hesitancy, the bladder may not empty fully. It is most important for the nurse to palpate the bladder for distention.

Keeping a distended bladder can cause reflux and continue to harbor bacteria. The urine output can be measured to determine the amount, but the urine also provides a look at the color for hematuria. The temperature should be measured, and antipyretics administered if necessary. Pain medication may be prescribed by the health care provider. The nurse can also recommend warm sitz baths and the use of a heating pad over the flank area for pain relief.

Question format: Multiple Choice Chapter 39: The Child with a Genitourinary Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 839

Chapter 40 1. The nurse caring for a child who has been put into a leg cast must be on the alert for signs of nerve and muscle damage. Which symptom might be an early warning signal that the child has developed compartment syndrome? The child: A. cannot plantarflex his foot.

B. feels increasing severe pain.

C. has a weak femoral pulse.

D. has blue-looking nail beds on the toes.

Answer: B Rationale: Any reports of pain in a child with a new cast or immobilized extremity need to be explored and monitored closely for the possibility of compartment syndrome.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 854 2. The caregivers of an 8-year-old child diagnosed with muscular dystrophy are discussing appropriate activities for their child. The nurse might suggest to these caregivers that they take which action in regard to their child's activities?

A. Find a Little League team that encourages participation of kids at all disability levels.

B. Find an art class that will allow the child to participate without physical exertion.

C. Modify family activities so they are more sedentary for the child.

D. Teach the child at home so that the child does not feel overly different.

Answer: A Rationale: The child must be encouraged to be as active as possible to delay muscle atrophy and contractures. To help keep the child active, physiotherapy, diet to avoid obesity, and parental encouragement are important. The nurse should advise the family to keep the child's life as normal as possible.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Caring Reference: p. 861

3. The nurse is talking with the caregiver of a 13-year-old diagnosed with scoliosis. The child has come to the clinic to be fitted with a brace to begin her treatment. The child appears upset and angry and states, "I hate this brace; I hate it already." In an effort to support this child, which statement would be the most appropriate for the nurse to make to this child's caregiver?

A. "Remind your child that her spine needs to be corrected in order to keep her whole musculoskeletal system healthy for a long, long time."

B. "Take your daughter to an oncology floor for a few minutes so she can see children who are much sicker than she is."

C. "If you can afford it, let your daughter choose an article or two of clothing that she can wear with the brace that will help her feel that she looks good."

D. "Children her age often withdraw during stressful times; let her have some time alone to think about the situation and to get used to the brace."

Answer: C Rationale: Help the child select clothing that blends with current styles but is loose enough to hide the brace. Self-image and the need to be like others are very important at this age.

Wearing a brace creates a distinct change in body image, especially in the older child or adolescent, at a time when body consciousness is at an all-time high. The need to wear the brace and deal with the limitations it involves may cause anger; the change in body image can cause a grief reaction. Handling these feelings successfully requires understanding support from the nurse, family, and peers. It is important for the child to have an opportunity to talk about his or her feelings.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 868 4. The nurse is caring for a group of children on the pediatric unit. The nurse should collect further data and explore the possibility of child abuse (child mistreatment) in which situation?

A. A 10-year-old with a simple fracture of the femur, which the caregiver reports as having been caused when the child fell down a set of stairs.

B. A 7-year-old with a spiral fracture of the humerus, which the caregiver reports as having been caused when the child was hit by a bat swung by a Little League teammate.

C. A 9-year-old with a compound fracture of the tibia, which the caregiver reports as having been caused when the child attempted a flip on a skateboard.

D. A 6-year-old with a greenstick fracture of the wrist, which the caregiver reports as having been caused when the child fell while ice-skating.

Answer: B

Rationale: Spiral fractures, which twist around the bone, are frequently associated with child abuse (child mistreatment) and are caused by a wrenching force. When a broken bone penetrates the skin, the fracture is called compound, or open. A simple, or closed, fracture is a single break in the bone without penetration of the skin. In a greenstick fracture, the bone bends and often just partially breaks.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 853 5. The caregiver of a child with a recent puncture wound on the arm calls the pediatrician's office reporting that after seeming well at bedtime last night, the child now has a temperature of 101 ℉ (38.3 ℃), pain at the site of the injury, and is unable to fully bend the elbow of the arm which had been injured. The nurse recommends the child be brought in to see the health care provider. What would likely be ordered for this child?

A. an x-ray B. a muscle biopsy C. blood work D. a surgical consult Answer: C Rationale: In osteomyelitis, diagnosis is based on laboratory findings of leukocytosis (15,000 to 25,000 cells or more), an increased ESR, and positive blood cultures.

Radiographic examination does not reveal the process until 5 to 10 days after the onset. A biopsy is not indicated with these symptoms.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 859 6. The nurse is caring for a child diagnosed with Legg–Calvé–Perthes disease (LCPD). What is the most important nursing intervention for the nurse to include in working with this child and his caregivers?

A. The nurse should provide information when the child or caregiver requests it.

B. The nurse should be a contact person when the child is hospitalized.

C. The nurse should support the caregivers in restricting activity during the treatment.

D. The nurse should help the caregivers to understand and help the child to effectively use the corrective devices.

Answer: D

Rationale: Nursing care focuses on helping the child and caregivers to manage the corrective device and on the importance of compliance to promote healing and to avoid long-term disability.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 863 7. The nurse admits an 11-year-old boy who reports lower leg pain after he was hit with a lacrosse stick during a game. The level of pain is not consistent with the description of the incident. With further questioning, the nurse discovers the child has had pain in that spot off and on for several months. The child has a biopsy, a bone scan and a bone marrow aspiration ordered by the care provider. What is the most likely condition the care provider is looking for?

A. osteosarcoma B. Ewing sarcoma C. Legg–Calvé–Perthes syndrome D. acute osteomyelitis Answer: B Rationale: Many times an injury draws attention to the pain at the site of the tumor with Ewing sarcoma. The pain may be sporadic for a period of time, but continues and becomes severe enough to keep the child awake at night. Metastasis to the lung and other bones may already have taken place by the time of diagnosis. A biopsy, bone scan, and bone marrow aspiration are done to further diagnose the tumor.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 863 8. The nurse is caring for a child diagnosed 3 months ago with juvenile idiopathic arthritis (JIA). The caregiver states that the child has recently reported little pain and is not currently taking aspirin or NSAIDs. The caregiver also tells the nurse that just to be on the safe side, she is continuing to keep the child from doing physical exercise. The mother states, "I think we have beaten this disease." In working with this child and the caregiver, which statement would be best for the nurse to make?

A. "It sounds as though things are going well. Be sure to restart the medication as soon as there is any flare-up of pain."

B. "That is not what is best. The medications aren't for pain; she needs to take aspirin every few days."

C. "Let's review some of the instructions. She does need to take an anti-inflammatory every day."

D. "I'm glad you're feeling optimistic. She should exercise now but give her aspirin before she does."

Answer: C Rationale: Teach family caregivers the importance of regular administration of the medications, even when the child is not experiencing pain. The primary purpose of aspirin or NSAIDs is not to relieve pain but to decrease joint inflammation.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 864 9. The caregiver of a 2-year-old who has a polyurethane resin cast on her arm calls the clinic to report that her child is crying and says that the cast has sand in it. The caregiver states that she has had casts herself and knows how badly they can itch. She says she always used a hanger to scratch but is worried that it will be too sharp for the child. Which statement would be appropriate for the nurse to make to this caregiver?

A. "Since the child's cast is synthetic, she could soak it with cool water."

B. "A plastic ruler is less likely than a hanger to cut the child's skin."

C. "Nothing should be put into the cast. You can blow cool air into it with a hair dryer."

D. "You could give the child an extra dose of acetaminophen and see if that helps."

Answer: C Rationale: Children and caregivers should be cautioned not to put anything inside the cast, no matter how much the casted area itches. Small toys and sticks or stick-like objects should be kept out of reach until the cast has been removed. Ice packs applied over the cast may help decrease the itching. Blowing cool air through a cast with a hair dryer set on a cool temperature or using a fan may help to relieve discomfort under a cast.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 855 10. In understanding the physiology of the musculoskeletal system, the nurse recognizes that which of the following are stored in the bones?

A. vitamins

B. minerals C. spinal fluid D. cartilage Answer: B Rationale: Minerals such as calcium, phosphorus, magnesium, and fluoride are stored in the bones.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 852 11. In understanding the function of the musculoskeletal system, the nurse recognizes that which of the following allows for movement of the body parts?

A. tendons B. ligaments C. joints D. cartilage Answer: C Rationale: Bones are attached to each other by connecting links called joints, which allow for movement of the body parts. Skeletal muscles attach to the bones, with a moveable joint between them. Tendons and ligaments hold the muscles and bones together. Cartilage is a type of connective tissue consisting of cells implanted in a gel-like substance, which gradually calcifies and becomes bone.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 851 12. In understanding the development of the musculoskeletal system, the nurse recognizes that what is implanted in a gel-like substance during fetal life?

A. Tendons B. Ligaments C. Joints D. Cartilage Answer: D

Rationale: During fetal life, tissue called cartilage, which is a type of connective tissue consisting of cells implanted in a gel-like substance, gradually calcifies and becomes bone.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 852 13. The musculoskeletal system is made up of various types of bones. Most bone growth is completed by which age?

A. 5 years of age B. 10 years of age C. 14 years of age D. 20 years of age Answer: D Rationale: Bone growth takes place between birth and puberty, with most growth being complete by 20 years of age.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 852 14. The nurse is working with a group of caregivers of school-aged children discussing fractures. The nurse explains that if the fragments of fractured bone are separated, the fracture is said to be: A. Incomplete B. Complete C. Greenstick D. Spiral Answer: B Rationale: If the fragments of fractured bone are separated, the fracture is said to be complete. If fragments remain partially joined, the fracture is termed incomplete.

Greenstick fractures are one kind of incomplete fracture, caused by incomplete ossification, common in children. Spiral fractures twist around the bone.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning

Reference: p. 852 15. The nurse is educating a group of caregivers about fractures seen in children. One of the caregivers states, "I have heard that if a bone breaks it can cause permanent damage and stop the growth of the bone." This statement is accurate if the break occurs in the: A. humerus.

B. joint.

C. xiphoid process.

D. epiphyseal plate.

Answer: D Rationale: Fractures in the area of the epiphyseal plate (growth plate) can cause permanent damage and severely impair growth.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 853 16. The nurse is discussing types of treatment used when working with children who have orthopedic disorders. Which form of treatment covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open?

A. Internal fixation device B. External fixation device C. Spica cast D. Stockinette Answer: C Rationale: The hip spica cast covers the lower part of the body, usually from the waist down, and either one or both legs while leaving the feet open. The cast maintains the legs in a frog-like position. Usually, there is a bar placed between the legs to help support the cast.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Teaching/Learning Reference: p. 854 17. The nurse is caring for a child who has just had a plaster cast applied to the arm. The nurse is correct in performing which action with this child?

A. Handling the cast with open palms when moving the arm.

B. Using only a draw sheet to move the casted arm.

C. Keeping a clove-hitch restraint gently tied on the hand to stabilize the arm.

D. Encouraging the child to move the arm slowly up and down to help the cast dry.

Answer: A Rationale: A wet plaster cast should be handled only with open palms because fingertips can cause indentations and result in pressure points. There is no reason the arm should be restrained or the arm moved to aid in the drying process.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 854 18. The caregiver of a child who has had a cast applied to the leg observes the nurse putting adhesive tape strips around the edge of the cast. The caregiver asks the nurse why she is doing this. The best response by the nurse would be: A. "We put these on so the child will not pull the padding from under the cast."

B. "These will help the cast look more attractive so the child won't feel self-conscious."

C. "These make a smooth edge on the cast so the skin is better protected."

D. "In case the child has an accident and misses the bedpan, these can be changed to keep the area dry."

Answer: C Rationale: If the cast has no protective edge, it should be petaled with adhesive tape strips.

These help keep the skin protected from the rough edge of the cast. If the cast is near the genital area, plastic should be taped around the edge to prevent wetting and soiling of the cast; petaling the cast does not provide protection to keep the cast dry.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 854 19. The nurse is doing neurovascular checks on a child who has had a cast applied to treat a fracture. The nurse observes for diminished or absent sensation and numbness or tingling.

In doing this the nurse is monitoring for which symptom?

A. pain B. pallor C. paresthesia D. paralysis Answer: C

Rationale: Paresthesia is diminished or absent sensation or numbness or tingling. Pallor is paleness of color and paralysis is the loss of function.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 855 20. The nurse is reinforcing discharge teaching with the caregivers of a child who is going home after a cast has been applied. The nurse explains to the caregivers that which issues should be reported if they occur or are seen related to this child? Select all that apply.

A. Any area on the cast that is warm to the touch B. A foul odor under the cast C. Any itching under or around the edges of the cast D. Drainage from under the cast E. Any pink color in the fingers or toes of casted extremity F. Looseness of the cast on the extremity Answer: A, B, D, F Rationale: In addition to the five Ps, any foul odor or drainage on or under the cast, "hot spots" on the cast (areas warm to the touch), looseness or tightness, or any elevation of temperature must be noted, documented, and reported. Family caregivers should be instructed to watch carefully for these same danger signals. Itching is common and does not need to be reported. Pink coloration of fingers and toes would be normal and not a concern.

Question format: Multiple Select Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 855 21. The nurse is reinforcing teaching with the caregivers of a child who has had a cast on the arm removed after 6 weeks. The caregiver makes the following statements. Which statement indicates an understanding of the teaching?

A. "As soon as we get home I will scrub his arm really well to remove the loose skin."

B. "He loves to play outside now that the weather is nice; I will have to remind him to use sunscreen."

C. "We will be careful to not let him put his little sister's baby oil on his arm for a few weeks."

D. "I usually let him take a tub bath, but we will keep him out of warm water for a couple of days."

Answer: B

Rationale: After cast removal, sunscreen should be applied to the previously casted area when the child will have sun exposure. The casted area should be soaked in warm water to help remove the crusty layer of accumulated skin. Application of oil or lotion may prove comforting. Family caregivers and the child must be cautioned against scrubbing or scraping this area because the tender layer of new skin underneath the crust may bleed.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 855 22. The type of traction in which a pin, wire, tongs, or other device is surgically inserted through a bone is: A. skin traction.

B. skeletal traction.

C. Russell traction.

D. Buck extension traction.

Answer: B Rationale: Skeletal traction exerts pull directly on skeletal structures by means of a pin, wire, tongs, or other device surgically inserted through a bone. Skin traction applies pull on tape, rubber, or a plastic material attached to the skin, which indirectly exerts pull on the musculoskeletal system. Examples of skin traction are Bryant traction, Buck extension traction, and Russell traction.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 856 23. The nurse is reinforcing teaching with the caregivers of a child who has been placed in an external fixation device for the treatment of an orthopedic condition. Which statement made by the caregivers indicates an understanding of the external fixation device?

A. "We will have to get some of the elastic bandages to place around the pins and pin sites."

B. "It will be hard, but we know our child will be in this device for a long time."

C. "He is very sensitive about the way the device looks. I am glad that his clothes will fully cover it so his friends won't tease him."

D. "If we see any drainage around the pins when we are cleaning them, we won't be concerned."

Answer: B

Rationale: External fixation devices are sometimes left in place for as long as 1 year. The pin sites are left open to the air and should be inspected and cleansed every 8 hours. The child and caregiver should be able to recognize the signs of infection at the pin sites. The appearance of the pins puncturing the skin and the unusual appearance of the device can be upsetting to the child.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Analyze Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 859 24. A nursing student tells the staff nurse on the pediatric orthopedic unit that she has heard of a musculoskeletal disorder in which there is an infection of the bone. Which disorder does this statement describe?

A. osteomyelitis B. muscular dystrophy C. osteosarcoma D. juvenile idiopathic arthritis Answer: A Rationale: Osteomyelitis is an infection of the bone usually caused by Staphylococcus aureus. Acute osteomyelitis is twice as common in boys and results from a primary infection.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 859 25. The nurse is caring for a child with osteomyelitis who has a leg wound. The highest priority nursing intervention for this child would be for the nurse to: A. minimize the movement of the leg.

B. follow transmission-based precautions.

C. monitor nutritional intake.

D. encourage the child to avoid weight bearing.

Answer: B Rationale: All of these interventions are done for the child with osteomyelitis who has a wound, but the highest priority would be to follow transmission-based precautions to prevent the spread of infection, especially if the wound is open and draining.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder

Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 860 26. The child diagnosed with muscular dystrophy uses a method of rising from the floor which is referred to as which of the following?

A. Legg–Calvé–Perthes B. Gowers sign C. Milwaukee brace D. Boston brace Answer: B Rationale: The child cannot rise easily to an upright position from a sitting or squatting position on the floor; instead, he or she develops Gowers sign, a method where the child rises from the floor by "walking up" the lower extremities with the hands.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 860 27. The nurse is caring for a child with a possible diagnosis of muscular dystrophy. The nurse explains to the parents that which of the following will likely be used to confirm this child's diagnosis?

A. an x-ray B. a muscle biopsy C. complete blood count D. a surgical consult Answer: B Rationale: A decrease in muscle fibers, which is seen in a muscle biopsy, can confirm the diagnosis of muscular dystrophy.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 861

28. A child diagnosed with muscular dystrophy has recently developed kyphosis. The home health nurse stresses to the caregivers that the child is at an increased risk for which injury?

A. falling when attempting to stand B. decreasing cognitive abilities C. possibility of respiratory infection D. excessive weight gain Answer: C Rationale: When a child with muscular dystrophy becomes wheelchair-bound, kyphosis (hunchback) develops and causes a decrease in respiratory function and an increase in the incidence of infections. Breathing exercises are a daily necessity for these children.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 862 29. Legg-Calvé-Perthes disease (LCPD) is more likely to be seen in which group?

A. Asian girls B. Black boys C. white boys D. Hispanic girls Answer: C Rationale: Legg-Calvé-Perthes disease (LCPD) is an aseptic necrosis of the head of the femur. It occurs 4 to 5 times more often in boys than in girls and 10 times more often in whites than in other ethnic groups.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 862 30. The nurse is caring for a child admitted with juvenile idiopathic arthritis (JIA). Which clinical manifestation would likely have been noted in the child with this diagnosis?

A. difficulty standing and walking B. inflammation of the joints C. poor posture and malformed vertebrae D. pain in the groin and a limp Answer: B

Rationale: In the child with juvenile idiopathic arthritis, joint inflammation occurs first; if untreated, inflammation leads to irreversible changes in joint cartilage, ligaments, and menisci (the crescent-shaped fibrocartilage in the knee joints), eventually causing complete immobility.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 862 31. The caregivers of a child with juvenile idiopathic arthritis are asking the nurse about exercise for their child. The nurse explains to the caregivers that gentle daily exercise is needed to prevent which condition from occurring?

A. scoliosis B. ankylosis C. kyphosis D. lordosis Answer: B Rationale: In the child with juvenile idiopathic arthritis, joints must be immobilized by splinting during active disease, but gentle daily exercise is necessary to prevent ankylosis (immobility of a joint). The nurse should stress to the caregivers the importance of encouraging the child to perform independent activities of daily living to maintain function and independence.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 864 32. The school nurse is doing a presentation to a group of caregivers of children diagnosed with scoliosis. One of the caregivers asks the nurse about structural scoliosis. Which condition is involved with the diagnosis of structural scoliosis?

A. poor posture B. muscle spasm caused by trauma C. unequal leg length D. rotated and malformed vertebrae Answer: D

Rationale: Structural scoliosis involves rotated and malformed vertebrae. Functional scoliosis can have several causes: poor posture, muscle spasm caused by trauma, or unequal length of legs.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 864 33. The nurse is discussing treatment for a child diagnosed with scoliosis. Which statement indicates the parents understand the nurse's education?

A. "Because our child has scoliosis, treatment will include halo traction."

B. "The treatment for our child's scoliosis is anticipated to last between 3 to 4 months."

C. "Because our child is being treated by using braces, the braces will have to be worn almost all the time."

D. "The most successful treatment for scoliosis is surgery before reaching adult age."

Answer: C Rationale: The Boston or the thoracolumbosacral orthosis (TLSO) brace is made of plastic and is customized to fit the child for treatment of scoliosis. The brace should be worn constantly, except during bathing or swimming, to achieve the greatest benefit. Halo traction may be used to treat clients with severe scoliosis, but not all clients. Children will be reassessed every 4 to 6 months to determine the prognosis for continuing brace therapy and potentially refitting. Bracing may be indicated for months or years. Surgery may be indicated, depending on the severity and complications resulting from the scoliosis; however, surgery is not the best option for all clients.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Teaching/Learning Reference: p. 865 34. A type of traction sometimes used in the treatment of the child with scoliosis is called: A. Russell traction.

B. halo traction.

C. Bryant traction.

D. Dunlop traction.

Answer: B Rationale: When a child has a severe spinal curvature or cervical instability, a form of traction known as halo traction may be used to reduce spinal curves and straighten the spine. Halo traction is achieved by using stainless steel pins inserted into the skull while

counter-traction is applied by using pins inserted into the femur. Weights are increased gradually to promote correction.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 859 35. In caring for a child being treated for scoliosis, the highest priority goal is which of the following?

A. The child will participate in age-appropriate activities.

B. The child's skin integrity will be maintained.

C. The child will verbalize acceptance of the treatment.

D. The child will remain free of injury.

Answer: D Rationale: The highest priority goal for the child being treated for scoliosis is preventing injury. Other important goals, but with less priority, include minimizing the disruption of activities and maintaining skin integrity and self-image. Goals for the child and caregiver include accepting the treatment and complying with long-term care.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 867 36. The nurse caring for a child diagnosed with juvenile idiopathic arthritis (JIA) should provide medication education to the caregivers for which first-choice medication to manage the child's pain and joint inflammation?

A. Acetaminophen B. Naproxen C. Aspirin D. Codeine Answer: B Rationale: Enteric-coated aspirin had long been the drug of choice for JIA, but because of the concern of aspirin therapy and Reye syndrome, NSAIDs such as naproxen, indomethacin, and ibuprofen are being used in the treatment of JIA. Acetaminophen is not an appropriate substitute because it lacks anti-inflammatory properties. Codeine is not prescribed for symptoms associated with JIA. Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder

Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 863 37. The nurse is caring for a child admitted with possible Legg–Calvé–Perthes disease.

Which assessment question should the nurse ask the child's caregivers to help support this diagnosis?

A. "Does your child have difficulty standing or walking?"

B. "Are your child's knees every swollen and red?"

C. "Have you ever been told your child has any malformed vertebrae?"

D. "Does your child report pain in the groin that results in a limp?"

Answer: D Rationale: Symptoms first noticed in Legg–Calvé–Perthes disease are pain in the hip or groin and a limp accompanied by muscle spasms and limitation of motion.

Question format: Multiple Choice Chapter 40: The Child with a Musculoskeletal Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 862

Chapter 41 1. An 8-month-old has been diagnosed with infantile eczema. At a follow-up appointment, the child's caregiver seems exhausted and angry. He explains that he has done all of the child's care because his wife is repulsed by the child's raw and uncomfortable appearance. What responses would be appropriate for the nurse to say to this caregiver?

A. "He will be better soon and your family can get back to normal."

B. "I understand her feelings. It is hard to see a child in pain sometimes."

C. "That's not fair to you; she should get some counseling to learn how to cope with illness better."

D. "That's not an uncommon reaction, although it's hard on you and on your child."

Answer: D Rationale: The family caregivers of the child with eczema are often frustrated and exhausted. Family caregivers may feel apprehensive or repulsed by this unsightly child. Support them in expressing their feelings and help them view this as a distressing but temporary skin condition. Although the caregiver can be assured that most cases of eczema clear up by the age of 2, this does little to relieve the present situation.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 880 2. A pediatric client who has been seriously burned is being given IV fluid replacements. It has been determined that the client will initially need 24 ounces of replacement fluids. In following a normal burn replacement treatment for this child, if the treatment is started at 10:00 AM, which of the following would be correct?

The child would have received: A. 12 ounces of IV fluid replacement by 4:00 PM. B. 12 ounces of IV fluid replacement by 6:00 PM. C. 18 ounces of IV fluid replacement by 4:00 PM. D. 18 ounces of IV fluid replacement by 6:00 PM. Answer: B Rationale: Intravenous fluids for maintenance and replacement of lost body fluids are estimated for the first 24 hours, with half of this calculated requirement given during the first 8 hours.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Analyze

Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 886 3. The caregiver of a fifth-grade boy calls the pediatrician's office and reports that her son has been scratching at his groin for a week or so. Despite his need for privacy, he's finally allowed the caregiver to look at the groin area. The caregiver describes the area to the nurse saying, "It looks like black pin dots that seem to have dark tails." The nurse suspects that the child may have which of the following?

A. lice B. scabies C. ringworm D. prickly heat Answer: B Rationale: Scabies burrows are visible as dark lines and the mite is seen as a black dot at the end of the burrow. Lice can be seen as tiny, pearly-white flecks attached to the hair shafts. They look much like dandruff, but dandruff flakes can be flicked off easily, whereas the nits are tightly attached and not easily removed. Ringworm of the scalp begins as a small papule on the scalp which then spreads, leaving scaly patches of baldness. Ringworm of the body appears as a scaly ring with clearing in the center. Ringworm of the feet is more commonly known as athlete's foot. It is evidenced by the scaling or cracking of the skin between the toes.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 878 4. The dermatologist treating a 16-year-old girl with a history of severe acne has ordered a pregnancy test so she can be started on a course of isotretinoin. The teen's caregiver has said that her daughter is a virgin and she refuses to allow her to have the required pregnancy testing. What would be the best action for the nurse to take?

A. Acknowledge the caregiver's discomfort about the pregnancy testing but encourage her to allow the daughter to have the testing so that she can use the medication.

B. Speak with the teen alone to ask her if she is sexually active. If she says she is not sexually active, let the provider know that it is okay to write the prescription.

C. Arrange for the daughter to have the pregnancy testing without the caregiver's knowledge.

D. Have the caregiver sign a permission form acknowledging that the girl has been given the drug without pregnancy testing.

Answer: A

Rationale: Isotretinoin is a pregnancy category X drug: It must not be used at all during pregnancy because of serious risk of fetal abnormalities. To rule out pregnancy, a urine test is done before beginning treatment. For the sexually active adolescent girl, an effective form of contraception must be used for a month before beginning and during isotretinoin therapy. The risk to the fetus, should pregnancy occur, should be discussed with the girl whether she is sexually active or not.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 876 5. The nurse admits a 10-year-old who has just eaten lobster and has hives over much of the body. In collecting data regarding this child, which question should the nurse ask the caregiver first?

A. "Has the child ever eaten shellfish before now?"

B. "Is your child allergic to peanuts or other foods?"

C. "Does anyone in your family have any food allergies?"

D. "Have you ever given your child antihistamines?"

Answer: A Rationale: The first time the child comes in contact with an allergen, no reaction may be evident, but an immune response is stimulated—helper lymphocytes stimulate B lymphocytes to make the immunoglobulin E (IgE) antibody. The IgE antibody attaches to mast cells and macrophages. When contacted again, the allergen attaches to the IgE receptor sites, and a response occurs in which certain substances, such as histamine, are released; these substances produce the symptoms known as allergy. Asking the other questions is important, but the first question the nurse should ask is related to this child and this situation.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 878 6. The caregiver of a 4-year-old girl who lives in a heavily wooded area calls the clinic nurse to report that the child has a swollen tick on her arm. What would be the best action for the caregiver to follow in removing the tick?

A. The caregiver should take the child to a health care facility where the tick can be removed aseptically.

B. The caregiver should have another adult hold the child still, light a match and let it burn for 1 second, then blow out the match and quickly hold it on the tick.

C. The caregiver should hold a gauze pad beneath the tick to catch the blood and carefully crush the tick.

D. The caregiver should use tweezers to carefully remove the tick without crushing it.

Answer: D Rationale: If a tick is found on the body, the tick should be carefully removed with tweezers. To prevent the release of pathogenic organisms, care should be taken not to crush the tick. A health care provider must be consulted if there is any suspicion that a deer tick has bitten a child or an adult.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 883 7. An adolescent girl and her caregiver present at the pediatrician's office. The adolescent reports severe abdominal pain. A diagnosis of pelvic inflammatory disease (PID) is made. The nurse notes in the child's chart that this is the third time she has been treated for PID. Which action by the nurse would be most appropriate?

A. Contact the necessary authorities to report a suspected case of sexual abuse.

B. Take the child to a private room and interview her regarding her sexual history and partners.

C. Take the caregiver to a private room and tell her that the child's diagnosis can only come from sexual activity.

D. Talk to the child and caregiver together and explain that the condition is often a result of a sexually transmitted infection and discuss the importance of safe sex practices.

Answer: B Rationale: Adolescents must be made aware of the seriousness of PID, a common result of a chlamydial infection. Pelvic inflammatory disease can cause sterility in the female, primarily by causing scarring in the fallopian tubes that prohibits the passage of the fertilized ovum into the uterus. A tubal pregnancy may be the consequence of a chlamydial infection. In the male, sterility may result from epididymitis caused by a chlamydial infection. All sexual partners must be treated.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 892 8. The nurse instructor is reviewing the integumentary system during a presentation to a group of student nurses. Which statement made by the instructor is the most accurate regarding the integumentary system?

A. "The sebaceous and sweat glands are fully functional in the infant."

B. "The largest organ of the body helps regulate body temperature."

C. "The integumentary system is not in place until after the child is born and then takes many years to mature."

D. "One role of the integumentary system is to distribute oxygen to the body cells."

Answer: B Rationale: The skin is the largest organ of the body. The skin helps regulate the body temperature by heating and cooling. The sebaceous and sweat glands are not fully functional until middle childhood. The major role of the skin is to protect the organs and structures of the body against bacteria, chemicals, and injury. Excretion in the form of perspiration is also a function of the skin glands, called the sweat glands. Sebaceous glands in the skin secrete oils to lubricate the skin and hair. The integumentary system is in place at birth, but the system is immature. A function of the respiratory system is to distribute oxygen to body cells.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 873 9. The public health nurse is discussing immunizations with a group of caregivers of infants. One of the mothers asks the nurse why the child will need immunizations.

Which statement would be the most appropriate for the nurse to make to this mother?

A. "The infant is born with immunity to some diseases, but those immunities decrease over the first year of life."

B. "The antibodies the fetus gets from the mother are in the placenta, so after birth they are no longer available to the infant."

C. "The immunities that the infant is born with are not for the same diseases they will be immunized against."

D. "Infants are unable to develop antibodies to protect them from diseases so they must be immunized."

Answer: A Rationale: During fetal life, the mother's antibodies cross the placenta, giving the fetus a temporary immunity against certain diseases. This immunity is present at birth and decreases during the first year of life. In the meantime, the infant begins developing antibodies to fight against pathogens and disease. In addition, during the first year of life immunizations are started to help the infant develop protection against certain diseases.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching/Learning Reference: p. 873 10. The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. They are discussing various disorders related to the integumentary system. One of the nurses describes a disorder by telling the group that it is common in children during the summer when it is hot or when the child is overdressed. Which disorder is the nurse most likely referring to?

A. seborrheic dermatitis B. miliaria rubra C. candidiasis D. impetigo Answer: B Rationale: Miliaria rubra, often called prickly heat, is common in children who are exposed to summer heat or are overdressed. It also may appear in febrile illnesses and may be mistaken for the rash of one of the communicable diseases.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 873 11. When teaching a group of caregivers of infants, the nurse is discussing the topic of diaper rash. The caregivers in the group make the following statements. Which statement is the most accurate related to the child with diaper rash.

A. "The formula she drinks sometimes causes her to have a diaper rash."

B. "My child gets diaper rash if I wash her clothes in the same detergent we use for the family."

C. "Sometimes if I leave the diaper off and let him be in the sunshine he gets diaper rash."

D. "They told me to use baby powder every time I change her so she won't get diaper rash."

Answer: B Rationale: Infants may have a sensitivity to some soaps or disposable diaper perfumes, and the use of strong laundry detergents without thorough rinsing can cause diaper rash. Diarrheal stools, prolonged exposure to wet or soiled diapers, use of plastic or rubber pants, infrequently changed disposable diapers, inadequate cleansing of the diaper area (especially after bowel movements), and yeast infections are also causative factors. Exposing the diaper area to the air helps clear up the dermatitis. The use of baby powder when diapering is discouraged because caked powder helps create an environment in which organisms thrive.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease

Cognitive Level: Understand Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 874 12. The nurse is collecting data on a 4-month-old child brought to the clinic by the caregiver. The nurse observes the child's mouth and notes a white coating that looks like milk curds. Which of the following questions would be most important for the nurse to ask the caregiver?

A. "Did you have a vaginal delivery with this baby?"

B. "Has your child been treated for any type of infection recently?"

C. "Are you breastfeeding or bottle feeding your baby?"

D. "Does everyone in your house wash their hands often?"

Answer: B Rationale: The symptoms the child has indicate the child most likely has thrush, which is caused by Candida albicans. Asking about recent infections is most important because episodes of thrush or diaper rash often appear after antibiotic therapy. Antibiotic therapy can change the balance of normal intestinal flora, leading to candidal overgrowth. Newborns can be exposed to a candidiasis vaginal infection in the mother during delivery, but since the child is not a newborn, this question would not be the most important. Poor handwashing practices and inadequate washing of bottles and nipples are contributing factors.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 874 13. The nurse is discussing medications to be given to a child who has been diagnosed with oral candidiasis (thrush). Which medication would most likely be prescribed for the child?

A. acetaminophen B. ampicillin C. aspirin D. nystatin Answer: D Rationale: Application of nystatin to the oral lesions every 6 hours is an effective treatment for oral candidiasis (thrush). Treatment for diaper rash caused by Candida albicans is nystatin ointment or cream applied to the affected area.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

Integrated Process: Nursing Process Reference: p. 875 14. The nurse is presenting an in-service to a group of nurses who will be working in a dermatology clinic. One participant asks the nurse about a bacterial skin infection that she has seen in children that involves honey-colored crusted lesions.

The nurse most likely is referring to: A. seborrheic dermatitis.

B. miliaria rubra (heat rash).

C. candidiasis.

D. impetigo.

Answer: D Rationale: Impetigo is a superficial bacterial skin infection. Impetigo in the newborn is usually bullous (blister-like, fluid filled); in the older child, the lesions are nonbullous and have a honey-colored, crusted appearance.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Safe, Effective Care Environment: Safety and Infection Control Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 875 15. The nurse is caring for an infant who has impetigo and is hospitalized. Which nursing action is priority?

A. The nurse soaks the skin with warm water.

B. The nurse applies topical antibiotics to the lesions.

C. The nurse follows contact precautions.

D. The nurse applies elbow restraints to the infant.

Answer: C Rationale: Impetigo is highly contagious and can spread quickly. The nurse should follow contact (skin and wound) precautions, including wearing a cover gown and gloves. The nurse will soak the crusts with warm water, apply topical antibiotics, and apply elbow restraints, but these are not as high a priority as trying to prevent the spread of the infection by following contact precautions.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 875

16. The nurse is discussing acne vulgaris with a group of adolescents. The teenagers make the following statements regarding the topic. Which statement is the most accurate regarding acne vulgaris?

A. "My mom says I have acne because I eat too much chocolate."

B. "Sometimes I get acne when I use my sister's makeup."

C. "My next door neighbor told me that acne was caused by a fungus."

D. "There is a new immunization that you can get to keep from having acne."

Answer: B Rationale: Irritation and irritating substances, such as vigorous scrubbing and cosmetics with a greasy base, can cause acne vulgaris. Increased hormone levels, hereditary factors, and anaerobic bacteria can cause acne vulgaris as well. Eating chocolate and fatty foods does not cause acne, but a well-balanced, nutritious diet does promote healing.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 876 17. The nurse is discussing skin disorders with a group of caregivers. Which caregiver statement indicates an understanding of tinea capitis?

A. "That is an infection that you get under your fingernails."

B. "I always tell my daughter to use her own hairbrush."

C. "My son got that infection when he was at the swimming pool."

D. "My husband had that once and his groin itched so much."

Answer: B Rationale: Ringworm of the scalp is called tinea capitis or tinea tonsurans. The most common cause is infection with Microsporum audouinii, which is transmitted from person to person through combs, towels, hats, barber scissors, or direct contact. A less common type, Microsporum canis, is transmitted from animal to child.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Teaching/Learning Reference: p. 876 18. Which of the following infections is often contracted by having contact with an infected dog or cat?

A. tinea capitis B. tinea corporis C. tinea pedis D. tinea cruris

Answer: B Rationale: The child usually contracts tinea corporis from contact with an infected dog or cat.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 877 19. The nurse caring for children with fungal infections most often administers which medication?

A. benadryl B. acetaminophen C. prednisone D. griseofulvin Answer: D Rationale: Griseofulvin, an oral antifungal, is the medication of choice for fungal infections. In some infections the treatment may be prolonged (3 months or more), and compliance must be reinforced.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 877 20. The nurse is reinforcing teaching regarding the treatment for head lice with the caregiver of a child who has the disorder. Which of the following is most accurate related to the treatment for the child with an infection of head lice?

A. The treatment will be done every day for about 2 weeks.

B. The treatment will need to be repeated about once per month for a year.

C. The treatment will need to be repeated in about 7 to 9 days.

D. The treatment is done one time and won't need to be repeated.

Answer: C Rationale: Nonprescription medications are available to treat cases of head lice. A second treatment is suggested in 7 to 9 days to kill the nits after they have hatched.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies

Integrated Process: Teaching/Learning Reference: p. 877 21. The nurse is discussing allergies with a group of caregivers of children who have food allergies. Which statement made by the caregivers indicates the most concerning issue faced by the caregivers of children with food allergies?

A. "My daughter loves milk; it is so hard to tell her that she can't drink it."

B. "I read all the labels, but sometimes it is not easy to understand the ingredients."

C. "When he goes to a friend's house I always have to pack a bag of snacks for him."

D. "We have had to change all of the things we prepare for meals at our house."

Answer: B Rationale: If a food allergy is suspected, an elimination diet may help identify the allergen. Eliminating the food suspected is sometimes difficult because there are often "hidden" ingredients in food products.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 879 22. Which treatment will most likely be the best long-term benefit for the child with an allergic condition in which it is difficult to remove or avoid the allergen?

A. use of corticosteroids B. electrical stimulation C. use of antihistamines D. hyposensitization Answer: D Rationale: When specific allergens have been identified, clients can either avoid them or, if this is impossible, undergo immunization therapy by injection. This process is called hyposensitization or immunotherapy. Hyposensitization is considered a safe procedure with considerable benefit for some children.

Symptomatic relief in allergic reactions can be gained through antihistamine or steroid therapy, but the best treatment is prevention.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 879

23. In working with infants diagnosed with atopic dermatitis, the nurse anticipates that when these children are older they will likely have a tendency to have which disorder?

A. hemophilia B. asthma C. rheumatoid arthritis D. otitis media Answer: B Rationale: Infants who have atopic dermatitis (infantile eczema) tend to have allergic rhinitis or asthma later in life.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 879 24. A mother brings her 2-year-old son to the clinic with a bumpy rash. Which statement by the mother would lead the nurse to suspect that the child may have atopic dermatitis?

A. "I feel so bad for him because he has asthma, and now he gets this rash."

B. "It started as a flat red rash in between his legs."

C. "We just had him to the barber for his first haircut."

D. "He just started swim lessons at the YMCA." Answer: A Rationale: Children who have atopic dermatitis are at increased risk for also developing allergic rhinitis (hay fever) and/or asthma. Diaper dermatitis does not usually result in a bumpy rash, but starts as a flat red rash in the convex skin creases. If the child has recently seen a barber he may have contracted tinea capitis. Contact in damp areas such as locker rooms or a swimming pool may indicate tinea pedis.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 879 25. The nurse caring for a child with a skin allergy recognizes that the highest priority in the treatment for skin allergies is aimed at: A. regulating skin and body temperature.

B. controlling nausea and vomiting.

C. reducing swelling and relieving itching.

D. managing pain and discomfort.

Answer: C Rationale: Treatment for skin allergies is aimed at reducing the swelling and relieving the itching. With swelling in various parts of the body, the child may have pain, nausea and vomiting, but reducing the swelling would prevent those symptoms from occurring.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 880 26. The camp nurse is caring for a child who was bitten on the leg by a dangerous spider. The child is being taken to a health care provider. What is the most appropriate action for the nurse to do with this child?

A. Administer pain medication.

B. Apply ice to the affected area.

C. Splint the leg.

D. Briskly scrub the site.

Answer: B Rationale: Spider bites can cause serious illness if untreated. Bites of black widow spiders, brown recluse spiders, and scorpions demand medical attention. Applying ice to the affected area until medical care is obtained can slow absorption of the poison.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 883 27. The nurse is collecting data on a child admitted to the burn unit with a partialthickness or second-degree burn. What is most accurate regarding this type of burn?

A. The nerve endings are destroyed.

B. The child will have minimal pain.

C. The child will likely have blisters.

D. There is no destruction of tissue.

Answer: C Rationale: In a partial-thickness or second-degree burn, the epidermis and underlying dermis are both injured and devitalized or destroyed. Blistering usually

occurs with an escape of body plasma, but regeneration of the skin occurs from the remaining viable epithelial cells in the dermis.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 884 28. A school-aged child is brought to the office of the camp nurse with a small, superficial burn (first-degree burn). Which action by the nurse would be most appropriate to take first?

A. Apply a topical anesthetic ointment.

B. Administer acetaminophen.

C. Cover the area with a sterile bandage.

D. Apply cold compresses to the area.

Answer: D Rationale: Cool water is an excellent emergency treatment for burns involving small areas. The immediate application of cool compresses or cool water to burn areas appears to inhibit capillary permeability and thus suppress edema, blister formation, and tissue destruction.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 885 29. The nurse is collecting data on a 4-year-old child admitted to the burn unit. The nurse is concerned about the possibility of the child going into hypovolemic shock.

Which of the following data would the nurse recognize as an indication that this may be occurring?

A. The child is complaining of intense pain.

B. The child's blood pressure is 128/86.

C. The child's face is bright red in color.

D. The child's apical pulse is 140 bpm.

Answer: D Rationale: Hypovolemic shock is the major manifestation in the first 48 hours in massive burns. Symptoms of shock are low blood pressure, rapid pulse, pallor, and often considerable apprehension. Intense pain is seldom a major factor.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Analyze Client Needs: Physiological Integrity: Physiological Adaptation

Integrated Process: Nursing Process Reference: p. 886 30. The nurse admits a child who has sustained a severe burn. The child's immunizations are up to date. Which immunization would the child most likely be given at this time?

A. hepatitis A vaccine B. hepatitis B vaccine C. tetanus toxoid vaccine D. Haemophilus influenzae type B vaccine Answer: C Rationale: If inoculations are up to date, a booster dose of tetanus toxoid is required to protect the child from infection introduced into the burn.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 886 31. The nurse is caring for an adolescent diagnosed with genital herpes. The drug of choice for treating genital herpes is: A. griseofluvin B. ceftriaxone C. acyclovir D. penicillin Answer: C Rationale: The drug acyclovir is useful in relieving or suppressing the symptoms of genital herpes.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 893 32. The nurse is caring for an adolescent diagnosed with syphilis. The drug of choice for treating syphilis is: A. griseofluvin B. ceftriaxone C. acyclovir D. penicillin Answer: D

Rationale: Syphilis responds to one intramuscular injection of penicillin G benzathine; if the child is sensitive to penicillin, oral doxycycline, tetracycline, or erythromycin can be administered as alternative treatment.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 893 33. The nurse is caring for a 16-year-old child with a diagnosis of acquired immunodeficiency syndrome (AIDS). What treatment goal has the highest priority for this child?

A. preventing spread of infection B. promoting comfort C. maintaining skin integrity D. improving nutrition Answer: A Rationale: Major goals for the child include maintaining the highest level of wellness possible by preventing infection and the spread of the infection. Because the adolescent has the belief that nothing can hurt him or her, and because of the increasing rate of sexual activity in this age group often involving multiple partners, the highest priority is teaching and preventing the spread of the infection. Other goals include maintaining skin integrity, minimizing pain, improving nutrition, alleviating social isolation, and diminishing a feeling of hopelessness. The primary goal for the family is improving coping skills and helping the teen cope with the illness.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process Reference: p. 893 34. Infectious mononucleosis ("mono") is caused by which of the following?

A. Treponema pallidum B. Epstein-Barr virus C. Microsporum canis D. Streptococcal bacterium Answer: B Rationale: Infectious mononucleosis ("mono") is caused by the Epstein-Barr virus, one of the herpes virus groups. The organism is transmitted through saliva.

Question format: Multiple Choice

Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 897 35. The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which skin condition best describes erythema?

A. redness of the skin produced by congestion of the capillaries B. small, circumscribed, solid elevation of the skin C. discolored skin spot not elevated at the surface D. small elevation of epidermis filled with a viscous fluid Answer: A Rationale: Erythema is redness of the skin produced by congestion of the capillaries.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 903 36. The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which skin condition best describes pustule?

A. redness of the skin produced by congestion of the capillaries B. small, circumscribed, solid elevation of the skin C. discolored skin spot not elevated at the surface D. small elevation of epidermis filled with a viscous fluid Answer: D Rationale: A pustule is a small elevation of epidermis filled with pus.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 903 37. The nurse is doing an in-service training on clinical manifestations seen in communicable diseases. Which best describes a macule?

A. redness of the skin produced by congestion of the capillaries B. small, circumscribed, solid elevation of the skin C. discolored skin spot not elevated at the surface D. small elevation of epidermis filled with a viscous fluid

Answer: C Rationale: A macule is a discolored skin spot not elevated above the surface.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Remember Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 903 38. A nurse is promoting vaccine administration. When instructing on the physiological changes, which statement best explains what occurs in the child when vaccines are administered?

A. The child develops a passive immunity.

B. The child becomes a carrier of the disease.

C. The child develops an active immunity.

D. The child becomes a host for the disease.

Answer: C Rationale: When a vaccine is given, active immunity occurs which then stimulates the development of antibodies to destroy infective agents without causing the disease.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 903 39. The nurse is caring for a child hospitalized with pertussis. Which nursing intervention would be the highest priority for this child?

A. The nurse will administer oxygen.

B. The nurse will encourage bed rest.

C. The nurse will administer antibiotics.

D. The nurse will monitor caloric intake.

Answer: A Rationale: The major complication of pertussis (whooping cough) is pneumonia and respiratory complications. Oxygen, bed rest, and monitoring for airway obstruction are nursing interventions. The highest priority is administering oxygen to maintain adequate oxygenation of cells.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Management of Care Integrated Process: Nursing Process

Reference: p. 899 40. The nurse is caring for a child diagnosed with Haemophilus Influenzae type B. Which of the following nursing interventions would be the highest priority in the prevention of complications seen with this disorder?

A. The nurse will monitor for seizure activity.

B. The nurse will elevate the head of the bed.

C. The nurse will administer antibiotics.

D. The nurse will monitor fluid intake.

Answer: C Rationale: A serious complication of Haemophilus Influenzae type B is meningitis.

Antibiotics are administered to treat the bacterium infection caused by Haemophilus Influenzae type B. Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Pharmacological and Parenteral Therapies Integrated Process: Nursing Process Reference: p. 900 41. The school nurse is teaching a group of teachers about various skin disorders seen in children. The nurse would identify the most obvious symptom of pediculosis as: A. scaly rings with clear centers located on the scalp.

B. white flecks that are firmly attached to the hair shafts.

C. small papule on the scalp.

D. scaling or cracking of the skin on the scalp.

Answer: B Rationale: The nits can be seen as tiny, pearly white flecks attached to the hair shafts. They look much like dandruff, but dandruff flakes can be flicked off easily, whereas the nits are tightly attached and not easily removed. Tinea capitis begins as a small papule on the scalp. Tinea corporis is ringworm that appear as a scaly ring with clearing in the center. Tinea pedis is evidenced by the scaling or cracking of the skin.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Understand Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 877 42. A 17-year-old is diagnosed with infectious mononucleosis. The nurse should discuss which intervention with the teenager's caregiver to best assure an uncomplicated recovery?

A. admission to the hospital for about 7 days B. a 10-day course of antibiotics C. a high-protein, high-fiber, low-fat diet D. precautions to avoid secondary infections Answer: D Rationale: No cure exists for infectious mononucleosis; treatment is based on symptoms. An analgesic-antipyretic, such as acetaminophen, usually is recommended for fever and headaches. Fluids and a soft, bland diet are encouraged to reduce throat irritation. Because the immune system is weakened, the child must take precautions to avoid secondary infections.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Teaching/Learning Reference: p. 897 43. The nurse is assessing a child who presents with a history of fever, malaise, fatigue, and headache. The nurse notes a bulls-eye rash on the child's right leg.

Which action will the nurse take?

A. Notify the primary health care provider.

B. Place the child on contact precautions.

C. Obtain an electrocardiography (ECG).

D. Clean the rash with rubbing alcohol.

Answer: A Rationale: The nurse would suspect the child has Lyme disease and notify the health care provider for additional testing and potential antibiotic therapy.

Precautions are not indicated for clients with Lyme disease. An ECG would only be needed if cardiac symptoms were noted. It is recommended to clean the site of the tick bite with rubbing alcohol when the tick is removed, not at a later time.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 902 44. The nurse is caring for a 9-year-old child with partial-thickness (second-degree) burns. The client rates the pain at an 8 on a 1 to 10 numerical pain scale. The nurse notes the client is sitting in the bed playing with toys and smiling. Which action will the nurse take?

A. Administer pain medication as prescribed.

B. Reassess the client's pain in 30 minutes.

C. Ask the parents to rate the client's pain.

D. Use another pain scale to measure the client's pain.

Answer: A Rationale: The nurse would administer the client pain medication as prescribed.

Pain is how a client describes and rates it, regardless of outward appearances. The nurse should not allow the child to continue to feel pain while waiting an additional 30 minutes, asking the parents their opinion, or using a different pain scale.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 884 45. A 6-year-old child is diagnosed with tinea pedis. Which prescription will the nurse question?

A. luliconazole cream daily for 2 weeks B. The child may return to school in 1 week.

C. Cleanse the skin with antibacterial soap.

D. Perform warm foot soaks daily.

Answer: B Rationale: Tinea pedis refers to a fungal infection that typically begins between the toes. The nurse would question the child being out of school for a week. While these infections are highly contagious, children can return to school once treatment is started. Tinea pedis can be treated with topical or oral antifungals or a combination of both. Topical agents, such as luliconazole, are used for 1 to 6 weeks, depending on the brand. Antibacterial soaps help reduce the risk of infection to the affected area. Warm soaks may help soothe painful muscles or joints and can help drain skin infections, if present.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Safe, Effective Care Environment: Safety and Infection Control Integrated Process: Nursing Process Reference: p. 877 46. The nurse is working with the caregiver of a neonate. The caregiver states, "My first baby had a disorder they called seborrheic dermatitis; what can I do to prevent this baby from having that?" Which response is the most appropriate?

A. "There is nothing you can do to prevent this disorder; it will go away by the time your neonate is a toddler."

B. "Be careful to not get any lotion or oil on the neonate's head, and that will help prevent the disorder."

C. "You should wash your neonate's hair every day to help prevent this disorder."

D. "If you will keep hats and bonnets off your neonate's head, you will not have to worry about the neonate getting the disorder."

Answer: C Rationale: Seborrheic dermatitis is commonly known as cradle cap. Daily washing of the neonate's hair and scalp can help prevent it.

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Reference: p. 873 47. The nurse is monitoring the urinary output of 3-year-old child admitted with a severe burn. The child weighs 44 lb (20 kg). Which would be a desirable and adequate urinary output for this child?

A. 1 to 2 mL/kg/hr B. 10 to 12 mL/kg/hr C. 15 to 25 mL/kg/hr D. 30 to 50 mL/hr Answer: A Rationale: Following a burn injury, an output of 1 to 2 mL/kg/hr for children weighing 30 kg (66 lb) or less, or 30 to 50 mL/hr for those weighing more than 30 kg is desirable. This child weighs 20 kg (44 lb).

Question format: Multiple Choice Chapter 41: The Child with an Integumentary Disorder/Communicable Disease Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 886

Chapter 42 1. The nurse is developing a plan of care for the child hospitalized with nonorganic failure to thrive (NFTT). The following nursing interventions would be included in this plan. Which nursing intervention would be the highest priority for this child?

A. The nurse should monitor fluid intake and urinary output.

B. The nurse should monitor bowel elimination.

C. The nurse should lubricate the skin to keep it moisturized and intact.

D. The nurse should teach and support the caregiver.

Answer: D Rationale: The family relationships of children with NFTT are often so disrupted that the child has no warm, close relationship with a family caregiver. For some reason, proper attachment has not occurred. The child cannot accomplish the developmental task of establishing basic trust. Treatment initially depends almost entirely on good nursing care. By teaching child care skills, acting as a role model, and supporting caregiver-child interactions, the nurse can help to both reverse the child's growth failure as well as begin an improved caregiver-child relationship.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 917 2. The nurse has gathered the following data on four different children. Which child will likely be further assessed and tested for autism spectrum disorder?

A. a 16-month-old who spends 30 minutes moving empty plastic bottles in and out of a container B. an 18-month-old who enjoys spinning until she falls, then announces, "Me fall!"

C. a 14-month-old whose reaction to his caregiver leaving him is to calmly repeat the statement, "Bye bye, Will. Bye bye, Will."

D. a 20-month-old who frequently walks on tiptoes and smiles at her caregiver when the caregiver looks at the child Answer: C Rationale: Children with autism spectrum disorder do not show the normal fear of separation from parents that most toddlers exhibit. Echolalia ("parrot speech") is typical of autistic children; they echo words they have heard, such as a television commercial, but offer no indication that they understand the words. Although autistic children are self-centered, their speech indicates that they seem to have no sense of self, because they never use the pronouns "I" or "me." Children with autism do not develop a smiling response to others nor an interest in being touched or cuddled. During their second year, autistic children become completely absorbed

in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. Their bodily movements are as follows: rocking, twirling, flapping arms and hands, walking on tiptoes, twisting and turning fingers. Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree, coupled with an almost total lack of response to other people.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 908 3. When weighing and measuring an adolescent whose ideal body weight is 105 pounds, the nurse would identify the child as obese if the child weighs which of the following?

A. 116 pounds B. 121 pounds C. 126 pounds D. 131 pounds Answer: C Rationale: Obesity generally is defined as an excessive accumulation of fat that increases body weight by 20 percent or more over ideal weight. Overweight, although not necessarily signifying obesity, means that a person's weight is more than average for height and body build.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Analyze Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 921 4. A 16-year-old girl is being seen for a long-overdue checkup. Her caregiver has come with her. She is calm, pleasant, and in good spirits. The caregiver reports to the nurse that she is relieved because for the past 6 months the teenager has been lethargic, angry, and sad. The mother reports that since she got her driver's license two days earlier, her child's mood has changed dramatically. Rather than resist this appointment, the girl had simply smiled and said, "It won't matter much, but okay, I'll be ready in a minute." The nurse recognizes that the child's seeming well-being and drastic change in behavior should be further investigated to determine if the child: A. is planning to commit suicide.

B. has been smoking marijuana.

C. is experimenting with alcohol.

D. is excited that she can drive now.

Answer: A Rationale: Attempted suicide rarely occurs without warning and usually is preceded by a long history of emotional problems, difficulty forming relationships, feelings of rejection, and low self-esteem. Suicidal adolescents may appear suddenly elated after a long period of acting dejected, and might verbalize their hopelessness with statements such as "I won't be around much longer," or "After Monday, it won't matter anyhow." Some deaths reported as accidents, particularly one-car accidents, are thought to be suicides.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 911 5. The nurse in the well-child clinic observes that a 5-year-old child in the waiting room is having trouble using a crayon to color. During the visit, the same child climbs off the table several times even after the nurse has asked him to stay on the table. Each time the nurse reminds him he says, "Oh, yeah," and happily climbs back up. The nurse suspects that the child has: A. attention deficit hyperactive disorder (ADHD).

B. autism spectrum disorder.

C. failure to thrive.

D. an addicted caregiver.

Answer: A Rationale: The child with ADHD may have these characteristics: Impulsiveness, easy distractibility, frequent fidgeting or squirming, difficulty sitting still, problems following through on instructions despite being able to understand them, inattentiveness when being spoken to, frequent losing of things, going from one uncompleted activity to another, difficulty taking turns, frequent excessive talking, and engaging in dangerous activities without considering the consequences.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 909 6. The nurse is collecting data on an 18-month-old old child with a diagnosis of autism spectrum disorder (ASD). What clinical manifestation would likely have been noted in the child with this diagnosis?

A. The child cries and runs to the door when the caregiver leaves the room.

B. The child smiles when the caregiver shows her a stuffed animal.

C. The child sits quietly in the caregiver's lap during the interview.

D. The child does not make eye contact.

Answer: D Rationale: Children with ASD often display hyperactivity, aggression, temper tantrums, or self-injury behaviors like head banging or hand-biting. They may resist cuddling, lack eye contact, be indifferent to touch or affection, and have little change in facial expression. They do not develop a smiling response to others nor an interest in being touched or cuddled. In fact, they can react violently to attempts to hold them. They do not show the normal fear of separation from parents that most toddlers exhibit. Often they seem not to notice when family caregivers are present.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 908 7. The nurse is observing a group of 2- and 3-year-olds in a play group. Which behavior noted in one of the children indicates to the nurse that the child may have autism spectrum disorder (ASD)?

A. After another child takes a toy, the child cries and stomps his feet.

B. A child playing in the kitchen area pretends to pour a glass of milk and repeats this over and over.

C. While the other children are eating a snack, the child walks around the room feeling the walls and ignores the caregiver who offers him a snack.

D. A child flips the light switch off and on until the caregiver asks her to stop and join the other children in playing.

Answer: C Rationale: Children with ASD become completely absorbed in strange repetitive behaviors such as spinning an object, flipping an electrical switch on and off, or walking around the room feeling the walls. If these movements are interrupted or if objects in the environment are moved, a violent temper tantrum may result. These tantrums may include self-destructive acts such as hand biting and head banging.

Although infants and toddlers normally are self-centered, ritualistic, and prone to displays of temper, autistic children show these characteristics to an extreme degree coupled with an almost total lack of response to other people.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 908

8. The nurse is working with a group caregivers of children who are diagnosed with autism. Which statement made by the parents shows an example of echolalia?

A. "When she watches TV and hears a commercial, she repeats one word from the commercial but doesn't seem to understand what she is saying."

B. "When we were in a room with a high ceiling, she was so excited when she said hello and she heard her voice that she said it over and over."

C. "She was at the park and the older kids were playing a game and she was staring at them as if she was wanted to try to copy what they were doing."

D. "When reading her a story book about owls, her sister kept telling her that when owls made noises they sounded like an echo. She seemed to understand that animals sounded different from people."

Answer: A Rationale: Echolalia ("parrot speech") is typical of autistic children; they echo words they have heard, such as from a television commercial, but they offer no indication that they understand the words.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 908 9. The nurse is working with a group of caregivers of school-aged children diagnosed with attention deficit hyperactivity disorder (ADHD). Which statement would be most appropriate for the nurse to make to this group of caregivers?

A. "These children study better with quiet background music such as the radio or a CD." B. "The medications your child is on may cause a decreased appetite."

C. "These children function best if given a set of instructions and then left to do the task."

D. "A frequent change in routine will be helpful so the child does not get bored."

Answer: B Rationale: Learning situations should be structured so that the child has minimal distractions. Structured, consistent guidance from the caregivers is needed.

Medication is used for some children, and these medications may suppress the appetite and affect the child's growth. The child should be given only one simple instruction at a time. Limiting distractions, using consistency, and offering praise for accomplishments are invaluable.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 909

10. The nurse is working with school-aged children who are having enuresis or encopresis. What will most likely be the first step in this child's treatment?

A. The child will be given medications.

B. The child will be taken to a therapist.

C. The child will have a complete physical exam.

D. The child will be given a strict daily schedule.

Answer: C Rationale: The child with enuresis or encopresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment.

A complete physical exam and assessment is done first to rule out any physical cause.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Basic Care and Comfort Integrated Process: Nursing Process Reference: p. 910 11. The nurse is doing in-service training with nurses who will be working with children who have concerns with drugs and alcohol. In discussing this topic, one of the nurses says she has heard that there may be physical and psychological signs that occur when a drug is no longer being used. Which term best describes what the nurse is referring to?

A. withdrawal symptoms B. dependence C. tolerance D. substance abuse Answer: A Rationale: Withdrawal symptoms, such as vomiting, chills, tremors, and hallucinations, are the physical and psychological symptoms that occur when the drug is no longer being used. The magnitude of physical dependence determines the severity of withdrawal symptoms.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 913 12. The ability of body tissues to endure and adapt to continued or increased use of a substance, so that the drug user requires larger doses of the drug to produce the desired effect, is called: A. withdrawal symptoms.

B. dependence.

C. tolerance.

D. substance abuse.

Answer: C Rationale: Continued use of an addictive substance can result in tolerance (the ability of body tissues to endure and adapt to continued or increased use of a substance); this dynamic means the drug user requires larger doses of the drug to produce the desired effect.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 913 13. The most common use disorder among children and adolescents is: A. marijuana.

B. oxycodone.

C. alcohol.

D. ecstasy.

Answer: C Rationale: Alcohol misuse occurs when a person ingests a quantity sufficient to cause intoxication. It is also the most common substance use disorder among children and adolescents.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 914 14. The nurse is discussing the use of alcohol with a group of adolescents. One of the teens says that she heard your fine motor control could be affected at low levels of alcohol. Another teen was correct in saying that most states consider a person under the influence of alcohol if the blood alcohol level is which of the following?

A. 0.03 % B. 0.05 % C. 0.06 % D. 0.08 % Answer: D

Rationale: Most states determine charges of driving under the influence using a standard of 0.1% blood alcohol content. However, many states have lowered the limit to 0.08%. Many children do not realize that fine motor control and judgment are affected at even lower levels, and driving ability may be decreased.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 915 15. The nurse is working with a group of caregivers of adolescents who have abused substances. One of the caregivers states, "My son used to do great in school. However, since he started using drugs he has no motivation, he is never on time, and he makes the worst decisions, especially when he is driving." These behaviors indicate that this adolescent was likely using which substance?

A. amphetamines B. anabolic steroids C. cocaine D. marijuana Answer: D Rationale: Marijuana affects judgment, sense of time, and motivation. These effects make driving hazardous and may even cause hallucinations at higher doses.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 915 16. Adolescent athletes sometimes take megadoses of which of the following substances because they believe it will increase their athletic abilities?

A. amphetamines B. anabolic steroids C. cocaine D. hallucinogens Answer: B Rationale: Adolescent athletes take anabolic steroids to build up muscle mass in the belief that the drug will increase their athletic ability. These athletes take megadoses of illegally obtained drugs.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Understand Client Needs: Psychosocial Integrity

Integrated Process: Nursing Process Reference: p. 916 17. The nurse is collecting data on an adolescent who is brought to the emergency center by her caregivers, who suspect that she has been using substances. The adolescent states that she has not had anything to eat nor any sleep in several days, but that she is nauseated. The nurse observes that she is diaphoretic, clenching her teeth, and complaining of blurred vision. Which substance would this adolescent most likely have been using?

A. cocaine B. alcohol C. hallucinogens D. ecstasy Answer: D Rationale: Ecstasy suppresses the need to eat, drink, or sleep. The drug can cause increased heart rate and blood pressure, muscle tension, teeth clenching, nausea, blurred vision, chills, and sweating.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 916 18. The nurse is caring for a 6-month-old infant diagnosed with nonorganic failure to thrive. Which of the following would the nurse most likely have noted with this child?

A. The child's mother is attentive, but the father appears uninterested in the child.

B. The child's weight and height are above average according to the growth charts.

C. The child smiles and laughs when the nurse picks up and holds the child.

D. The child plays and sleeps quietly for long periods of time without fussing.

Answer: D Rationale: Infants with NFTT often are listless, well below average weight and height, have poor muscle tone and a loss of subcutaneous fat, and are immobile for long periods of time. They may be unresponsive to (or actually try to avoid) cuddling and vocalization. Family relationships, particularly the mother-child relationship, often provide important insights into the problem.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 917

19. The nurse is collecting data for a child diagnosed with nonorganic failure to thrive, and notes that the child voluntarily vomits after eating. This is referred to as: A. rumination.

B. tolerance.

C. self-inflicted starvation.

D. encopresis.

Answer: A Rationale: A common characteristic noted in the child with nonorganic failure to thrive is rumination (voluntary regurgitation), perhaps as a means of selfsatisfaction when the desired response is not received from the caregiver.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Remember Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 917 20. The nurse is doing a presentation on the diagnosis of bulimia to a group of pediatric nurses. Which clinical manifestation would the nurse teach this group to observe for in the adolescent with bulimia?

A. dry skin and brittle nails B. constipation C. soft hair on their backs and arms D. hypokalemia Answer: D Rationale: In the child with bulimia, hypokalemia may occur, especially if the child abuses diuretics to prevent weight gain.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 918 21. Which characteristic is commonly noted in the child with anorexia nervosa?

A. The child is impulsive and inattentive when spoken to.

B. The child has rigid study skills and ritualistic behavior.

C. The child has trouble sitting still and is fidgety.

D. The child is inactive and participates in sedentary activities.

Answer: B

Rationale: Anorexic children often are described as successful students who tend to be perfectionists and are always trying to please parents, teachers, and other adults. They may make demands on themselves for cleanliness and order in their environment, or they may engage in rigid schedules for studying and other ritualistic behavior.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 917 22. The nurse is collecting data on a 16-year-old girl with the diagnosis of bulimia.

What would the nurse most likely note in this child?

A. The child is of normal weight for her height according to the growth charts.

B. The child socializes with friends and shares all her dreams and secrets with them.

C. The child has a ritualistic program of exercise that she does every day after school.

D. The child is a perfectionist and tries hard to please her parents and teachers.

Answer: A Rationale: The typical bulimic person is a white female in late adolescence. Most often, the bulimic person is of normal weight or is slightly overweight.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 918 23. The nurse is discussing health concerns and issues with a group of caregivers of adolescents. Which statement made by a caregiver would indicate a need for follow-up by the nurse?

A. "My 16-year-old spends so much time with his girlfriend, it worries me."

B. "I don't know if I want my 15-year-old son to drive; I know that at that age teens sometimes don't use good judgement."

C. "Our daughter has never had any health problems, and now she has developed so many cavities."

D. "My daughter is already 15 and she hasn't ever had a menstrual period."

Answer: C Rationale: The clues to bulimia nervosa may be few but include dental caries and erosion from frequent exposure to stomach acid, throat irritation, and endocrine and electrolyte imbalances.

Question format: Multiple Choice

Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Analyze Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 918 24. The nurse is caring for a child with an eating disorder. Which is the priority treatment for the disorder?

A. Develop a behavior modification plan B. Correct fluid and electrolyte imbalances C. Supervise and document food intake D. Monitor urine for presence of ketones Answer: B Rationale: If the child's condition is at a critical stage with fluid and electrolyte deficiencies, parenteral fluids should be administered immediately to hydrate the client before additional treatment can be implemented.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Physiological Integrity: Physiological Adaptation Integrated Process: Nursing Process Reference: p. 919 25. Which disorder is a concern in adulthood as well as in childhood for the person who is overweight or obese during childhood?

A. anorexia B. alcoholism C. diabetes mellitus D. chronic asthma Answer: C Rationale: Type 2 diabetes mellitus, which formerly was seen almost exclusively in adults and is associated with being overweight, is now being diagnosed in childhood with long-range health concerns.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Remember Client Needs: Physiological Integrity: Reduction of Risk Potential Integrated Process: Nursing Process Reference: p. 921 26. The nurse recognizes in working with children that the child who has polyphagia will likely exhibit which of the following?

A. abuse of several drugs B. overuse of laxatives

C. compulsive overeating D. withdrawal symptoms Answer: C Rationale: Some children experience polyphagia (compulsive overeating). They lack control of their food intake, cannot postpone their urge to eat, hide food for later secret consumption, eat when not hungry or to escape from worries, and expend a great deal of energy thinking about securing and eating food.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 922 27. The nurse is working with a group of caregivers of adolescents who have abused substances. One of the caregivers states, "I have heard that some drugs have the effect of causing an excited feeling and it makes the person more social."

Which drug would most likely have the effect this caregiver is describing?

A. barbiturates B. anabolic steroids C. cocaine D. marijuana Answer: C Rationale: The psychological effect of using cocaine is a feeling of euphoria and increased sociability.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 915 28. The nurse is doing an in-service training with nurses who will be working with children who have concerns with drugs and alcohol. In discussing this topic, one of the nurses says that sometimes a person has a compulsive need to use a substance for its satisfying or pleasurable effects. Which term best describes what the nurse is referring to?

A. withdrawal symptoms B. dependence C. tolerance D. substance abuse Answer: B

Rationale: The use or abuse of substances can lead to addiction or dependence (a compulsive need to use a substance for its satisfying or pleasurable effects).

Dependence may be psychological, physical, or both.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Understand Client Needs: Psychosocial Integrity Integrated Process: Teaching/Learning Reference: p. 913 29. A 10-year-old girl has a pattern of school success, solid peer relationships, and a healthy family life. The girl's caregiver reports for the past 3 weeks the child has reported abdominal pain with vomiting and diarrhea, and tells the caregiver she doesn't feel good just before it's time to go to school. However, after the caregiver lets her stay home, she is fine by mid-morning. She is also fine on weekends.

Which question should the nurse prioritize to this caregiver?

A. "Have you explored with your child if something is causing her to be afraid to go to school?"

B. "Does your child have new dental caries or other signs of bulimia?"

C. "Could it be that your child is being abused by another family member or by her teacher?"

D. "Does your child eat a different breakfast on weekends than the one she eats on school days?"

Answer: A Rationale: School phobia may be the child's unconscious reaction to a seemingly overwhelming problem at school. The parent can unwittingly reinforce school phobia by permitting the child to stay home. The symptoms of vomiting, diarrhea, abdominal or other pain, and even a low-grade fever, are genuine and are caused by anxiety that may approach panic. They disappear with relief of the immediate anxiety after the child has been given permission to stay home.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Caring Reference: p. 911 30. The nurse is working on forming a contract with a hospitalized adolescent diagnosed with anorexia nervosa. Which information should the nurse prioritize with the client when making the contract?

A. Remind the adolescent about the consequences of misbehavior.

B. Stress to the client that he or she is in control of the outcome of the care.

C. Encourage the caregivers to take responsibility for the adolescent.

D. Reward the client after several days of successful behavior.

Answer: B

Rationale: Contract agreements are often recommended for people with eating disorders. These agreements, which are usually part of a behavioral modification plan, specify the client's and the staff's responsibilities for the diet, activity expectations for the client, and other aspects of the client's behavior. The contract also may spell out specific privileges that can be gained by meeting the contract goals. This places the client in greater control of the outcome. Some type of reward should be achieved daily to encourage continued participation in the agreement.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 919 31. The nurse is caring for an adolescent with anorexia nervosa. What intervention should the nurse include in the care of this client?

A. Encourage the client and the client's family to participate in family therapy.

B. Take daily weights to document weight gain.

C. Encourage at least 30 minutes of exercise daily to help the client feel like he or she is not gaining weight too fast.

D. Encourage the family to vary their daily routine at home so the client does not get bored.

Answer: A Rationale: Both the client and the client's family need to be included in the plan of care along with therapy sessions to help better treat the adolescent. Clients should be weighed weekly, not daily. The focus needs to move to better nutrition and a goal of a 0.5 to 2 lb (0.25 to 1 kg) weekly weight gain. A structured routine of meals and snacks needs to be established. Daily exercise is not encouraged.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Psychosocial Integrity Integrated Process: Nursing Process Reference: p. 919 32. A parent expresses concern that the child has an autism spectrum disorder. The nurse obtains a health history of the symptoms to understand the parent's concern.

Which question would the nurse ask first?

A. "Does your child interact with you when playing?"

B. "Does your child only eat the same food?"

C. "Does your child respond to his or her name?"

D. "Is your child happy when friends come to visit?"

Answer: A

Rationale: Children on the autism spectrum have a very wide range of symptoms.

Children have impaired social interactions and communication. They may have stereotypical and preservative behaviors. Two indicators a child is on the autism spectrum is the lack of ability to point at objects by 18 months of age and the lack of ability to gaze jointly with another. By asking if the child interacts with the parent when playing, the nurse is seeking to determine these two cardinal signs. All of the answer choices are correct questions to ask as part of the history because the child could have a multitude of symptoms. These answer choices help provide information into the diagnosis.

Question format: Multiple Choice Chapter 42: The Child with a Psychosocial Disorder Cognitive Level: Apply Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process Reference: p. 908