Test Bank for Safe Maternity & Pediatric Nursing Care 1E by Linnard-Palmer & Gloria Coats

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Chapter 1: Healthy People 2020 and Initiatives for Healthy Families MULTIPLE CHOICE 1. Which statement is accurate regarding the Healthy People 2020 initiative related to

families, children, and infants?

1) Most of the Healthy People documents apply specifically to infants and children.

2) Healthy People documents address the good health of adults, which benefits children.

3) There are no Healthy People initiatives specifically addressing infants or children.

4) The only initiative impacting families, infants, and children encourages breastfeeding.

ANS: 2

Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: Describe how the Healthy People 2020 initiative relates to families, children, and infants.

Chapter page reference: 4 Heading: Leading Health Indicators Integrated processes: Caring Client need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2 3 4

Very few of the Healthy People 2020 initiatives are specific to families, children, or infants.

By helping adults stay healthy, Healthy People 2020 creates healthier families with healthier children, so this statement is accurate.

Some Healthy People 2020 initiatives do address children, but they are in the minority.

There are initiatives impacting families, infants, and children other than the one mentioned in the chapter on breastfeeding.

PTS: 1

CON: Promoting Health

2. What two federal agencies oversee objectives related to maternal, infant, and child health

in the Healthy People 2020 initiative?

1) The Department of Agriculture and the Centers for Disease Control and Prevention 2) The Department of Children and Youth Services and the Health Resources and Services Administration 3) The Centers for Medicare & Medicaid Services and the Health Resources and Services Administration 4) The Centers for Disease Control and Prevention and the Health Resources and Services Administration ANS: 4

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Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: List government agencies that are involved in the Healthy People objectives.

Chapter page reference: 3 Heading: Historical Perspective Integrated processes: Caring Client need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2 3 4

The Department of Agriculture is not involved in overseeing objectives.

The Department of Children and Youth Services is not involved in overseeing objectives.

The Centers for Medicare & Medicaid Services has no role in overseeing objectives.

The Centers for Disease Control and Prevention and the Health Resources and Services Administration are the agencies that oversee the objectives of Healthy People 2020.

PTS: 1

CON: Promoting Health

3. Who created the original Healthy People initiative?

1) The Centers for Disease Control and Prevention 2) The Health Resources and Services Administration 3) President Jimmy Carter 4) The surgeon general of the United States ANS: 4

Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: Describe how the Healthy People 2020 initiative relates to families, children, and infants.

Chapter page reference: 4 Heading: Leading Health Indicators Integrated processes: Caring Client need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2 3

Although the Centers for Disease Control and Prevention oversees the objectives, it did not create the original Healthy People initiative.

Although the Health Resources and Services Administration oversees the objectives, it did not create the original Healthy People initiative.

President Jimmy Carter supported the original Healthy People initiative; he did not create it.

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The surgeon general of the United States created the original Healthy People initiative to promote better health in the country.

PTS: 1

CON: Promoting Health

4. Which initiative did not demonstrate improvement over the past decades?

1) Air quality 2) Childhood exposure to secondhand smoke 3) Suicide and depression in adolescents 4) Increased physical activity for adults ANS: 3

Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: Describe historical perspectives related to the Healthy People initiative.

Chapter page reference: 1 Heading: Historical Perspective Integrated processes: Caring Client need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2 3 4

Air quality has improved, although problems still exist in some areas.

Childhood exposure to secondhand smoke has declined as a result of a reduction in the number of adults who smoke.

Unfortunately, suicide and depression in adolescents is still a significant problem that has not improved and is actually getting worse.

Adults are more active, and physical activity has improved over the past decade.

PTS: 1

CON: Promoting Health

5. One initiative of Healthy People 2020 is to increase the proportion of infants who are

breastfed. What is the maternity nurse’s primary role in helping to meet this initiative?

1) All nurses should become lactation consultants.

2) Increasing the percentage of employers that offer a place to pump breast milk 3) Providing support and teaching immediately after birth 4) Increasing the percentage of live births in hospitals ANS: 3

Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: Discuss how the Healthy People objectives apply to maternal and child well-being.

Chapter page reference: 4-6 Heading: Application: Healthy People 2020 Objective – Increase Proportion of Infants Who Are Breastfed Integrated processes: Caring Client need: Health Promotion and Maintenance

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Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2 3

4

There is no need for all nurses to become lactation consultants, and this is not the primary role of nurses.

Although nurses can advocate for pumping areas in the workplace, this is not the primary role of nurses in meeting this initiative.

Nurses can take an active role in teaching and supporting new mothers in breastfeeding their babies after birth, but it is important to allow the patient autonomy to make her own decision.

Nurses cannot increase the percentage of live births in hospitals, but they can contribute to this initiative (although this has nothing to do with meeting the breastfeeding initiative).

PTS: 1

CON: Promoting Health

6. How can maternal and pediatric nurses promote Healthy People objectives for their

clients?

1) Provide all patients with a copy of the current Healthy People objectives 2) Plan care that includes teaching and support for Healthy People objectives 3) Require all new mothers to breastfeed while hospitalized 4) Discourage the father from ever bottle feeding the newborn ANS: 2

Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: Explain how maternal and pediatric nurses can be instrumental in promoting Healthy People objectives for their clients.

Chapter page reference: 6 Heading: Healthy People 2020 Leads to Healthy Families Integrated processes: Caring Client need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2

3 4

Providing patients with a copy of the current initiatives is not the most effective means of helping clients meet these initiatives.

The nurse, who has a primary role in health promotion, can plan care that keeps the Healthy People objectives in mind and can provide teaching and support to help patients meet the objectives.

Breastfeeding is a choice each woman makes, and it cannot be required of all new mothers.

Discouraging the father from ever bottle feeding the newborn is not realistic, reasonable, or helpful.

PTS: 1

CON: Promoting Health

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7. When the Healthy People 2020 initiatives are reviewed, which initiative related to infants

and young children has shown improvement?

1) Suicide rates in adolescents 2) Increased life expectancy 3) Babies put to bed on their backs 4) Infant mortality rates ANS: 3

Chapter number and title: 1: Healthy People 2020 and Initiatives for Healthy Families Chapter learning objective: Analyze the progress, or lack of, for each of the Leading Health Indicators that pertain to families.

Chapter page reference: 3 Heading: Introduction Integrated processes: Caring Client need: Health Promotion and Maintenance Cognitive level: Comprehension [Understanding] Concept: Promoting Health Difficulty: Easy Feedback 1 2 3 4

The suicide rate in adolescents has not shown improvement and is actually worsening.

Increased life expectancy is seen in adults, not infants and young children.

More babies are sleeping on their backs, with a significant decline in the frequency of sudden infant death syndrome as a result.

Unfortunately, infant mortality rates are increasing and have not improved.

PTS: 1

CON: Promoting Health

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8. A patient chooses to have the certified nurse midwife (CNM) provide care during her pregnancy. What does the CNMs scope of practice include? a. Practice independent from medical supervision b. Comprehensive prenatal care c. Attendance at all deliveries d. Cesarean sections ANS: B The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated deliveries, and ensures that a backup physician is available in case of unforeseen problems.

DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 12 TOP: Advance Practice Nursing Roles KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. Which medical pioneer discovered the relationship between the incidence of puerperal fever and unwashed hands? a. Karl Cred b. Ignaz Semmelweis c. Louis Pasteur d. Joseph Lister ANS: B Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by the unwashed hands of physicians and medical students.

DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: The Past KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10.

A pregnant woman who has recently immigrated to the United States comments to the nurse, I

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

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

DIF: Cognitive Level: Application REF: Page 7-8 OBJ: 8 TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation 11. An urban area has been reported to have a high perinatal mortality rate. What information does this provide? a. Maternal and infant deaths per 100,000 live births per year b. Deaths of fetuses weighing more than 500 g per 10,000 births per year c. Deaths of infants up to 1 year of age per 1000 live births per year d. Fetal and neonatal deaths per 1000 live births per year ANS: D The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.

DIF: Cognitive Level: Comprehension REF: Page 12, Box 1-6 OBJ: 9 TOP: The Present-Child Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 12.

What is the focus of current maternity practice?

a. Hospital births for the majority of women b. The traditional family unit c. Separation of labor rooms from delivery rooms d. A quality family experience for each patient ANS: D Current maternity practice focuses on a high-quality family experience for all families, traditional or otherwise.

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DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7 TOP: The Present-Maternity Care KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance 13.

Who advocated the establishment of the Childrens Bureau?

a. Lillian Wald b. Florence Nightingale c. Florence Kelly d. Clara Barton ANS: A Lillian Wald is credited with suggesting the establishment of a federal Childrens Bureau.

DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 1 | 2 TOP: The Past KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14.

What was the result of research done in the 1930s by the Childrens Bureau?

a. Children with heart problems are now cared for by pediatric cardiologists. b. The Child Abuse and Prevention Act was passed. c. Hot lunch programs were established in many schools. d. Childrens asylums were founded.

ANS: C School hot lunch programs were developed as a result of research by the Childrens Bureau on the effects of economic depression on children.

DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 2 | 3 TOP: The Past KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 15. What government program was implemented to increase the educational exposure of preschool children? a. WIC b. Title XIX of Medicaid c. The Childrens Charter d. Head Start ANS: D Head Start programs were established to increase educational exposure of preschool children.

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DIF: Cognitive Level: Knowledge REF: Page 3 OBJ: 5 TOP: Government Influences in Maternity and Pediatric Care KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. What guidelines define multidisciplinary patient care in terms of expected outcome and timeframe from different areas of care provision? a. Clinical pathways b. Nursing outcome criteria c. Standards of care d. Nursing care plan ANS: A Clinical pathways, also known as critical pathways or care maps, are collaborative guidelines that define patient care across disciplines. Expected progress within a specified timeline is identified.

DIF: Cognitive Level: Knowledge REF: Page 12 OBJ: 14 TOP: Health Care Delivery Systems KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 17. A nursing student has reviewed a hospitalized pediatric patient chart, interviewed her mother, and collected admission data. What is the next step the student will take to develop a nursing care plan for this child? a. Identify measurable outcomes with a timeline. b. Choose specific nursing interventions for the child. c. Determine appropriate nursing diagnoses. d. State nursing actions related to the childs medical diagnosis.

ANS: C The nurse uses assessment data to select appropriate nursing diagnoses from the NANDA-I list.

Outcomes and interventions are then developed to address the relevant nursing diagnoses.

DIF: Cognitive Level: Application REF: Page 11 OBJ: 13 TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 18. A nursing student on an obstetric rotation questions the floor nurse about the definition of the LVN/LPN scope of practice. What resource can the nurse suggest to the student? a. American Nurses Association

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b. States board of nursing c. Joint Commission d. Association of Womens Health, Obstetric and Neonatal Nurses ANS: B The scope of practice of the LVN/LPN is published by the states board of nursing.

DIF: Cognitive Level: Comprehension REF: Page 3, Legal and Ethical Considerations OBJ: 18 TOP: Critical Thinking KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 19. What was recommended by Karl Cred in 1884? a. All women should be delivered in a hospital setting. b. Chemical means should be used to combat infection. c. Podalic version should be done on all fetuses. d. Silver nitrate should be placed in the eyes of newborns.

ANS: D In 1884 Karl Cred recommended the use of 2% silver nitrate in the eyes of newborns to reduce the incidence of blindness.

DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: Use of Silver Nitrate KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. What is the purpose of the White House Conference on Children and Youth? a. Set criteria for normal growth patterns. b. Examine the number of live births in minority populations. c. Raise money to support well-child clinics in rural areas. d. Promote comprehensive child welfare.

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

DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 3 TOP: White House Conferences KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. How many hours of hospital stay does legislation currently allow for a postpartum patient

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who has delivered vaginally without complications? a. 24 b. 48 c. 36 d. 72 ANS: B Postpartum patients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have had a cesarean delivery usually stay 4 days.

DIF: Cognitive Level: Knowledge REF: Page 6 OBJ: 7 TOP: Hospital Terms for Postpartum Patients KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. How does the clinical pathway or critical pathway improve quality of care? a. Lists diagnosis-specific implementations b. Outlines expected progress with stated timelines c. Prioritizes effective nursing diagnoses d. Describes common complications ANS: B Critical pathways outline expected progress with stated timelines. Any deviation from those timelines is called a variance.

DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14 TOP: Critical Pathway KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 23. A patient asks the nurse to explain what is meant by gene therapy. What is the nurses best response? a. Gene therapy can replace missing genes. b. Gene therapy evaluates the parents genes. c. Gene therapy can change the sex of the fetus. d. Gene therapy supports the regeneration of defective genes.

ANS: A Gene therapy can replace missing or defective genes.

DIF: Cognitive Level: Knowledge REF: Page 8 OBJ: 7

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TOP: Gene Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 24. The nurse is clarifying information to a patient regarding diagnosis-related groups (DRGs). What is the nurses best response when the patient asks how DRGs reduce medical care costs? a. By determining payment based on diagnosis b. By requiring two medical opinions to confirm a diagnosis c. By organizing HMOs d. By defining a person who will require hospitalization ANS: A DRGs determine the amount of payment and length of hospital stay based on the diagnosis.

DIF: Cognitive Level: Comprehension REF: Page 8 OBJ: 11 TOP: DRGs KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 25. What is the best example of a Nursing Interventions Classification (NIC) intervention? a. Patient will ambulate in the hall independently for 10 minutes three times a day. b. Nurse will report temperature elevations to the charge nurse. c. Nurse will offer extra liquids at all meals. d. Patient will express pain relief after massage.

ANS: C NIC is a guide to nursing actions.

DIF: Cognitive Level: Comprehension REF: Page 12 | Page 14 OBJ: 15 TOP: NICs KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 26. How does electronic charting ensure comprehensive charting more effectively than handwritten charting? a. Provides a uniform style of chart b. Requires certain responses before allowing the user to progress c. All documentation is reflective of the nursing care plan d. Requires a daily audit by the charge nurse ANS: B Comprehensive electronic documentation is ensured by requiring specific input in designated categories before the user can progress through the system.

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DIF: Cognitive Level: Comprehension REF: Page 15-16 OBJ: 22 TOP: Computer Charting KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 27. The nurse reminds family members that the philosophy of family-centered care is to provide control to the family over health care decisions. What is the appropriate term for this type of control? a. Empowerment b. Insight c. Regulation d. Organization ANS: A The term empowerment refers to the control a family has over its own health care decisions.

DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 7 TOP: Empowerment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 28. A patient in the prenatal clinic is concerned about losing her job because of her pregnancy. The nurse instructs her that the Family Medical Leave Act (FMLA) allows an employee to be absent from work without pay. How many weeks does the FMLA allow a woman to recover from childbirth or care for a sick family member without loss of benefits or pay status? a. 4 b. 6 c. 10 d. 12 ANS: D The FMLA allows for employees to leave work for up to 12 weeks to recover from childbirth or to care for an ill family member without losing benefits or pay status.

DIF: Cognitive Level: Knowledge REF: Page 3 OBJ: 5 TOP: FMLA KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 29. What term appropriately describes the nurse who is able to adapt health care practices to meet the needs of various cultures? a. Culturally aware

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b. Culturally sensitive c. Culturally competent d. Culturally adaptive ANS: C The nurse who is able to adapt health care to meet the needs of various cultures is said to be culturally competent.

DIF: Cognitive Level: Knowledge REF: Page 7 OBJ: 8 TOP: Cultural Competency KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 30. What is one major advantage to the application of critical thinking? a. Problem-free care b. Limitation of approaches to care c. Decreased need for assessment d. Problem prevention ANS: D Critical thinking results in problem prevention in designing nursing care.

DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 19 TOP: Critical Thinking KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 31. Student practical nurses are discussing the North American Nursing Diagnosis Association International (NANDA-I) taxonomy in post conference on the acute care clinical setting. The students are aware that the role of the LPN with nursing diagnosis formulation is what? a. To initiate and identify nursing diagnosis specific to patient b. To update changes in nursing diagnosis as needed c. To have an understanding of nursing diagnosis terminology d. To accurately document nursing diagnosis on patient plan of care ANS: C The registered nurse is responsible to initiate, identify, update, and document nursing diagnoses.

The licensed practical nurse is responsible to have an understanding of nursing diagnosis terminology.

DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 17 TOP: NANDA-I taxonomy KEY: Nursing Process Step: Nursing Diagnosis

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MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques MULTIPLE RESPONSE 32. What services are birthing centers able to provide? (Select all that apply.) a. Prenatal care b. Labor and delivery services c. Classes for new mothers d. Adoption referrals e. Family planning ANS: A, B, C, E Birthing centers are capable of providing full-service obstetric care, classes for new mothers, and family planning. Birthing centers do not offer adoption services.

DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7 TOP: Birthing Centers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care 33. What developments in the early 20th century encouraged women to seek hospitalization for childbirth? (Select all that apply.) a. Use of specialized obstetric instruments b. Use of anesthesia c. Physicians closer relationships with hospitals d. Focus on family-centered care e. Insurance coverage ANS: A, B, C In the early 1900s, the development of specialized obstetric instruments, better modes of anesthesia, and the physicians reliance on hospital services were instrumental in encouraging women to seek hospitalization for childbirth.

DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7 TOP: Hospitalization for Childbirth KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 34. What nonfamily-centered policies were prevalent in the 1960s? (Select all that apply.) a. Waiting room for fathers b. Sedation of mother during labor c. Delay of reunion of mother and infant

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d. Lenient visiting hours e. Restrictions of visitations by minor children ANS: A, B, C, E Hospital policies in the 1960s provided a separate waiting room for fathers while the mother went through labor in a sedated state. The reunion of mother and infant was delayed for several hours because of the sedation. Visiting hours were rigid and disallowed the visitation of minor children.

DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7 TOP: Nonfamily-centered Practices KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 35. The nurse is aware that there is a legal responsibility to report certain diseases and conditions to county or state health authorities. Which would be included? (Select all that apply.) a. Tuberculosis b. Child abuse c. Industrial accidents d. Sexually transmitted diseases e. Food-borne infections ANS: A, B, D, E The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and sexually transmitted diseases), food-borne infections, child abuse, and threats of suicide.

DIF: Cognitive Level: Comprehension REF: Page 6, Legal and Ethical Considerations box OBJ: 6 TOP: Reportable Diseases KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 36. An inservice program at a long-term care facility is reviewing the Nursing Outcomes Classification (NOC) with nursing staff. After the presentation the nurses review resident care plans. Which of the following are found to be appropriately written outcomes? (Select all that apply.) a. Suction patient orally every 4 hours and as needed. b. Auscultate lung sounds every 2 hours. c. Provide Tylenol as ordered by health care provider. d. Patient states Pain has decreased after medication administration. e. Patient blood pressure recorded as 120/72 after dressing change.

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ANS: D, E NOC was developed to identify outcomes of nursing care that are directly influenced by nursing actions. Outcomes are defined as the behaviors and feelings of the patient in response to the nursing care given. Suctioning patient, auscultating lung sounds, and providing Tylenol are nursing actions.

DIF: Cognitive Level: Application REF: Page 12-14 OBJ: 16 TOP: Nursing Outcomes Classification (NOC) KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 37. Practical nursing students are using critical thinking skills to study for an upcoming test. What will these students include when studying? (Select all that apply.) a. Memorization of facts first b. Prioritizing information c. Relating facts to other facts d. Making assumptions e. Reviewing before the test ANS: B, C, E Using critical thinking when studying involves understanding facts before memorizing, prioritizing information to be memorized, relating facts to other facts, using all five senses, reviewing before tests, and reading critically. Critical thinking does not involve assumption as does general thinking.

DIF: Cognitive Level: Comprehension REF: Page 15 OBJ: 20 TOP: Critical Thinking KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment 38. What factors have played a role in meeting the goals of Healthy People 2020 as it relates the goals for outcomes of pregnancy? (Select all that apply.) a. Early prenatal care b. Increased number of surgical births c. NICU care d. Use of prenatal glucocorticoids e. Fetal surgery ANS: A, C, D, E Early prenatal care, fetal surgery, use of prenatal glucocorticoids, technology, and NICU care

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have played a role in increasing the positive outcome of pregnancy, and the goals of Healthy People 2020 may well be met. Increase in surgical births and multiple gestations do not work toward meeting the goals of Healthy People 2020.

DIF: Cognitive Level: Comprehension REF: Page 16-17 OBJ: 21 TOP: Healthy People 2020 KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection 39. A community health nurse is providing specialized care to patients in the home setting.

What kind of specialized care may this nurse be providing? (Select all that apply.) a. Glucose monitoring b. Heparin therapy c. Family education d. Total parenteral nutrition e. Provision of referral services ANS: A, B, D Glucose monitoring, heparin therapy, and total parenteral nutrition are categorized as specialized care that may be provided by the community health nurse. Family education and provision of referral are categorized as therapeutic care.

DIF: Cognitive Level: Application REF: Page 16-17 OBJ: 23 TOP: Community Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 40. The nurse who is very conscientious about hand hygiene is following the concepts set out by and

.

ANS: Lister, Pasteur OR Pasteur, Lister Both Lister and Pasteur set out that handwashing could reduce incidence of infection by crosscontamination.

DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP: Handwashing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control

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41. The first White House Conference on Children and Youth was called by President .

ANS: Theodore Roosevelt Theodore Roosevelt called the first White House Conference in 1909.

DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 1 TOP: White House Conferences KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 42. The nurse reviewing the specific recovery goals set out on a clinical pathway observed that two goals were not met by their designated timeline. The nurse records a negative for these two goals.

ANS: variance Using a clinical pathway model with goals and associated timelines, the nurse must record a negative variance when a timeline is not met and consider a new approach or an extended timeline.

DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14 TOP: Variances KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Management of Care 43.

.

is purposeful, goal-directed thinking

based on scientific evidence rather than assumption or memorization.

ANS: Critical thinking Critical thinking is purposeful and goal-directed thinking as oppo

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Chapter 2. Culture MULTIPLE CHOICE 1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry ANS: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.

DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9 TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 2. What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery? a. Well-contracted with its upper border at or just below the umbilicus b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus c. Relaxed with its upper border level with the umbilicus d. Relaxed with its upper border two or three fingerbreadths below the umbilicus ANS: A Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.

DIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2 TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What statement made by a new mother indicates she needs additional information about breastfeeding? a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast. b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk. c. The baby has been nursing every 2 to 3 hours. d. If the baby gets fussy between feedings, I give her a bottle of water.

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

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DIF: Cognitive Level: Comprehension REF: Page 223-227 OBJ: 14 TOP: BreastfeedingSupplemental Feedings KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the physician. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Position the patient flat.

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

DIF: Cognitive Level: Application REF: Page 202 OBJ: 9 TOP: Boggy Uterus KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. What type of lochia will the nurse assess initially after delivery? a. Serosa b. Rubra c. Alba d. Vaginalis ANS: B The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy.

Lochia rubra lasts for up to 3 days postpartum.

DIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4 TOP: Lochia Rubra KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity.

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

DIF: Cognitive Level: Application REF: Page 203 OBJ: 18 TOP: Hemorrhage KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What instruction should the nurse teach the postpartum woman about perineal self-care? a. Perform perineal self-care at least twice a day. b. Cleanse with warm water in a squeeze bottle from front to back. c. Remove perineal pads from the rectal area toward the vagina. d. Use cool water to decrease edema of the perineum.

ANS: B Cleansing from front to back prevents contamination from the rectal area.

DIF: Cognitive Level: Application REF: Page 204 OBJ: 2 TOP: Perineal Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. A postpartum woman is not immune to rubella. What will the nurse expect? a. The rubella virus vaccine should be administered before discharge. b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup. c. The woman should be instructed not to get pregnant until she receives the rubella vaccine. d. No intervention is indicated at this time because the woman is not at risk for rubella.

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

DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2 TOP: Rubella KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. Which statement indicates the new mother is breastfeeding correctly? a. I will alternate breasts when feeding the baby. b. I keep the baby on a 4-hour feeding schedule. c. I let the baby stay on the first breast only 5 minutes. d. I put only the nipple in the babys mouth when I am breastfeeding.

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

DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4 OBJ: 14 TOP: Breastfeeding KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is counseling a lactating mother about diet. What would the nurse include with this information? a. Consume 500 more calories than her usual prepregnancy diet. b. Eat less meat and more fruits and vegetables. c. Drink 3 to 4 tall glasses of fluid daily. d. Eat 1000 more calories than her usual prepregnancy diet.

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

DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15 TOP: BreastfeedingMaternal Nutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond? a. A woman will not ovulate in the absence of menstrual flow. b. Most nonlactating women resume menstruation about 2 months postpartum. c. Generally, a woman does not ovulate in the first few cycles after childbirth. d. The return of menstruation is delayed when a woman does not breastfeed.

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

DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4 TOP: Return of Menses KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. In what situation will the physician order RhoGAM?

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a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother becomes sensitized. c. A sensitized infant has a rising bilirubin level. d. An unsensitized infant exhibits no outward signs.

ANS: A The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rhpositive infant.

DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4 TOP: RhoGAM KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss? a. Conduction b. Radiation c. Evaporation d. Convection ANS: C Newborns lose heat quickly after birth as fluid evaporates from their bodies.

DIF: Cognitive Level: Comprehension REF: Page 216, Table 9-3 OBJ: 2 TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. What will the nurses instructions for a new mother to care for the infants umbilical cord include? a. Keeping the area covered with a sterile dressing b. Dressing the stump with antibiotic ointment at every diaper change c. Fastening the diaper low to allow for air circulation d. Giving the newborn a daily tub bath until the cord falls off ANS: C Diaper placement below the umbilical stump allows for drying by air circulation.

DIF: Cognitive Level: Application REF: Page 218-219, Skill 9-6 OBJ: 2 TOP: Umbilical Cord Care

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KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort? a. Wear a well-fitting bra continuously for several days. b. Stand in a warm shower, letting the water spray over the breasts. c. Express small amounts of milk from the breasts several times a day. d. Massage the breasts when they ache.

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

DIF: Cognitive Level: Application REF: Page 230 OBJ: 18 TOP: Suppression of Lactation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down ANS: B In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.

DIF: Cognitive Level: Analysis REF: Page 212, Table 9-2 OBJ: 6 TOP: Postpartum Psychological Stages KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Physiological Adaptation 17. A primipara tells the nurse, My afterpains get worse when I am breastfeeding. What is the most appropriate nursing response? a. Ill get you some aspirin to relieve the cramping that you feel. b. Afterpains are more intense with your first baby.

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c. Breastfeeding releases a hormone that causes your uterus to contract. d. A change of position when youre breastfeeding might help.

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

DIF: Cognitive Level: Application REF: Page 201 OBJ: 2 TOP: Afterpains with Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding? a. Positioning the bottle so that the nipple is full of formula during the entire feeding b. Heating the infant formula in a microwave c. Burping the infant after 4 ounces and again when the bottle is empty d. Propping a bottle for a feeding ANS: A The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.

DIF: Cognitive Level: Comprehension REF: Page 232, Skill 9-7 OBJ: 17 TOP: Formula Feeding KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion.

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

DIF: Cognitive Level: Application REF: Page 209 OBJ: 5 TOP: Postpartum Cesarean Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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20. The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective? a. I can thaw frozen breast milk in the microwave. b. Ill put enough breast milk for one day in a container. c. Breast milk can be stored in glass containers. d. Breast milk can be kept in the refrigerator for up to 3 months.

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

DIF: Cognitive Level: Comprehension REF: Page 229 OBJ: 14 TOP: Storing Breast Milk KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. What should the nurse implement for security purposes when bringing the infant from the nursery to the mother? a. Ask, Is this your band number? b. Confirm room number of mother. c. Ask the mother to identify herself verbally. d. Check the band number of the infant with that of the mother.

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

DIF: Cognitive Level: Application REF: Page 216-217 OBJ: 8 TOP: Security Identification Procedure KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. Below what blood glucose level is the newborn considered hypoglycemic? a. Below 70 mg/dL b. Below 60 mg/dL c. Below 50 mg/dL d. Below 40 mg/dL ANS: D A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant

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should be fed to prevent a further drop.

DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 8 TOP: Hypoglycemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 23. The nurse is caring for a woman of Middle Eastern descent on the first postpartum day.

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

ANS: A The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement.

DIF: Cognitive Level: Application REF: Page 200 OBJ: 3 TOP: Cultural Influences KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Cultural Awareness 24. A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action? a. Contact the hospital chaplain. b. Request the couples clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn.

ANS: C If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. If there is any doubt as to whether the infant is

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alive, the baptism is given conditionally: If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. The physician is attending to the patients immediate health needs.

DIF: Cognitive Level: Application REF: Page 213 OBJ: 7 TOP: Grieving Parents KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Grief and Loss 25. A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. Consider formula feeding for the first few days. b. Pumping breast milk would be best for now. c. Take pain medication 30 to 40 minutes prior to nursing. d. Use the football hold when breastfeeding.

ANS: D The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding.

DIF: Cognitive Level: Application REF: Page 224-225, Figure 9-10 OBJ: 12 TOP: Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 26. Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.) a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole ANS: A, C The only signs of preterm are the thin skin and the slowly responding ear.

DIF: Cognitive Level: Application REF: Page 217 OBJ: 2 TOP: Gestational Age Assessment KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 27. The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability.

ANS: B, C, D, E The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.

DIF: Cognitive Level: Application REF: Page 209-211 OBJ: 5 TOP: Postpartum Shower KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 28. What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.

DIF: Cognitive Level: Comprehension REF: Page 208 OBJ: 18 TOP: Postpartum Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula

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b. Concentrated liquid formula c. Powdered formula d. Cows milk e. Canned evaporated milk ANS: A, B, C Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants needs and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.

DIF: Cognitive Level: Comprehension REF: Page 231 OBJ: 17 TOP: Formula Choices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 30. The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborns favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding.

ANS: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.

DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 16 TOP: Weaning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 31. The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) ANS: moderate

amount of lochia.

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A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge.

DIF: Cognitive Level: Application REF: Page 202, Skill 9-2 OBJ: 2 TOP: Estimating Lochia Discharge KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 32. The nurse explains that the three infections that are contraindications to breastfeeding are ,

, and

.

ANS: human immunodeficiency virus (HIV), hepatitis B, hepatitis C Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk, as can the viruses that cause hepatitis B and C. DIF: Cognitive Level: Comprehension REF: Page 222 OBJ: 13 TOP: Contraindication for Breastfeeding KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 33. The hormone responsible for milk production is

.

ANS: prolactin During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation.

DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11 TOP: Prolactin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 34. The hormone responsible for milk let-down or ejection from the breasts is ANS: oxytocin The milk let-down reflex is caused by the hormone oxytocin.

DIF: Cognitive Level: Knowledge REF: Page 223 OBJ: 11

.

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TOP: Oxytocin KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35.

refers to changes that the reproductive organs, particularly the uterus,

undergo after birth to return to their prepregnancy size and condition.

ANS: Involution

Chapter 3. Women’s Health Promotion Across the Life Span MULTIPLE CHOICE 1. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patients obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110 ANS: C Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para.

DIF: Cognitive Level: Application REF: Page 48, Box 4-1 OBJ: 1 TOP: Definition of Terms KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How frequently will the nurse assist the patient to schedule these appointments? a. Every 3 weeks until the 6th month, then every 2 weeks until delivery b. Every 4 weeks until the 7th month, after which appointments will become more frequent c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy ANS: B

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Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 to 3 weeks through 36 weeks. From 36 weeks until delivery, visits are weekly.

DIF: Cognitive Level: Application REF: Page 46 OBJ: 2 | 3 TOP: Prenatal Visits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present. What is Chadwicks sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline ANS: A Chadwicks sign is the purplish or bluish discoloration of the cervix and vagina.

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during pregnancy. What would the nurse explain as the cause of Chadwicks sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area ANS: D Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area.

DIF: Cognitive Level: Comprehension REF: Page 49 OBJ: 6 | 7 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that the woman understands the information? a. Blood pressure goes up toward the end of pregnancy.

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b. My breathing will get deeper and a little faster. c. Ill notice a decreased pigmentation in my skin. d. There will be a curvature in the upper spine area.

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

DIF: Cognitive Level: Comprehension REF: Page 52 OBJ: 7 | 13 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. A woman reports that her last normal menstrual period began on August 5, 2013. What is this womans expected delivery date using Ngeles rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014 ANS: C To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary.

DIF: Cognitive Level: Analysis REF: Page 48, Box 4-2 OBJ: 5 TOP: Determining Estimated Date of Delivery KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device? a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks ANS: C The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device.

DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 3 | 7

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TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding.

ANS: D The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min.

This should be recorded as normal. The FHR drops in the late stages of pregnancy.

DIF: Cognitive Level: Application REF: Page 50 OBJ: 3 TOP: Assessing Fetal Heart Tone KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. A womans prepregnant weight is determined to be average for her height. What will the nurse advise the woman regarding recommended weight gain during pregnancy? a. 10 to 20 pounds b. 15 to 25 pounds c. 25 to 35 pounds d. 28 to 40 pounds ANS: C The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds.

DIF: Cognitive Level: Knowledge REF: Page 57 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the woman responds, I dont like milk. What dietary adjustments could the nurse recommend? a. Increase intake of organ meats.

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b. Eat more green leafy vegetables. c. Choose more fresh fruits, particularly citrus fruits. d. Include molasses and whole-grain breads in the diet.

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

DIF: Cognitive Level: Application REF: Page 60 OBJ: 8 | 13 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom? a. Eat three well-balanced meals per day and limit snacks. b. Drink a full glass of fluid at the beginning of each meal. c. Have crackers handy at the bedside, and eat a few before getting out of bed. d. Eat a bland diet and avoid concentrated sweets.

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

DIF: Cognitive Level: Application REF: Page 65, Table 4-6 OBJ: 10 TOP: Common Discomforts in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago.

What is the nurses initial action? a. Assess food intake. b. Weigh the patient again. c. Take the blood pressure. d. Notify the physician.

ANS: C The marked weight gain may be an indication of gestational hypertension. The blood pressure should be assessed before notifying the physician.

DIF: Cognitive Level: Application REF: Page 53 OBJ: 4

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TOP: Gestational Hypertension KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Fried fish b. Olive oil c. Red meat d. Leafy green vegetables ANS: C Foods rich in DHA are red meat, flounder, halibut, and soybean and canola oil. Frying fish negatively alters the DHA. DIF: Cognitive Level: Application REF: Page 55 OBJ: 8 TOP: Nutrition in Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The nurse encourages adequate intake of folic acid for women of childbearing age before and during pregnancy. What is folic acid thought to decrease the incidence of in fetal development? a. Structural heart defects b. Craniofacial deformities c. Limb deformities d. Neural tube defects ANS: D Folic acid can reduce the incidence of neural tube defects such as spina bifida and anencephaly.

DIF: Cognitive Level: Knowledge REF: Page 45 | Page 61 OBJ: 8 TOP: Nutrition for Pregnancy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 15. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCG detected in the urine

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d. Fetal heartbeat ANS: D Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner.

DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 6 | 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope? a. 4 weeks b. 12 weeks c. 18 weeks d. 24 weeks ANS: C The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy.

DIF: Cognitive Level: Knowledge REF: Page 50 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move?

What is the nurses best response? a. You may notice the baby moving around the 4th or 5th month. b. Quickening varies with every woman. c. Youll feel something by the end of the first trimester. d. The baby will be big enough for you to feel in your 8th month.

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

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 7 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. A pregnant woman inquires about exercising during pregnancy. What information should the nurse include when planning to educate this woman? a. Exercise elevates the mothers temperature and improves fetal circulation. b. Exercise increases catecholamines, which can prevent preterm labor. c. A regular schedule of moderate exercise during pregnancy is beneficial. d. Pregnant women should limit water intake during exercise.

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

DIF: Cognitive Level: Comprehension REF: Page 62 OBJ: 9 | 13 TOP: Exercise During Pregnancy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and counseling for adolescents different from other age populations? a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurses advice.

ANS: A The pregnant adolescent must cope with two of lifes most stress-laden transitions simultaneously: adolescence and parenthood.

DIF: Cognitive Level: Comprehension REF: Page 69 OBJ: 12 TOP: Psychological Adaptations to Pregnancy KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 20. At what age is a woman who becomes pregnant for the first time described as an elderly primip? a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old

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ANS: D A woman over the age of 35 who becomes pregnant for the first time is described as an elderly primip.

DIF: Cognitive Level: Knowledge REF: Page 69 OBJ: 12 TOP: Elderly Primip KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physical Adaptation 21. The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the appropriate term for this sign? a. Chadwicks b. Hegars c. McDonalds d. Goodells ANS: D Goodells sign is one of the probable signs of pregnancy and describes a softened cervix and vagina.

DIF: Cognitive Level: Knowledge REF: Page 49 OBJ: 1 | 6 | 7 TOP: Goodells Sign KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physical Adaptation 22. When obtaining a prenatal history on a pregnant patient the nurse notes a family history of sickle cell disease. Given this information, what lab test can the nurse anticipate the physician will order? a. Endovaginal ultrasound b. Pap test c. Complete blood count d. Hemoglobin electrophoresis ANS: D Hemoglobin electrophoresis identifies presence of sickle cell trait or disease (in women of African or Mediterranean descent). It is ordered in the first trimester, if indicated.

DIF: Cognitive Level: Comprehension REF: Page 46, Table 4-1 OBJ: 3 TOP: Prenatal laboratory tests KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care

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

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

DIF: Cognitive Level: Application REF: Page 72 OBJ: 4 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care 24. A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does the nurse explain as the most likely cause of this symptom? a. Supine hypotension syndrome b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition ANS: A Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. Symptoms of supine hypotension syndrome include faintness, lightheadedness, dizziness, and agitation.

DIF: Cognitive Level: Comprehension REF: Page 53 OBJ: 7 TOP: Physiological Changes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prenatal Care MULTIPLE RESPONSE 25. A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to Hawaii. What would the nurse recommend that the patient do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return. b. Eat a large meal before boarding the flight.

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c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently.

ANS: C, D, E Because of the increase in clotting potential, the pregnant patient is prone to a thromboembolism.

Adequate hydration, frequent position changes, and movement decrease the risk.

DIF: Cognitive Level: Application REF: Page 64-65 OBJ: 10 TOP: Flight Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 26. The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine ANS: A, B A waddling gait and joint instability are the only signs that relate to joint changes. The other discomforts are related to the enlarging uterus with its attendant weight.

Chapter 4. Human Reproduction and Fetal Development MULTIPLE CHOICE 1. What is the total number of chromosomes contained in a mature sperm or ovum? a. 22 b. 23 c. 44 d. 46 ANS: B Gametes (sex chromosomes) contain 23 chromosomes.

DIF: Cognitive Level: Knowledge REF: Page 31 OBJ: 2

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TOP: Gametogenesis KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A pregnant woman states, My husband hopes I will give him a boy because we have three girls. What will the nurse explain to this woman? a. The sex chromosome of the fertilized ovum determines the gender of the child. b. When the sperm and ovum are united, there is a 75% chance the child will be a girl. c. When the pH of the female reproductive tract is acidic, the child will be a girl. d. If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced.

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

DIF: Cognitive Level: Comprehension REF: Page 33 OBJ: 3 TOP: Sex Determination KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. What is the most common site for fertilization? a. Lower segment of the uterus b. Outer third of the fallopian tube near the ovary c. Upper portion of the uterus d. Area of the fallopian tube farthest from the ovary ANS: B Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.

DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. The embryo is termed a fetus at which stage of prenatal development? a. 2 weeks b. 4 weeks c. 9 weeks d. 16 weeks ANS: C The fetus (third stage of prenatal development) begins at the ninth week and continues until the 40th week of gestation or until birth.

DIF: Cognitive Level: Knowledge REF: Page 36 OBJ: 4

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TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries ANS: A The umbilical vein transports richly oxygenated blood from the placenta to the fetus.

DIF: Cognitive Level: Knowledge REF: Page 39-40 OBJ: 7 TOP: Fetal Circulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 6. Where is the usual location for implantation of the zygote? a. Upper section of the posterior uterine wall b. Lower portion of the uterus near the cervical os c. Inner third of the fallopian tube near the uterus d. Lateral aspect of the uterine wall ANS: A The zygote usually implants in the upper section of the posterior uterine wall.

DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 3 TOP: Implantation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the uterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis ANS: C The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.

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DIF: Cognitive Level: Knowledge REF: Page 35 OBJ: 4 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 8. Which hormone is responsible for converting the endometrium into decidual cells for implantation? a. Estrogen b. Human chorionic gonadotropin c. Human placental lactogen d. Progesterone ANS: D At high levels, progesterone maintains the endometrial lining for implantation of the zygote.

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6 TOP: Placenta KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A patient asks the nurse when her infants heart will begin to pump blood. What will the nurse reply? a. By the end of week 3 b. Beginning in week 8 c. At the end of week 16 d. Beginning in week 24 ANS: A The fetal heart begins to pump by week 3 of gestation.

DIF: Cognitive Level: Knowledge REF: Page 36 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. What organ does the ductus venosus shunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs d. Kidneys ANS: A Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the

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inferior vena cava.

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 7 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 11. What complication can result from untreated respiratory distress in the newborn? a. Esophageal atresia b. Gastric dilation c. Cold stress d. Reopening of the foramen ovale ANS: D Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.

DIF: Cognitive Level: Comprehension REF: Page 40 OBJ: 7 TOP: Fetal Circulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 12. During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High birth-weight twins ANS: A Dizygotic twins always have two amnions and two chorions (placentas).

DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8 TOP: Multifetal Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin that is pink and smooth d. Eyes that are closed

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

DIF: Cognitive Level: Comprehension REF: Page 37-38, Table 3-1 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. At what point in prenatal development do the lungs begin to produce surfactant? a. 17 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: C During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur.

DIF: Cognitive Level: Knowledge REF: Page 37, Table 3-1 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. A woman missed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test. Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen ANS: C Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent?

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a. Congenital heart defects b. Neural tube defects c. Mental retardation d. Premature birth ANS: B It is now known that folic acid supplements can prevent neural tube defects such as spina bifida.

DIF: Cognitive Level: Comprehension REF: Page 37 OBJ: 5 TOP: Prenatal Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability? a. 14 weeks b. 20 weeks c. 25 weeks d. 30 weeks ANS: B By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of viability).

DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 5 TOP: Prenatal Developmental Milestones KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not? a. 10% b. 25% c. 50% d. 100% ANS: C If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.

DIF: Cognitive Level: Comprehension REF: Page 34 OBJ: 4

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TOP: Dominant Traits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. The nurse explains that the birth weight of monozygotic twins is frequently below average.

What is the most likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition ANS: D The single placenta may not be able to provide adequate nutrition to two fetuses.

DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8 TOP: Low Birth-weight Twins KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix? a. They are destroyed by the acidic pH of the vagina. b. They survive up to 5 days and can cause pregnancy. c. They lose their motility in about 12 hours after intercourse. d. They are usually pushed out of the vagina by the muscular action of the vaginal wall.

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

DIF: Cognitive Level: Comprehension REF: Page 33 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse? a. Age b. Estrogen level c. Body temperature d. Level of feminine hygiene ANS: B

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

DIF: Cognitive Level: Knowledge REF: Page 33 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. Of what is the normal umbilical cord comprised? a. 1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b. 1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus ANS: C The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus.

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 6 TOP: Fetal Circulation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 23. What part of the fetal body derives from the mesoderm? a. Nails b. Oil glands c. Muscles d. Lining of the bladder ANS: C The mesoderm is responsible for the development of muscles. Nails and oil glands derive from the ectoderm. The lining of the bladder derives from the endoderm.

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1 OBJ: 4 TOP: Embryonic development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound? a. 4 weeks gestational age b. 6 weeks gestational age

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c. 10 weeks gestational age d. 16 weeks gestational age ANS: C The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound examination.

DIF: Cognitive Level: Knowledge REF: Page 37 OBJ: 5 TOP: Fetal Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development MULTIPLE RESPONSE 25. A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm ANS: A, B, C The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm.

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1 OBJ: 4 TOP: Primary Germ Layers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 26. What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus ANS: A, E The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin; allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for

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the fetus. Although the fetus does swallow amniotic fluid, it has no nutritional value.

DIF: Cognitive Level: Knowledge REF: Page 35, Box 3-1 OBJ: 6 TOP: Amniotic Fluid KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 27. A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What facts will the nurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twins share a placenta. c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases with maternal age.

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

DIF: Cognitive Level: Comprehension REF: Page 42 OBJ: 8 TOP: Dizygotic Twins KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development COMPLETION 28. The nurse explains that prior to fertilization each cell is reduced from 46 chromosomes to 23 chromosomes. This is referred to as the

number.

ANS: haploid When each cell reduces its chromosomes from 46 to 23, it is called the haploid number.

DIF: Cognitive Level: Knowledge REF: Page 32 OBJ: 2 TOP: Haploid Number KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 29. The component of development that programs the genetic code into the nucleus of the cell is .

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ANS: DNA The DNA programs the genetic code to the nucleus of the cell to be replicated.

DIF: Cognitive Level: Knowledge REF: Page 31 | Page 34 OBJ: 4 TOP: DNA KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 30. The vessels comprising the umbilical cord are cushioned and protected by a substance called .

ANS: Whartons jelly Whartons jelly is a substance in the umbilical cord that cushions and protects the vessels.

DIF: Cognitive Level: Knowledge REF: Page 39 OBJ: 1 TOP: Fetal Circulation KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 31. The normal volume of amniotic fluid is approximately

mL at 37 weeks

gestation.

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

Chapter 5. Physical and Psychological Changes of Pregnancy MULTIPLE CHOICE 1. A pregnant clients mother is worried that her daughter is not big enough at 20 weeks of gestation. The nurse palpates and measures the fundal height at 20 cm, which is even with the

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womans umbilicus. Which should the nurse report to the client and her mother?

a .

Youre right. Well inform the practitioner immediately.

b .

Lightening has occurred, so the fundal height is lower than expected.

c .

The body of the uterus is at the belly button level, just where it should be at this time.

d .

When you come for next months appointment, well check you again to make sure that the baby is growing.

ANS: C At 20 weeks, the fundus is usually located at the umbilical level. Because the uterus grows in a predictable pattern, obstetric nurses should know that the uterus of 20 weeks gestation is located at the level of the umbilicus. Lightening has not yet occurred. At 20 weeks, the uterus should be at the umbilical level. The descent of the fetal head (lightening) occurs in late pregnancy.

Waiting until the next appointment avoids the direct question and might increase the anxiety of the mother and grandmother.

PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. While the vital signs of a pregnant client in her third trimester are being assessed, the client complains of feeling faint, dizzy, and agitated. Which nursing intervention is appropriate?

a .

Have the client stand up and retake her blood pressure.

b .

Have the client sit down and hold her arm in a dependent position.

c .

Have the client turn to her left side and recheck her blood pressure in 5 minutes.

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d .

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Have the client lie supine for 5 minutes and recheck her blood pressure on both arms.

ANS: C Blood pressure is affected by positions during pregnancy. The supine position may cause occlusion of the vena cava and descending aorta. Turning the pregnant woman to a lateral recumbent position alleviates pressure on the blood vessels and quickly corrects supine hypotension. Pressures are significantly higher when the patient is standing. This would cause an increase in systolic and diastolic pressures. The arm should be supported at the same level of the heart. The supine position may cause occlusion of the vena cava and descending aorta, creating hypotension.

PTS: 1 DIF: Cognitive Level: Analysis REF: 96 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 3. A pregnant client has come to the emergency department with complaints of nasal congestion and epistaxis. Which is the correct interpretation of these symptoms by the health care provider?

a .

Nasal stuffiness and nosebleeds are caused by a decrease in progesterone.

b .

These conditions are abnormal. Refer the client to an ear, nose, and throat specialist.

c .

Estrogen relaxes the smooth muscles in the respiratory tract, so congestion and epistaxis are within normal limits.

d .

Estrogen causes increased blood supply to the mucous membranes and can result in congestion and nosebleeds.

ANS: D As capillaries become engorged, the upper respiratory tract is affected by the subsequent edema and hyperemia, which causes these conditions, seen commonly during pregnancy. Progesterone is responsible for the heightened awareness of the need to breathe in pregnancy. Progesterone

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levels increase during pregnancy. The client should be reassured that these symptoms are within normal limits. No referral is needed at this time. Relaxation of the smooth muscles in the respiratory tract is affected by progesterone.

PTS: 1 DIF: Cognitive Level: Analysis REF: 97 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 4. Which suggestion is appropriate for the pregnant client who is experiencing heartburn?

a .

Drink plenty of fluids at bedtime.

b .

Eat only three meals a day so the stomach is empty between meals.

c .

Drink coffee or orange juice immediately on arising in the morning.

d .

Use Tums or Alkamints to obtain relief, as directed by the health care provider.

ANS: D Antacids high in calcium (e.g., Tums, Alkamints) can provide temporary relief. Fluids overstretch the stomach and may precipitate reflux when lying down. Instruct the woman to eat five or six small meals per day rather than three full meals. Coffee and orange juice stimulate acid formation in the stomach.

PTS: 1 DIF: Cognitive Level: Understanding REF: 114 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 5. While providing education to a primiparous client regarding the normal changes of pregnancy, what is important for the nurse to explain about Braxton Hicks contractions?

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a .

These contractions may indicate preterm labor.

b .

These are contractions that never cause any discomfort.

c .

Braxton Hicks contractions only start during the third trimester.

d .

These occur throughout pregnancy, but you may not feel them until the third trimester.

ANS: D Throughout pregnancy, the uterus undergoes irregular contractions called Braxton Hicks contractions. During the first two trimesters, the contractions are infrequent and usually not felt by the woman until the third trimester. Braxton Hicks contractions do not indicate preterm labor.

Braxton Hicks contractions can cause some discomfort, especially in the third trimester. Braxton Hicks contractions occur throughout the whole pregnancy.

PTS: 1 DIF: Cognitive Level: Application REF: 94 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 6. What is the reason for vascular volume increasing by 40% to 60% during pregnancy?

a .

Prevents maternal and fetal dehydration

b .

Eliminates metabolic wastes of the mother

c .

Provides adequate perfusion of the placenta

d .

Compensates for decreased renal plasma flow

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ANS: C The primary function of increased vascular volume is to transport oxygen and nutrients to the fetus via the placenta. Preventing maternal and fetal dehydration is not the primary reason for the increase in volume. Assisting with pulling metabolic wastes from the fetus for maternal excretion is one purpose of the increased vascular volume. Renal plasma flow increases during pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 94 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. Physiologic anemia often occurs during pregnancy because of:

a .

inadequate intake of iron.

b .

the fetus establishing iron stores.

c .

dilution of hemoglobin concentration.

d .

decreased production of erythrocytes.

ANS: C When blood volume expansion is more pronounced and occurs earlier than the increase in red blood cells, the woman will have physiologic anemia, which is the result of dilution of hemoglobin concentration rather than inadequate hemoglobin. Inadequate intake of iron may lead to true anemia. If the woman does not take an adequate amount of iron, true anemia may occur when the fetus pulls stored iron from the maternal system. There is increased production of erythrocytes during pregnancy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 95 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which is a positive sign of pregnancy?

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a .

Amenorrhea

b .

Breast changes

c .

Fetal movement felt by the woman

d .

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ANS: D The only positive signs of pregnancy are auscultation of fetal heart tones, visualization of the fetus by ultrasound, and fetal movement felt by the examiner. Amenorrhea is a presumptive sign of pregnancy. Breast changes are a presumptive sign of pregnancy. Fetal movement is a presumptive sign of pregnancy.

9. Which is a major concern among members of lower socioeconomic groups?

a .

Practicing preventive health care

b .

Meeting health needs as they occur

c .

Maintaining an optimistic view of life

d .

Maintaining group health insurance for their families

ANS: B Because of their economic uncertainty, lower socioeconomic groups place more emphasis on meeting the needs of the present rather than on future goals. Lower socioeconomic groups may value health care but generally cannot afford preventive health care. They may struggle for basic needs and often do not see a way to improve their situation. It is difficult to maintain optimism.

Lower socioeconomic groups usually do not have group health insurance.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 134 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 10. Which comment made by a new mother exhibits understanding of her toddlers response to a new sibling?

a .

I cant believe he is sucking his thumb again.

b .

He is being difficult and I dont have time to deal with him.

c .

When we brought the baby home, we made Michael stop sleeping in the crib.

d .

My husband is going to stay with the baby so I can take Michael to the park tomorrow.

ANS: D It is important for a mother to seek time alone with her toddler to reassure him that he is loved. It is normal for a child to regress when a new sibling is introduced into the home. The toddler may have feelings of jealousy and resentment toward the new baby taking attention away from him.

Frequent reassurance of parental love and affection are important. Changes in sleeping arrangements should be made several weeks before the birth so the child does not feel displaced by the new baby.

PTS: 1 DIF: Cognitive Level: Analysis REF: 132 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 11. While teaching an Asian client about prenatal care, the nurse notes that the client refuses to make eye contact. Which is the most likely cause?

a .

A submissive attitude

b .

Lack of understanding

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c .

Embarrassment about the subject

d .

Cultural beliefs about eye contact

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ANS: D The nurse must understand that making eye contact means different things in different cultures.

The nurse should have a basic understanding of normal responses of various cultures within her community. Asians believe that eye contact shows disrespect, not submission. Many Asian women may nod and smile during client teaching, but this does not show understanding. They are responding that they heard you; validation of information is important. Modesty is important in some cultures, but the main response with this questions is the cultural beliefs.

PTS: 1 DIF: Cognitive Level: Understanding REF: 138 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 12. The nurse in labor and birth is caring for a Muslim client during the active phase of labor.

The nurse notes that the client quickly draws away when touched. Which intervention should the nurse implement?

a .

Ask the charge nurse to reassign you to another client.

b .

Assume that she doesnt like you and decrease your time with her.

c .

Continue to touch her as much as you need to while providing care.

d .

Limit touching to a minimum because physical contact may not be acceptable in her culture.

ANS: D Touching is an important component of communication in various cultures, but if the client appears to find it offensive, the nurse should respect her cultural beliefs and limit touching her.

Asking the charge nurse to reassign you could be offensive to the client. A Muslims response to

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touch does not reflect like or dislike. By continuing to touch her, the nurse is showing disrespect for her cultural beliefs.

PTS: 1 DIF: Cognitive Level: Application REF: 138 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity 13. Which client may require more help and understanding when integrating the newborn into the family?

a .

A primipara from an upper income family

b .

A primipara who comes from a large family

c .

A multipara (gravida 2) who has a supportive husband and mother

d .

A multipara (gravida 6) who has two children younger than 3 years

ANS: D Pregnancy tasks are more complex for the multipara (gravida 6), and she may need special assistance to integrate the infant into the family structure. A primipara from an upper income family has the financial resources to assist her with daily care of the home. This leaves her free to concentrate on the newborns needs. The primipara with a large support system has help available to her. The multipara (gravida 2) who has a supportive husband and mother has a support system to assist with integrating the infant into the family structure.

PTS: 1 DIF: Cognitive Level: Analysis REF: 133 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 14. An Asian-American expectant father tells the nurse that he seems to be gaining weight, just like his wife. The nurse recognizes that this behavior is most likely a reflection of which?

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a .

Couvade

b .

Embarrassment

c .

Ambivalence regarding the pregnancy

d .

Limited interest in the well-being of his wife

ANS: A Couvade is when expectant fathers sometimes experience physical symptoms similar to those of pregnant women, such as loss of appetite, nausea, headache, fatigue, and weight gain. The father did not express anything that would indicate embarrassment. There is no indication in the fathers statement that he is ambivalent to the pregnancy. There is no data in the question that indicates that the father is not interested in his wife.

PTS: 1 DIF: Cognitive Level: Understanding REF: 131 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 15. An expectant couple asks the nurse about intercourse during pregnancy and whether it is safe for the baby. What should the nurse tell the couple?

a .

Intercourse is safe until the third trimester.

b .

Safer sex practices should be used once the membranes rupture.

c .

Intercourse should be avoided if any spotting from the vagina occurs afterward.

d .

Intercourse and orgasm are often contraindicated if a history of or signs of preterm labor are present.

ANS: D

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Uterine contractions that accompany orgasm can stimulate labor and would be problematic if the woman is at risk for or has a history of preterm labor. Intercourse can continue as long as the pregnancy is progressing normally. Rupture of the membranes may require abstaining from intercourse. Safer sex practices are always recommended. Some spotting can normally occur as a result of the increased fragility and vascularity of the cervix and vagina during pregnancy.

PTS: 1 DIF: Cognitive Level: Application REF: 126 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 16. A pregnant client comes into the medical clinic stating that her family and friends are telling her that she is always talking about the pregnancy and nothing else. She is concerned that something is wrong with her. What psychological behavior is she exhibiting?

a .

Antepartum obsession

b .

Ambivalence

c .

Uncertainty

d .

Introversion

ANS: D The client is exhibiting behaviors associated with introversion and/or narcissism. These are normal findings during pregnancy as long as they do not become obsessive to the exclusion of everything else. The client is talking about the pregnancy but there is no evidence that it is affecting her perception of reality and/or ability to perform ADLs. It is normal for pregnant women to focus on the self as being of prime importance in their life initially during the pregnancy. Some women may feel ambivalent about their pregnancy, which is a normal reaction.

However, this clients behavior does not support this finding. Some women react with uncertainty at the news of being pregnant, which is a normal reaction. However, this clients behavior does not support this finding.

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PTS: 1 DIF: Cognitive Level: Application REF: 125 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 17. During the course of the pregnancy, the client states that she feels a deep connection with her unborn child. This behavior illustrates the maternal task acquisition of:

a .

safe passage.

b .

gaining acceptance.

c .

fostering an interconnection.

d .

developing empathy through physical actions.

ANS: C During pregnancy, it is important for the mother to relate to and connect with the unborn child as part of the initial attachment and bonding experience. Safe passage refers to securing safety as a primary concern through the pregnancy and birth process. Gaining acceptance relates to behaviors acknowledging the pregnancy as a part of ones maternal role. Pregnant woman may appear to be more nurturing during pregnancy, but this is not necessarily associated through physical actions.

PTS: 1 DIF: Cognitive Level: Application REF: 128 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 18. A pregnant client relates a story of how her boyfriend is feeling her aches and pains associated with her pregnancy. She is concerned that her boyfriend is making fun of her concerns. How would you respond to this client statement?

a .

Tell her not to worry because it is natural for her boyfriend to make her feel better by identifying with her pregnancy.

b .

Refer the client to a psychologist for counseling to deal with this problem because it is clearly upsetting her.

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c .

Explain that her boyfriend may be experiencing couvade syndrome and that this is a normal finding seen with male partners.

d .

Ask the client specifically to define her concerns related to her relationship with her boyfriend and suggest methods to stop this type of behavior by her significant other.

ANS: C Provide factual information that will help reduce stress and modify acceptance. Telling her not to worry does not address the possibility that her boyfriend may be experiencing couvade syndrome. The client is expressing concern but does not have all the facts related to couvade syndrome and requires education, rather than referral. Couvade syndrome is not an abnormal condition and should be treated with acceptance and understanding.

PTS: 1 DIF: Cognitive Level: Application REF: 131 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity 19. Which of the following would be considered to be a system barrier to the birth of prenatal care?

a .

Adolescent pregnant client

b .

Inability to schedule an appointment with the health care provider because of a busy medical practice

c .

Pregnant client has no health insurance

d .

Having to sign in for the initial appointment and complete health history records

ANS: B A delay in the ability to schedule an appointment with a health care provider is an example of a system barrier to the birth of prenatal care. An adolescent pregnant client would not be

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considered to be a system barrier but rather a psychosocial factor that would affect the pregnancy state. Having no health insurance is an example of a financial barrier to the birth of prenatal care.

Completing a health history record is part of a comprehensive assessment.

PTS: 1 DIF: Cognitive Level: Application REF: 134 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 20. The nurse reveals to the patient that the over-the-counter test is verified and that she is pregnant. The patient confides to the nurse, We have wanted to be pregnant for some time. These last few days I have been questioning our decision. I am feeling really bad right now. What is the nurses best response?

a .

You will come around in time and you will grow to love this baby.

b .

Dont feel bad. It is the hormones of pregnancy talking right now.

c .

Why do you think you are feeling bad when you wanted to be pregnant?

d .

Your feelings are understandable. Ambivalence is not uncommon right now.

ANS: D Early in pregnancy, ambivalence is not uncommon because pregnancy is a life-changing event, even if planned and strongly desired. The client needs reassurance and validation of these natural feelings. Although it is true that the patient will grow to love the baby, this statement does not acknowledge her ambivalent feelings. Dont feel bad dismisses the patients natural feelings and is a nontherapeutic response. Why is nontherapeutic and places the patient on the defensive in her response.

Chapter 6. Nursing Care During Pregnancy MULTIPLE CHOICE 1. The nurse is preparing to perform Leopolds maneuvers. Why are Leopolds maneuvers used by

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practitioners?

a .

To determine the status of the membranes

b .

To determine cervical dilation and effacement

c .

To determine the best location to assess the fetal heart rate

d .

To determine whether the fetus is in the posterior position

ANS: C Leopolds maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

PTS: 1 DIF: Cognitive Level: Application REF: 227 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 2. Which comfort measure should a nurse use to assist a laboring woman to relax?

a .

Recommend frequent position changes.

b .

Palpate her filling bladder every 15 minutes.

c .

Offer warm wet cloths to use on the clients face and neck.

d .

Keep the room lights lit so the client and her coach can see everything.

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ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours.

Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

PTS: 1 DIF: Cognitive Level: Application REF: 236 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 3. Which assessment finding could indicate hemorrhage in the postpartum patient?

a .

Elevated pulse rate

b .

Elevated blood pressure

c .

Firm fundus at the midline

d .

Saturation of two perineal pads in 4 hours

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

PTS: 1 DIF: Cognitive Level: Analysis REF: 224 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 4. Which is an essential part of nursing care for a laboring client?

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a .

Helping the woman manage the pain

b .

Eliminating the pain associated with labor

c .

Feeling comfortable with the predictable nature of intrapartal care

d .

Sharing personal experiences regarding labor and birth to decrease her anxiety

ANS: A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 220 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 5. A client at 40 weeks gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:

a .

fetal movement.

b .

irregular contractions for 1 hour.

c .

a trickle of fluid from the vagina.

d .

thick pink or dark red vaginal mucus.

ANS: C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation

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for infection or cord compression. The lack of fetal movement needs further assessment.

Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Application REF: 221 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 6. Which client at term should go to the hospital or birth center the soonest after labor begins?

a .

Gravida 2, para 1, who lives 10 minutes away

b .

Gravida 1, para 0, who lives 40 minutes away

c .

Gravida 2, para 1, whose first labor lasted 16 hours

d .

Gravida 3, para 2, whose longest previous labor was 4 hours

ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor.

The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

PTS: 1 DIF: Cognitive Level: Analysis REF: 221 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment

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7. A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:

a .

contraction pattern, amount of discomfort, and pregnancy history.

b .

fetal heart rate, maternal vital signs, and the womans nearness to birth.

c .

last food intake, when labor began, and cultural practices the couple desires.

d .

identification of ruptured membranes, the womans gravida and para, and her support person.

ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits.

Identification of ruptured membranes, the womans gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

PTS: 1 DIF: Cognitive Level: Application REF: 222 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from admission). Membranes are intact. The nurse should expect the client to be:

a .

discharged home with a sedative.

b .

admitted for extended observation.

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c .

admitted and prepared for a cesarean birth.

d .

discharged home to await the onset of true labor.

ANS: D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?

a .

Inform the mother that the rate is normal.

b .

Reassess the fetal heart rate in 5 minutes because the rate is too high.

c .

Report the fetal heart rate to the physician or nurse-midwife immediately.

d .

Tell the mother that she is going to have a boy because the heart rate is fast.

ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: 235 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Which should the nurse recognize as being associated with fetal compromise?

a .

Active fetal movements

b .

Fetal heart rate in the 140s

c .

Contractions lasting 90 seconds

d .

Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

PTS: 1 DIF: Cognitive Level: Application REF: 235 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

a .

Every 15 minutes

b .

Every 30 minutes

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c .

Every 45 minutes

d .

Every 1 hour

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ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

PTS: 1 DIF: Cognitive Level: Application REF: 231 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 12. Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth?

a .

Bloody mucous discharge increases.

b .

The vulva bulges and encircles the fetal head.

c .

The membranes rupture during a contraction.

d .

The fetal head is felt at 0 station during the vaginal examination.

ANS: B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates

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engagement.

PTS: 1 DIF: Cognitive Level: Analysis REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 13. During labor a vaginal examination should be performed only when necessary because of the risk of:

a .

infection.

b .

fetal injury.

c .

discomfort.

d .

perineal trauma.

ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury.

Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

PTS: 1 DIF: Cognitive Level: Understanding REF: 231, 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 14. A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes her husbands hand away and shouts, Dont touch me! This behavior is most likely:

a .

abnormal labor.

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b .

a sign that she needs analgesia.

c .

normal and related to hyperventilation.

d .

common during the transition phase of labor.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

PTS: 1 DIF: Cognitive Level: Application REF: 223 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 15. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. The Apgar score for this infant is:

a .

7.

b .

8.

c .

9.

d .

10.

ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue hands and feet. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The baby received 2 points

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for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 16. If a womans fundus is soft 30 minutes after birth, the nurses first response should be to:

a .

massage the fundus.

b .

take the blood pressure.

c .

notify the physician or nurse-midwife.

d .

place the woman in Trendelenburg position.

ANS: A The nurses first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. The nurse thoroughly dries the infant immediately after birth primarily to:

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a .

reduce heat loss from evaporation.

b .

stimulate crying and lung expansion.

c .

increase blood supply to the hands and feet.

d .

remove maternal blood from the skin surface.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss.

Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

PTS: 1 DIF: Cognitive Level: Understanding REF: 248 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 18. The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

a .

Request a social service consult for psychosocial support.

b .

Observe for other signs that the mother may not be accepting of the infant.

c .

Document this evidence of normal early maternal-infant attachment behavior.

d .

Determine whether the mother is too fatigued to interact normally with her infant.

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ANS: C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

PTS: 1 DIF: Cognitive Level: Analysis REF: 251 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity 19. Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?

a .

Fluid volume deficit (FVD) related to fluid loss during labor and birth process

b .

Fatigue related to length of labor requiring increased energy expenditure

c .

Acute pain related to increased intensity of contractions

d .

Anxiety related to imminent birth process

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 244 OBJ: Nursing Process Step: Nursing Diagnosis MSC: Client Needs: Psychosocial Integrity 20. Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?

a .

Length of second-stage labor is 2 hours.

b .

Client has received an epidural for pain control during the labor process.

c .

Client is using breathing techniques during contractions to maximize pain relief.

d .

Client is receiving parenteral fluids during the course of labor to maintain hydration.

ANS: B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

PTS: 1 DIF: Cognitive Level: Application REF: 244 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Safe and Effective Care Environment/Management of Care 21. A gravida 1, para 0, 38 weeks gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, 1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this

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time?

a .

Performing more frequent vaginal exams will not make the labor go any quicker.

b .

Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.

c .

Tell the client that she will check every 30 minutes.

d .

Medicate the client as needed for anxiety so that the labor can progress.

ANS: B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address clients anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

Chapter 7. Promoting a Healthy Pregnancy MULTIPLE CHOICE 1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap smear?

a .

Lubricant

b .

Speculum

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c .

Fixative agent

d .

Gloves and eye protectors

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ANS: A Lubricants interfere with the accuracy of the cytology report. A speculum is needed to see the cervix. A fixative agent is applied to the slide to prevent drying or disruption of the specimen.

The examiner should always use standard precautions.

PTS: 1 DIF: Cognitive Level: Application REF: 722 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 2. A 45-year-old client asks how often she should have a mammogram. The most appropriate answer is:

a .

whenever she feels a lump.

b .

every year beginning at age 40.

c .

they are unnecessary until age 50.

d .

every year if you have risk factors.

ANS: B The American Cancer Society recommends that women have an annual mammogram after 40 years of age. Mammography should be done routinely following the American Cancer Society guidelines. Mammograms are necessary when a woman is in her 40s. Women with high-risk factors may need them more often.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 722 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 3. While performing a self-breast exam, the client notes an area on the right breast that is nodular, with some associated tenderness. This is a new onset finding because the exams were not problematic in the past,. The left breast examination is unremarkable. The client calls to report her findings to the clinical nurse because this is not her typical result. What action should the nurse take next?

a .

Refer the client to an oncologist because the results sound suspicious.

b .

Ask the client to come in for an office visit so that the findings can be validated but tell her that this information is within the normal range of presentation.

c .

Have the client wear a tight-fitting bra and tell her that the tenderness is associated with ovulation and will pass.

d .

Have the client repeat the self-breast exam in 2 weeks and call back with findings to provide a basis for comparison.

ANS: B Although these findings are within the normal range of presentation for breast tissue, they are not in the normal presentation for this client. The client has called to express concern; therefore, the nurse should have the client schedule an appointment for assessment and evaluation. There is no need for referral to a specialist at this time. Wearing a tight fitting bra may help provide support but does not address the physical findings and concern of the client. Repeating the self-breast exam may be required but it does not address the clients current concerns; therefore, the client should be seen by a health care provider.

PTS: 1 DIF: Cognitive Level: Application REF: 720, 721 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 4. Findings of a Pap smear exam denote atypical cells of undetermined significance (ASCUS).

The Pap test is repeated at 6 months and the same finding of ASCUS are reported. Which

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therapeutic treatment option would the nurse expect the practitioner to order?

a .

Mammography

b .

Bone scan

c .

Transvaginal ultrasound

d .

Biopsy

ANS: D Based on the standard of care, a colposcopy or biopsy of the cervix is indicated. A Pap smear is done to evaluate the cervix. There is no indication that mammography, which is used to assess and evaluate breast tissue, is required. There is no evidence to warrant a bone scan. Although a transvaginal ultrasound might be included in the treatment plan, the Pap smear indicates cervical pathology so a colposcopy or biopsy is indicated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 724 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 5. Which administration concern is included in the plan of care for the HPV (human papillomavirus) vaccine?

a .

It is available in liquid form.

b .

It involves a series of two injections.

c .

Injections should be given over a 3-month period.

d .

The individual should sit down for 15 minutes following the injection.

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ANS: D There is a possibility that the client can faint in reaction to this type of immunization, so a safety concern should be included in the plan of care. It is available only in injection form. It is given as a series of three injections. The series of three injections should be given over a 6-month period according to Centers for Disease Control and Prevention (CDC) recommendations.

PTS: 1 DIF: Cognitive Level: Analysis REF: 726 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Pharmacologic and Parenteral Therapies MULTIPLE RESPONSE 6. While interviewing a 48-year-old client during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this client to begin annual screening, it is important for her to understand the reasons why women avoid testing.

These reasons include which of the following? (Select all that apply.)

a .

Fear of x-ray exposure

b .

Expense of the procedure

c .

Reluctance to hear bad news

d .

Having heard that the test is painful

e .

Belief that lack of family history makes this test unnecessary

ANS: A, B, C, D Fear of x-ray exposure, expense, reluctance to hear bad news, and fear of pain are reasons women avoid having a mammogram done. Although the test is expensive, it is usually covered by health insurance, and many communities offer low-cost or free screening to women without insurance. It is important to acknowledge that some discomfort occurs with screening.

Scheduling the test immediately at the end of a period makes it less painful. The risk of radiation

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exposure is minimal to none. Nurses play a vital role in providing information and reassurance to help women overcome these fears. Even clients with no family history should have a regular screening done. The nurse should emphasize that a combination of breast self-examination and mammography needs to be performed at regular intervals. Women with a family history may need to begin screening at a younger age and have additional testing such as ultrasound performed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 722 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 7. Healthy People 2020 goals directed at womens health issues focus on which areas? (Select all that apply.)

a .

Increased screening for cervical and colorectal cancers

b .

Reduction of cancer survivor rate based on clinical management treatment

c .

Decreased morbidity and mortality related to breast cancer

d .

Reduction in hospitalization for hip fractures in the older female population

e .

Reduction in deaths associated with cardiovascular causes such as stroke and coronary artery disease (CAD)

ANS: A, C, D, E Healthy People 2020 goals directed at womens health focus on increased access to screening for cervical and colorectal cancers, decreased deaths occurring from breast cancer and heart disease, and decreased hospitalization for hip fractures. A reduction of the cancer survival rate would reflect increased morbidity and mortality.

Chapter 8 & Chapter 9. Nursing Care of the Woman With Complications During Pregnancy

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Chapter 9. Nursing Care During Labor and Childbirth MULTIPLE CHOICE 1. The nurse is preparing to perform Leopolds maneuvers. Why are Leopolds maneuvers used by practitioners?

a .

To determine the status of the membranes

b .

To determine cervical dilation and effacement

c .

To determine the best location to assess the fetal heart rate

d .

To determine whether the fetus is in the posterior position

ANS: C Leopolds maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the status of the fetal membranes. Dilation and effacement are best determined by vaginal examination. Assessment of fetal position is more accurate with vaginal examination.

PTS: 1 DIF: Cognitive Level: Application REF: 227 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 2. Which comfort measure should a nurse use to assist a laboring woman to relax?

a .

Recommend frequent position changes.

b .

Palpate her filling bladder every 15 minutes.

c .

Offer warm wet cloths to use on the clients face and neck.

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d .

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Keep the room lights lit so the client and her coach can see everything.

ANS: A Frequent maternal position changes reduce the discomfort from constant pressure and promote fetal descent. A full bladder intensifies labor pain. The bladder should be emptied every 2 hours.

Women in labor get hot and perspire. Cool cloths are much better. Soft indirect lighting is more soothing than irritating bright lights.

PTS: 1 DIF: Cognitive Level: Application REF: 236 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 3. Which assessment finding could indicate hemorrhage in the postpartum patient?

a .

Elevated pulse rate

b .

Elevated blood pressure

c .

Firm fundus at the midline

d .

Saturation of two perineal pads in 4 hours

ANS: A An increasing pulse rate is an early sign of excessive blood loss. If the blood volume were diminishing, the blood pressure would decrease. A firm fundus indicates that the uterus is contracting and compressing the open blood vessels at the placental site. Saturation of one pad within the first hour is the maximum normal amount of lochial flow. Two pads within 4 hours is within normal limits.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 224 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 4. Which is an essential part of nursing care for a laboring client?

a .

Helping the woman manage the pain

b .

Eliminating the pain associated with labor

c .

Feeling comfortable with the predictable nature of intrapartal care

d .

Sharing personal experiences regarding labor and birth to decrease her anxiety

ANS: A Helping a client manage the pain is an essential part of nursing care because pain is an expected part of normal labor and cannot be fully relieved. Labor pain cannot be fully relieved. The labor nurse should always be assessing for unpredictable occurrences. Decreasing anxiety is important, but managing pain is a top priority.

PTS: 1 DIF: Cognitive Level: Application REF: 220 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 5. A client at 40 weeks gestation should be instructed to go to a hospital or birth center for evaluation when she experiences:

a .

fetal movement.

b .

irregular contractions for 1 hour.

c .

a trickle of fluid from the vagina.

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d .

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thick pink or dark red vaginal mucus.

ANS: C A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or cord compression. The lack of fetal movement needs further assessment.

Irregular contractions are a sign of false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It does not require professional assessment unless the bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Application REF: 221 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 6. Which client at term should go to the hospital or birth center the soonest after labor begins?

a .

Gravida 2, para 1, who lives 10 minutes away

b .

Gravida 1, para 0, who lives 40 minutes away

c .

Gravida 2, para 1, whose first labor lasted 16 hours

d .

Gravida 3, para 2, whose longest previous labor was 4 hours

ANS: D Multiparous women usually have shorter labors than do nulliparous women. The woman described in option D is multiparous with a history of rapid labors, increasing the likelihood that her infant might be born in uncontrolled circumstances. A gravida 2 would be expected to have a longer labor than the gravida in option C. The fact that she lives close to the hospital allows her to stay home for a longer period of time. A gravida 1 will be expected to have the longest labor.

The gravida 2 would be expected to have a longer labor than the gravida 3, especially because her first labor was 16 hours.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 221 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Safe and Effective Care Environment 7. A woman who is gravida 3, para 2, enters the intrapartum unit. The most important nursing assessments are:

a .

contraction pattern, amount of discomfort, and pregnancy history.

b .

fetal heart rate, maternal vital signs, and the womans nearness to birth.

c .

last food intake, when labor began, and cultural practices the couple desires.

d .

identification of ruptured membranes, the womans gravida and para, and her support person.

ANS: B All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural practices the couple desires is an assessment that can occur later in the admission process, if time permits.

Identification of ruptured membranes, the womans gravida and para, and her support person are assessments that can occur later in the admission process if time permits.

PTS: 1 DIF: Cognitive Level: Application REF: 222 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. A primigravida at 39 weeks of gestation is observed for 2 hours in the intrapartum unit. The fetal heart rate has been normal. Contractions are 5 to 9 minutes apart, 20 to 30 seconds in duration, and of mild intensity. Cervical dilation is 1 to 2 cm and uneffaced (unchanged from

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admission). Membranes are intact. The nurse should expect the client to be:

a .

discharged home with a sedative.

b .

admitted for extended observation.

c .

admitted and prepared for a cesarean birth.

d .

discharged home to await the onset of true labor.

ANS: D The situation describes a client with normal assessments who is probably in false labor and will probably not deliver rapidly once true labor begins. The client will probably be discharged, but there is no indication that a sedative is needed. These are all indications of false labor; there is no indication that further assessment or observations are indicated. These are all indications of false labor without fetal distress. There is no indication that a cesarean birth is indicated.

PTS: 1 DIF: Cognitive Level: Application REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. The nurse auscultates the fetal heart rate and determines a rate of 152 bpm. Which nursing intervention is appropriate?

a .

Inform the mother that the rate is normal.

b .

Reassess the fetal heart rate in 5 minutes because the rate is too high.

c .

Report the fetal heart rate to the physician or nurse-midwife immediately.

d .

Tell the mother that she is going to have a boy because the heart rate is fast.

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ANS: A The FHR is within the normal range, so no other action is indicated at this time. The FHR is within the expected range; reassessment should occur, but not in 5 minutes. The FHR is within the expected range; no further action is necessary at this point. The gender of the baby cannot be determined by the FHR.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 235 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 10. Which should the nurse recognize as being associated with fetal compromise?

a .

Active fetal movements

b .

Fetal heart rate in the 140s

c .

Contractions lasting 90 seconds

d .

Meconium-stained amniotic fluid

ANS: D When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm. The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow for a return of adequate blood flow.

PTS: 1 DIF: Cognitive Level: Application REF: 235 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. The nurse is caring for a low-risk client in the active phase of labor. At which interval should the nurse assess the fetal heart rate?

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a .

Every 15 minutes

b .

Every 30 minutes

c .

Every 45 minutes

d .

Every 1 hour

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ANS: B For the fetus at low risk for complications, guidelines for frequency of assessments are at least every 30 minutes during the active phase of labor. 15-minute assessments would be appropriate for a fetus at high risk. 45-minute assessments during the active phase of labor are not frequent enough to monitor for complications. 1-hour assessments during the active phase of labor are not frequent enough to monitor for complications.

PTS: 1 DIF: Cognitive Level: Application REF: 231 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 12. Which nursing assessment indicates that a woman who is in the second stage of labor is almost ready to give birth?

a .

Bloody mucous discharge increases.

b .

The vulva bulges and encircles the fetal head.

c .

The membranes rupture during a contraction.

d .

The fetal head is felt at 0 station during the vaginal examination.

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ANS: B A bulging vulva that encircles the fetal head describes crowning, which occurs shortly before birth. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth. Birth of the head occurs when the station is +4. A 0 station indicates engagement.

PTS: 1 DIF: Cognitive Level: Analysis REF: 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 13. During labor a vaginal examination should be performed only when necessary because of the risk of:

a .

infection.

b .

fetal injury.

c .

discomfort.

d .

perineal trauma.

ANS: A Vaginal examinations increase the risk of infection by carrying vaginal microorganisms upward toward the uterus. Properly performed vaginal examinations should not cause fetal injury.

Vaginal examinations may be uncomfortable for some women in labor, but that is not the main reason for limiting them. A properly performed vaginal examination should not cause perineal trauma.

PTS: 1 DIF: Cognitive Level: Understanding REF: 231, 233 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 14. A 25-year-old primigravida client is in the first stage of labor. She and her husband have been holding hands and breathing together through each contraction. Suddenly, the client pushes

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her husbands hand away and shouts, Dont touch me! This behavior is most likely:

a .

abnormal labor.

b .

a sign that she needs analgesia.

c .

normal and related to hyperventilation.

d .

common during the transition phase of labor.

ANS: D The transition phase of labor is often associated with an abrupt change in behavior, including increased anxiety and irritability. This change of behavior is an expected occurrence during the transition phase. If she is in the transitional phase of labor, analgesia may not be appropriate if the birth is near. Hyperventilation will produce signs of respiratory alkalosis.

PTS: 1 DIF: Cognitive Level: Application REF: 223 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Psychosocial Integrity 15. At 1 minute after birth, the nurse assesses the newborn to assign an Apgar score. The apical heart rate is 110 bpm, and the infant is crying vigorously with the limbs flexed. The infants trunk is pink, but the hands and feet are blue. The Apgar score for this infant is:

a .

7.

b .

8.

c .

9.

d .

10.

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ANS: C The Apgar score is 9 because 1 point is deducted from the total score of 10 for the infants blue hands and feet. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The baby received 2 points for each of the categories except color. Because the infants hands and feet were blue, this category is given a grade of 1. The infant had 1 point deducted because of the blue color of the hands and feet.

PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 16. If a womans fundus is soft 30 minutes after birth, the nurses first response should be to:

a .

massage the fundus.

b .

take the blood pressure.

c .

notify the physician or nurse-midwife.

d .

place the woman in Trendelenburg position.

ANS: A The nurses first response should be to massage the fundus to stimulate contraction of the uterus to compress open blood vessels at the placental site, limiting blood loss. The blood pressure is an important assessment to determine the extent of blood loss but is not the top priority. Notification should occur after all nursing measures have been attempted with no favorable results. The Trendelenburg position is contraindicated for this woman at this point. This position would not allow for appropriate vaginal drainage of lochia. The lochia remaining in the uterus would clot and produce further bleeding.

PTS: 1 DIF: Cognitive Level: Application REF: 249

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OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. The nurse thoroughly dries the infant immediately after birth primarily to:

a .

reduce heat loss from evaporation.

b .

stimulate crying and lung expansion.

c .

increase blood supply to the hands and feet.

d .

remove maternal blood from the skin surface.

ANS: A Infants are wet with amniotic fluid and blood at birth, which accelerates evaporative heat loss.

Rubbing the infant does stimulate crying but is not the main reason for drying the infant. The main purpose of drying the infant is to prevent heat loss. Drying the infant after birth does not remove all of the maternal blood.

PTS: 1 DIF: Cognitive Level: Understanding REF: 248 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 18. The nurse notes that a client who has given birth 1 hour ago is touching her infant with her fingertips and talking to him softly in high-pitched tones. Based on this observation, which action should the nurse take?

a .

Request a social service consult for psychosocial support.

b .

Observe for other signs that the mother may not be accepting of the infant.

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c .

Document this evidence of normal early maternal-infant attachment behavior.

d .

Determine whether the mother is too fatigued to interact normally with her infant.

ANS: C Normal early maternal-infant behaviors are tentative and include fingertip touch, eye contact, and using a high-pitched voice when talking to the infant. There is no indication at this point that a social service consult is necessary. The signs are of normal attachment behavior. These are signs of normal attachment behavior; no other assessment is necessary at this point. The mother may be fatigued but is interacting with the infant in an expected manner.

PTS: 1 DIF: Cognitive Level: Analysis REF: 251 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Psychosocial Integrity 19. Which nursing diagnosis would take priority in the care of a primipara client with no visible support person in attendance who has entered the second stage of labor after a first stage of labor lasting 4 hours?

a .

Fluid volume deficit (FVD) related to fluid loss during labor and birth process

b .

Fatigue related to length of labor requiring increased energy expenditure

c .

Acute pain related to increased intensity of contractions

d .

Anxiety related to imminent birth process

ANS: D A primipara is experiencing the birthing event for the first time and may experience anxiety because of fear of the unknown. It would be important to recognize this because the client is alone in the labor-birth room and will need additional support and reassurance. Although FVD may occur as a result of fluid loss, prospective management of labor clients includes the use of

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parenteral fluid therapy; the client should be monitored for FVD and, if symptoms warrant, receive intervention. Because the client has been in labor for 4 hours, this is not considered to be a prolonged labor pattern for a primipara client. Although the client may be tired, this nursing diagnosis would not be a priority unless there were other symptoms manifested. Because the client is entering the second stage of labor, she will be allowed to push with contractions. Thus, in terms of pain management, medication will not be administered at this time because of imminent birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 244 OBJ: Nursing Process Step: Nursing Diagnosis MSC: Client Needs: Psychosocial Integrity 20. Which of the following behaviors would be applicable to a nursing diagnosis of risk for injury in a client who is in labor?

a .

Length of second-stage labor is 2 hours.

b .

Client has received an epidural for pain control during the labor process.

c .

Client is using breathing techniques during contractions to maximize pain relief.

d .

Client is receiving parenteral fluids during the course of labor to maintain hydration.

ANS: B A client who has received medication during labor is at risk for injury as a result of altered sensorium, so this presentation is applicable to the diagnosis. A length of 2 hours for the second stage of labor is within the range of normal. Breathing techniques help maintain control over the labor process. Fluids administered during the labor process are used to prevent potential fluid volume deficit.

PTS: 1 DIF: Cognitive Level: Application REF: 244

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OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Safe and Effective Care Environment/Management of Care 21. A gravida 1, para 0, 38 weeks gestation is in the transition phase of labor with SROM and is very anxious. Vaginal exam, 8 cm, 100% effaced, 1 station vertex presentation. She wants the nurse to keep checking her by performing repeated vaginal exams because she is sure that she is progressing rapidly. What is the best response that the nurse can provide to this client at this time?

a .

Performing more frequent vaginal exams will not make the labor go any quicker.

b .

Even though she is in transition, frequent vaginal exams must be limited because of the potential for infection.

c .

Tell the client that she will check every 30 minutes.

d .

Medicate the client as needed for anxiety so that the labor can progress.

ANS: B Data reveals a primipara in labor who is in transition (8 to 10 cm) with ruptured membranes. At this point, vaginal exams should be limited until the client feels further pressure and/or has increased bloody show, indicating fetal descent. Telling the client that performing more frequent vaginal exams will not make the labor go any quicker would not be therapeutic because this does not address clients anxiety. Telling the client that the nurse will continue checking every 30 minutes without adequate clinical indication is not the standard of care. Medicating the client is not an appropriate intervention at this time because effective communication will help alleviate stress, and the use of medications during transition may affect maternal and/or fetal well-being during birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 231, 233 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care 22. When using the second Leopolds maneuver in fetal assessment, the nurse would palpate

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(the):

a .

both sides of the maternal abdomen.

b .

lower abdomen above the symphysis pubis.

c .

both upper quadrants of the maternal abdomen .

d .

lower abdomen for flexion of the presenting part.

ANS: A The second Leopolds maneuver involves determining the location of the fetal back and is performed by palpating both sides of the maternal abdomen. Palpating the lower abdomen above the symphysis pubis is the third maneuver. Palpating the upper quadrants of the maternal abdomen is the first maneuver. Palpating the lower abdomen for flexion of the presenting part is the fourth maneuver.

PTS: 1 DIF: Cognitive Level: Application REF: 230, 231 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 23. A nursing priority during admission of a laboring client who has not had prenatal care is:

a .

obtaining admission labs.

b .

identifying labor risk factors.

c .

discussing her birth plan choices.

d .

explaining importance of prenatal care.

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ANS: B When a client has not had prenatal care, the nurse must determine through interviewing and examination the presence of any pregnancy or labor risk factors, obtain admission labs, and discuss birth plan choices. Explaining the importance of prenatal care can be accomplished after the patients history has been completed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 223 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity 24. The nurse has given the newborn an Apgar score of 5. She should then:

a .

begin ventilation and compressions.

b .

do nothing except place the infant under a radiant warmer.

c .

observe the infant and recheck the score after 10 minutes.

d .

gently stimulate by rubbing the infants back while administering O2.

ANS: D An infant who receives a score of 4 to 6 requires only additional oxygen and gentle stimulation.

An infant who receive a score of 3 or less requires ventilation and compressions. An infant who scores less than 7 requires more intervention than placement under a radiant warmer. Observing and rechecking the infant will not improve newborns transition to extrauterine life.

PTS: 1 DIF: Cognitive Level: Application REF: 249 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 25. The client in labor experiences a spontaneous rupture of membranes. What information

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related to this event must the nurse include in the clients record?

a .

Fetal heart rate

b .

Pain level

c .

Test results ensuring that the fluid is not urine

d .

The clients understanding of the event

ANS: A Charting related to membrane rupture includes the time, FHR, and character and amount of the fluid. Pain is not associated with this event. When it is obvious that the fluid is amniotic fluid, which is anticipated during labor, it is not necessary to verify this by testing. The clients understanding of the event would only need to be documented if it presents a problem.

PTS: 1 DIF: Cognitive Level: Understanding REF: 222 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential 26. At 5 minutes after birth, the nurse assesses that the neonates heart rate is 96 bpm, respirations are spontaneous, with a strong cry, body posture is flexed with vigorous movement, reflexes are brisk, and there is cyanosis of the hands and feet. What Apgar score will the nurse assign?

a .

7

b .

8

c .

9

d .

10

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ANS: B The neonate is assigned a score of 1 for heart rate and color and a score of 2 for respiratory effort, muscle tone, and reflex response, for a combined total of 8.

PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential 27. The gynecologist performs an amniotomy. What will the nurses role include immediately following the procedure?

a .

Assessing for ballottement

b .

Conducting a pH and/or fern test

c .

Labeling of specimens for chromosomal analysis

d .

Recording the character and amount of amniotic fluid

ANS: D An amniotomy is a procedure in which the amniotic sac is deliberately ruptured. It is important to note and record the character and amount of amniotic fluid following this procedure.

Assessing for ballottement is not indicated. Conducting a pH or fern test is not needed because an amniotomy releases amniotic fluid. An amniocentesis, not an amniotomy, is used to collect a specimen for chromosomal analysis.

PTS: 1 DIF: Cognitive Level: Understanding REF: 229 OBJ: Nursing Process Step: Assessment

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MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential 28. The nurse assesses the amniotic fluid. Which characteristic presents the lowest risk of fetal complications?

a .

Bloody

b .

Clear with bits of vernix caseosa

c .

Green and thick

d .

Yellow and cloudy with foul odor

ANS: B Amniotic fluid should be clear and may include bits of vernix caseosa, the creamy white fetal skin lubricant. Green fluid indicates that the fetus passed meconium before birth. The newborn may need extra respiratory suctioning at birth if the fluid is heavily stained with meconium.

Cloudy, yellowish, strong-smelling, or foul-smelling fluid suggests infection. Bloody fluid may indicate partial placental separation.

PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity: Reduction of Risk Potential 29. The nurse assists the midwife during a vaginal examination of the client in labor. What does the nurse recognize as the primary reason that a vaginal exam is done at this time?

a .

To apply internal monitoring electrodes

b .

To assess for Goodells sign

c .

To determine cervical dilation and effacement

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d .

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To determine strength of contractions

ANS: C The primary purpose of a vaginal exam during labor is to determine cervical dilation and effacement and fetal descent. Goodells sign is assessed in early pregnancy, not during labor.

Although application of monitoring electrodes is done by entering the vagina, it is not the primary purpose of a vaginal exam. Vaginal exams are not done to determine the strength of contractions.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 30. A woman arrives to the labor and birth unit at term. She is greeted by a staff nurse and a nursing student. The student reviews the initial intake assessment with the staff nurse. Which action will the staff nurse have to correct?

a .

Obtain a fetal heart rate.

b .

Determine the estimated due date.

c .

Auscultate anterior and posterior breath sounds.

d .

Ask the client when she last had something to eat.

ANS: C On admission to the labor and birth unit, a focused assessment is performed. This includes the following: names of mother and support person(s); name of her physician or nurse-midwife if she had prenatal care; number of pregnancies and prior births, including whether the birth was vaginal or cesarean; status of membranes; expected date of birth; problems during this or other pregnancies; allergies to medications, foods, or other substances; time and type of last oral intake; maternal vital signs and FHR; and painlocation, intensity, factors that intensify or relieve, duration, whether constant or intermittent, and whether the pain is acceptable to the woman.

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Generally, women of childbearing years are healthy and auscultation of lung sounds can be delayed until the initial intake assessment has been completed.

PTS: 1 DIF: Cognitive Level: Analysis REF: 227 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 31. The health care provider has asked the nurse to prepare for an amniotomy. What is the nurses priority action with this procedure?

a .

Perform Leopolds maneuvers.

b .

Determine the color of the amniotic fluid.

c .

Assess the fetal heart rate immediately after the procedure.

d .

Prepare the patient for a change in her pain level after the procedure.

ANS: C An amniotomy is the artificial rupture of the membranes performed with an AmniHook inserted through the cervix. The FHR is assessed for at least 1 minute when the membranes rupture. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through the cord. Leopolds maneuvers should be performed before the amniotomy, which will give an indication of fetal position and station. Color of the fluid can indicate fetal status; however, circulatory assessment is the priority. If the patient is in active labor, a decrease in the amount of amniotic fluid will result in increased intensity of contractions. There is no information in the stem to indicate that the patient is in labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 229 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 32. The nurse is preparing to initiate intravenous (IV) access on a patient in the active phase of labor. Which size IV cannula is best for this patient?

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a .

18-gauge

b .

20-gauge

c .

22-gauge

d .

24-gauge

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ANS: A The larger the number, the smaller the diameter of the cannula. The nurse should select the largest bore cannula possible. IV access is initiated for hydration prior to epidural placement and for use in an emergency. Both require the rapid administration of fluid, which is most easily accomplished with a large bore cannula.

PTS: 1 DIF: Cognitive Level: Understanding REF: 229 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 33. The nurse notes a concerning fetal heart rate pattern for a patient in active labor. The health care provider has prescribed the placement of a Foley catheter. What priority nursing action will the nurse implement when placing the catheter?

a .

Place the catheter as quickly as possible.

b .

Place a small pillow under the patients left hip.

c .

Omit the use of a cleansing agent, such as Betadine.

d .

Set up the catheter tray before positioning the patient.

ANS: B To promote placental function, the nurse can place a small pillow or rolled blanket under the

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patients left hip to shift the weight of the uterus off the aorta and inferior vena cava. Catheter placement is a sterile procedure, with very prescribed steps. Placing the catheter quickly might lead to skipping a step and place the patient at risk for infection. Use of a cleansing agent, such as Hibiclens or Betadine, is included in the catheter placement procedure to ensure a sterile area for placement. Setting up the catheter tray before positioning the patient is the standard of care.

PTS: 1 DIF: Cognitive Level: Analysis REF: 235 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 34. The nurse examines a primiparas cervix at 8-9/100%/+2; it is tight against the fetal head. The patient reports a strong urge to bear down. What is the nurses priority action?

a .

Palpate her bladder for fullness.

b .

Assess the frequency and duration of her contractions.

c .

Determine who will stay with the patient for the birth.

d .

Encourage the patient to exhale in short breaths with contractions.

ANS: D Teach the woman to exhale in short breaths if pushing is likely to injure her cervix or cause cervical edema. Pushing against a cervix that does not easily yield to pressure from the presenting part may result in cervical edema, which can block labor progress or cause cervical lacerations. A full bladder may impede the progress of labor. Although this is an important nursing action, it does not address the patients urge to push. This patient is in the transition phase of the first stage of labor. Her contractions will be every 2 to 3 minutes and last 60 to 90 seconds.

Determining the frequency and duration of the contractions does not add to the known assessment data for this patient. Determining who will attend the birth, although nice to know, does not address her urge to push.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 237 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 35. The labor nurse is reviewing the cardinal maneuvers with a group of nursing students. Which maneuver will immediately follow the birth of the babys head?

a .

Expulsion

b .

Restitution

c .

Internal rotation

d .

External rotation

ANS: B After the head emerges, it realigns with the shoulders (restitution). External rotation occurs as the fetal shoulders rotate internally, aligning their transverse diameter with the anteroposterior diameter of the pelvic outlet. Expulsion occurs when the baby is completely delivered. Internal rotation occurs prior to birth of the head.

PTS: 1 DIF: Cognitive Level: Understanding REF: 247 OBJ: Nursing Process Step: Planning MSC: Client needs: Health Promotion and Maintenance 36. The nurse is performing Leopolds maneuvers on a client. Which figure depicts the Leopolds maneuver that determines whether the fetal presenting part is engaged in the maternal pelvis.

Refer to Figures a to d.

a . b .

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c . d .

ANS: C The maneuver that determines whether the presenting part is engaged (widest diameter at or below a zero station) in the maternal pelvis is done by palpating the suprapubic area. Next, an attempt is made to grasp the presenting part gently between the thumb and fingers. If the presenting part is not engaged, the grasping movement of the fingers moves it upward in the uterus. If the presenting part is engaged, the fetus will not move upward in the uterus. Palpating the uterine fundus distinguishes between a cephalic and breech presentation. Holding the left hand steady on one side of the uterus while palpating the opposite side of the uterus determines on which side of the uterus is the fetal back and on which side are the fetal arms and legs.

Placing your hands on each side of the uterus with fingers pointed toward the inlet determines whether the head is flexed (vertex) or extended (face).

PTS: 1 DIF: Cognitive Level: Analysis REF: 230 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity MULTIPLE RESPONSE 37. A laboring client is 10 cm dilated but does not feel the urge to push. The nurse understands that according to laboring down, the advantages of waiting until an urge to push are which of the following? (Select all that apply.)

a .

Less maternal fatigue

b .

Less birth canal injuries

c .

Decreased pushing time

d .

Faster descent of the fetus

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e .

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An increase in frequency of contractions

ANS: A, B, C Delayed pushing has been shown to result in less maternal fatigue and decreased pushing time.

Pushing vigorously sooner than the onset of the reflexive urge may contribute to birth canal injury because her vaginal tissues are stretched more forcefully and rapidly than if she pushed spontaneously and in response to her bodys signals. A brief slowing of contractions often occurs at the beginning of the second stage.

PTS: 1 DIF: Cognitive Level: Analysis REF: 238 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 38. Which interventions should be performed in the birth room to facilitate thermoregulation of the newborn? (Select all that apply.)

a .

Place the infant covered with blankets in the radiant warmer.

b .

Dry the infant off with sterile towels.

c .

Place stockinette cap on infants head.

d .

Bathe the newborn within 30 minutes of birth.

e .

Remove wet linen as needed.

ANS: B, C, E Following birth, the newborn is at risk for hypothermia. Therefore, nursing interventions are aimed at maintaining warmth. Drying the infant off, in addition to maintaining warmth, helps stimulate crying and lung expansion, which helps in the transition period following birth. Placing a cap on the infants head helps prevent heat loss. Removal of wet linens helps minimize further heat loss caused by exposure. Newborns should not be covered while in a radiant warmer with blankets because this will impede birth of heat transfer. Bathing a newborn should be delayed for

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at least a few hours so that the newborn temperature can stabilize during the transition period.

PTS: 1 DIF: Cognitive Level: Analysis REF: 248 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care 39. When taking care of a client in labor who is not considered to be at risk, which assessments should be included in the plan of care? (Select all that apply.)

a .

Check the DTR each shift.

b .

Monitor and record vital signs frequently during the course of labor.

c .

Document the FHR pattern, noting baseline and response to contraction patterns.

d .

Indicate on the EFM tracing when maternal position changes are done.

e .

Provide food, as tolerated, during the course of labor.

ANS: B, C, D Nursing care of the normal laboring client would include monitoring and documentation of vital signs as part of the labor assessment, documentation the FHR, checking patterns to look for assurance of fetal well-being by evaluating baseline and the fetal response to contraction patterns, and noting any position changes on the monitor tracing to evaluate the fetal response.

Providing dietary offerings during the course of labor is not part of the nursing care plan because the introduction of food may lead to nausea and vomiting in response to the labor process and might affect the mode of birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 229 OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care 40. Which interventions are required following an amniotomy procedure? (Select all that apply.)

a .

Notation related to amount of fluid expelled

b .

Color and consistency of fluid

c .

Fetal heart rate

d .

Maternal blood pressure

e .

Maternal heart rate

ANS: A, B, C Following amniotomy (AROM), observation and documentation of the amount of fluid, color and consistency, and fetal heart rate should be done. Maternal assessments related to blood pressure and heart rate are not required.

PTS: 1 DIF: Cognitive Level: Application REF: 229 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 41. The nurse is monitoring a client in the active stage of labor. Which conditions associated with fetal compromise should the nurse monitor? (Select all that apply.)

a .

Maternal hypotension

b .

Fetal heart rate of 140 to 150 bpm

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c .

Meconium-stained amniotic fluid

d .

Maternal fever38 C (100.4 F) or higher

e .

Complete uterine relaxation of more than 30 seconds between contractions

ANS: A, C, D Conditions associated with fetal compromise include maternal hypotension (may divert blood flow away from the placenta to ensure adequate perfusion of the maternal brain and heart), meconium-stained (greenish) amniotic fluid, and maternal fever (38 C [100.4 F] or higher). Fetal heart rate of 110 to 160 bpm for a term fetus is normal. Complete uterine relaxation is a normal finding.

PTS: 1 DIF: Cognitive Level: Analysis REF: 234 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 42. The nurse is caring for a client in the fourth stage of labor. Which assessment findings should the nurse identify as a potential complication? (Select all that apply.)

a .

Soft boggy uterus

b .

Maternal temperature of 99 F

c .

High uterine fundus displaced to the right

d .

Intense vaginal pain unrelieved by analgesics

e .

Half of a lochia pad saturated in the first hour after birth

ANS: A, C, D Assessment findings that may indicate a potential complication in the fourth stage include a soft

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boggy uterus, high uterine fundus displaced to the right, and intense vaginal pain unrelieved by analgesics. The maternal temperature may be slightly elevated after birth because of the inflammation to tissues, and half of a lochia pad saturated in the first hour after birth is within expected amounts.

PTS: 1 DIF: Cognitive Level: Analysis REF: 249 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity SHORT ANSWER 43. The nurse in the birth room receives an order to give a newborn 0.3 mg of naloxone (Narcan) intramuscularly. The medication vial reads naloxone (Narcan), 0.4 mg/mL. The nurse should prepare how many milliliters to administer the correct dose? Fill in the blank and record your answer using two decimal places. mL

ANS: 0.75 Use the medication calculation formula to calculate the correct dose: Desired/available volume = milliliters per dose (0.3 mg/0.4 mg) 1 mL = 0.75 mL/dose

Chapter 10. Nursing Care of the Woman With Complications During Labor and Birth MULTIPLE CHOICE 1. A client with preeclampsia is being treated with bed rest and intravenous magnesium sulfate.

The drug classification of this medication is a:

a .

diuretic.

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b .

tocolytic.

c .

anticonvulsant.

d .

antihypertensive.

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ANS: C Anticonvulsant drugs act by blocking neuromuscular transmission and depress the central nervous system to control seizure activity. Diuresis is a therapeutic response to magnesium sulfate. A tocolytic drug slows the frequency and intensity of uterine contractions but is not used for that purpose in this scenario. Decreased peripheral blood pressure is a therapeutic response (side effect) of the anticonvulsant magnesium sulfate.

PTS: 1 DIF: Cognitive Level: Understanding REF: 523 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 2. Which is the only known cure for preeclampsia?

a .

Magnesium sulfate

b .

Delivery of the fetus

c .

Antihypertensive medications

d .

Administration of aspirin (ASA) every day of the pregnancy

ANS: B If the fetus is viable and near term, birth is the only known cure for preeclampsia. Magnesium sulfate is one of the medications used to treat but not cure preeclampsia. Antihypertensive medications are used to lower the dangerously elevated blood pressures in preeclampsia and eclampsia. Low doses of aspirin (60 to 80 mg) have been administered to women at high risk for

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developing preeclampsia.

PTS: 1 DIF: Cognitive Level: Understanding REF: 519 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 3. The clinic nurse is performing a prenatal assessment on a pregnant client at risk for preeclampsia. Which clinical sign is not included as a symptom of preeclampsia?

a .

Edema

b .

Proteinuria

c .

Glucosuria

d .

Hypertension

ANS: C Glucose into the urine is not one of the three classic symptoms of preeclampsia. The first sign noted by the pregnant client is rapid weight gain and edema of the hands and face. Proteinuria usually develops later than the edema and hypertension. The first indication of preeclampsia is usually an increase in the maternal blood pressure.

PTS: 1 DIF: Cognitive Level: Application REF: 521 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 4. Which intrapartal assessment should be avoided when caring for a client with HELLP syndrome?

a .

Abdominal palpation

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b .

Venous sample of blood

c .

Checking deep tendon reflexes

d .

Auscultation of the heart and lungs

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ANS: A Palpation of the abdomen and liver could result in a sudden increase in intraabdominal pressure, leading to rupture of the subcapsular hematoma. Assessment of heart and lungs is performed on every patient. Checking reflexes is not contraindicated. Venous blood is checked frequently to observe for thrombocytopenia.

PTS: 1 DIF: Cognitive Level: Application REF: 529 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 5. A nurse is explaining to the nursing students working on the antepartum unit how to assess edema. Which edema assessment score indicates edema of the lower extremities, face, hands, and sacral area?

a .

+1

b .

+2

c .

+3

d .

+4

ANS: C Edema of the extremities, face, and sacral area is classified as +3 edema. Edema classified as +1 indicates minimal edema of the lower extremities. Marked edema of the lower extremities is +2

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edema. Generalized massive edema (+4) includes the accumulation of fluid in the peritoneal cavity.

PTS: 1 DIF: Cognitive Level: Application REF: 526 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 6. A client is admitted with vaginal bleeding at approximately 10 weeks of gestation. Her fundal height is 13 cm. Which potential problem should be investigated?

a .

Placenta previa

b .

Hydatidiform mole

c .

Abruptio placentae

d .

Disseminated intravascular coagulation (DIC)

ANS: B Gestational trophoblastic disease (hydatidiform mole) is usually detected in the first trimester of pregnancy. The frequency of this condition is highest at both ends of a womans reproductive life.

Placenta previa usually occurs in the third trimester. Painless uterine bleeding is the classic symptom. Abruptio placentae usually occurs in the third trimester. Painful uterine bleeding is the classic symptom. DIC is a life-threatening complication of abruptio placentae, in which procoagulation and anticoagulation factors are simultaneously activated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 7. Which maternal condition always necessitates birth by cesarean section?

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a .

Partial abruptio placentae

b .

Total placenta previa

c .

Ectopic pregnancy

d .

Eclampsia

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ANS: B In total placenta previa, the placenta completely covers the cervical os. The fetus would die if a vaginal birth occurred. If the client has stable vital signs and the fetus is alive, a vaginal birth can be attempted. If the fetus has died, a vaginal birth is preferred. The most common ectopic pregnancy is a tubal pregnancy, which is usually detected and treated in the first trimester. Labor can be safely induced if the eclampsia is under control.

PTS: 1 DIF: Cognitive Level: Understanding REF: 512 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Spontaneous termination of a pregnancy is considered to be an abortion if:

a .

the pregnancy is less than 20 weeks.

b .

the fetus weighs less than 1000 g.

c .

the products of conception are passed intact.

d .

there is no evidence of intrauterine infection.

ANS: A An abortion is the termination of pregnancy before the age of viability (20 weeks). The weight of the fetus is not considered because some fetuses of an older age may have a low birth weight. A

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spontaneous abortion may be complete or incomplete. A spontaneous abortion may be caused by many problems, one being intrauterine infection.

PTS: 1 DIF: Cognitive Level: Understanding REF: 505 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 9. An abortion when the fetus dies but is retained in the uterus is called:

a .

inevitable.

b .

missed.

c .

incomplete.

d .

threatened.

ANS: B A missed abortion refers to a dead fetus being retained in the uterus. An inevitable abortion means that the cervix is dilating with the contractions. An incomplete abortion means that not all the products of conception were expelled. With a threatened abortion, the client has cramping and bleeding but not cervical dilation.

PTS: 1 DIF: Cognitive Level: Understanding REF: 506 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 10. A placenta previa when the placental edge just reaches the internal os is called:

a .

total.

b .

partial.

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c .

low-lying.

d .

marginal.

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ANS: D A placenta previa that does not cover any part of the cervix is termed marginal. With a total placenta previa, the placenta completely covers the os. With a partial previa, the lower border of the placenta is within 3 cm of the internal cervical os but does not completely cover the os. A complete previa is termed total. The placenta completely covers the internal cervical os.

PTS: 1 DIF: Cognitive Level: Understanding REF: 513 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. Which would indicate concealed hemorrhage in abruptio placentae?

a .

Bradycardia

b .

Hard boardlike abdomen

c .

Decrease in fundal height

d .

Decrease in abdominal pain

ANS: B Concealed hemorrhage occurs when the edges of the placenta do not separate. The formation of a hematoma behind the placenta and subsequent infiltration of the blood into the uterine muscle results in a very firm, boardlike abdomen. The client will have shock symptoms that include tachycardia. The fundal height will increase as bleeding occurs. Abdominal pain may increase.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 516 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 12. The priority nursing intervention when admitting a pregnant client who has experienced a bleeding episode in late pregnancy is to:

a .

monitor uterine contractions.

b .

assess fetal heart rate and maternal vital signs.

c .

place clean disposable pads to collect any drainage.

d .

perform a venipuncture for hemoglobin and hematocrit levels.

ANS: B Assessment of the fetal heart rate (FHR) and maternal vital signs will assist the nurse in determining the degree of the blood loss and its effect on the client and fetus. Monitoring uterine contractions is important, but not the top priority. It is important to assess future bleeding, but the top priority is client and fetal well-being. The most important assessment is to check client and fetal well-being. The blood levels can be obtained later.

PTS: 1 DIF: Cognitive Level: Application REF: 516 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 13. A primigravida of 28 years of age is admitted to the antepartum unit with a diagnosis of hyperemesis gravidarum. Nursing care is based on which of the following?

a .

She should be isolated from her family.

b .

This condition is caused by psychogenic factors.

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c .

The treatment is similar to that for morning sickness.

d .

She should be assessed for signs of dehydration and starvation.

ANS: D The cause of hyperemesis gravidarum is unknown, but dehydration and starvation are the major complications. Emotional support is essential to the care of this client. She needs the opportunity to express how it feels to live with constant nausea. The cause is unknown. The first attempts to control the nausea are to treat it like morning sickness, but if treatment is not successful, further care is needed.

PTS: 1 DIF: Cognitive Level: Application REF: 518 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 14. A 17-year-old primigravida has gained 4 pounds since her last prenatal visit. Her blood pressure is 140/92 mm Hg. The most important nursing action is to:

a .

advise her to cut down on fast foods that are high in fat.

b .

caution her to avoid salty foods and to return in 2 weeks.

c .

assess weight gain, location of edema, and urine for protein.

d .

recommend she stay home from school for a few days to reduce stress.

ANS: C The nurse should further assess the client for hypertension, generalized edema, and proteinuria, which are classic signs of pregnancy-induced hypertension. Cutting down on fast foods will not relieve the symptoms of pregnancy-induced hypertension. She is at risk for pregnancy-induced hypertension and should be evaluated at this visit. Rest may be the treatment at first, but she needs further assessment to determine if pregnancy-induced hypertension is the problem.

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PTS: 1 DIF: Cognitive Level: Application REF: 526 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 15. A client with preeclampsia is admitted complaining of pounding headache, visual changes, and epigastric pain. Nursing care is based on the knowledge that these signs indicate:

a .

gastrointestinal upset.

b .

effects of magnesium sulfate.

c .

anxiety caused by hospitalization.

d .

worsening disease and impending convulsion.

ANS: D Headache and visual disturbances are caused by increased cerebral edema. Epigastric pain indicates distention of the hepatic capsules and often warns that a convulsion is imminent.

Gastrointestinal upset is not an indication as severe as the headache and visual disturbance. She has not yet been started on magnesium sulfate as a treatment. The signs and symptoms do not describe anxiety.

PTS: 1 DIF: Cognitive Level: Analysis REF: 520 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 16. Rh incompatibility can occur if the client is Rh-negative and the:

a .

fetus is Rh-negative.

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b .

fetus is Rh-positive.

c .

father is Rh-positive.

d .

father and fetus are both Rh-negative.

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ANS: B For Rh incompatibility to occur, the mother must be Rh-negative and her fetus Rh-positive. If the fetus is Rh-negative, the blood types are compatible and no problems should occur. The fathers Rh factor is a concern only as it relates to the possible Rh factor of the fetus. If the fetus is Rhnegative, the blood type with the mother is compatible. The fathers blood type does not enter into the problem.

PTS: 1 DIF: Cognitive Level: Understanding REF: 530 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 17. In which situation would a dilation and curettage (D&C) be indicated?

a .

Complete abortion at 8 weeks

b .

Incomplete abortion at 16 weeks

c .

Threatened abortion at 6 weeks

d .

Incomplete abortion at 10 weeks

ANS: D D&C is carried out to remove the products of conception from the uterus and can be done safely until week 14 of gestation. If all the products of conception have been passed (complete abortion), a D&C is not done. If the pregnancy is still viable (threatened abortion), a D&C is not

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done.

PTS: 1 DIF: Cognitive Level: Understanding REF: 506 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 18. Which orders should the nurse expect for a client admitted with a threatened abortion?

a .

NPO

b .

Pad count

c .

Ritodrine IV

d .

Meperidine (Demerol), 50 mg now

ANS: B A client admitted with a threatened abortion should be instructed to count the number of perineal pads used and to note the quantity and color of blood on the pads. Ritodrine is not the first drug of choice for tocolytic medications. There is no reason for having the client NPO. At times, dehydration may produce contractions, so hydration is important. Demerol will not decrease the contractions but may mask the severity of the contractions.

PTS: 1 DIF: Cognitive Level: Application REF: 505 OBJ: Nursing Process Step: Planning MSC: Client Needs: Health Promotion and Maintenance 19. Which data found on a clients health history would place her at risk for an ectopic pregnancy?

a .

Ovarian cyst 2 years ago

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b .

Recurrent pelvic infections

c .

Use of oral contraceptives for 5 years

d .

Heavy menstrual flow of 4 days duration

ANS: B Infection and subsequent scarring of the fallopian tubes prevent normal movement of the fertilized ovum into the uterus for implantation. Ovarian cysts do not cause scarring of the fallopian tubes. Oral contraceptives do not increase the risk for ectopic pregnancies. Heavy menstrual flow of 4 days duration will not cause scarring of the fallopian tubes, which is the main risk factor for ectopic pregnancies.

PTS: 1 DIF: Cognitive Level: Understanding REF: 508 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 20. Which finding on a prenatal visit at 10 weeks might suggest a hydatidiform mole?

a .

Blood pressure of 120/80 mm Hg

b .

Complaint of frequent mild nausea

c .

Fundal height measurement of 18 cm

d .

History of bright red spotting for 1 day weeks ago

ANS: C The uterus in a hydatidiform molar pregnancy is often larger than would be expected on the basis of the duration of the pregnancy. A client with a molar pregnancy may have early-onset, pregnancy-induced hypertension. Nausea increases in a molar pregnancy because of the increased production of human chorionic gonadotropin (hCG). The history of bleeding is

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normally described as being of a brownish color.

PTS: 1 DIF: Cognitive Level: Analysis REF: 510 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 21. Which routine nursing assessment is contraindicated for a client admitted with suspected placenta previa?

a .

Determining cervical dilation and effacement

b .

Monitoring FHR and maternal vital signs

c .

Observing vaginal bleeding or leakage of amniotic fluid

d .

Determining frequency, duration, and intensity of contractions

ANS: A Vaginal examination of the cervix may result in perforation of the placenta and subsequent hemorrhage. Monitoring FHR and maternal vital signs is a necessary part of the assessment for this client. Monitoring for bleeding and rupture of membranes is not contraindicated with this client. Monitoring contractions is not contraindicated with this client.

PTS: 1 DIF: Cognitive Level: Analysis REF: 512 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 22. The primary symptom present in abruptio placentae that distinguishes it from placenta previa is:

a .

vaginal bleeding.

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b .

rupture of membranes.

c .

presence of abdominal pain.

d .

changes in maternal vital signs.

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ANS: C Pain in abruptio placentae occurs in response to increased pressure behind the placenta and within the uterus. Placenta previa manifests with painless vaginal bleeding. Both abruptio placentae and placenta previa may have vaginal bleeding. Rupture of membranes may occur with both conditions. Maternal vital signs may change with both if bleeding is pronounced.

PTS: 1 DIF: Cognitive Level: Understanding REF: 515 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 23. A laboratory finding indicative of DIC is:

a .

decreased fibrinogen.

b .

increased platelets.

c .

increased hematocrit.

d .

decreased thromboplastin time.

ANS: A DIC develops when the blood-clotting factor thromboplastin is released into the maternal bloodstream as a result of placental bleeding. Thromboplastin activates widespread clotting, which uses the available fibrinogen, resulting in a decreased fibrinogen level. The platelet count will decrease. The hematocrit may decrease if bleeding is pronounced. The thromboplastin time

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is prolonged.

PTS: 1 DIF: Cognitive Level: Analysis REF: 507 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 24. Which assessment in a client diagnosed with preeclampsia who is taking magnesium sulfate would indicate a therapeutic level of medication?

a .

Drowsiness

b .

Urinary output of 20 mL/hr

c .

Normal deep tendon reflexes

d .

Respiratory rate of 10 to 12 breaths/min

ANS: C Magnesium sulfate is administered for preeclampsia to reduce the risk of seizures from cerebral irritability. Hyperreflexia (deep tendon reflexes above normal) is a symptom of cerebral irritability. If the dosage of magnesium sulfate is effective, reflexes should decrease to normal or slightly below normal levels. Drowsiness is another sign of CNS depression from magnesium toxicity. A urinary output of 20 mL/hr is not adequate output. A respiratory rate of 10 to 12 breaths/min is too slow and could be indicative of magnesium toxicity.

PTS: 1 DIF: Cognitive Level: Analysis REF: 525 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 25. A client taking magnesium sulfate has a respiratory rate of 10 breaths/min. In addition to discontinuing the medication, which action should the nurse take?

a .

Increase the clients IV fluids.

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b .

Administer calcium gluconate.

c .

Vigorously stimulate the client.

d .

Instruct the client to take deep breaths.

ANS: B Calcium gluconate reverses the effects of magnesium sulfate. Increasing the clients IV fluids will not reverse the effects of the medication. Stimulation will not increase the respirations. Deep breaths will not be successful in reversing the effects of the magnesium sulfate.

PTS: 1 DIF: Cognitive Level: Application REF: 525 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 26. A 32-year-old primigravida is admitted with a diagnosis of ectopic pregnancy. Nursing care is based on which of the following?

a .

Hemorrhage is the major concern.

b .

She will be unable to conceive in the future.

c .

Bed rest and analgesics are the recommended treatment.

d .

A D&C will be performed to remove the products of conception.

ANS: A Severe bleeding occurs if the fallopian tube ruptures. If the tube must be removed, her fertility will decrease but she will not be infertile. The recommended treatment is to remove the pregnancy before hemorrhaging. A D&C is done on the inside of the uterine cavity. The ectopic

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is located within the tubes.

PTS: 1 DIF: Cognitive Level: Understanding REF: 507, 508 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 27. You are taking care of a client who had a therapeutic abortion following an episode of vaginal bleeding and ultrasound confirmation of a blighted ovum. Lab work is ordered 2 weeks postprocedure as a follow-up to medical care. Which result indicates that additional intervention is needed?

a .

Hemoglobin, 13.2 mg/dL

b .

White blood cell count, 10,000 mm3

c .

Beta-hCG detected in serum

d .

Fasting blood glucose level, 80 mg/dL

ANS: C The presence of beta-hCG in serum 2 weeks after the procedure is clinically significant and indicates the possibility that there may have been a molar pregnancy (hydatidiform). Thus, further examination is required. None of the other lab results warrant intervention because they are within normal limits.

PTS: 1 DIF: Cognitive Level: Analysis REF: 509 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 28. A female client presents to the emergency room complaining of lower abdominal cramping with scant bleeding of approximately 2 days duration. This morning, the quality and location of the pain changed and she is now experiencing pain in her shoulder. The clients last menstrual period was 28 days ago, but she reports that her cycle is variable, ranging from 21 to 45 days.

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Which clinical diagnosis does the nurse suspect?

a .

Ectopic pregnancy

b .

Appendicitis

c .

Food poisoning

d .

Gastroenteritis

ANS: A Even though the clients menstrual cycle has variability, all women are considered to be pregnant until proven otherwise. The clients presenting symptoms are typical for ectopic pregnancy, so the client should be monitored for the possible complication of rupture and shock.

PTS: 1 DIF: Cognitive Level: Application REF: 507, 508 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 29. A client who was pregnant had a spontaneous abortion at approximately 4 weeks gestation.

At the time of the miscarriage, it was thought that all products of conception were expelled. Two weeks later, the client presents at the clinic office complaining of crampy abdominal pain and a scant amount of serosanguineous vaginal drainage with a slight odor. The pregnancy test is negative. Vital signs reveal a temperature of 100 F, with blood pressure of 100/60 mm Hg, irregular pulse 88 beats/min (bpm), and respirations, 20 breaths/min. Based on these assessment data, what does the nurse anticipate as a clinical diagnosis?

a .

Ectopic pregnancy

b .

Uterine infection

c .

Gestational trophoblastic disease

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d .

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Endometriosis

ANS: B The client is exhibiting signs of uterine infection, with elevated temperature, vaginal discharge with odor, abdominal pain, and blood pressure and pulse manifesting as shock-trended vitals.

Because the pregnancy test is negative, an undiagnosed ectopic pregnancy and gestational trophoblastic disease are ruled out. There is no supportive evidence to indicate a clinical diagnosis of endometriosis at this time; however, it is more likely that this is an infectious process that must be aggressively treated.

PTS: 1 DIF: Cognitive Level: Analysis REF: 506 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 30. A client with no prenatal care delivers a healthy male infant via the vaginal route, with minimal blood loss. During the labor period, vital signs were normal. At birth, significant maternal hypertension is noted. When the client is questioned, she relates that there is history of heart disease in her family but that she has never been treated for hypertension. Blood pressure is treated in the hospital setting and the client is discharged. The client returns at her scheduled 6week checkup and is found to be hypertensive. Which type of hypertension do you think the client is exhibiting?

a .

Pregnancy-induced hypertension (PIH)

b .

Gestational hypertension

c .

Preeclampsia superimposed on chronic hypertension

d .

Undiagnosed chronic hypertension

ANS: D Even though the client has no documented prenatal care or medical history, she does relate a

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family history that is positive for heart disease. Additionally, the clients blood pressure increased following birth and was treated in the hospital and resolved. Now the client appears at the 6week checkup with hypertension. Typically, gestational hypertension resolves by the end of the 6-week postpartum period. The fact that this has not resolved is suspicious for undiagnosed chronic hypertension. There is no evidence to suggest that the client was preeclamptic prior to the birth.

PTS: 1 DIF: Cognitive Level: Analysis REF: 515 OBJ: Nursing Process Step: Diagnosis MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 31. A high-risk labor client progresses from preeclampsia to eclampsia. Aggressive management is instituted, and the fetus is delivered via cesarean section. Which finding in the immediate postoperative period indicates that the client is at risk of developing HELLP syndrome?

a .

Platelet count of 50,000/mL

b .

Liver enzyme levels within normal range

c .

Negative for edema

d .

No evidence of nausea or vomiting

ANS: A HELLP syndrome is characterized by hemolysis, elevated liver enzyme levels, and a low platelet count. A platelet count of 50,000/mL indicates thrombocytopenia.

PTS: 1 DIF: Cognitive Level: Analysis REF: 529 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Pathophysiology 32. As the triage nurse in the emergency room, you are reviewing results for the high- risk

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obstetric client who is in labor because of traumatic injury experienced as a result of a motor vehicle accident (MVA). You note that the Kleihauer-Betke test is positive. Based on this information, you anticipate that:

a .

immediate birth is required.

b .

the client should be transferred to the critical care unit for closer observation.

c .

RhoGAM should be administered.

d .

a tetanus shot should be administered.

ANS: A A positive Kleihauer-Betke test indicates that fetal bleeding is occurring in the maternal circulation. This is a serious complication and, because the client is a trauma victim, it is highly likely that she is experiencing an abruption. Therefore, the client should be delivered as quickly as possible to improve outcomes. There is no evidence to support that RhoGAM should be administered, because we have no information related to Rh factor and/or blood type. Similarly, a tetanus shot is not indicated at this time because there is no evidence of penetrating trauma.

The client should be transferred to the obstetric area for birth, not the critical care unit setting.

PTS: 1 DIF: Cognitive Level: Analysis REF: 516 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity: Medical Emergencies 33. A client who had premature rupture of the membranes (PROM) earlier in the pregnancy at 28 weeks returns to the labor unit 1 week later complaining that she is now in labor. The labor and birth nurse performs the following assessments. The vaginal exam is deferred until the physician is in attendance. The client is placed on electronic fetal monitoring (EFM) and a baseline FHR of 130 bpm is noted. No contraction pattern is observed. The client is then transferred to the antepartum unit for continued observation. Several hours later, the client complains that she does not feel the baby move. Examination of the abdomen reveals a fundal height of 34 cm. Muscle tone is no different from earlier in the hospital admission. The client is placed on the EFM and no fetal heart tones are observed. What does the nurse suspect is occurring?

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a .

Placental previa

b .

Active labor has started

c .

Placental abruption

d .

Hidden placental abruption

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ANS: D The clients signs and symptoms indicate that a hidden abruption is occurring. Fundal height has increased and there is an absence of fetal heart tones. This is a medical emergency and the physician should be contacted to come directly to the unit for intervention and imminent birth.

Chapter 11. Birth-Related Procedures MULTIPLE CHOICE 1. The nurse knows that a urinary catheter is added to the instrument table if a forceps-assisted birth is anticipated. The correct rationale for this intervention is that:

a .

a sterile urine specimen is needed preoperatively.

b .

an empty bladder provides more room in the pelvis.

c .

spontaneous release of urine might contaminate the sterile field.

d .

a Foley catheter prevents the membranes from spontaneously rupturing.

ANS: B Catheterization provides room for the application of the forceps blades and limits bladder

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trauma. A clean-catch urinalysis is usually sufficient for preoperative treatment. Urine is sterile.

The membranes must be ruptured and the cervix completely dilated for a forceps-assisted birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 314 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 2. After a forceps-assisted birth, the client is observed to have continuous bright red lochia but a firm fundus. Which other data would indicate the presence of a potential vaginal wall hematoma?

a .

Lack of an episiotomy

b .

Mild, intermittent perineal pain

c .

Lack of pain in the perineal area

d .

Edema and discoloration of the labia and perineum

ANS: D The nurse should monitor for edema and discoloration. Using a cold application to the labia and perineum reduces pain by numbing the area and limiting bruising and edema for the first 12 hours. An episiotomy is performed as the fetal head distends the perineum. The pain with vaginal hematoma is severe and constant. The pain associated with vaginal hematoma is severe.

PTS: 1 DIF: Cognitive Level: Understanding REF: 314 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 3. The nurse is positioning the Foley catheter prior to a cesarean birth. Which position should the nurse use to place the catheter drainage tubing and catheter bag?

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a .

Place near the head of the table.

b .

Position on top of the patients leg.

c .

Place at the foot and clamp during the cesarean section.

d .

Position at the foot of the surgeon under the sterile drapes.

ANS: A The drain tube of the catheter should be positioned under the clients to promote drainage and to keep the catheter away from the operative area. Urinary output must be continuously monitored.

An early sign of hypovolemia is decreasing urinary output. The anesthesia clinician must monitor urine output during the surgery so it should not be clamped. The surgeon might step on the drainage bag if the catheter were below the drapes, and no one could monitor the urine output.

PTS: 1 DIF: Cognitive Level: Application REF: 322 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment 4. Which condition is a contraindication for an amniotomy?

a .

2 station

b .

Breech presentation

c .

Dilation less than 3 cm

d .

Right occiput posterior position

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ANS: A A prolapsed cord can occur if the membranes artificially rupture when the presenting part is not engaged. The presenting part should be cephalic. The dilation must be enough to determine labor. Right occiput posterior is a cephalic presentation appropriate for an amniotomy.

PTS: 1 DIF: Cognitive Level: Understanding REF: 305 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. Which client status is an acceptable indication for serial oxytocin induction of labor?

a .

Multiple fetuses

b .

Polyhydramnios

c .

History of long labors

d .

Past 42 weeks of gestation

ANS: D Continuing a pregnancy past the normal gestational period is likely to be detrimental to fetal health. Multiple fetuses overdistend the uterus, making induction of labor high risk.

Polyhydramnios overdistends the uterus, making induction of labor high risk. A history of rapid labors is a reason for induction of labor because of the possibility that the baby would otherwise be born in uncontrolled circumstances.

PTS: 1 DIF: Cognitive Level: Understanding REF: 308 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 6. The nurse is explaining the technique of internal version to a group of nursing students. Which describes the technique of internal version?

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a .

Manipulation of the fetus from a breech to a cephalic presentation before labor begins

b .

Manipulation of the fetus from a transverse lie to a longitudinal lie before cesarean birth

c .

Manipulation of the second twin from an oblique lie to a transverse lie before labor begins

d .

Manipulation of the second twin from a transverse lie to a breech presentation during vaginal birth

ANS: D Internal version is used only during vaginal birth to manipulate the second twin into a presentation that allows it to be born vaginally. For internal version to occur, the cervix needs to be completely dilated. For internal version to occur, the cervix needs to be dilated. Internal version is done to turn the second twin after the first twin is born.

PTS: 1 DIF: Cognitive Level: Application REF: 311 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. The greatest risk to the newborn after an elective cesarean birth is:

a .

tachypnea because of maternal anesthesia.

b .

tachycardia because of maternal narcotics.

c .

trauma because of manipulation during birth.

d .

prematurity because of miscalculation of gestation.

ANS: D Regardless of the many criteria used to determine gestational age, inadvertent preterm birth still occurs. Maternal anesthesia may cause respiratory distress. Maternal narcotics may cause

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respiratory distress. There is less trauma with a cesarean birth.

PTS: 1 DIF: Cognitive Level: Understanding REF: 317 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 8. Which client is most at risk for a uterine rupture?

a .

A gravida 4 who had a classic cesarean incision

b .

A gravida 5 who had two vaginal births and one cesarean birth

c .

A gravida 3 who has had two low-segment transverse cesarean births

d .

A gravida 2 who had a low-segment vertical incision for birth of a 10-lb infant

ANS: A The classic cesarean incision is made into the upper uterine segment. This part of the uterus contracts forcefully during labor, and an incision in this area may rupture in subsequent pregnancies. The client who had two vaginal deliveries and one cesarean is not a high-risk candidate. Low-segment transverse cesarean scars do not predispose her to uterine rupture. Lowsegment incisions do not raise the risk of uterine ruptures.

PTS: 1 DIF: Cognitive Level: Understanding REF: 317 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 9. Before the health care provider performs an external version, the nurse should expect an order for a:

a .

Foley catheter.

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b .

tocolytic drug.

c .

local anesthetic.

d .

contraction stress test (CST).

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ANS: B A tocolytic drug will relax the uterus before and during version, making manipulation easier. The bladder should be emptied, but catheterization is not necessary. A local anesthetic is not used with external version. CST is used to determine the fetal response to stress.

PTS: 1 DIF: Cognitive Level: Analysis REF: 312 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 10. A maternal indication for the use of vacuum extraction is:

a .

a wide pelvic outlet.

b .

maternal exhaustion.

c .

a history of rapid deliveries.

d .

failure to progress past 0 station.

ANS: B The client who is exhausted will be unable to assist with the expulsion of the fetus. With a wide pelvic outlet, vacuum extraction would not be necessary. With a rapid birth, vacuum extraction would not be necessary. A station of 0 is too high for a vacuum extraction.

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PTS: 1 DIF: Cognitive Level: Understanding REF: 313 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. The priority nursing intervention following an amniotomy is to:

a .

change the clients gown.

b .

assess the fetal heart rate.

c .

assess the color of the amniotic fluid.

d .

estimate the amount of amniotic fluid.

ANS: B The fetal heart rate must be assessed immediately after the rupture of the membranes to determine whether cord prolapse or compression has occurred. Changing the gown is important for client comfort but is not the top priority. Assessing the amount of amniotic fluid is important but is not the top priority. Estimating the amount of amniotic fluid is not a top priority for this client.

PTS: 1 DIF: Cognitive Level: Application REF: 305 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 12. For which client should the oxytocin (Pitocin) infusion be discontinued immediately?

a .

A client in transition with contractions every 2 minutes lasting 90 seconds each

b .

A client in early labor with contractions every 5 minutes lasting 40 seconds each

c .

A client in active labor with contractions every 3 minutes lasting 60 seconds each

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d .

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A client in active labor with contractions every 2 to 3 minutes lasting 70 to 80 seconds each

ANS: A This clients contraction pattern represents hyperstimulation, and inadequate resting time occurs between contractions to allow placental perfusion. Oxytocin may assist this clients contractions to become closer and more efficient when the contractions are 5 minutes apart. There is an appropriate resting period between this clients contractions. There is an appropriate resting period between this clients contractions for her stage of labor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 306 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 13. The priority nursing care associated with an oxytocin infusion is:

a .

measuring urinary output.

b .

evaluating cervical dilation.

c .

monitoring uterine response.

d .

increasing infusion rate every 30 minutes.

ANS: C Because of the risk of hyperstimulation, which could result in decreased placental perfusion and uterine rupture, the nurses priority intervention is monitoring uterine response. Monitoring urinary output is important with Pitocin but not the top priority. Monitoring labor progression is important but not the top priority. The infusion rate may be increased but only after proper assessment that it is appropriate.

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PTS: 1 DIF: Cognitive Level: Application REF: 306 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 14. Which event indicates a complication of an external version?

a .

Maternal pulse rate of 100 bpm

b .

Fetus returning to the original position

c .

Increased maternal anxiety after the version

d .

Fetal bradycardia persisting 10 minutes after the version

ANS: D Fetal bradycardia after a version may indicate that the umbilical cord has become compressed, and the fetus is having hypoxia. There are few risks to the client during an external version. The fetus may return to the original position, but this is not a complication of the version. Anxiety may occur before the version but should decrease after the procedure is completed.

PTS: 1 DIF: Cognitive Level: Application REF: 311 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 15. Immediately following the forceps-assisted birth of an infant, which action should the nurse implement?

a .

Assess the infant for signs of trauma.

b .

Apply a cold pack to the infants scalp.

c .

Give the infant prophylactic antibiotics.

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d .

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Measure the circumference of the infants head.

ANS: A Forceps birth can result in local irritation, bruising, or lacerations of the fetal scalp. This would put the infant at risk for cold stress and would be contraindicated. Prophylactic antibiotics are not necessary with a forceps birth. Measuring the circumference of the head is part of the initial nursing assessment.

PTS: 1 DIF: Cognitive Level: Application REF: 314 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 16. Nursing care before a cesarean birth should include:

a .

full perineal shave preparation.

b .

administering a clear oral antacid.

c .

injection of narcotic preoperative medications.

d .

straight catheterization to empty the bladder.

ANS: B General anesthesia may be needed unexpectedly for cesarean birth. An oral antacid neutralizes gastric acid and reduces potential lung injury if the client vomits and aspirates gastric contents during anesthesia. Perineal preparation is not necessary for a cesarean section. Some agencies will do an abdominal prep just before the surgery. A narcotic at this point would put the fetus at high risk for respiratory distress. The catheterization should be indwelling to keep the bladder small during the surgery.

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PTS: 1 DIF: Cognitive Level: Application REF: 318 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. A gravida 2, para 1 client is admitted to the labor and birth unit in labor. She states that she had a cesarean birth with her first pregnancy. The most critical information the nurse must obtain at this point is:

a .

the onset of contractions.

b .

her estimated date of birth.

c .

when the client ate last and what she consumed.

d .

the type of uterine incision with the first pregnancy.

ANS: D A vertical incision creates a greater risk of uterine rupture in a subsequent labor than a transverse incision. The onset of labor is not the most important information that is needed at this point.

This is important information to prepare for a fetus that may not be term. However, it is not the most critical question. If a cesarean birth is necessary this information is needed but not as critical as the type of previous incision.

PTS: 1 DIF: Cognitive Level: Understanding REF: 318 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 18. Which is an appropriate response to a clients comment that she is worried about having a cesarean birth?

a .

Dont worry. Everything will be okay.

b .

Clients commonly worry about surgery.

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c .

What are your feelings about having a cesarean birth?

d .

I know youre worried, but this is a routine procedure.

ANS: C Allowing the client to express her feelings is the most appropriate nursing response. The nurse should never provide the client with false reassurance or disregard her feelings. Saying to not worry is belittling the clients concerns and does not allow her to express her concerns. Saying clients commonly worry about surgery is closed-ended and belittling to the clients feelings.

Acknowledging the worry but stating that the procedure is just routine is stating that the clients feelings are not important.

PTS: 1 DIF: Cognitive Level: Application REF: 321 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity 19. While assisting with a vacuum extraction birth, which should the nurse immediately report to the physician?

a .

Maternal pulse rate of 100 bpm

b .

Maternal blood pressure of 120/70 mm Hg

c .

Persistent fetal bradycardia below 100 bpm

d .

Decreased intensity of uterine contractions

ANS: C Fetal bradycardia may indicate fetal distress and may require immediate intervention. Maternal pulse rate may increase due to the pushing process. Blood pressure of 120/70 mm Hg is within expected norms for this stage of labor. Decreased intensity of uterine contractions indicates the

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birth is imminent at this point.

PTS: 1 DIF: Cognitive Level: Application REF: 314 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 20. To monitor for potential hemorrhage in the client who has just had a cesarean birth, which action should the recovery room nurse implement?

a .

Monitor her urinary output.

b .

Maintain an intravenous infusion at 1 mL/hr.

c .

Assess the abdominal dressings for drainage.

d .

Assess the uterus for firmness every 15 minutes.

ANS: D Maintaining contraction of the uterus is important for controlling bleeding from the placental site. Maintaining proper fluid balance will not control hemorrhage. Monitoring urine output is an important assessment, but hemorrhage will first be noted vaginally. Assessing the abdominal dressing is an important assessment to prevent future hemorrhaging from occurring but is not the first priority assessment in the recovery room.

PTS: 1 DIF: Cognitive Level: Application REF: 323 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 21. The nurse is preparing to administer a vaginal prostaglandin preparation to ripen the cervix of a client. With which client should the nurse question the use of vaginal prostaglandin as a cervical ripening agent?

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a .

The client who has a Bishops score of 5

b .

The client who is at 42 weeks of gestation

c .

The client who had a previous low transverse cesarean birth

d .

The client who had previous surgery in the upper uterus

ANS: D Prostaglandins are contraindicated in clients who have had a previous surgery in the upper uterus, such as a previous classic cesarean incision or extensive surgery for uterine fibroids. A side effect of prostaglandin administration is hyperstimulation of the uterus. A Bishops score of 5, 42 weeks of gestation, or a previous low transverse cesarean birth are not contraindications for cervical ripening.

PTS: 1 DIF: Cognitive Level: Analysis REF: 306 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity 22. A vaginal exam for a laboring multipara client who is 42 weeks gestation reveals the following information: 4 cm, minimal effacement, 2 station. Which clinical factors would affect the clinical management decision not to rupture membranes with an AmniHook?

a .

Vaginal dilation

b .

Client is a multipara

c .

Presenting part is at 2 station

d .

Gestational age

ANS: C

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The fact that the presenting part is not engaged causes concern because there is increased risk of a prolapsed cord on artificial rupture of membranes (AROM). Vaginal dilation is adequate for attempt to rupture membranes. The fact that a client is a multipara is not a significant reason to affect clinical decision making with regard to AROM. Postdates of pregnancy may warrant a more aggressive approach to speed the labor and birth process.

PTS: 1 DIF: Cognitive Level: Analysis REF: 304 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance/Ante/Intra/Postpartum and Newborn Care 23. A client who is receiving oxytocin (Pitocin) infusion for the augmentation of labor is experiencing a contraction pattern of more than eight contractions in a 10-minute period. Which intervention would be a priority?

a .

Increase rate of Pitocin infusion to help spread out contraction pattern.

b .

Place oxygen on client at 8 to 10 L/min via face mask and turn client to left side.

c .

Stop Pitocin infusion.

d .

Call physician to obtain an order for initiation of magnesium sulfate.

ANS: C The client is exhibiting uterine tachysystole (uterine tetany). Priority intervention is to stop the infusion. The next course of action is to place oxygen on the client and reposition and increase the flow rate of the primary infusion. If the condition does not improve, the physician may be called for additional orders.

PTS: 1 DIF: Cognitive Level: Analysis REF: 310 OBJ: Nursing Process Step: Implementation

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MSC: Client Needs: Safe and Effective Care Environment 24. Which clinical finding indicates the use of vacuum extraction as a birth method?

a .

Mentum presentation of the fetus

b .

Presence of caput succedaneum

c .

Maternal exhaustion as a result of ineffective pushing during second stage of labor

d .

Physician preference

ANS: C Vacuum extraction is used in place of forceps as an assistive method to help with the birth of the fetus. It is not used in nonvertex presentations. Mentum presentation is where the chin is the presenting part. Vacuum extraction should not be used in the presence of caput succedaneum (swelling) or in the presence of excessive molding.

PTS: 1 DIF: Cognitive Level: Application REF: 313 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 25. Which of the following factors would lead to an increased risk for a prolapsed cord to occur during an amniotomy?

a .

Presenting part engaged

b .

Postdated pregnancy

c .

Preterm pregnancy

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d .

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Term pregnancy

ANS: C Prolapsed cord is more likely to occur when the presenting part is not engaged and the pregnancy is preterm because the fetus would be smaller and there would potentially be more amniotic fluid. If the presenting part is engaged and the pregnancy is at term or postdated, it is less likely that a prolapsed cord would occur.

PTS: 1 DIF: Cognitive Level: Analysis REF: 304 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 26. A client is being sent into the labor and birth unit for a serial induction of labor. The Bishops score is 7. What would the nurse anticipate as the sequence of treatment planned for this client?

a .

Administration of laminaria with EFM followed by amniotomy and oxytocin (Pitocin) infusion in a 12-hour period

b .

Amniotomy on the first day in conjunction with EFM followed by oxytocin (Pitocin) infusion on the following clinical day

c .

Administration of oxytocin (Pitocin) on the first day followed by amniotomy on the second clinical day

d .

Administration of laminaria with EFM on the first day followed by oxytocin (Pitocin) infusion on the second day and evaluation of progress; on the third day, continued oxytocin (Pitocin) infusion with amniotomy

ANS: D A serial induction looks at a progressive treatment plan that is based on the best outcome, that of a successful birth. Because the Bishops score is 7, this indicates that certain conditions are not favorable for an induction. Therefore, the use of mechanical methods for cervical ripening maybe warranted. A serial induction is typically done over a 3-day period in which cervical ripening is followed by 2 days of Pitocin infusion, and on the last day an amniotomy is

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performed in conjunction with the infusion.

PTS: 1 DIF: Cognitive Level: Analysis REF: 308 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity/Reduction of Risk Potential 27. On vaginal exam, the clients cervix is anterior, soft, 70% effaced, dilated 2 cm, and the presenting part is at 0 station. The Bishops score for this client is:

a .

6.

b .

9.

c .

10.

d .

12.

ANS: B On the Bishops scoring system, an anterior cervix = 2 points, soft cervix = 2 points, 70% effaced = 2 points, 2 cm dilated = 1 point, and 0 station = 2 points, for a total score of 9.

PTS: 1 DIF: Cognitive Level: Application REF: 307 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 28. Select the situation that describes the safest administration of oxytocin induction and cervical ripening agents.

a .

Concurrent use of oxytocin and dinoprostone (Cervidil)

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b .

Misoprostol (Cytotec) 25 mcg, followed in 4 hours by oxytocin induction in vaginal birth after cesarean section (VBAC) client

c .

Dinoprostone (Cervidil) 10 mg in place for 12 hours followed by oxytocin induction in 1 hour

d .

Maximum dose of dinoprostone (Prepidil) 2 mg/24 hr followed in 4 hours by oxytocin induction

ANS: C Dinoprostone (Cervidil) in a 10-mg, time-release insert may be left in place for up to 12 hours and oxytocin induction can be safely started 1 hour after insert is removed. Oxytocin and cervical ripening agents cannot be administered at the same time. Misoprostol (Cytotec) is contraindicated in a women with previous cesarean. The maximum dose of dinoprostone (Prepidil) 1.5 mg/24 hr.

PTS: 1 DIF: Cognitive Level: Analysis REF: 308 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Physiologic Integrity 29. When a laboring client receiving 12 mU of pitocin for induction develops a contraction pattern of every 2 minutes lasting 80 seconds and recurring late decelerations, the nurse should immediately:

a .

stop oxytocin infusion.

b .

administer O2 at 8 TO 10 L/min.

c .

reposition client to left side-lying position.

d .

increase the rate of the primary nonadditive infusion.

ANS: A Uterine hyperstimulation can reduce placental blood flow and decrease fetal oxygenation. Late

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decelerations are caused by uteroplacental insufficiency. Stopping the oxytocin infusion will reduce uterine activity and increase fetal oxygenation. Administering O2, repositioning the client, and increasing the rate of the primary nonadditive infusion will not be effective until hyperstimulation is resolved.

PTS: 1 DIF: Cognitive Level: Application REF: 310 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 30. Which assessment would be important for a 6-hour-old infant who has bruising over the cheeks from a forceps birth?

a .

Presence of newborn reflexes

b .

Symmetry of facial movements

c .

Caput and molding of the head

d .

Anterior and posterior fontanels

ANS: B Following a forceps birth, the infant may have ecchymoses and facial nerve injury. Facial asymmetry suggests facial nerve damage. Changes in newborn reflexes, presence of caput and molding, and changes in the anterior and posterior fontanels are not risks associated with trauma to the infants face.

PTS: 1 DIF: Cognitive Level: Analysis REF: 313 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 31. Which aspect of newborn assessment may be limited by the application of a vacuum extractor at birth?

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a .

Anterior fontanel

b .

Coronal suture lines

c .

Posterior fontanel

d .

Biparietal diameter

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ANS: C The vacuum extractor is applied on the occipital bone and may create scalp edema at the application site. The posterior fontanel connects the occipital bone to the parietal bones. The anterior fontanel, coronal suture lines, and parietal bones are not part of the application area for a vacuum extractor.

PTS: 1 DIF: Cognitive Level: Analysis REF: 313 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 32. In which client situation could an amniotomy be safely performed?

a .

G1 P0, 38 weeks gestation, 20% effaced, closed cervix

b .

G2 P1, 40 weeks gestation, with fetus in a breech presentation

c .

G2 P0, 39 weeks gestation, 70% effaced, cervix dilated 2 cm

d .

G3 P2, 41 weeks gestation, early labor complicated with hydramnios

ANS: C The cervix must be partially open to allow the membranes to be ruptured. An amniotomy cannot be performed when the cervix is closed. Breech presentation would be delivered by cesarean section and membranes would be ruptured at birth. Rupturing the membranes in a client with

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hydramnios can result in abruptio placentae.

PTS: 1 DIF: Cognitive Level: Application REF: 307 OBJ: Nursing Process Step: Analysis MSC: Client Needs: Health Promotion and Maintenance 33. When the client receiving an oxytocin (Pitocin) drip at 16 mU/min develops hypertonic stimulation, FHR 138 bpm with accelerations, and no decelerations, the nurses best response would be to:

a .

stop the drip immediately.

b .

decrease the dose to 14 mU/min.

c .

reassess the patient at 5 minute intervals.

d .

reposition the patient to the left side-lying position.

ANS: B In the absence of any adverse fetal response, hypertonic stimulation can be managed by reducing the infusion rate by 1 to 2 mU/min until uterine hyperstimulation is resolved. Stopping the drip immediately is not necessary unless hyperstimulation continues and adverse fetal responses occur. Reassessing and repositioning are of no benefit in this situation.

Chapter 12. Postpartum Nursing Care

1

A woman who is 12 hours postpartum had a pulse rate around 80 beats per

.

minute during pregnancy. Now, the nurse finds a pulse of 60 beats per minute.

Which of these actions should the nurse take?

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A

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Document the finding, as it is a normal finding at this time.

) B

Contact the physician, as it indicates early DIC.

) C

Contact the physician, as it is a first sign of postpartum eclampsia.

) D

Obtain an order for a CBC, as it suggests postpartum anemia.

)

2

To decrease the pain associated with an episiotomy immediately after birth,

.

which action by the nurse would be most appropriate?

A

Offer warm blankets.

) B

Encourage the woman to void.

) C

Apply an ice pack to the site.

) D

Offer a warm sitz bath.

)

3

A postpartum client has a fourth-degree perineal laceration. The nurse would

.

expect which of the following medications to be ordered?

A

Ferrous sulfate (Feosol)

) B

Methylergonovine (Methergine)

) C )

Docusate (Colace)

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D

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Bromocriptine (Parlodel)

)

4

Which statement would alert the nurse to the potential for impaired bonding

.

between mother and newborn?

A

You have your daddys eyes.

) B

He looks like a frog to me.

) C

Where did you get all that hair?

) D

He seems to sleep a lot.

)

5

After a normal labor and birth, a client is discharged from the hospital 12 hours

.

later. When the community health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further intervention?

A

Presence of lochia serosa

) B

Frequent scant voidings

) C

Fundus firm, below umbilicus

) D

Milk filling in both breasts

)

6

A primipara client who is bottle feeding her baby begins to experience breast

.

engorgement on her third postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort?

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A

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Express some milk from your breasts every so often to relieve the distention.

) B

Remove your bra to relieve the pressure on your sensitive nipples and breasts.

) C

Apply ice packs to your breasts to reduce the amount of milk being produced.

) D

Take several warm showers daily to stimulate the milk let-down reflex.

)

7

The nurse administers RhoGAM to an Rh-negative client after delivery of an

.

Rh-positive newborn based on the understanding that this drug will prevent her from:

A

Becoming Rh positive

) B

Developing Rh sensitivity

) C

Developing AB antigens in her blood

) D

Becoming pregnant with an Rh-positive fetus

)

8

Which of the following factors in a clients history would alert the nurse to an

.

increased risk for postpartum hemorrhage?

A

Multiparity, age of mother, operative delivery

) B

Size of placenta, small baby, operative delivery

) C )

Uterine atony, placenta previa, operative procedures

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D

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Prematurity, infection, length of labor

)

9

After teaching parents about their newborn, the nurse determines that the

.

teaching was successful when they identify the development of a close emotional attraction to a newborn by parents during the first 30 to 60 minutes after birth as which of the following?

A

Reciprocity

) B

Engrossment

) C

Bonding

) D

Attachment

)

1

A nurse is working as part of a committee to establish policies to promote

0

bonding and attachment. Which practice would be least effective in achieving

.

this goal?

A

Allowing unlimited visiting hours on maternity units

) B

Offering round-the-clock nursery care for all infants

) C

Promoting rooming-in

) D )

Encouraging infant contact immediately after birth

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1

When developing the plan of care for the parents of a newborn, the nurse

1

identifies interventions to promote bonding and attachment based on the

.

rationale that bonding and attachment are most supported by which measure?

A

Early parentinfant contact following birth

) B

Expert medical care for the labor and birth

) C

Good nutrition and prenatal care during pregnancy

) D

Grandparent involvement in infant care after birth

)

1

A postpartum woman is having difficulty voiding for the first time after giving

2

birth. Which of the following would be least effective in helping to stimulate

.

voiding?

A

Pouring warm water over her perineal area

) B

Having her hear the sound of water running nearby

) C

Placing her hand in a basin of cool water

) D

Standing her in the shower with the warm water on

)

1

The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz

3

bath. Which of the following would be a priority?

.

A )

Placing the call light within her reach

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B

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Teaching her how the sitz bath works

) C

Telling her to use the sitz bath for 30 minutes

) D

Cleaning the perineum with the peri-bottle

)

1

A nurse is reviewing the medical record of a postpartum client. The nurse

4

identifies that the woman is at risk for a postpartum infection based on which of

.

the following? (Select all that apply.)

A

History of diabetes

) B

Labor of 12 hours

) C

Rupture of membranes for 16 hours

) D

Hemoglobin level 10 mg/dL

) E

Placenta requiring manual extraction

)

1

A nurse is completing a postpartum assessment. Which finding would alert the

5

nurse to a potential problem?

.

A

Lochia rubra with a fleshy odor

) B )

Respiratory rate of 16 breaths per minute

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C

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Temperature of 101 F

) D

Pain rating of 2 on a scale from 0 to 10

)

1

The nurse is assessing a postpartum clients lochia and finds that there is about a

6

4-inch stain on the perineal pad. The nurse documents this finding as which of

.

the following?

A

Scant

) B

Light

) C

Moderate

) D

Large

)

1

When reviewing the medical record of a postpartum client, the nurse notes that

7

the client has experienced a third-degree laceration. The nurse understands that

.

the laceration extends to which of the following?

A

Superficial structures above the muscle

) B

Through the perineal muscles

) C

Through the anal sphincter muscle

) D )

Through the anterior rectal wall

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1

A nurse is observing a postpartum client interacting with her newborn and notes

8

that the mother is engaging with the newborn in the en face position. Which of

.

the following would the nurse be observing?

A

Mother placing the newborn next to bare breast.

) B

Mother making eye-to-eye contact with the newborn

) C

Mother gently stroking the newborns face

) D

Mother holding the newborn upright at the shoulder

)

1

After teaching a group of students about risk factors associated with postpartum

9

hemorrhage, the instructor determines that the teaching was successful when the

.

students identify which of the following as a risk factor? (Select all that apply.)

A

Prolonged labor

) B

Placenta previa

) C

Null parity

) D

Hydramnios

) E

Labor augmentation

)

2

A postpartum woman who is breast-feeding tells the nurse that she is

0

experiencing nipple pain. Which of the following would be least appropriate for

.

the nurse to suggest?

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A

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Use of a mild analgesic about 1 hour before breast-feeding

) B

Application of expressed breast milk to the nipples

) C

Application of glycerin-based gel to the nipples

) D

Reinstruction about proper latching-on technique

)

2

A nurse is developing a teaching plan for a postpartum woman who is breast-

1

feeding about sexuality and contraception. Which of the following would the

.

nurse most likely include? (Select all that apply.)

A

Resumption of sexual intercourse about two weeks after delivery

) B

Possible experience of fluctuations in sexual interest

) C

Use of a water-based lubricant to ease vaginal discomfort

) D

Use of combined hormonal contraceptives for the first three weeks

) E

Possibility of increased breast sensitivity during sexual activity

)

2

After teaching a postpartum woman about breast-feeding, the nurse determines

2

that the teaching was successful when the woman states which of the following?

.

A )

I should notice a decrease in abdominal cramping during breast-feeding.

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B

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I should wash my hands before starting to breast-feed.

) C

The baby can be awake or sleepy when I start to feed him.

) D

The babys mouth will open up once I put him to my breast.

)

2

A postpartum woman who is bottle-feeding her newborn asks the nurse, About

3

how much should my newborn drink at each feeding? The nurse responds by

.

saying that to feel satisfied, the newborn needs which amount at each feeding?

A

1 to 2 ounces

) B

2 to 4 ounces

) C

4 to 6 ounces

) D

6 to 8 ounces

)

2

A nurse is observing a postpartum woman and her partner interact with the their

4

newborn. The nurse determines that the parents are developing parental

.

attachment with their newborn when they demonstrate which of the following?

(Select all that apply.)

A

Frequently ask for the newborn to be taken from the room

) B

Identify common features between themselves and the newborn

) C )

Refer to the newborn as having a monkey-face

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D

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Make direct eye contact with the newborn

) E

Refrain from checking out the newborns features

)

2

After reviewing information about postpartum blues, a group of students

5

demonstrate understanding when they state which of the following about this

.

condition?

A

Postpartum blues is a long-term emotional disturbance.

) B

Sleep usually helps to resolve the blues.

) C

The mother loses contact with reality.

) D

Extended psychotherapy is needed for treatment.

) Answer Key

1.

A

2.

C

3.

C

4.

B

5.

B

6.

C

7.

B

8.

C

9.

C

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10.

B

11.

A

12.

C

13.

A

14.

A, D, E

15.

C

16.

B

17.

C

18.

B

19.

B, D, E

20.

A

21.

B, C, E

22.

B

23.

B

24.

B, D

25.

B

Chapter 13. Postpartum Complications MULTIPLE CHOICE 1. Which statement by a postpartum client indicates that further teaching is not needed regarding thrombus formation?

a .

Ill keep my legs elevated with pillows.

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b .

Ill sit in my rocking chair most of the time.

c .

Ill stay in bed for the first 3 days after my baby is born.

d .

Ill put my support stockings on every morning before rising.

ANS: D Venous congestion begins as soon as the client stands up. The stockings should be applied before she rises from the bed in the morning. The client should avoid knee pillows because they increase pressure on the popliteal space. Sitting in a chair with legs in a dependent position causes pooling of blood in the lower extremities. As soon as possible, the client should ambulate frequently.

PTS: 1 DIF: Cognitive Level: Application REF: 607 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 2. The nurse knows that late postpartum hemorrhage can be prevented by:

a .

manually removing the placenta.

b .

inspecting the placenta after birth.

c .

administering broad-spectrum antibiotics.

d .

pulling on the umbilical cord to hasten the birth of the placenta.

ANS: B If a portion of the placenta is missing, the clinician can explore the uterus, locate the missing fragments, and remove the potential cause of late postpartum hemorrhage. Manual removal of the placenta increases the risk of postpartum hemorrhage. Broad-spectrum antibiotics will be given if postpartum infection is suspected. The placenta is usually delivered 5 to 30 minutes after

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birth of the baby without pulling on the cord. That can cause uterine inversion.

PTS: 1 DIF: Cognitive Level: Application REF: 602 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 3. A multiparous client is admitted to the postpartum unit after a rapid labor and birth of a 4000g infant. Her fundus is boggy, lochia is heavy, and vital signs are unchanged. The nurse has the client void and massages her fundus, but the fundus remains difficult to find and the rubra lochia remains heavy. Which action should the nurse take next?

a .

Recheck vital signs.

b .

Insert a Foley catheter.

c .

Notify the health care provider.

d .

Continue to massage the fundus.

ANS: C Treatment of excessive bleeding requires the collaboration of the health care provider and the nurses. Do not leave the client alone. The nurse should call the clinician while a second nurse rechecks the vital signs. The client has voided successfully, so a Foley catheter is not needed at this time. The uterine muscle can be overstimulated by massage, leading to uterine atony and rebound hemorrhage.

PTS: 1 DIF: Cognitive Level: Application REF: 604 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 4. Early postpartum hemorrhage is defined as a blood loss greater than:

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a .

500 mL within 24 hours after a vaginal birth.

b .

750 mL within 24 hours after a vaginal birth.

c .

1000 mL within 48 hours after a cesarean birth.

d .

1500 mL within 48 hours after a cesarean birth.

ANS: B The average amount of bleeding after a vaginal birth is 500 mL. Early postpartum hemorrhage occurs in the first 24 hours, not 48 hours. Blood loss after a cesarean averages 1000 mL. Late postpartum hemorrhage is 48 hours and later.

PTS: 1 DIF: Cognitive Level: Understanding REF: 598 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 5. A steady trickle of bright red blood from the vagina in the presence of a firm fundus suggests:

a .

uterine atony.

b .

perineal hematoma.

c .

infection of the uterus.

d .

lacerations of the genital tract.

ANS: D Undetected lacerations will bleed slowly and continuously. Bleeding from lacerations is uncontrolled by uterine contraction. The fundus would not be firm with uterine atony. A hematoma would be internal. Swelling and discoloration would be noticed, but bright bleeding

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would not be. With an infection of the uterus, there would be an odor to the lochia and systemic symptoms such as fever and malaise.

PTS: 1 DIF: Cognitive Level: Understanding REF: 601 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 6. A postpartum client would be at increased risk for postpartum hemorrhage if she delivered a(n):

a .

5-lb, 2-oz infant with outlet forceps.

b .

6.5-lb infant after a 2-hour labor.

c .

7-lb infant after an 8-hour labor.

d .

8-lb infant after a 12-hour labor.

ANS: B A rapid labor and birth may cause exhaustion of the uterine muscle and prevent contraction.

Delivering a 5-lb, 2-oz infant with outlet forceps would put this client at risk for lacerations because of the forceps. A 7-lb infant after an 8-hour labor is a normal labor progression. Less than 3 hours is rapid and can produce uterine muscle exhaustion. An 8-lb infant after a 12-hour labor is a normal labor progression. Less than 3 hours is a rapid birth and can cause the uterine muscles not to contract.

PTS: 1 DIF: Cognitive Level: Understanding REF: 605 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 7. Which instruction should be included in the discharge teaching plan to assist the client in recognizing early signs of complications?

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a .

Palpate the fundus daily to ensure that it is soft.

b .

Report any decrease in the amount of brownish red lochia.

c .

The passage of clots as large as an orange can be expected.

d .

Notify the health care provider of any increase in the amount of lochia or a return to bright red bleeding.

ANS: D An increase in lochia or a return to bright red bleeding after the lochia has become pink indicates a complication. The fundus should stay firm. The lochia should decrease in amount. Large clots after discharge are a sign of complications and should be reported.

PTS: 1 DIF: Cognitive Level: Application REF: 599 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 8. The nurse should expect medical intervention for subinvolution to include:

a .

oral fluids to 3000 mL/day.

b .

intravenous fluid and blood replacement.

c .

oxytocin intravenous infusion for 8 hours.

d .

oral methylergonovine maleate (Methergine) for 48 hours.

ANS: D Methergine provides long-sustained contraction of the uterus. There is no correlation between

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dehydration and subinvolution. There is no indication that excessive blood loss has occurred.

Oxytocin provides intermittent contractions.

PTS: 1 DIF: Cognitive Level: Understanding REF: 605 OBJ: Nursing Process Step: Planning MSC: Client Needs: Physiologic Integrity 9. If nonsurgical treatment for subinvolution is ineffective, which surgical procedure is appropriate to correct the cause of this condition?

a .

Hysterectomy

b .

Laparoscopy

c .

Laparotomy

d .

Dilation and curettage (D&C)

ANS: D D&C allows examination of the uterine contents and removal of any retained placenta or membranes. Hysterectomy is not indicated for this condition. A hysterectomy is the removal of the uterus. Laparoscopy is not indicated for this condition. A laparoscopy is the insertion of an endoscope through the abdominal wall to examine the peritoneal cavity. Laparotomy is not indicated for this condition. A laparotomy is a surgical incision into the peritoneal cavity to explore the peritoneal cavity.

PTS: 1 DIF: Cognitive Level: Understanding REF: 602 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 10. A sign of thrombophlebitis is:

a .

visible varicose veins.

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b .

positive Homans sign.

c .

pedal edema in the affected leg.

d .

local tenderness, heat, and swelling.

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ANS: D Tenderness, heat, and swelling are classic signs of thrombophlebitis that appear at the site of the inflammation. Varicose veins may predispose the client to thrombophlebitis, but are not a sign. A positive Homans sign is indicative of deep vein thrombosis (DVT).

PTS: 1 DIF: Cognitive Level: Understanding REF: 606 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 11. Which nursing measure would be appropriate to prevent thrombophlebitis in the recovery period following a cesarean birth?

a .

Limit the clients oral intake of fluids for the first 24 hours.

b .

Assist the client in performing leg exercises every 2 hours.

c .

Ambulate the client as soon as her vital signs are stable.

d .

Roll a bath blanket and place it firmly behind the clients knees.

ANS: B Leg exercises promote venous blood flow and prevent venous stasis while the client is still on bed rest. Limiting oral intake will produce hemoconcentration, which may lead to thrombophlebitis. The client may not have full return of leg movements, and ambulating is contraindicated. The blanket behind the knees will cause pressure and decrease venous blood

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flow.

PTS: 1 DIF: Cognitive Level: Application REF: 607 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Health Promotion and Maintenance 12. Which temperature indicates the presence of postpartum infection?

a .

99.6 F in the first 48 hours

b .

100 F for 2 days postpartum

c .

100.4 F in the first 24 hours

d .

100.8 F on the second and third postpartum days

ANS: D A temperature elevation to greater than 100.4 F on two postpartum days, not including the first 24 hours, indicates infection. 99.6 F in the first 48 hours is an expected finding because of dehydration. To be classified as an infection, the temperature needs to be greater than 100.4 F. It is anticipated that women have an elevated temperature the first 24 hours.

PTS: 1 DIF: Cognitive Level: Understanding REF: 609 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Health Promotion and Maintenance 13. A white blood cell (WBC) count of 35,000 cells/mm3 on the morning of the first postpartum day indicates:

a .

possible infection.

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b .

normal WBC limit.

c .

serious infection.

d .

suspicion of a sexually transmitted disease.

ANS: A A WBC count in the upper ranges of normal (20,000 to 30,000 cells/mm3) may indicate an infection. An elevated WBC count is anticipated but becomes a concern as it hits the upper range. An elevated WBC count may be an indication of different types of infection.

PTS: 1 DIF: Cognitive Level: Understanding REF: 614 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 14. The client who is being treated for endometritis is placed in the Fowler position because it:

a .

promotes comfort and rest.

b .

facilitates drainage of lochia.

c .

prevents spread of infection to the urinary tract.

d .

decreases tension on the reproductive organs.

ANS: B Lochia and infectious material are eliminated by gravity drainage. The Fowler position may not be the position of comfort, but it does allow for drainage. Good hygiene practice aids in preventing the spread of infection to the urinary tract. This position aids in the drainage of lochia and infectious material.

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PTS: 1 DIF: Cognitive Level: Comprehension REF: 611 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 15. Nursing measures that help prevent postpartum urinary tract infection include:

a .

forcing fluids to at least 3000 mL/day.

b .

promoting bed rest for 12 hours after birth.

c .

encouraging the intake of orange, grapefruit, or apple juice.

d .

discouraging voiding until the sensation of a full bladder is present.

ANS: A Adequate fluid intake prevents urinary stasis, dilutes urine, and flushes out waste products. The client should be encouraged to ambulate early. Juices such as cranberry juice can discourage bacterial growth. With pain medications, trauma to the area, and anesthesia, the sensation of a full bladder may be decreased. The client needs to be encouraged to void frequently.

PTS: 1 DIF: Cognitive Level: Application REF: 612 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 16. Which measure may prevent mastitis in a breastfeeding client?

a .

Wearing a tight-fitting bra

b .

Applying ice packs prior to feeding

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c .

Initiating early and frequent feedings

d .

Nursing the infant for 5 minutes on each breast

ANS: C Early and frequent feedings prevent stasis of milk, which contributes to engorgement and mastitis. Five minutes does not empty the breast adequately. This will produce stasis of the milk.

A firm-fitting bra will support the breast, but not prevent mastitis. The breast should not be bound. Warm packs before feeding will increase the flow of milk.

PTS: 1 DIF: Cognitive Level: Application REF: 612 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 17. A client with mastitis is concerned about breastfeeding while she has an active infection.

Which is an appropriate response by the nurse?

a .

Organisms will be inactivated by gastric acid.

b .

Organisms that cause mastitis are not passed to the milk.

c .

The infant is not susceptible to the organisms that cause mastitis.

d .

The infant is protected from infection by immunoglobulins in the breast milk.

ANS: B The organisms are localized in the breast tissue and are not excreted in the breast milk. The organism will not get into the infants gastrointestinal system. Because of an immature immune system, infants are susceptible to many infections. However, this infection is in the breast tissue and is not excreted in the breast milk. The client is just producing the immunoglobulin from this

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infection, so it is not available for the infant.

PTS: 1 DIF: Cognitive Level: Application REF: 612 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity 18. The nurse expecting a uterine infection in a postpartum client should assess the:

a .

episiotomy site.

b .

odor of the lochia.

c .

abdomen for distention.

d .

pulse and blood pressure.

ANS: B An abnormal odor of the lochia indicates infection in the uterus. The infection may move to the episiotomy site if proper hygiene is not followed. The abdomen becomes distended usually because of a decrease of peristalsis, such as after cesarean section. The pulse may be altered with an infection, but the odor of the lochia will be an earlier sign and will be more specific.

PTS: 1 DIF: Cognitive Level: Application REF: 615 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity 19. Following a difficult vaginal birth of a singleton pregnancy, the client starts bleeding heavily.

Clots are expressed and a Foley catheter is inserted to empty the bladder because the uterine fundus is soft and displaced laterally from midline. Vital signs are 99.8 F, pulse 90 beats/min, respirations 20 breaths/min, and BP 130/90 mm Hg. Which pharmacologic intervention is indicated?

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a .

Oxytocin (Pitocin) to be administered in a piggyback solution

b .

Administration of methylergonovine (Methergine)

c .

Administration of prostaglandin analogue

d .

Increase in parenteral fluids

ANS: C Prostaglandin analogues can be administered intramuscularly to stop uterine bleeding. Although Pitocin may be indicated in an attempt to stop uterine bleeding, it is not administered in a piggyback solution. Methergine is contraindicated in the presence of hypertension. Increasing fluids will not stop uterine bleeding.

PTS: 1 DIF: Cognitive Level: Analysis REF: 600 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Physiologic Integrity/Pharmacologic Parental Therapies 20. Following a vaginal birth, a client has lost a significant amount of blood and is starting to experience signs of hypovolemic shock. Which clinical signs would be consistent with this clinical diagnosis?

a .

Decrease in blood pressure, with an increase in pulse pressure

b .

Compensatory response of tachycardia and decreased pulse pressure

c .

Decrease in heart rate and an increase in respiratory effort

d .

Flushed skin

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ANS: B Clinical signs consistent with the beginning of hypovolemic shock include normal blood pressure, decreased pulse pressure, compensatory tachycardia, and pale, cool skin color.

PTS: 1 DIF: Cognitive Level: Application REF: 602 OBJ: Nursing Process Step: Assessment MSC: Client Needs: Physiologic Integrity/Physiologic Adaptation 21. A client has been treated with oxytocin (Pitocin) for postpartum hemorrhage. Bleeding has stabilized and slowed down considerably. The peripad in place reveals a moderate amount of bright red blood, with no clots expelled when massaging the fundus. The client now complains of having difficulty breathing. Auscultation of breath sounds reveals adventitious sounds. Based on this clinical presentation, the priority nursing action is to:

a .

evaluate intake and output of the past 12 hours following birth.

b .

initiate a rapid response intervention.

c .

obtain an order from the physician for type and crossmatch of 2 units packed red blood cells (PRBCs).

d .

reposition the client and reassess in 15 minutes. Initiate frequent vital sign assessments.

ANS: B Oxytocin (Pitocin) can have antidiuretic effects when used in large amounts. Given the recent client history, she has received an additional Pitocin infusion relative to the direct observation of postpartum hemorrhage. Adventitious breath sounds and the clients complaints of difficulty breathing suggest that the client is progressing to pulmonary edema. An appropriate intervention is to initiate a rapid response intervention so that the client can be stabilized. Calling the physician for a type and crossmatch order is not indicated. Repositioning the client, even with the initiation of frequent vital signs, will not treat the emerging clinical condition. Evaluation of intake and output, although necessary, is not the priority nursing action at this time.

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PTS: 1 DIF: Cognitive Level: Analysis REF: 604 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Safe and Effective Care Environment/Establishing Priorities 22. A postpartum client has developed deep vein thrombosis (DVT) and treatment with warfarin (Coumadin) has been initiated. Which dietary selection should be modified in view of this treatment regimen?

a .

Fresh fruits

b .

Milk

c .

Lentils

d .

Soda

ANS: C Foods that are high in vitamin K should be restricted and/or limited in consumption while on Coumadin therapy. Vitamin K is the antidote to Coumadin activity.

Chapter 14. Physiological and Behavioral Adaptations of the Newborn MULTIPLE CHOICE 1. While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting? a. Molding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle ANS: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial

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bone. It does not cross the suture line.

DIF: Cognitive Level: Comprehension REF: Page 283 OBJ: 1 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant? a. Molding doesnt cause any problems. Dont worry about it. b. Did you deliver vaginally or by cesarean section? c. The babys head conformed to the shape of the birth canal. It will go away soon. d. A traumatic delivery can cause molding.

ANS: C The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal.

DIF: Cognitive Level: Application REF: Page 283 OBJ: 1 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. What symptom assessed in the newborn shortly after delivery should be reported? a. Cyanosis of the hands and feet b. Irregular heart rate c. Mucus draining from the nose d. Sternal or chest retractions ANS: D Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.

DIF: Cognitive Level: Analysis REF: Page 289 OBJ: 3 TOP: Newborn AssessmentRespiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior? a. The Moro reflex

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b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality ANS: A The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.

DIF: Cognitive Level: Analysis REF: Page 282, Figure 12-3 | Page 284, Table 12-1 OBJ: 2 TOP: Newborn Reflexes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A first-time mother reports that she is experiencing difficulty breastfeeding her newborn.

Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck ANS: B The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in anticipation of food.

DIF: Cognitive Level: Application REF: Page 282 | Page 284, Figure 12-1 OBJ: 2 TOP: Newborn Reflexes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped ANS: D The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two

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frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age.

DIF: Cognitive Level: Comprehension REF: Page 283 | Page 285 Skill 12-1 OBJ: 3 TOP: Newborn AssessmentHead KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. What statement indicates the parent understands the guidelines for bathing a newborn? a. Ill use a mild soap to clean all of the body parts. b. I am going to add bath oil to the water to keep the babys skin soft. c. I should shampoo the head after washing the rest of the body. d. Ill wash from the feet upward and change the washcloth for the face.

ANS: C The shampoo is done last because the large surface area of the head predisposes the infant to heat loss.

DIF: Cognitive Level: Comprehension REF: Page 295 | Page 298 Skill 12-5 OBJ: 8 TOP: Home CareBathing the Infant KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6 C (98 F) b. An apical pulse rate of 178 beats/min c. Respirations of 35 breaths/min d. Blood pressure of 80/50 mm Hg ANS: B The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should be reported.

DIF: Cognitive Level: Comprehension REF: Page 290 OBJ: 3 TOP: Newborn AssessmentVital Signs KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth? a. Yellow

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b. Brown c. Greenish brown d. Black and tarry ANS: A The stool of a breastfed infant is bright yellow, soft, and pasty.

DIF: Cognitive Level: Application REF: Page 299, Figure 12-15 OBJ: 8 TOP: Newborn AssessmentGastrointestinal System KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. What is nurses most helpful response? a. Give the baby one serving of fruit per day. b. Increase the amount and frequency of her feedings. c. It sounds like the baby is uncomfortable because she is constipated. d. Newborns might strain with bowel movements because their muscles arent fully developed.

ANS: D Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.

DIF: Cognitive Level: Application REF: Page 300 OBJ: 8 TOP: Newborn AssessmentGastrointestinal System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later? a. 2900 b. 3100 c. 3300 d. 3800 ANS: C In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

DIF: Cognitive Level: Analysis REF: Page 291-292 OBJ: 3 TOP: Newborn AssessmentWeight

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KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause? a. Premature stimulation of the ovarian hormones by the pituitary system b. Cessation of female sex hormones transferred in utero from mother to infant c. The increased amount of circulating blood from the mother throughout pregnancy d. Trauma to the genitalia during the birth process ANS: B Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.

DIF: Cognitive Level: Comprehension REF: Page 293 OBJ: 8 TOP: Newborn AssessmentGenitourinary KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much.

What is the most appropriate nursing response to this mother? a. Tell me how many hours per day your baby sleeps. b. It is normal for newborns to sleep most of the day. c. Newborns generally sleep 12 to 15 hours per day. d. You will find as the baby gets older, he sleeps less.

ANS: A Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by too much before giving any information.

DIF: Cognitive Level: Application REF: Page 287 OBJ: 8 TOP: Discharge Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner? a. Infant refuses a feeding b. Infant has an axillary temperature of 97 F c. Infant has three pasty, yellow-brown stools in 24 hours

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d. Infants diaper is not wet after 8 hours ANS: D Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.

DIF: Cognitive Level: Comprehension REF: Page 292 OBJ: 8 TOP: Discharge Planning KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Neonates can distinguish a mothers voice from other sounds in the first days of life.

ANS: D The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days of life.

DIF: Cognitive Level: Knowledge REF: Page 283-284 OBJ: 8 TOP: Newborn AssessmentHearing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse? a. Do nothing because this is a normal occurrence. b. Report the discrepancy to the pediatrician immediately. c. Decrease the interval between the infants feedings. d. Try feeding the infant a different type of formula.

ANS: A It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

DIF: Cognitive Level: Application REF: Page 291-292 OBJ: 3 TOP: Newborn AssessmentWeight KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 17. Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents? a. Contact a pediatric dermatologist for topical medication. b. Squeeze out the white material after cleansing the face. c. Wash the infants face with a mild astringent several times a day. d. Leave the milia alone; it will disappear spontaneously. No treatment is needed.

ANS: D Milia require no treatment. This skin manifestation will disappear spontaneously.

DIF: Cognitive Level: Application REF: Page 294 | Page 297 Table 12-3 OBJ: 5 TOP: Newborn AssessmentSkin KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth.

What is the nurses first action? a. Place the tip in the nose and squeeze the bulb gently. b. Suction secretions from the nose before the mouth. c. Depress the bulb before inserting the syringe tip into the mouth. d. Insert the tip into the back of the mouth to reach mucus.

ANS: C The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

DIF: Cognitive Level: Application REF: Page 288 | Page 289 Skill 12-2 OBJ: 3 TOP: Newborn AssessmentRespiratory KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. Which finding needs to be reported promptly to the childs pediatrician? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infants body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infants skin has a yellowish tinge.

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ANS: D Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.

DIF: Cognitive Level: Analysis REF: Page 294 OBJ: 6 TOP: Newborn AssessmentSkin (Jaundice) KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. What action does the nurse implement to protect newborns from infection while in the nursery? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care.

ANS: C Handwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.

DIF: Cognitive Level: Application REF: Page 300 OBJ: 7 TOP: Preventing Infection KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. Which assessment of the newborn should be reported? a. Head circumference is 5 cm greater than the chest circumference b. Hands and feet are warm with a blue color c. Temperature is 36.6 C (97.8 F) d. Head has a longer than normal shape to it ANS: A The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm.

DIF: Cognitive Level: Analysis REF: Page 285, Skill 12-1 OBJ: 3 TOP: Newborn Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What

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does the nurse explain this transitory skin discoloration is called? a. Epsteins pearls b. Milia c. Stork bites d. Mongolian spots ANS: D Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.

DIF: Cognitive Level: Comprehension REF: Page 294 OBJ: 5 TOP: Mongolian Spots KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first? a. White blood cell count of 18,000 b. Hemoglobin of 18.5 c. Hematocrit of 56 d. Bilirubin of 15 ANS: D A bilirubin of 15 is elevated and requires further immediate investigation.

DIF: Cognitive Level: Analysis REF: Page 294, Table 12-2 OBJ: 3 TOP: Labwork KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 24. The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight ANS: A, B, C, D The Apgar score is a standardized method of evaluating the newborns condition immediately

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after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes.

DIF: Cognitive Level: Application REF: Page 289 OBJ: 3 TOP: Apgar Score KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 25. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling ANS: A, B, C, E Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.

DIF: Cognitive Level: Comprehension REF: Page 288 OBJ: 8 TOP: Noninvasive Pain Relief KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 26. The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts ANS: A, C Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

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Chapter 15. Nursing Care of the Newborn MULTIPLE CHOICE 1. The nurse is assessing a preterm infant. To what does the infants level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infants weight as compared to the gestational age d. Ability of the organs to function outside of the uterus ANS: D Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.

DIF: Cognitive Level: Knowledge REF: Page 309 OBJ: 1 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what? a. Skin breakdown b. Renal failure c. Brain damage d. Heart failure ANS: C The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.

DIF: Cognitive Level: Comprehension REF: Page 316 OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life? a. Weak or absent sucking or swallowing reflex b. Inability to digest food properly c. Refusal to take formula by mouth d. Need for a larger quantity of formula at each feeding

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ANS: A When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

DIF: Cognitive Level: Comprehension REF: Page 317 OBJ: 4 TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What deficiency causes a preterm infant respiratory distress syndrome? a. Protein b. Estrogen c. Hyaline d. Surfactant ANS: D The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.

DIF: Cognitive Level: Knowledge REF: Page 311 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding? a. Check tube placement by injecting air into the stomach. b. Weigh the infant before the feeding. c. Aspirate stomach contents. d. Check serum glucose level.

ANS: C When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.

DIF: Cognitive Level: Application REF: Page 317 OBJ: 6 TOP: Preterm InfantNutrition KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity? a. Prostaglandins

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b. Oxytocin c. Magnesium sulfate d. Corticosteroids ANS: D Surfactant production can be increased by administering corticosteroids to the mother before delivery.

DIF: Cognitive Level: Comprehension REF: Page 312 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infants feet or back. c. Ventilate with an Ambu bag. d. Perform nasopharyngeal suctioning.

ANS: B Gently rubbing the infants back, ankles, or feet may stimulate the infant to breathe.

DIF: Cognitive Level: Application REF: Page 312 OBJ: 4 TOP: Preterm InfantApnea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate? a. Seizures b. Bradycardia c. Dysrhythmias d. Tetany ANS: B The infant receiving intravenous calcium gluconate should be monitored for bradycardia.

DIF: Cognitive Level: Application REF: Page 314 OBJ: 4 TOP: Hypocalcemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. What is the rationale for placing a preterm infant born at 34 weeks of gestation in an

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incubator? a. The infant has a small body surface-to-weight ratio. b. Heat increases the flow of oxygen to the extremities. c. The infants temperature control mechanism is immature. d. Heat within the incubator facilitates drainage of mucus.

ANS: C The preterm infant is at risk for heat loss for several reasons, one of which is that the heat regulating center in the brain is immature.

DIF: Cognitive Level: Comprehension REF: Page 314 OBJ: 5 TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 10. What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy? a. Monitor arterial oxygen levels with a pulse oximeter. b. Position the head slightly lower than the body. c. Administer low concentrations of oxygen. d. Keep the infants eyes covered at all times.

ANS: A Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority in the neonatal intensive care unit (NICU).

DIF: Cognitive Level: Application REF: Page 315 OBJ: 4 TOP: Retinopathy of Prematurity KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate? a. Respiratory distress syndrome b. Postmaturity syndrome c. Apneic episode d. Cold stress ANS: A Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.

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DIF: Cognitive Level: Analysis REF: Page 310-311 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool? a. Assess for abdominal distention. b. Decrease the amount of the next feeding. c. Institute enteric precautions. d. Get a culture of the next stool.

ANS: A Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.

DIF: Cognitive Level: Application REF: Page 317 OBJ: 4 TOP: Necrotizing Enterocolitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents? a. To bring in colorful pictures and toys to place in the incubator b. That stimulating the infant during feedings increases intake c. To stroke the infant during feeding to increase intake d. Not to disturb the infant between feedings ANS: C During gavage feedings, stroking the infant gently can provide stimulation.

DIF: Cognitive Level: Application REF: Page 317 OBJ: 8 TOP: Family Reaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry.

The nurse is aware that these symptoms indicate what? a. Respiratory distress syndrome b. Hypoglycemia

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c. Necrotizing enterocolitis d. Renal failure ANS: B The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infants glycogen stores are not adequate.

DIF: Cognitive Level: Analysis REF: Page 314 OBJ: 4 TOP: Postterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response? a. Preterm infants usually remain smaller than term infants throughout childhood. b. Your daughter will be the same size as other children by the time she is 1 year old. c. Prematurity is associated with short stature but does not affect weight gain. d. It takes about two years for the preterm infant to catch up to a full-term infant.

ANS: D In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the second year.

DIF: Cognitive Level: Application REF: Page 320 OBJ: 8 TOP: Preterm Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant? a. 1 to 3 mL/kg/hr b. 4 to 6 mL/kg/hr c. 7 to 9 mL/kg/hr d. 10 to 14 mL/kg/hr ANS: A The optimum output for a preterm infant is 1 to 3 mL/kg/hr.

DIF: Cognitive Level: Comprehension REF: Page 316 OBJ: 4 TOP: Immature Kidneys KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic

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might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin ANS: D The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.

DIF: Cognitive Level: Comprehension REF: Page 309 OBJ: 2 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. The nurse in a pediatricians office is preparing to do a developmental assessment on a 3month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth? a. 1 b. 2 c. 3 d. 4 ANS: B The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.

DIF: Cognitive Level: Analysis REF: Page 320 OBJ: 2 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. The mother of a postterm infant asks the nurse why the infant is being watched so closely.

What is the nurses most appropriate response? a. The placenta does not function adequately as it ages. b. Infants born postmaturely are generally large. c. Delivery of the postterm infant is more difficult. d. There is less amniotic fluid.

ANS: A Fetal distress may occur in the postterm infant because placental functioning becomes inadequate

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with maturity.

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9 TOP: Postterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 20. What symptoms of cold stress might the nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 40 mg/dL c. Warm skin with low core temperature d. Increased respiratory rate and periods of apnea ANS: D Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.

DIF: Cognitive Level: Comprehension REF: Page 314, Nursing Tip OBJ: 5 TOP: Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 21. The nurse is caring for an infant born at 43 weeks. What would the physical assessment reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body ANS: A Loss of vernix caseosa leaves the skin dry, causing peeling.

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9 TOP: Postterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. What term describes the age of a neonate that is based on the actual time in utero? a. Maturational age b. Gestational age c. Neurological age d. Chronological age

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ANS: B The gestational age is the age based on the actual time in the uterus.

DIF: Cognitive Level: Knowledge REF: Page 309 OBJ: 1 TOP: Gestational Age KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Growth and Development 23. How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator? a. Every hour b. Every 2 hours c. Every 4 hours d. Every 8 hours ANS: B DIF: Cognitive Level: Comprehension REF: Page 314 OBJ: 5 TOP: Thermoregulation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 24. Why is the postterm neonate at risk for cold stress? a. Inadequate vernix caseosa b. Hypoxia from a deteriorated placenta c. Polycythemia d. Fat stores have been used in utero for nourishment ANS: D Fat stores have been used in utero for nourishment during the extended pregnancy.

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9 TOP: Postterm Cold Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age d. Late preterm ANS: C

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Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks.

DIF: Cognitive Level: Analysis REF: Page 308-309 OBJ: 1 TOP: Gestational Age KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 26. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function? a. Immediately b. Within 3 days c. 1 to 2 weeks d. At least 1 month ANS: B In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours.

DIF: Cognitive Level: Comprehension REF: Page 312 OBJ: 4 TOP: Respiratory Distress Syndrome KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 27. The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia ANS: A, B, E The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.

DIF: Cognitive Level: Comprehension REF: Page 321 OBJ: 9

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TOP: Potential Problems of the Postterm Infant KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 28. The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma ANS: A, B, C The predisposing causes of preterm birth are numerous; in many instances the cause is unknown.

Prematurity may be caused by multiple births, illness of the mother (e.g., malnutrition, heart disease, diabetes mellitus, or infectious conditions), or the hazards of pregnancy itself, such as gestational hypertension, placental abnormalities that may result in premature rupture of the membranes, placenta previa (in which the placenta lies over the cervix instead of higher in the uterus), and premature separation of the placenta. Studies also indicate the relationships between prematurity and poverty, smoking, alcohol consumption, and abuse of cocaine and other drugs.

Hyperemesis gravidarum and chloasma are not risk factors for preterm birth.

DIF: Cognitive Level: Comprehension REF: Page 309 OBJ: 3 TOP: Preterm Birth KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 29. The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.) a. Paleness b. Transparent skin c. Superficial scalp veins d. Vomiting e. Bulging fontanelles ANS: A, D, E Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn.

Transparent skin and superficial scalp veins are expected findings.

DIF: Cognitive Level: Application REF: Page 319, Table 13-1

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OBJ: 4 TOP: Potential Problems of the Preterm Infant KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 30. The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of weeks.

ANS: 34 Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.

Chapter 16. Newborn Nutrition MULTIPLE CHOICE 1. What type of development is the nurse assessing when an infant can lift his or her head before he or she can sit? a. Specific to general b. Proximodistal c. Cephalocaudal d. General to specific ANS: C Cephalocaudal development proceeds from head to toe.

DIF: Cognitive Level: Comprehension REF: Page 353, Figure 15-1 OBJ: 1 TOP: Cephalocaudal Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 2. What is a unique organization of characteristics that determines an individuals pattern of behavior? a. Environment

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b. Heredity c. Personality d. Experience ANS: C One definition of personality states that it is a unique organization of characteristics that determines the individuals typical or recurrent pattern of behavior.

DIF: Cognitive Level: Knowledge REF: Page 360 OBJ: 1 TOP: Personality Development KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 3. An infants birth weight is 7 pounds, 8 ounces. What can the nurse project the weight to be at 6 months? a. 12 pounds b. 15 pounds c. 18 pounds d. 22 pounds ANS: B An infant usually doubles his or her birth weight by 5 to 6 months.

DIF: Cognitive Level: Analysis REF: Page 353, Figure 15-1 OBJ: 4 TOP: Weight Prediction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 4. What would the nurse further investigate when assessing patterns of growth in a child? a. Previous weight was in the 75th percentile, and present weight is in the 25th percentile. b. Height is in the 90th percentile, and weight is in the 75th percentile. c. Last weight was in the 5th percentile, and present weight is in the 10th percentile. d. Weight is in the 50th percentile, and siblings weight at the same age was in the 75th percentile.

ANS: A The child showing a difference of two or more percentile levels from an established growth pattern should undergo further evaluation.

DIF: Cognitive Level: Analysis REF: Page 356 OBJ: 4 TOP: Growth KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 5. A mother reports that she and her husband have had one child together, but both have children from previous marriages living in their home. The nurse will base the care planning on what type of family? a. Nuclear b. Blended c. Alternate d. Extended ANS: B A blended family involves the remarriage of persons with children.

DIF: Cognitive Level: Comprehension REF: Page 359, Table 15-1 OBJ: 6 | 7 TOP: The Family KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The mother of a 7-month-old reports that the first lower central incisor has erupted. She asks the nurse, How many teeth will he have by his first birthday? The nurse explains that the infant will have how many teeth by 1 year of age? a. 2 b. 4 c. 6 d. 8 ANS: C The 1-year-old infant usually has about 6 teeth, 4 above and 2 below.

DIF: Cognitive Level: Knowledge REF: Page 380 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 7. At a well-baby visit, parents of a 6-month-old ask when to take the infant for the first dental visit. What is the nurses best response? a. If the teeth are brushed regularly, the child should see a dentist by 3 years of age. b. The first dental visit should be arranged after the first tooth erupts. c. The child should have a dental examination when all deciduous teeth have erupted. d. A dental visit by 1 year of age is recommended by the American Academy of Pediatric Dentistry.

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ANS: D The Academy of Pediatric Dentistry recommends that the first dental visit occur by 1 year of age.

DIF: Cognitive Level: Application REF: Page 380 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse is planning anticipatory guidance for a caregiver of a preschool-age child. The nurse will explain that permanent teeth begin erupting at what age? a. 4 years old b. 6 years old c. 8 years old d. 10 years old ANS: B Permanent teeth do not erupt through the gums until the sixth year.

DIF: Cognitive Level: Knowledge REF: Page 381 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 9. A mother asks the nurse how much food should be offered to her 2-year-old. What is a good rule of thumb for serving size (in tablespoons) per year of age? a. 2 b. 3 c. 4 d. 5 ANS: A The rule of thumb for serving sizes is to offer 1 tablespoon of each food group per year of age.

DIF: Cognitive Level: Comprehension REF: Page 380 OBJ: 9 TOP: Rule of Thumb for Serving Sizes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 10. An assessment of a childs nutritional status reveals the child is alert, with shiny hair, firm gums, firm mucous membranes, and regular elimination. How would this childs nutritional status be described? a. Overnourished

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b. Undernourished c. Well nourished d. Borderline ANS: C Well-nourished children show steady gains in height and weight and have shiny hair, firm gums and mucous membranes, and regular elimination.

DIF: Cognitive Level: Analysis REF: Page 379 OBJ: 9 TOP: Nutrition KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse encourages a Puerto Rican family to bring food to a child because he is not eating the food served on his hospital tray. What can the nurse expect the child to eat? a. Dried beans mixed with rice b. Crisp vegetables c. Spaghetti and meatballs d. Wild berries, roots, and seeds ANS: A A common food choice of Americans of Puerto Rican descent is dried beans mixed with rice.

DIF: Cognitive Level: Comprehension REF: Page 372, Table 15-6 OBJ: 7 TOP: Feeding the Ill Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. What does self-feeding help to develop in the toddler? a. Good nutrition b. A sense of independence c. Adequate height and weight d. Healthy teeth ANS: B By the end of the second year, toddlers can feed themselves. This helps them to develop a sense of independence.

DIF: Cognitive Level: Comprehension REF: Page 368, Table 15-3 OBJ: 2 TOP: Feeding the Healthy Child

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KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 13. What activity would the nurse choose to meet Eriksons developmental task of industry when caring for a 7-year-old? a. Completing a 50-piece jigsaw puzzle b. Looking at a comic book c. Playing a game of I Spy with the nurse d. Coloring a picture in a coloring book ANS: A In the developmental period of late childhood, children are striving to develop a sense of industry. The completion of a jigsaw puzzle is industrious play.

DIF: Cognitive Level: Analysis REF: Page 368, Table 15-3 | Page 370, Table 15-5 OBJ: 11 TOP: Personality Development KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 14. What does the nurse recognize as an example of Piagets concrete operational thinking? a. 2-year-old says, Its nighttime when his room is darkened. b. 4-year-old refers to the hospital as my house. c. 5-year-old coloring a picture of a puppy says, This is my puppy. d. 7-year-old says, I am sick because I have germs in my chest.

ANS: D The 7-year-olds remark reflecting the cause and effect of germs and illness is an example of operational thinking. All other options are examples of preoperational thought, which is egocentric and symbolic.

DIF: Cognitive Level: Analysis REF: Page 369, Table 15-4 OBJ: 8 TOP: Cognitive Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 15. The nurse has discussed with a mother the process of introducing solid foods to her 6-monthold infant. What statement by the mother leads the nurse to determine that learning has taken place? a. I will give my infant rice cereal first.

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b. I will give my infant yellow vegetables first. c. I will give my infant egg yolks first. d. I will give my infant fruits first.

ANS: A Solid foods are usually introduced at about 6 months of age, starting with rice cereal, which is the least allergenic.

DIF: Cognitive Level: Comprehension REF: Page 375, Figure 15-9 OBJ: 9 TOP: Feeding the Healthy Child KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 16. What is the best nursing action when an 8-year-old child comes to the school nurse with his central incisor in his hand and reports he knocked his tooth out on the water fountain? a. Give him an ice cube to suck on. b. Have him wash his mouth out with peroxide and water. c. Wrap the tooth in a clean tissue. d. Wash off the tooth and place it in a container of milk.

ANS: D The tooth should be washed off and put in a container of milk to preserve it for possible reimplantation.

DIF: Cognitive Level: Application REF: Page 383, Nursing Tip OBJ: 10 TOP: Loss of Tooth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 17. The mother of a 7-month-old states, The baby is eating food now. Should I give him regular milk, too? What is the nurses best response? a. You should give the baby low-fat milk. b. Try the milk. See if he has any digestive problems. c. Continue breast milk or iron-fortified formula until 1 year of age. d. At this age, infants can tolerate lactose-free or soy-based milk.

ANS: C Whole milk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2 years of age.

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DIF: Cognitive Level: Application REF: Page 377, Nursing Tip OBJ: 9 TOP: Nutrition and Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 18. When a small group of preschool-age children were playing house, each child was pretending to be a particular family member. What type of play does the nurse recognize these children are participating in? a. Parallel b. Cooperative c. Symbolic d. Fantasy ANS: B In cooperative play, children play with each other, each taking a specific role.

DIF: Cognitive Level: Analysis REF: Page 384, Table 15-10 OBJ: 11 TOP: Play KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 19. When the nurse asks a 10-year-old Native American if he is ready to go to therapy, he does not answer immediately. How does the nurse interpret this response? a. Indecision b. Considering the answer in silence c. Shyness with strangers d. Fear of medical personnel ANS: B Native Americans value silence. They need to sit and consider matters before replying to questions.

DIF: Cognitive Level: Analysis REF: Page 367, Table 15-2 OBJ: 7 TOP: Ethnic ConsiderationsAmerican Indian KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. A mother tells the nurse, My 11-month-old son is not as active as my other children were at this age. He is the youngest of four and the older children love to dote on him. Which factor is influencing this childs language development?

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a. Heredity b. Sex c. Mothers health during pregnancy d. Ordinal position ANS: D Motor development of the youngest child may be prolonged if the child is babied by others in the family.

DIF: Cognitive Level: Analysis REF: Page 357 OBJ: 5 TOP: Factors Influencing Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 21. A mother tells her 4-year-old child that balls should be played with outside and not inside the house. Why is the child likely to obey the rule? a. The child does not want to be punished. b. The child wants to please her mother. c. The child respects authority figures. d. The child believes that following the rules is right.

ANS: A According to Kohlberg, children in the preconventional stage (4 to 7 years) are obedient to their parents for fear of punishment.

DIF: Cognitive Level: Comprehension REF: Page 368, Table 15-3 OBJ: 8 TOP: Moral Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 22. What should the nurse avoid when demonstrating a bath procedure to parents of Vietnamese origin? a. Talking directly to the mother b. Exposing the childs genitals c. Touching the childs head d. Using cool water ANS: C The Vietnamese are very sensitive about anyone touching a childs head because that is where consciousness lies.

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DIF: Cognitive Level: Application REF: Page 363, Table 15-2 OBJ: 7 TOP: Ethnic ConsiderationsVietnamese KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 23. What does the nurse calculate the basal metabolic index (BMI) of an 8-year-old child who is 48 inches tall (1.2 meters) and weighs 100 pounds (45.4 kg) to be? a. 28.9 b. 32.4 c. 34.8 d. 37.6 ANS: B The formula for BMI calculation is weight in kg divided by height in meters (squared): 45.4 (weight in kg) divided by 1.4 (1.2 squared) = 32.4. A BMI of over 30 is classified as obese.

DIF: Cognitive Level: Analysis REF: Page 379, Skill 15-2 OBJ: 9 TOP: Calculation of BMI KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 24. What toy is developmentally appropriate for the nurse to suggest to entertain a 5-year-old child? a. Jack-in-the-box b. Book of nursery rhymes c. Model airport with toy planes d. Model car construction kit ANS: C At this age children are into creative play. The model airport with toy planes is the most developmentally appropriate.

DIF: Cognitive Level: Application REF: Page 384, Table 15-10 OBJ: 11 TOP: Play Activities KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 25. The nurse caring for a 4-year-old postoperative patient instructs him to blow bubbles. What nursing intervention is the nurse most likely implementing by using this form of therapeutic

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play? a. Providing pain relief b. Encouraging deep breathing c. Decreasing risk of infection d. Maintaining body temperature ANS: B Play can also be therapeutic and aid in the recovery process. An example of therapeutic play is the game of having the child blow bubbles to promote deep breathing.

DIF: Cognitive Level: Application REF: Page 384 OBJ: 14 TOP: Therapeutic Play KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 26. The mother of a 7-year-old pediatric patient asks the nurse about her childs sleep requirement. What is the most accurate response by the nurse? a. 7 to 10 hours a night b. 5 to 7 hours a night with one daytime nap c. 11 to 13 hours a night d. 4 to 6 hours a night with two daytime naps ANS: C Sleep patterns vary with age. The neonate sleeps 8 to 9 hours per night and naps an equal amount of time during the day. The 2-year-old may sleep 10 hours during the night and have only one short daytime nap. The 7-year-old usually requires 11 to 13 hours of sleep and rarely has a daytime nap. These patterns may be altered by cultural practices.

DIF: Cognitive Level: Comprehension REF: Page 355 OBJ: 5 TOP: Sleep KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention MULTIPLE RESPONSE 27. How do children differ from adults? (Select all that apply.) a. Higher metabolic rate b. Greater surface area in relation to their weight c. Less mature organ systems d. More fluid reserves e. Continuously changing growth and development pattern

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ANS: A, B, C, E Children are in a continuous growth and development pattern. Children have a greater surface area and a higher metabolic rate. All of their organ systems are not mature.

DIF: Cognitive Level: Comprehension REF: Page 350-351 OBJ: 3 TOP: Adult Versus Child KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 28. What approaches should the nurse suggest for introducing a toddler to new foods? (Select all that apply.) a. Serve one food at a time. b. Avoid showing personal likes or dislikes. c. Offer foods in small amounts, less than a teaspoon. d. Entice the toddler to eat with sweets. e. Serve food warm.

ANS: A, B, C, E Foods should be introduced in small, warm servings, one food at a time. Sweets and milk should not be offered until after solid food.

DIF: Cognitive Level: Comprehension REF: Page 376, Table 15-8, 377 OBJ: 9 TOP: Solid Food KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 29. Which healthy snack foods would the school nurse suggest to a group of adolescents? (Select all that apply.) a. Bubble gum b. Chocolate-covered peanuts c. Raw vegetables d. Cheese e. Dried fruits ANS: C, D Cheese and raw vegetables are acceptable healthy snacks. Bubble gum, chocolate-covered peanuts, and dried fruits all contain high amounts of sugar.

DIF: Cognitive Level: Comprehension REF: Page 376, Table 15-8, 379 OBJ: 9 TOP: Healthy Snacks

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KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Growth and Development 30. The nurse suggests to the parents of an obese 10-year-old that they use the Portion Plate for Kids placemat. How does this tool help with selection of portion sizes? (Select all that apply.) a. Cartoon characters eating healthy foods b. Tips on healthy food choices c. Portion measurement in tablespoons for common food d. Calorie values for cup-size portions of common foods e. Familiar objects such as a deck of cards to measure servings ANS: B, E The Portion Plate for Kids is a placemat that uses common objects such as a deck of playing cards or a baseball to measure serving portions.

Chapter 17. Nursing Care of the Newborn at Risk MULTIPLE CHOICE 1. A macrosomic infant is born after a difficult forceps-assisted delivery. After stabilization the infant is weighed, and the birth weight is 4550 g (9 pounds, 6 ounces). The nurses most appropriate action is to:

a .

Leave the infant in the room with the mother.

b .

Take the infant immediately to the nursery.

c .

Perform a gestational age assessment to determine whether the infant is large for gestational age.

d .

Monitor blood glucose levels frequently and observe closely for signs of hypoglycemia.

ANS: D This infant is macrosomic (more than 4000 g) and is at high risk for hypoglycemia. Blood

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glucose levels should be monitored frequently, and the infant should be observed closely for signs of hypoglycemia. Observation may occur in the nursery or in the mothers room, depending on the condition of the fetus. Regardless of gestational age, this infant is macrosomic.

PTS: 1 DIF: Cognitive Level: Application REF: 668 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 2. Infants of mothers with diabetes (IDMs) are at higher risk for developing:

a .

Anemia.

c .

Respiratory distress syndrome.

b .

Hyponatremia.

d .

Sepsis.

ANS: C IDMs are at risk for macrosomia, birth injury, perinatal asphyxia, respiratory distress syndrome, hypoglycemia, hypocalcemia, hypomagnesemia, cardiomyopathy, hyperbilirubinemia, and polycythemia. They are not at risk for anemia, hyponatremia, or sepsis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 682 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 3. An infant was born 2 hours ago at 37 weeks of gestation and weighing 4.1 kg. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of:

a .

Birth injury.

c .

Hypoglycemia.

b .

Hypocalcemia.

d .

Seizures.

ANS: C

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Hypoglycemia is common in the macrosomic infant. Signs of hypoglycemia include jitteriness, apnea, tachypnea, and cyanosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 682 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 4. When assessing the preterm infant the nurse understands that compared with the term infant, the preterm infant has:

a .

Few blood vessels visible through the skin.

b .

More subcutaneous fat.

c .

Well-developed flexor muscles.

d .

Greater surface area in proportion to weight.

ANS: D Preterm infants have greater surface area in proportion to their weight. More subcutaneous fat and well-developed muscles are indications of a more mature infant.

PTS: 1 DIF: Cognitive Level: Analysis REF: 685 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 5. On day 3 of life, a newborn continues to require 100% oxygen by nasal cannula. The parents ask whether they can hold their infant during his next gavage feeding. Given that this newborn is physiologically stable, what response would the nurse give?

a .

Parents are not allowed to hold infants who depend on oxygen.

b .

You may hold only your babys hand during the feeding.

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c .

Feedings cause more physiologic stress, so the baby must be closely monitored.

Therefore, I dont think you should hold the baby.

d .

You may hold your baby during the feeding.

ANS: D You may hold your baby during the feeding is an accurate statement. Parental interaction via holding is encouraged during gavage feedings so that the infant will associate the feeding with positive interactions. Nasal cannula oxygen therapy allows for easier feedings and psychosocial interactions. The parent can swaddle the infant during gavage feedings to help the infant associate the feeding with positive interactions. Some parents like to do kangaroo care while gavage feeding their infant. Swaddling or kangaroo care during feedings provides positive interactions for the infant.

PTS: 1 DIF: Cognitive Level: Application REF: 700 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 6. A premature infant with respiratory distress syndrome receives artificial surfactant. How would the nurse explain surfactant therapy to the parents?

a .

Surfactant improves the ability of your babys lungs to exchange oxygen and carbon dioxide.

b .

The drug keeps your baby from requiring too much sedation.

c .

Surfactant is used to reduce episodes of periodic apnea.

d .

Your baby needs this medication to fight a possible respiratory tract infection.

ANS: A Surfactant can be administered as an adjunct to oxygen and ventilation therapy. With administration of artificial surfactant, respiratory compliance is improved until the infant can generate enough surfactant on his or her own. Surfactant has no bearing on the sedation needs of

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the infant. Surfactant is used to improve respiratory compliance, including the exchange of oxygen and carbon dioxide. The goal of surfactant therapy in an infant with respiratory distress syndrome (RDS) is to stimulate production of surfactant in the type 2 cells of the alveoli. The clinical presentation of RDS and neonatal pneumonia may be similar. The infant may be started on broad-spectrum antibiotics to treat infection.

PTS: 1 DIF: Cognitive Level: Application REF: 687 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 7. When providing an infant with a gavage feeding, which of the following should be documented each time?

a .

The infants abdominal circumference after the feeding

b .

The infants heart rate and respirations

c .

The infants suck and swallow coordination

d .

The infants response to the feeding

ANS: D Documentation of a gavage feeding should include the size of the feeding tube, the amount and quality of the residual from the previous feeding, the type and quantity of the fluid instilled, and the infants response to the procedure. Abdominal circumference is not measured after a gavage feeding. Vital signs may be obtained before feeding. However, the infants response to the feeding is more important. Some older infants may be learning to suck, but the important factor to document would be the infants response to the feeding (including attempts to suck).

PTS: 1 DIF: Cognitive Level: Application REF: 700 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 8. An infant is to receive gastrostomy feedings. What intervention should the nurse institute to prevent bloating, gastrointestinal reflux into the esophagus, vomiting, and respiratory

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compromise?

a .

Rapid bolusing of the entire amount in 15 minutes

b .

Warm cloths to the abdomen for the first 10 minutes

c .

Slow, small, warm bolus feedings over 30 minutes

d .

Cold, medium bolus feedings over 20 minutes

ANS: C Feedings by gravity are done slowly over 20- to 30-minute periods to prevent adverse reactions.

Rapid bolusing of the entire amount in 15 minutes would most likely lead to the adverse reactions listed. Temperature stability in the newborn is critical. Warm cloths to the abdomen for the first 10 minutes would not be appropriate because it is not a thermoregulated environment.

Additionally, abdominal warming is not indicated with feedings of any kind. Small feedings at room temperature are recommended to prevent adverse reactions.

PTS: 1 DIF: Cognitive Level: Application REF: 700 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 9. An infant at 26 weeks of gestation arrives intubated from the delivery room. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurses most appropriate action would be to:

a .

Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician.

b .

Continue to observe and make no changes until the saturations are 75%.

c .

Continue with the admission process to ensure that a thorough assessment is completed.

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d .

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Notify the parents that their infant is not doing well.

ANS: A Listening to breath sounds and ensuring the patency of the endotracheal tube, increasing oxygen, and notifying a physician are appropriate nursing interventions to assist in optimal oxygen saturation of the infant. Oxygenation of the infant is crucial. O2 saturation should be maintained above 92%. Oxygenation status of the infant is crucial. The nurse should delay other tasks to stabilize the infant. Notifying the parents that the infant is not doing well is not an appropriate action. Further assessment and intervention are warranted before determination of fetal status.

PTS: 1 DIF: Cognitive Level: Application REF: 688 OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity 10. A newborn was admitted to the neonatal intensive care unit after being delivered at 29 weeks of gestation to a 28-year-old multiparous, married, Caucasian woman whose pregnancy was uncomplicated until premature rupture of membranes and preterm birth. The newborns parents arrive for their first visit after the birth. The parents walk toward the bedside but remain approximately 5 feet away from the bed. The nurses most appropriate action would be to:

a .

Wait quietly at the newborns bedside until the parents come closer.

b .

Go to the parents, introduce himself or herself, and gently encourage the parents to come meet their infant; explain the equipment first, and then focus on the newborn.

c .

Leave the parents at the bedside while they are visiting so they can have some privacy.

d .

Tell the parents only about the newborns physical condition, and caution them to avoid touching their baby.

ANS: B The nurse is instrumental in the initial interactions with the infant. The nurse can help the parents see the infant, rather than focus on the equipment. The importance and purpose of the apparatus

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that surrounds their infant also should be explained to them. Parents often need encouragement and recognition from the nurse to acknowledge the reality of the infants condition. Parents need to see and touch their infant as soon as possible to acknowledge the reality of the birth and the infants appearance and condition. Encouragement from the nurse is instrumental in this process.

Telling the parents only about the newborns physical condition and cautioning them to avoid touching their baby is an inappropriate action.

PTS: 1 DIF: Cognitive Level: Application REF: 705 OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity 11. Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal mucosa.

The signs of NEC are nonspecific. Some generalized signs include:

a .

Hypertonia, tachycardia, and metabolic alkalosis.

b .

Abdominal distention, temperature instability, and grossly bloody stools.

c .

Hypertension, absence of apnea, and ruddy skin color.

d .

Scaphoid abdomen, no residual with feedings, and increased urinary output.

ANS: B Some generalized signs of NEC include decreased activity, hypotonia, pallor, recurrent apnea and bradycardia, decreased oxygen saturation values, respiratory distress, metabolic acidosis, oliguria, hypotension, decreased perfusion, temperature instability, cyanosis, abdominal distention, residual gastric aspirates, vomiting, grossly bloody stools, abdominal tenderness, and erythema of the abdominal wall. The infant may display hypotonia, bradycardia, and metabolic acidosis.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 693 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 12. An infant is being discharged from the neonatal intensive care unit after 70 days of

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hospitalization. The infant was born at 30 weeks of gestation with several conditions associated with prematurity, including respiratory distress syndrome, mild bronchopulmonary dysplasia, and retinopathy of prematurity requiring surgical treatment. During discharge teaching the infants mother asks the nurse whether her baby will meet developmental milestones on time, as did her son who was born at term. The nurses most appropriate response is:

a .

Your baby will develop exactly like your first child did.

b .

Your baby does not appear to have any problems at the present time.

c .

Your baby will need to be corrected for prematurity. Your baby is currently 40 weeks of postconceptional age and can be expected to be doing what a 40-weekold infant would be doing.

d .

Your baby will need to be followed very closely.

ANS: C The age of a preterm newborn is corrected by adding the gestational age and the postnatal age.

The infants responses are evaluated accordingly against the norm expected for the corrected age of the infant. Although it is impossible to predict with complete accuracy the growth and development potential of each preterm infant, certain measurable factors predict normal growth and development. The preterm infant experiences catch-up body growth during the first 2 to 3 years of life. The growth and developmental milestones are corrected for gestational age until the child is approximately 2.5 years old. Stating that the baby does not appear to have any problems at the present time is inaccurate. Development will need to be evaluated over time.

PTS: 1 DIF: Cognitive Level: Application REF: 676 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 13. A pregnant woman was admitted for induction of labor at 43 weeks of gestation with sure dates. A nonstress test (NST) in the obstetricians office revealed a nonreactive tracing. On artificial rupture of membranes, thick, meconium-stained fluid was noted. The nurse caring for the infant after birth should anticipate:

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a .

Meconium aspiration, hypoglycemia, and dry, cracked skin.

b .

Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome.

c .

Golden yellow- to green stainedskin and nails, absence of scalp hair, and an increased amount of subcutaneous fat.

d .

Hyperglycemia, hyperthermia, and an alert, wide-eyed appearance.

ANS: A Meconium aspiration, hypoglycemia, and dry, cracked skin are consistent with a postmature infant. Excessive vernix caseosa covering the skin, lethargy, and respiratory distress syndrome would be consistent with a very premature infant. The skin may be meconium stained, but the infant would most likely have longer hair and decreased amounts of subcutaneous fat.

Postmaturity with a nonreactive NST would indicate hypoxia. Signs and symptoms associated with fetal hypoxia are hypoglycemia, temperature instability, and lethargy.

PTS: 1 DIF: Cognitive Level: Analysis REF: 685 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 14. In caring for the preterm infant, what complication is thought to be a result of high arterial blood oxygen level?

a .

Necrotizing enterocolitis (NEC)

c .

Bronchopulmonary dysplasia (BPD)

b .

Retinopathy of prematurity (ROP)

d .

Intraventricular hemorrhage (IVH)

ANS: B ROP is thought to occur as a result of high levels of oxygen in the blood. NEC is caused by the interference of blood supply to the intestinal mucosa. Necrotic lesions occur at that site. BPD is caused by the use of positive pressure ventilation against the immature lung tissue. IVH results from rupture of the fragile blood vessels in the ventricles of the brain. It is most often associated

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with hypoxic injury, increased blood pressure, and fluctuating cerebral blood flow.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 690 OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity 15. In the assessment of a preterm infant, the nurse notices continued respiratory distress even though oxygen and ventilation have been provided. The nurse should suspect:

a .

Hypovolemia and/or shock.

c .

Central nervous system injury.

b .

A nonneutral thermal environment.

d .

Pending renal failure.

ANS: A The nurse should suspect hypovolemia and/or shock. Other symptoms could include hypotension, prolonged capillary refill, and tachycardia followed by bradycardia. Intervention is necessary.

PTS: 1 DIF: Cognitive Level: Application REF: 680 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Physiologic Integrity 16. Premature infants who exhibit 5 to 10 seconds of respiratory pauses followed by 10 to 15 seconds of compensatory rapid respiration are:

a .

Suffering from sleep or wakeful apnea.

b .

Experiencing severe swings in blood pressure.

c .

Trying to maintain a neutral thermal environment.

d .

Breathing in a respiratory pattern common to premature infants.

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ANS: D This pattern is called periodic breathing and is common to premature infants. It may still require nursing intervention of oxygen and/or ventilation. Apnea is a cessation of respirations for 20 seconds or longer. It should not be confused with periodic breathing.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 684 OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance 17. The nurse practicing in the perinatal setting should promote kangaroo care regardless of an infants gestational age. This intervention:

a .

Is adopted from classical British nursing traditions.

b .

Helps infants with motor and central nervous system impairment.

c .

Helps infants to interact directly with their parents and enhances their temperature regulation.

d .

Gets infants ready for breastfeeding.

ANS: C Kangaroo care is skin-to-skin holding in which the infant, dressed only in a diaper, is placed directly on the parents bare chest and then covered. The procedure helps infants interact with their parents and regulates their temperature, among other developmental benefits.

PTS: 1 DIF: Cognitive Level: Knowledge REF: 699 OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance 18. For clinical purposes, preterm and post-term infants are defined as:

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a .

Preterm before 34 weeks if appropriate for gestational age (AGA) and before 37 weeks if small for gestational age (SGA).

b .

Post-term after 40 weeks if large for gestational age (LGA) and beyond 42 weeks if AGA.

c .

Preterm before 37 weeks, and post-term beyond 42 weeks, no matter the size for gestational age at birth.

d .

Preterm, SGA before 38 to 40 weeks, and post-term, LGA beyond 40 to 42 weeks.

ANS: C Preterm and post-term are strictly measures of timebefore 37 weeks and beyond 42 weeks, respectivelyregardless of size for gestational age.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 664 OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance 19. With regard to small for gestational age (SGA) infants and intrauterine growth restrictions (IUGR), nurses should be aware that:

a .

In the first trimester diseases or abnormalities result in asymmetric IUGR.

b .

Infants with asymmetric IUGR have the potential for normal growth and development.

c .

In asymmetric IUGR weight is slightly more than SGA, whereas length and head circumference are somewhat less than SGA.

d .

Symmetric IUGR occurs in the later stages of pregnancy.

ANS: B IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester; SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy. Weight is less than the 10th percentile; head circumference is greater than the 10th

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percentile. Infants with asymmetric IUGR have the potential for normal growth and development.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 664 OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance 20. As related to the eventual discharge of the high risk newborn or transfer to a different facility, nurses and families should be aware that:

a .

Infants will stay in the neonatal intensive care unit (NICU) until they are ready to go home.

b .

Once discharged to home, the high risk infant should be treated like any healthy term newborn.

c .

Parents of high risk infants need special support and detailed contact information.

d .

If a high risk infant and mother need transfer to a specialized regional center, it is better to wait until after birth and the infant is stabilized.

ANS: C High risk infants can cause profound parental stress and emotional turmoil. Parents need support, special teaching, and quick access to various resources available to help them care for their baby.

Parents and their high risk infant should spend a night or two in a predischarge room, where care for the infant is provided away from the NICU. Just because high risk infants are discharged does not mean that they are normal, healthy babies. Follow-up by specialized practitioners is essential. Ideally, the mother and baby are transported with the fetus in utero; this reduces neonatal morbidity and mortality.

PTS: 1 DIF: Cognitive Level: Comprehension REF: 664 OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity 21. Necrotizing enterocolitis (NEC) is an acute inflammatory disease of the gastrointestinal mucosa that can progress to perforation of the bowel. Approximately 2% to 5% of premature infants succumb to this fatal disease. Care is supportive; however, known interventions may

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decrease the risk of NEC. To develop an optimal plan of care for this infant, the nurse must understand which intervention has the greatest effect on lowering the risk of NEC:

a .

Early enteral feedings

c .

Exchange transfusion

b .

Breastfeeding

d .

Prophylactic probiotics

ANS: B A decrease in the incidence of NEC is directly correlated with exclusive breastfeeding. Breast milk enhances maturation of the gastrointestinal tract and contains immune factors that contribute to a lower incidence or severity of NEC, Crohns disease, and celiac illness. The neonatal intensive care unit nurse can be very supportive of the mother in terms of providing her with equipment to pump breast milk, ensuring privacy, and encouraging skin-to-skin contact with the infant. Early enteral feedings of formula or hyperosmolar feedings are a risk factor known to contribute to the development of NEC. The mother should be encouraged to pump or feed breast milk exclusively. Exchange transfusion may be necessary; however, it is a known risk factor for the development of NEC. Although still early, a study in 2005 found that the introduction of prophylactic probiotics appeared to enhance the normal flora of the bowel and therefore decrease the severity of NEC when it did occur. This treatment modality is not as widespread as encouraging breastfeeding; however, it is another strategy that the care providers of these extremely fragile infants may have at their disposal.

PTS: 1 DIF: Cognitive Level: Application REF: 693 OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity 22. As a result of large body surface in relation to weight, the preterm infant is at high risk for heat loss and cold stress. By understanding the four mechanisms of heat transfer (convection, conduction, radiation, and evaporation), the nurse can create an environment for the infant that prevents temperature instability. While evaluating the plan that has been implemented, the nurse knows that the infant is experiencing cold stress when he or she exhibits:

a .

Decreased respiratory rate.

b .

Bradycardia followed by an increased heart rate.

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c .

Mottled skin with acrocyanosis.

d .

Increased physical activity.

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ANS: C The infant has minimal to no fat stores. During times of cold stress the skin will become mottled, and acrocyanosis will develop, progressing to cyanosis. Even if the infant is being cared for on a radiant warmer or in an isolette, the nurses role is to observe the infant frequently to prevent heat loss and respond quickly if signs and symptoms occur. The respiratory rate increases followed by periods of apnea. The infant initially tries to conserve heat and burns more calories, after which the metabolic system goes into overdrive. In the preterm infant experiencing heat loss, the heart rate initially increases, followed by periods of bradycardia. In the term infant, the natural response to heat loss is increased physical activity. However, in a term infant experiencing respiratory distress or in a preterm infant, physical activity is decreased.

PTS: 1 DIF: Cognitive Level: Analysis REF: 696 OBJ: Nursing Process: Evaluation MSC: Client Needs: Physiologic Integrity 23. Because of the premature infants decreased immune functioning, what nursing diagnosis should the nurse include in a plan of care for a premature infant?

a .

Delayed growth and development

c .

Ineffective infant feeding pattern

b .

Ineffective thermoregulation

d .

Risk for infection

ANS: D The nurse needs to understand that decreased immune functioning increases the risk for infection. Growth and development, thermoregulation, and feeding may be affected, although only indirectly.

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Chapter 18. Health Promotion of the Infant: Birth to One Year MULTIPLE CHOICE 1. A nurse is assessing a 12-month-old infant. Which statement best describes the infants physical development a nurse should expect to find? a. Anterior fontanel closes by age 6 to 10 months. b. Binocularity is well established by age 8 months. c. Birth weight doubles by age 5 months and triples by age 1 year. d. Maternal iron stores persist during the first 12 months of life.

ANS: C Growth is very rapid during the first year of life. The birth weight has approximately doubled by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months.

Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.

PTS: 1 DIF: Cognitive Level: Understand REF: 309 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development 2. The nurse is assessing a 6-month-old healthy infant who weighed 7 pounds at birth. The nurse should expect the infant to now weigh approximately how many pounds? a. 10 b. 15 c. 20 d. 25 ANS: B Birth weight doubles at about age 5 to 6 months. At 6 months, a child who weighed 7 pounds at birth would weigh approximately 15 pounds; 10 pounds is too little. The infant would have gone from the 50th percentile at birth to below the 5th percentile; 20 to 25 pounds is too much. The infant would have tripled the birth weight at 6 months.

PTS: 1 DIF: Cognitive Level: Understand REF: 309 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development 3. The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior

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fontanel is closed. The nurse should interpret this as a(n): a. normal finding. b. finding requiring a referral. c. abnormal finding. d. normal finding, but requires rechecking in 1 month.

ANS: A This is a normal finding. The anterior fontanel closes between ages 12 and 18 months. No further intervention is required.

PTS: 1 DIF: Cognitive Level: Apply REF: 309 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 4. A nurse is assessing a 6-month-old infant. The nurse recognizes the posterior fontanel usually closes at which age? a. 6 to 8 weeks b. 10 to 12 weeks c. 4 to 6 months d. 8 to 10 months ANS: A The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks; 10 to 12 weeks, 4 to 6 months, and 8 to 10 months are too late. The posterior fontanel is usually closed by age 8 weeks.

PTS: 1 DIF: Cognitive Level: Remember REF: 309 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 5. The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infants stools. The nurses explanation of this is based on which statement? a. Child should not be given fibrous foods until digestive tract matures at age 4 years. b. Child should not be given any solid foods until this digestive problem is resolved. c. This is abnormal and requires further investigation. d. This is normal because of the immaturity of digestive processes at this age.

ANS: D The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are

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passed incompletely broken down in the feces. An excess quantity of fiber predisposes the child to large, bulky stools. This is normal for the child and is a normal part of the maturational process; no further investigation is necessary.

PTS: 1 DIF: Cognitive Level: Apply REF: 309 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 6. A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands, but she will not voluntarily grasp it. The nurse should interpret this as: a. normal development. b. significant developmental lag. c. slightly delayed development due to prematurity. d. suggestive of a neurologic disorder such as cerebral palsy.

ANS: A Holding a rattle but not voluntarily grasping it is indicative of normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. The infant is expected to be able to perform this task by age 3 months. If the childs age is corrected because of being 2 weeks preterm, the child is at the midpoint of the range for this developmental task and the behavior is age appropriate. No evidence of neurologic dysfunction is present.

PTS: 1 DIF: Cognitive Level: Apply REF: 315 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 7. In terms of fine motor development, what should the infant of 7 months be able to do? a. Transfer objects from one hand to the other and bang cubes on a table. b. Use thumb and index finger in crude pincer grasp and release an object at will. c. Hold a crayon between the fingers and make a mark on paper. d. Release cubes into a cup and build a tower of two blocks.

ANS: A By age 7 months, infants can transfer objects from one hand to the other, crossing the midline, and bang objects on a hard surface. The crude pincer grasp is apparent at about age 9 months, and releasing an object at will is seen around 8 months. The child can scribble spontaneously at age 15 months. At age 12 months, the child can release cubes into a cup and build a small tower.

PTS: 1 DIF: Cognitive Level: Understand REF: 315

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TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 8. At what age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months ANS: C Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.

PTS: 1 DIF: Cognitive Level: Understand REF: 316 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 9. The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurses response should be based on knowledge that this is: a. unacceptable because of the risk of sudden infant death syndrome (SIDS). b. unacceptable because it does not encourage achievement of developmental milestones. c. acceptable to encourage fine motor development. d. acceptable to encourage head control and turning over.

ANS: D These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs and then be placed on their abdomens when awake to enhance development of milestones such as head control. The face-down position while awake and on the back for sleep are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor, development.

PTS: 1 DIF: Cognitive Level: Analyze REF: 315-316 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 10. By which age should the nurse expect an infant to be able to pull to a standing position? a. 6 months b. 8 months

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c. 11 to 12 months d. 14 to 15 months ANS: C Most infants can pull themselves to a standing position at age 9 months. Infants who are not able to pull themselves to standing by age 11 to 12 months should be further evaluated for developmental dysplasia of the hip. At 6 months, infants have just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs. Any infant who cannot pull to a standing position by age 1 year should be referred for further evaluation.

PTS: 1 DIF: Cognitive Level: Understand REF: 317 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 11. According to Piaget, the 6-month-old infant should be in which developmental stage? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata ANS: C Infants are usually in the secondary circular reaction stage from ages 4 to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results.

Shaking is performed to hear the noise of the rattle, not just for shaking. The use of reflexes is primarily during the first month of life. Primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from ages 1 to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.

PTS: 1 DIF: Cognitive Level: Remember REF: 319 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 12. A nurse is conducting a teaching session for parents of infants. The nurse explains that which behavior indicates that an infant has developed object permanence? a. Recognizes familiar face, such as mother b. Recognizes familiar object, such as bottle c. Actively searches for a hidden object d. Secures objects by pulling on a string

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ANS: C During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to the mother. They cry, smile, vocalize, and show distinct preference for the mother. This preference is one of the stages that influences the attachment process but is too early for object permanence. Recognizing familiar objects is an important transition for the infant, but it does not signal object permanence. The ability to understand cause and effect is part of secondary schemata development.

PTS: 1 DIF: Cognitive Level: Understand REF: 319 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 13. A parent asks the nurse at what age do most infants begin to fear strangers? The nurse should give which response? a. 2 months b. 4 months c. 6 months d. 12 months ANS: C Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the infants ability to discriminate between familiar and unfamiliar people. At 2 months, infants are just beginning to respond differentially to the mother. At age 4 months, the infant is beginning the process of separation-individuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the child does not fear strangers at this age.

PTS: 1 DIF: Cognitive Level: Understand REF: 321 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 14. The nurse is interviewing the father of a 10-month-old infant. She is playing on the floor when she notices an electric outlet and reaches up to touch it. Her father says no firmly and removes her from near the outlet. The nurse should use this opportunity to teach the father that the infant: a. is old enough to understand the word no.

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b. is too young to understand the word no. c. should already know that electric outlets are dangerous. d. will learn safety issues better if she is spanked.

ANS: A By age 10 months, children are able to associate meaning with words. The father is using both verbal and physical cues to alert the child to dangerous situations. The child should be old enough to understand the word no. The 10-month-old is too young to understand the purpose of an electric outlet. The father is using both verbal and physical cues to teach safety measures.

Physical discipline should be avoided.

PTS: 1 DIF: Cognitive Level: Apply REF: 322 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 15. A 4-month-old was born at 35 weeks of gestation. She seems to be developing normally, but her parents are concerned because she is a more difficult baby than their other child, who was term. The nurse should explain that: a. infants temperaments are part of their unique characteristics. b. infants become less difficult if they are not kept on scheduled feedings and structured routines. c. the infants behavior is suggestive of failure to bond completely with her parents. d. the infants difficult temperament is the result of painful experiences in the neonatal period.

ANS: A Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infants unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in routines. The infants temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to the infants temperament.

PTS: 1 DIF: Cognitive Level: Understand REF: 322 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 16. Which information could be given to the parents of a 12-month-old child regarding appropriate play activities? a. Give large push-pull toys for kinetic stimulation. b. Place cradle gym across crib to facilitate fine motor skills.

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c. Provide child with finger-paints to enhance fine motor skills. d. Provide stick horse to develop gross motor coordination.

ANS: A The 12-month-old child is able to pull to standing and walk holding on or independently.

Appropriate toys for a child this age include large pull toys for kinesthetic stimulation. A cradle gym should not be placed across the crib. Finger-paints are appropriate for older children. A 12month-old child does not have the stability to use a stick horse.

PTS: 1 DIF: Cognitive Level: Apply REF: 322 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development 17. The nurse is discussing development and play activities with the parent of a 2-month-old.

Recommendations should include giving a first rattle at about which age? a. 2 months b. 4 months c. 7 months d. 9 months ANS: B It is recommended that a brightly colored toy or rattle be given to the child at age 4 months.

Grasping has begun as a deliberate act, and the infant grasps, holds, and begins shaking to hear a noise; 2 months is too young. The infant still has primarily reflex grips; 7 to 9 months is too old for the first rattle. The child should be given toys that provide for further exploration.

PTS: 1 DIF: Cognitive Level: Apply REF: 322 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 18. Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation? a. Playing peek-a-boo b. Playing pat-a-cake c. Imitating animal sounds d. Showing how to clap hands ANS: A Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Pat-a-cake and showing how to clap hands will help with

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kinetic stimulation. Imitating animal sounds will help with auditory stimulation.

PTS: 1 DIF: Cognitive Level: Apply REF: 322 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 19. Which would be the best play activity for a 6-month-old infant to provide tactile stimulation? a. Allow to splash in bath. b. Give various colored blocks. c. Play music box, tapes, or CDs. d. Use infant swing or stroller.

ANS: A The feel of the water while the infant is splashing will provide tactile stimulation. Various colored blocks would provide visual stimulation for a 4- to 6-month-old infant. Music box, tapes, and CDs provide auditory stimulation. Swings and strollers provide kinesthetic stimulation.

PTS: 1 DIF: Cognitive Level: Apply REF: 322 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Health Promotion and Maintenance 20. At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? a. 1 month b. 2 months c. 3 months d. 4 months ANS: B At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. The 3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.

PTS: 1 DIF: Cognitive Level: Understand REF: 321 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 21. At what age does an infant start to recognize familiar faces and objects, such as a feeding bottle? a. 1 month

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b. 2 months c. 3 months d. 4 months ANS: C The child can recognize familiar objects at approximately age 3 months. For the first 2 months of life, infants watch and observe their surroundings. The 4-month-old infant is able to anticipate feeding after seeing the bottle.

PTS: 1 DIF: Cognitive Level: Understand REF: 310 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 22. A parent asks the nurse when will my infant start to teethe? The nurse responds that the earliest age at which an infant begins teething with eruption of lower central incisors is months. a. 4 b. 6 c. 8 d. 12 ANS: B Teething usually begins at age 6 months with the eruption of the lower central incisors; 4 months is too early for teething. By age 8 months, the infant has the upper and lower central incisors. At age 12 months, the infant has six to eight deciduous teeth.

PTS: 1 DIF: Cognitive Level: Apply REF: 325 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 23. The nurse is guiding parents in selecting a daycare facility for their infant. Which is especially important to consider when making the selection? a. Health practices of facility b. Structured learning environment c. Socioeconomic status of children d. Cultural similarities of children ANS: A Health practices should be most important. With the need for diaper changes and assistance with feeding, young children are at increased risk when hand washing and other hygienic measures

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are not adhered to. A structured learning environment is not suitable for this age child. The socioeconomic status of children should have little effect on the choice of facility. Cultural similarities of children may be important to the families, but the health care practices of the facility are more important.

PTS: 1 DIF: Cognitive Level: Understand REF: 323-234 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 24. Austin, age 6 months, has six teeth. The nurse should recognize that this is: a. normal tooth eruption. b. delayed tooth eruption. c. unusual and dangerous. d. earlier-than-normal tooth eruption.

ANS: D Six months is earlier than expected. Most infants at age 6 months have two teeth. Although unusual, it is not dangerous.

PTS: 1 DIF: Cognitive Level: Understand REF: 325 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 25. The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive, inflexible, high-top shoes. The nurse should explain that: a. soft and flexible shoes are generally better. b. high-top shoes are necessary for support. c. inflexible shoes are necessary to prevent in-toeing and out-toeing. d. this type of shoe will encourage the infant to walk sooner.

ANS: A The main purpose of the shoe is protection. Soft, well-constructed, athletic-type shoes are best for infants and children. High-top shoes are not necessary for support but may help to keep the childs foot in the shoe. Inflexible shoes can delay walking and can aggravate in-toeing and out- toeing and impede development of the supportive foot muscles.

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Chapter 19. Health Promotion of the Toddler MULTIPLE CHOICE 1. Which factor is most important in predisposing toddlers to frequent infections? a. Respirations are abdominal. b. Pulse and respiratory rates are slower than those in infancy. c. Defense mechanisms are less efficient than those during infancy. d. Toddlers have a short, straight internal ear canal and large lymph tissue.

ANS: D Toddlers continue to have the short, straight internal ear canal of infants. The lymphoid tissue of the tonsils and adenoids continues to be relatively large. These two anatomic conditions combine to predispose the toddler to frequent infections. The abdominal respirations and lowered pulse and respiratory rate of toddlers do not affect their susceptibility to infection. The defense mechanisms are more efficient compared with those of infancy.

PTS: 1 DIF: Cognitive Level: Analyze REF: 379 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 2. The psychosocial developmental tasks of toddlerhood include which characteristic? a. Development of a conscience b. Recognition of sex differences c. Ability to get along with age-mates d. Ability to delay gratification ANS: D If the need for basic trust has been satisfied, then toddlers can give up dependence for control, independence, and autonomy. One of the tasks that the toddler is concerned with is the ability to delay gratification. Development of a conscience occurs during the preschool years. The recognition of sex differences occurs during the preschool years. The ability to get along with age-mates develops during the preschool and school-age years.

PTS: 1 DIF: Cognitive Level: Understand REF: 380 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 3. The child of 15 to 30 months is likely to be struggling with which developmental task?

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a. Trust b. Initiative c. Autonomy d. Intimacy ANS: C Autonomy vs shame and doubt is the developmental task of toddlers. Trust vs mistrust is the developmental stage of infancy. Initiative vs guilt is the developmental stage of early childhood.

Intimacy and solidarity vs isolation is the developmental stage of early adulthood.

PTS: 1 DIF: Cognitive Level: Remember REF: 380 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 4. A parent of an 18-month-old boy tells the nurse that he says no to everything and has rapid mood swings. If he is scolded, he shows anger and then immediately wants to be held. The nurses best interpretation of this behavior is included in which statement? a. This is normal behavior for his age. b. This is unusual behavior for his age. c. He is not effectively coping with stress. d. He is showing he needs more attention.

ANS: A Toddlers use distinct behaviors in the quest for autonomy. They express their will with continued negativity and the use of the word no. Children at this age also have rapid mood swings. The nurse should reassure the parents that their child is engaged in expected behavior for an 18month-old. Having a rapid mood swing is an expected behavior for a toddler.

PTS: 1 DIF: Cognitive Level: Understand REF: 379 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 5. A nurse is planning care for a 17-month-old child. According to Piaget, which stage should the nurse expect the child to be in cognitively? a. Trust b. Preoperational c. Secondary circular reaction d. Tertiary circular reaction ANS: D

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The 17-month-old child is in the fifth stage of the sensorimotor phase, tertiary circular reactions.

The child uses active experimentation to achieve previously unattainable goals. Trust is Eriksons first stage. Preoperational is the stage of cognitive development usually present in older toddlers and preschoolers. Secondary circular reactions last from about ages 4 to 8 months.

PTS: 1 DIF: Cognitive Level: Remember REF: 380 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Health Promotion and Maintenance 6. Which is descriptive of a toddlers cognitive development at age 20 months? a. Searches for an object only if he or she sees it being hidden b. Realizes that out of sight is not out of reach c. Puts objects into a container but cannot take them out d. Understands the passage of time, such as just a minute and in an hour ANS: B At this age, the child is in the final sensorimotor stage. Children will now search for an object in several potential places, even though they saw only the original hiding place. Children have a more developed sense of objective permanence. They will search for objects even if they have not seen them hidden. When a child puts objects into a container but cannot take them out, this is indicative of tertiary circular reactions. An embryonic sense of time exists, although the children may behave appropriately to time-oriented phrases; their sense of timing is exaggerated.

PTS: 1 DIF: Cognitive Level: Understand REF: 381 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 7. Although a 14-month-old girl received a shock from an electric outlet recently, her parent finds her about to place a paper clip in another outlet. Which is the best interpretation of this behavior? a. Her cognitive development is delayed. b. This is typical behavior because toddlers are not very developed. c. This is typical behavior because of the inability to transfer knowledge to new situations. d. This is not typical behavior because toddlers should know better than to repeat an act that caused pain.

ANS: C During the tertiary circular reactions stage, children have only a rudimentary sense of the classification of objects. The appearance of an object denotes its function for these children. The

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slot of an outlet is for putting things into. Her cognitive development is appropriate for her age.

Trying to put things into an outlet is typical behavior for a toddler. Only some awareness exists of a causal relation between events.

PTS: 1 DIF: Cognitive Level: Understand REF: 381 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 8. Two toddlers are playing in a sandbox when one child suddenly grabs a toy from the other child. Which is the best interpretation of this behavior? a. This is typical behavior because toddlers are aggressive. b. This is typical behavior because toddlers are egocentric. c. Toddlers should know that sharing toys is expected of them. d. Toddlers should have the cognitive ability to know right from wrong.

ANS: B Play develops from the solitary play of infancy to the parallel play of toddlers. The toddler plays alongside other children, not with them. This typical behavior of the toddler is not intentionally aggressive. Shared play is not within their cognitive development. Toddlers do not conceptualize shared play. Because the toddler cannot view the situation from the perspective of the other child, it is okay to take the toy. Therefore, no right or wrong is associated with taking a toy.

PTS: 1 DIF: Cognitive Level: Analyze REF: 385 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 9. Steven, 16 months old, falls down a few stairs. He gets up and scolds the stairs as if they caused him to fall. This is an example of which of the following? a. Animism b. Ritualism c. Irreversibility d. Delayed cognitive development ANS: A Animism is the attribution of lifelike qualities to inanimate objects. By scolding the stairs, the toddler is attributing human characteristics to them. Ritualism is the need to maintain the sameness and reliability. It provides a sense of comfort to the toddler. Irreversibility is the inability to reverse or undo actions initiated physically. Steven is acting in an age-appropriate

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manner.

PTS: 1 DIF: Cognitive Level: Understand REF: 382 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 10. Which should the nurse expect for a toddlers language development at age 18 months? a. Vocabulary of 25 words b. Increasing level of comprehension c. Use of holophrases d. Approximately one third of speech understandable ANS: B During the second year of life, level of comprehension and understanding of speech increases and is far greater than the childs vocabulary. This is also true for bilingual children, who are able to achieve this linguistic milestone in both languages. The 18-month-old child has a vocabulary of 10 or more words. At this age, the child does not use the one-word sentences that are characteristic of the 1-year-old child. The child has a limited vocabulary of single words that are comprehensible.

PTS: 1 DIF: Cognitive Level: Understand REF: 384 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 11. Which statement is correct about toilet training? a. Bladder training is usually accomplished before bowel training. b. Wanting to please the parent helps motivate the child to use the toilet. c. Watching older siblings use the toilet confuses the child. d. Children must be forced to sit on the toilet when first learning.

ANS: B Voluntary control of the anal and urethral sphincters is achieved sometime after the child is walking. The child must be able to recognize the urge to let go and to hold on. The child must want to please parent by holding on rather than pleasing self by letting go. Bowel training precedes bladder training. Watching older siblings provides role modeling and facilitates imitation for the toddler. The child should be introduced to the potty chair or toilet in a nonthreatening manner.

PTS: 1 DIF: Cognitive Level: Understand REF: 385

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TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 12. Which characteristic best describes the gross motor skills of a 24-month-old child? a. Skips and can hop in place on one foot b. Rides tricycle and broad jumps c. Jumps with both feet and stands on one foot momentarily d. Walks up and down stairs and runs with a wide stance ANS: D The 24-month-old child can go up and down stairs alone with two feet on each step and runs with a wide stance. Skipping and hopping on one foot are achieved by 4-year-old children.

Jumping with both feet and standing on one foot momentarily are achieved by 30-month-old children. Tricycle riding and broad jumping are achieved at age 3.

PTS: 1 DIF: Cognitive Level: Remember REF: 379 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 13. In the clinic waiting room, a nurse observes a parent showing an 18-month-old child how to make a tower out of blocks. The nurse should recognize in this situation that: a. blocks at this age are used primarily for throwing. b. toddlers are too young to imitate the behavior of others. c. toddlers are capable of building a tower of blocks. d. toddlers are too young to build a tower of blocks.

ANS: C Building with blocks is a good parent-child interaction. The 18-month-old child is capable of building a tower of three or four blocks. The ability to build towers of blocks usually begins at age 15 months. With ongoing development, the child is able to build taller towers. The 18month-old child imitates others around him or her.

PTS: 1 DIF: Cognitive Level: Apply REF: 380 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 14. At what age should the nurse expect a child to give both first and last names when asked? a. 15 months b. 18 months

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c. 24 months d. 30 months ANS: D At 30 months, the child is able to give both first and last names and refer to self with an appropriate pronoun. At 15 and 18 months, the child is too young to give his or her own name.

At 24 months, the child is able to give first name and refer to self by that name.

PTS: 1 DIF: Cognitive Level: Understand REF: 384 | 387 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 15. The parents of a newborn say that their toddler hates the baby; he suggested that we put him in the trash can so the trash truck could take him away. Which is the nurses best reply? a. Lets see if we can figure out why he hates the new baby. b. Thats a strong statement to come from such a small boy. c. Lets refer him to counseling to work this hatred out. Its not a normal response. d. That is a normal response to the birth of a sibling. Lets look at ways to deal with this.

ANS: D The arrival of a new infant represents a crisis for even the best-prepared toddler. Toddlers have their entire schedule and routines disrupted because of the new family member. The nurse should work with parents on ways to involve the toddler in the newborns care and to help focus attention on the toddler. The toddler does not hate the infant. This is an expected response to the changes in routines and attention that affect the toddler. The toddler can be provided with a doll to tend to the dolls needs at the same time the parent is performing similar care for the newborn.

PTS: 1 DIF: Cognitive Level: Apply REF: 389 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 16. A toddlers parent asks the nurse for suggestions on dealing with temper tantrums. Which is the most appropriate recommendation? a. Punish the child. b. Leave the child alone until the tantrum is over. c. Remain close by the child but without eye contact. d. Explain to child that this is wrong.

ANS: C The parent should be told that the best way to deal with temper tantrums is to ignore the

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behaviors, provided that the actions are not dangerous to the child. Tantrums are common in toddlers as the child becomes more independent and overwhelmed by increasingly complex tasks. The parents and caregivers need to have consistent and developmentally appropriate expectations. Punishment and explanations will not be beneficial. The parents presence is necessary both for safety and to provide a feeling of control and security to the child when the tantrum is over.

PTS: 1 DIF: Cognitive Level: Apply REF: 389-390 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 17. A parent asks the nurse about negativism in toddlers. Which is the most appropriate recommendation? a. Punish the child. b. Provide more attention. c. Ask child not always to say no. d. Reduce the opportunities for a no answer.

ANS: D The nurse should suggest to the parent that questions be phrased with realistic choices rather than yes or no answers. This provides the toddler with a sense of control and reduces the opportunity for negativism. Negativism is not an indication of stubbornness or insolence and should not be punished. The negativism is not a function of attention; the child is testing limits to gain an understanding of the world. The toddler is too young to be asked to not always say no.

PTS: 1 DIF: Cognitive Level: Apply REF: 390 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 18. Which technique is best for dealing with the negativism of the toddler? a. Offer the child choices. b. Remain serious and intent. c. Provide few or no choices for child. d. Quietly and calmly ask the child to comply.

ANS: A The child should have few opportunities to respond in a negative manner. Questions and requests should provide choices. This allows the child to be in control and reduces opportunities for negativism. The child will continue trying to assert control. The toddler is too young for verbal

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explanations. The negativism is the child testing limits. These should be clearly defined by structured choices.

PTS: 1 DIF: Cognitive Level: Understand REF: 390 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 19. The parents of a 2-year-old tell the nurse that they are concerned because the toddler has started to use baby talk since the arrival of their new baby. The nurse should recommend which intervention? a. Ignore the baby talk. b. Explain to the toddler that baby talk is for babies. c. Tell the toddler frequently, You are a big kid now. d. Encourage the toddler to practice more advanced patterns of speech.

ANS: A The baby talk is a sign of regression in the toddler. It should be ignored, while praising the child for developmentally appropriate behaviors. Regression is childrens way of expressing stress. The parents should not introduce new expectations and allow the child to master the developmental tasks without criticism.

PTS: 1 DIF: Cognitive Level: Apply REF: 389-390 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 20. Parents tell the nurse that their toddler daughter eats little at mealtime, only sits at the table with the family briefly, and wants snacks all the time. Which intervention should the nurse recommend? a. Give her nutritious snacks. b. Offer rewards for eating at mealtimes. c. Avoid snacks so she is hungry at mealtimes. d. Explain to her in a firm manner what is expected of her.

ANS: A Most toddlers exhibit a physiologic anorexia in response to the decreased nutritional requirement associated with the slower growth rate. Parents should help the child develop healthy eating habits. The toddler is often unable to sit through a meal. Frequent nutritious snacks are a good way to ensure proper nutrition. To help with developing healthy eating habits, food should be not be used as positive or negative reinforcement for behavior. The child may develop habits of

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overeating or eat nonnutritious foods in response.

PTS: 1 DIF: Cognitive Level: Apply REF: 390 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 21. A father tells the nurse that his daughter wants the same plate and cup used at every meal, even if they go to a restaurant. The nurse should explain that this is: a. a sign the child is spoiled. b. a way to exert unhealthy control. c. regression, common at this age. d. ritualism, common at this age.

ANS: D The child is exhibiting the ritualism that is characteristic at this age. Ritualism is the need to maintain sameness and reliability. It provides a sense of comfort to the toddler. It will dictate certain principles in feeding practices, including rejecting a favorite food because it is served in a different container. Ritualism is not indicative of a child who has unreasonable expectations, but rather normal development. Toddlers use ritualistic behaviors to maintain necessary structure in their lives. This is not regression, which is a retreat from a present pattern of functioning.

PTS: 1 DIF: Cognitive Level: Apply REF: 391 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 22. Developmentally, most children at age 12 months: a. use a spoon adeptly. b. relinquish the bottle voluntarily. c. eat the same food as the rest of the family. d. reject all solid food in preference to the bottle.

ANS: C By age 12 months, most children are eating the same food that is prepared for the rest of the family. Using a spoon usually is not mastered until age 18 months. The parents should be engaged in weaning a child from a bottle if that is the source of liquid. Toddlers should be encouraged to drink from a cup at the first birthday and be weaned from the bottle totally by 14 months. The child should be weaned from a milk- or formula-based diet to a balanced diet that includes iron-rich sources of food.

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PTS: 1 DIF: Cognitive Level: Understand REF: 391 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 23. The most effective way to clean a toddlers teeth is for the: a. child to brush regularly with a toothpaste of his or her choice. b. parent to stabilize the chin with one hand and brush with the other. c. parent to brush the mandibular occlusive surfaces, leaving the rest for the child. d. parent to brush the front labial surfaces, leaving the rest for the child.

ANS: B For young children, the most effective cleaning of teeth is by the parents. Different positions can be used if the childs back is to the adult. The adult should use one hand to stabilize the chin and the other to brush the childs teeth. The child can participate in brushing, but for a thorough cleaning, adult intervention is necessary.

PTS: 1 DIF: Cognitive Level: Understand REF: 394 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 24. Which is an appropriate recommendation for preventing tooth decay in young children? a. Substitute raisins for candy. b. Substitute sugarless gum for regular gum. c. Use honey or molasses instead of refined sugar. d. When sweets are to be eaten, select a time not during meals.

ANS: B Regular gum has high sugar content. When the child chews gum, the sugar is in prolonged contact with the teeth. Sugarless gum is less cariogenic than regular gum. Raisins, honey, and molasses are highly cariogenic and should be avoided. Sweets should be consumed with meals so that the teeth can be cleaned afterward. This decreases the amount of time that the sugar is in contact with the teeth.

PTS: 1 DIF: Cognitive Level: Analyze REF: 395 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 25. Which is the leading cause of death during the toddler period? a. Injuries

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b. Infectious diseases c. Congenital disorders d. Childhood diseases ANS: A Injuries are the single most common cause of death in children ages 1 through 4 years. This represents the highest rate of death from injuries of any childhood age group except adolescence.

Infectious diseases and childhood diseases are less common causes of deaths in this age group.

Congenital disorders are the second leading cause of death in this age group.

PTS: 1 DIF: Cognitive Level: Understand REF: 396 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment 26. Kimberlys parents have been using a rearward-facing, convertible car seat since she was born. Most car seats can be safely switched to the forward-facing position when the child reaches which age? a. 1 b. 2 c. 3 d. 4 ANS: B It is now recommended that all infants and toddlers ride in rear-facing car safety seats until they reach the age of 2 years or height recommended by the car seat manufacturer. Children 2 years old and older who have outgrown the rear-facing height or weight limit for their car safety seat should use a forward-facing car safety seat with a harness up to the maximum height or weight recommended by the manufacturer. One year is too young to switch to a forward-facing position.

PTS: 1 DIF: Cognitive Level: Understand REF: 396 | 398 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment 27. The nurse recommends to parents that peanuts are not a good snack food for toddlers. The nurses rationale for this action is that they: a. are low in nutritive value. b. are high in sodium. c. cannot be entirely digested. d. can be easily aspirated.

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ANS: D Foreign-body aspiration is common during the second year of life. Although they chew well, this age child may have difficulty with large pieces of food, such as meat and whole hot dogs, and with hard foods, such as nuts or dried beans. Peanuts have many beneficial nutrients, but should be avoided because of the risk of aspiration in this age group. The sodium level may be a concern, but the risk of aspiration is more important. Many foods pass through the gastrointestinal tract incompletely undigested. This is not necessarily detrimental to the child.

Chapter 20. Health Promotion of the Preschooler MULTIPLE CHOICE 1. Which should the nurse expect of a healthy 3-year-old child? a. Jump rope. b. Ride a two-wheel bicycle. c. Skip on alternate feet. d. Balance on one foot for a few seconds.

ANS: D Three-year-olds are able to accomplish this gross motor skill. Jumping rope, riding a two-wheel bicycle, and skipping on alternate feet are gross motor skills of 5-year-olds.

PTS: 1 DIF: Cognitive Level: Understand REF: 408 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 2. In terms of fine motor development, which should the 3-year-old child be expected to do? a. Lace shoes and tie shoelaces with a bow. b. Use scissors to cut pictures, and print a few numbers. c. Draw a person with seven parts and correctly identify the parts. d. Draw a circle and name what has been drawn.

ANS: D Three-year-olds are able to accomplish this fine motor skill. Being able to lace shoes and tie shoelaces with a bow, use scissors to cut pictures, and print a few numbers, or draw a person with seven parts and correctly identify the parts are fine motor skills of 4- or 5-year-olds.

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PTS: 1 DIF: Cognitive Level: Understand REF: 408 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 3. A nurse is assessing a preschool-age child and notes the child exhibits magical thinking.

According to Piaget, which describes magical thinking? a. Events have cause and effect. b. God is like an imaginary friend. c. Thoughts are all-powerful. d. If the skin is broken, the childs insides will come out.

ANS: C Because of their egocentrism and transductive reasoning, preschoolers believe that thoughts are all-powerful. Cause-and-effect implies logical thought, not magical thinking. Thinking God is like an imaginary friend is an example of concrete thinking in a preschoolers spiritual development. Thinking that if the skin is broken, the childs insides will come out is an example of concrete thinking in development of body image.

PTS: 1 DIF: Cognitive Level: Apply REF: 409 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 4. A nurse, instructing parents of a hospitalized preschool child, explains that which is descriptive of the preschoolers understanding of time? a. Has no understanding of time b. Associates time with events c. Can tell time on a clock d. Uses terms like yesterday appropriately ANS: B In a preschoolers understanding, time has a relation with events such as Well go outside after lunch. Preschoolers develop an abstract sense of time at age 3 years. Children can tell time on a clock at age 7 years. Children do not fully understand use of time-oriented words until age 6 years.

PTS: 1 DIF: Cognitive Level: Understand REF: 409 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

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5. The nurse is caring for a hospitalized 4-year-old boy. His parents tell the nurse that they will be back to visit at 6 PM. When the child asks the nurse when his parents are coming, the nurses best response is a. They will be here soon. b. They will come after dinner. c. Let me show you on the clock when 6 PM is. d. I will tell you every time I see you how much longer it will be.

ANS: B A 4-year-old child understands time in relation to events such as meals. Children perceive soon as a very short time. The nurse may lose the childs trust if his parents do not return in the time he perceives as soon. Children cannot read or use a clock for practical purposes until age 7 years. I will tell you every time I see you how much longer it will be assumes the child understands the concepts of hours and minutes, which are not developed until age 5 or 6 years.

PTS: 1 DIF: Cognitive Level: Apply REF: 409 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 6. A 4-year-old child is hospitalized with a serious bacterial infection. The child tells the nurse that he is sick because he was bad. Which is the nurses best interpretation of this comment? a. Sign of stress b. Common at this age c. Suggestive of maladaptation d. Suggestive of excessive discipline at home ANS: B Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think they are directly responsible for events, making them feel guilty for things outside their control. Children of this age show stress by regressing developmentally or acting out.

Maladaptation is unlikely. Telling the nurse that he is sick because he was bad does not imply excessive discipline at home.

PTS: 1 DIF: Cognitive Level: Analyze REF: 409 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 7. A 4-year-old child tells the nurse that she does not want another blood sample drawn because I need all my insides, and I dont want anyone taking them out. Which is the nurses best

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interpretation of this? a. Child is being overly dramatic. b. Child has a disturbed body image. c. Preschoolers have poorly defined body boundaries. d. Preschoolers normally have a good understanding of their bodies.

ANS: C Preschoolers have little understanding of body boundaries, which leads to fears of mutilation.

The child is not capable of being dramatic at 4 years of age. She truly has fear. Body image is just developing in the school-age child. Preschoolers do not have good understanding of their bodies.

PTS: 1 DIF: Cognitive Level: Apply REF: 410 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 8. Which play is most typical of the preschool period? a. Solitary b. Parallel c. Associative d. Team ANS: C Associative play is group play in similar or identical activities but without rigid organization or rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children play in teams.

PTS: 1 DIF: Cognitive Level: Understand REF: 411 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 9. Imaginary playmates are beneficial to the preschool child because they: a. take the place of social interactions. b. take the place of pets and other toys. c. become friends in times of loneliness. d. accomplish what the child has already successfully accomplished.

ANS: C One purpose of an imaginary friend is to be a friend in time of loneliness. Imaginary friends do not take the place of social interaction, but may encourage conversation. Imaginary friends do

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not take the place of pets or toys. Imaginary friends accomplish what the child is still attempting.

PTS: 1 DIF: Cognitive Level: Understand REF: 412 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 10. Which characteristic best describes the language of a 3-year-old child? a. Asks meanings of words b. Follows directional commands c. Describes an object according to its composition d. Talks incessantly regardless of whether anyone is listening ANS: D Because of the dramatic vocabulary increase at this age, 3-year-olds are known to talk incessantly regardless of whether anyone is listening. A 4- to 5-year-old asks lots of questions and can follow simple directional commands. A 6-year-old can describe an object according to its composition.

PTS: 1 DIF: Cognitive Level: Understand REF: 410 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 11. By which age should the nurse expect that most children could obey prepositional phrases such as under, on top of, beside, and behind? a. 18 months b. 24 months c. 3 years d. 4 years ANS: D At 4 years, children can understand directional phrases. Children at 18 months, 24 months, and 3 years are too young.

PTS: 1 DIF: Cognitive Level: Understand REF: 410 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 12. Which is a useful skill that the nurse should expect a 5-year-old child to be able to master? a. Tie shoelaces. b. Use knife to cut meat.

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c. Hammer a nail. d. Make change out of a quarter.

ANS: A Tying shoelaces is a fine motor task of 5-year-olds. Using a knife to cut meat is a fine motor task of a 7-year-old. Hammering a nail and making change out of a quarter are fine motor and cognitive tasks of an 8- to 9-year-old.

PTS: 1 DIF: Cognitive Level: Understand REF: 414 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 13. The nurse is guiding parents in selecting a daycare facility for their child. Which is especially important to consider when making the selection? a. Structured learning environment b. Socioeconomic status of children c. Cultural similarities of children d. Teachers knowledgeable about development ANS: D A teacher knowledgeable about development will structure activities for learning. A structured learning environment is not necessary at this age. Socioeconomic status is not the most important factor in selecting a preschool. Preschool is about expanding experiences with others, so cultural similarities are not necessary.

PTS: 1 DIF: Cognitive Level: Apply REF: 412 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 14. Parents tell the nurse that they found their 3-year-old daughter and a male cousin of the same age inspecting each other closely as they used the bathroom. Which is the most appropriate recommendation the nurse should make? a. Punish children so this behavior stops. b. Neither condone nor condemn the curiosity. c. Allow children unrestricted permission to satisfy this curiosity. d. Get counseling for this unusual and dangerous behavior.

ANS: B Three-year-olds become aware of anatomic differences and are concerned about how the other works. Such exploration should not be condoned or condemned. Children should not be punished

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for this normal exploration. Encouraging the children to ask questions of the parents and redirecting their activity are more appropriate than giving permission. Exploration is ageappropriate and not dangerous behavior.

PTS: 1 DIF: Cognitive Level: Apply REF: 410 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 15. The parent of a 4-year-old boy tells the nurse that the child believes that monsters and boogeymen are in his bedroom at night. The nurses best suggestion for coping with this problem is to: a. let the child sleep with his parents. b. keep a night-light on in the childs bedroom. c. help the child understand that these fears are illogical. d. tell the child frequently that monsters and boogeymen do not exist.

ANS: B A night-light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents will not get rid of the fears. A 4-year-old child is in the preconceptual age and cannot understand logical thought.

PTS: 1 DIF: Cognitive Level: Apply REF: 418 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 16. Preschoolers fears can best be dealt with by which intervention? a. Actively involving them in finding practical methods to deal with the frightening experience b. Forcing them to confront the frightening object or experience in the presence of their parents c. Using logical persuasion to explain away their fears and help them recognize how unrealistic the fears are d. Ridiculing their fears so that they understand that there is no need to be afraid ANS: A Actively involving them in finding practical methods to deal with the frightening experience is the best way to deal with fears. Forcing a child to confront fears may make the child more afraid.

Preconceptual thought prevents logical understanding. Ridiculing fears does not make them go away.

PTS: 1 DIF: Cognitive Level: Apply REF: 416

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TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 17. Which accurately describes the speech of the preschool child? a. Dysfluency in speech patterns is normal. b. Sentence structure and grammatic usage are limited. c. By age 5 years, child can be expected to have a vocabulary of about 1000 words. d. Rate of vocabulary acquisition keeps pace with the degree of comprehension of speech.

ANS: A Dysfluency includes stuttering and stammering, a normal characteristic of language development. Children speak in sentences of three or four words at age 3 to 4 years and eight words by age 5 years. At 5 years, children have a vocabulary of 2100 words. Children often gain vocabulary beyond degree of comprehension.

PTS: 1 DIF: Cognitive Level: Understand REF: 417 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 18. A nurse is teaching parents about language development for preschool children. Which dysfunctional speech pattern is a normal characteristic the parents might expect? a. Lisp b. Stammering c. Echolalia d. Repetition without meaning ANS: B Stammering and stuttering are normal dysfluency patterns in preschool-age children. Lisps are not a normal characteristic of language development. Echolalia and repetition are traits of toddlers language.

PTS: 1 DIF: Cognitive Level: Apply REF: 417 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 19. During the preschool period, injury prevention efforts should emphasize: a. constant vigilance and protection. b. punishment for unsafe behaviors. c. education for safety and potential hazards.

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d. limitation of physical activities.

ANS: C Education for safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Constant vigilance and protection is not practical at this age because preschoolers are becoming more independent. Punishment may make children scared of trying new things. Limitation of physical activities is not appropriate.

PTS: 1 DIF: Cognitive Level: Understand REF: 419-420 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Safe and Effective Care Environment 20. Parents are concerned that their child is showing aggressive behaviors. Which suggestion should the nurse make to the parents? a. Supervise television viewing. b. Ignore the behavior. c. Punish the child for the behavior. d. Accept the behavior if the child is male.

ANS: A Television is also a significant source for modeling at this impressionable age. Research indicates there is a direct correlation between media exposure, both violent and educational media, and preschoolers exhibiting physical and relational aggression (Ostrov, Gentile, and Crick, 2006). Therefore, parents should be encouraged to supervise television viewing. The behavior should not be ignored because it can escalate to hyperaggression. The child should not be punished because it may reinforce the behavior if the child is seeking attention. For example, children who are ignored by a parent until they hit a sibling or the parent learn that this act garners attention. The behavior should not be accepted from a male child; this is using a double standard and aggression should not be equated with masculinity.

PTS: 1 DIF: Cognitive Level: Apply REF: 416-417 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 21. Which snack should the nurse recommend parents offer to their slightly overweight preschool child? a. Carbonated beverage b. 10% fruit juice c. Low fat chocolate milk

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d. Whole milk ANS: C Milk and dairy products are excellent sources of calcium and vitamin D (fortified). Low-fat milk may be substituted, so the quantity of milk may remain the same while limiting fat intake overall.

Parents should be educated regarding non-nutritious fruit drinks, which usually contain less than 10% fruit juice yet are often advertised as healthy and nutritious; sugar content is dramatically increased and often precludes an adequate intake of milk by the child. In young children, intake of carbonated beverages that are acidic or that contain high amounts of sugar is also known to contribute to dental caries. Low fat milk should be substituted for whole milk if the child is slightly overweight.

PTS: 1 DIF: Cognitive Level: Apply REF: 417 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. In terms of language and cognitive development, a 4-year-old child would be expected to have which traits? (Select all that apply.) a. Think in abstract terms. b. Follow directional commands. c. Understand conservation of matter. d. Use sentences of eight words. e. Tell exaggerated stories. f. Comprehend another persons perspective.

ANS: B, E Children ages 3 to 4 years can give and follow simple commands and tell exaggerated stories.

Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. Five-year-old children use sentences with eight words with all parts of speech. A 4-year-old child cannot comprehend anothers perspective.

PTS: 1 DIF: Cognitive Level: Apply REF: 413 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 2. Which toys should a nurse provide to promote imaginative play for a 3-year-old hospitalized child? (Select all that apply.)

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a. Plastic telephone b. Hand puppets c. Jigsaw puzzle (100 pieces) d. Farm animals and equipment e. Jump rope ANS: A, B, D To promote imaginative play for a 3-year-old child, the nurse should provide: dress-up clothes, dolls, housekeeping toys, dollhouses, play-store toys, telephones, farm animals and equipment, village sets, trains, trucks, cars, planes, hand puppets, or medical kits. A 100-piece jigsaw puzzle and a jump rope would be appropriate for a young, school-age child but not a 3-year-old child.

Chapter 21. Health Promotion of the School-Aged Child MULTIPLE CHOICE 1. The nurse is teaching a group of 10- to 12-year-old children about physical development during the school-age years. Which statement made by a participant, indicates the correct understanding of the teaching? a. My body weight will be almost triple in the next few years. b. I will grow an average of 2 inches per year from this point on. c. There are not that many physical differences among school-age children. d. I will have a gradual increase in fat, which may contribute to a heavier appearance.

ANS: B In middle childhood, growth in height and weight occurs at a slower pace. Between the ages of 6 and 12 years, children grow 2 inches per year. In middle childhood, childrens weight will almost double; they gain 3 kg/year. At the end of middle childhood, girls grow taller and gain more weight than boys. Children take on a slimmer look with longer legs in middle childhood.

PTS: 1 DIF: Cognitive Level: Apply REF: 458 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 2. Generally, the earliest age at which puberty begins is a. 13; 13 b. 11; 11

years in girls,

in boys.

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c. 10; 12 d. 12; 10 ANS: C Puberty signals the beginning of the development of secondary sex characteristics. This begins earlier in girls than in boys. Usually a 2-year difference occurs in the age of onset. Girls and boys do not usually begin puberty at the same age. Girls generally begin puberty 2 years earlier than boys.

PTS: 1 DIF: Cognitive Level: Understand REF: 459 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 3. Which describes the cognitive abilities of school-age children? a. Have developed the ability to reason abstractly b. Are capable of scientific reasoning and formal logic c. Progress from making judgments based on what they reason to making judgments based on what they see d. Are able to classify, to group and sort, and to hold a concept in their minds while making decisions based on that concept ANS: D In Piagets stage of concrete operations, children have the ability to group and sort and make conceptual decisions. Children cannot reason abstractly and logically until late adolescence.

Making judgments based on what they reason to making judgments based on what they see is not a developmental skill.

PTS: 1 DIF: Cognitive Level: Understand REF: 460 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 4. Which describes moral development in younger school-age children? a. The standards of behavior now come from within themselves. b. They do not yet experience a sense of guilt when they misbehave. c. They know the rules and behaviors expected of them but do not understand the reasons behind them. d. They no longer interpret accidents and misfortunes as punishment for misdeeds.

ANS: C Children who are ages 6 and 7 years know the rules and behaviors expected of them but do not

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understand the reasons for these rules and behaviors. Young children do not believe that standards of behavior come from within themselves, but that rules are established and set down by others. Younger school-age children learn standards for acceptable behavior, act according to these standards, and feel guilty when they violate them. Misfortunes and accidents are viewed as punishment for bad acts.

PTS: 1 DIF: Cognitive Level: Understand REF: 460 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 5. Which statement characterizes moral development in the older school-age child? a. They are able to judge an act by the intentions that prompted it rather than just by the consequences. b. Rules and judgments become more absolute and authoritarian. c. They view rule violations in an isolated context. d. They know the rules but cannot understand the reasons behind them.

ANS: A Older school-age children are able to judge an act by the intentions that prompted the behavior rather than just by the consequences. Rules and judgments become less absolute and authoritarian. Rule violation is likely to be viewed in relation to the total context in which it appears. The situation and the morality of the rule itself influence reactions.

PTS: 1 DIF: Cognitive Level: Understand REF: 460 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 6. An 8-year-old girl tells the nurse that she has cancer because God is punishing her for being bad. She shares her concern that if she dies, she will go to hell. The nurse should interpret this as: a. a belief common at this age. b. a belief that forms the basis for most religions. c. suggestive of excessive family pressure. d. suggestive of a failure to develop a conscience.

ANS: A Children at this age may view illness or injury as a punishment for a real or imagined misdeed.

The belief in divine punishment is common for an 8-year-old child.

PTS: 1 DIF: Cognitive Level: Analyze REF: 460

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TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 7. Parents ask the nurse whether it is common for their school-age child to spend a lot of time with peers. The nurse should respond, explaining that the role of the peer group in the life of school-age children provides: a. opportunity to become defiant. b. time to remain dependent on their parents for a longer time. c. time to establish a one-on-one relationship with the opposite sex. d. security as they gain independence from their parents.

ANS: D Peer-group identification is an important factor in gaining independence from parents. Children learn how to relate to people in positions of leadership and authority and how to explore ideas and the physical environment. Becoming defiant in a peer-group relationship may lead to bullying. Peer-group identification helps in gaining independence rather than remaining dependent. One-on-one opposite sex relationships do not occur until adolescence. School-age children form peer groups of the same sex.

PTS: 1 DIF: Cognitive Level: Understand REF: 462 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 8. A group of boys ages 9 and 10 years have formed a boys-only club that is open to neighborhood and school friends who have skateboards. This should be interpreted as: a. behavior that encourages bullying and sexism. b. behavior that reinforces poor peer relationships. c. characteristic of social development at this age. d. characteristic of children who later are at risk for membership in gangs.

ANS: C One of the outstanding characteristics of middle childhood is the creation of formalized groups or clubs. Peer-group identification and association are essential to a childs socialization. Poor relationships with peers and a lack of group identification can contribute to bullying. A boysonly club does not have a direct correlation with later gang activity.

PTS: 1 DIF: Cognitive Level: Analyze REF: 462 TOP: Integrated Process: Nursing Process: Assessment

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MSC: Area of Client Needs: Health Promotion and Maintenance 9. A school nurse observes school-age children playing at recess. Which is descriptive of the play the nurse expects to observe? a. Individuality in play is better tolerated than at earlier ages. b. Knowing the rules of a game gives an important sense of belonging. c. They like to invent games, making up the rules as they go. d. Team play helps children learn the universal importance of competition and winning.

ANS: B Play involves increased physical skill, intellectual ability, and fantasy. Children form groups and cliques and develop a sense of belonging to a team or club. At this age, children begin to see the need for rules. Conformity and ritual permeate their play. Their games have fixed and unvarying rules, which may be bizarre and extraordinarily rigid. With team play, children learn about competition and the importance of winning, an attribute highly valued in the United States.

PTS: 1 DIF: Cognitive Level: Understand REF: 463 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 10. Teasing can be common during the school-age years. The nurse should recognize that which applies to teasing? a. Can have a lasting effect on children b. Is not a significant threat to self-concept c. Is rarely based on anything that is concrete d. Is usually ignored by the child who is being teased ANS: A Teasing in this age group is common and can have a long-lasting effect. Increasing awareness of differences, especially when accompanied by unkind comments and taunts from others, may make a child feel inferior and undesirable. Physical impairments such as hearing or visual defects, ears that stick out, or birth marks assume great importance.

PTS: 1 DIF: Cognitive Level: Understand REF: 462 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 11. Which is characteristic of dishonest behavior in children ages 8 to 10 years? a. Cheating during games is now more common.

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b. Lying results from the inability to distinguish between fact and fantasy. c. They may steal because their sense of property rights is limited. d. They may lie to meet expectations set by others that they have been unable to attain.

ANS: D Older school-age children may lie to meet expectations set by others to which they have been unable to measure up. Cheating usually becomes less frequent as the child matures. In this age group, children are able to distinguish between fact and fantasy. Young children may lack a sense of property rights; older children may steal to supplement an inadequate allowance, or it may be an indication of serious problems.

PTS: 1 DIF: Cognitive Level: Understand REF: 466-467 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 12. A 9-year-old girl often comes to the school nurse complaining of stomach pains. Her teacher says she is completing her school work satisfactorily but lately has been somewhat aggressive and stubborn in the classroom. The school nurse should recognize this as: a. signs of stress. b. developmental delay. c. physical problem causing emotional stress. d. lack of adjustment to school environment.

ANS: A Signs of stress include stomach pains or headache, sleep problems, bed-wetting, changes in eating habits, aggressive or stubborn behavior, reluctance to participate, or regression to early behaviors. This child is exhibiting signs of stress.

PTS: 1 DIF: Cognitive Level: Apply REF: 467-468 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 13. Which statement best describes fear in the school-age child? a. They are increasingly fearful for body safety. b. Most of the new fears that trouble them are related to school and family. c. They should be encouraged to hide their fears to prevent ridicule by peers. d. Those who have numerous fears need continuous protective behavior by parents to eliminate these fears.

ANS: B

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During the school-age years, children experience a wide variety of fears, but new fears relate predominantly to school and family. During the middle-school years, children become less fearful for body safety than they were as preschoolers. Parents and other persons involved with children should discuss childrens fears with them individually or as a group activity. Sometimes school-age children hide their fears to avoid being teased. Hiding their fears does not end them and may lead to phobias.

PTS: 1 DIF: Cognitive Level: Analyze REF: 467-468 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 14. The father of a 12-year-old child tells the nurse that he is concerned about his son getting fat.

His son is at the 50th percentile for height and the 75th percentile for weight on the growth chart.

The most appropriate nursing action is to: a. reassure the father that his child is not fat. b. reassure the father that his child is just growing. c. suggest a low-calorie, low-fat diet. d. explain that this is typical of the growth pattern of boys at this age.

ANS: D This is a characteristic pattern of growth in preadolescent boys, where the growth in height has slowed in preparation for the pubertal growth spurt, but weight is still gained. The nurse should review this with both the father and the child and develop a plan to maintain physical exercise and a balanced diet. It is false reassurance to tell the father that his son is not fat. His weight is high for his height. The child needs to maintain his physical activity. The father is concerned, so an explanation is required. A nutritional diet with physical activity should be sufficient to maintain his balance.

PTS: 1 DIF: Cognitive Level: Apply REF: 466 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 15. A child has an evulsed (knocked-out) tooth. Which medium should the nurse instruct the parents to place the tooth in for transport to the dentist? a. In cold milk b. In cold water c. In warm salt water d. In a dry, clean jar

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ANS: A An evulsed tooth should be placed in a suitable medium for transplant, either cold milk or saliva (under the child or parents tongue). Cold milk is a more suitable medium for transport than cold water, warm salt water, or a dry, clean jar.

PTS: 1 DIF: Cognitive Level: Apply REF: 471 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity 16. The school nurse has been asked to begin teaching sex education in the fifth grade. The nurse should recognize that: a. children in fifth grade are too young for sex education. b. children should be discouraged from asking too many questions. c. correct terminology should be reserved for children who are older. d. sex can be presented as a normal part of growth and development.

ANS: D When sexual information is presented to school-age children, sex should be treated as a normal part of growth and development. Fifth-graders are usually 10 or 11 years old. This age is not too young to speak about physiologic changes in their bodies. They should be encouraged to ask questions. Preadolescents need precise and concrete information.

PTS: 1 DIF: Cognitive Level: Apply REF: 471 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 17. The school nurse is conducting a class on bicycle safety. Which statement made by a participant indicates a need for further teaching? a. Most bicycle injuries occur from a fall off the bicycle. b. Head injuries are the major causes of bicycle-related fatalities. c. I should replace my helmet every 5 years. d. I can ride double with a friend if the bicycle has an extra large seat.

ANS: D Children should not ride double. Most injuries result from falls. The most important aspect of bicycle safety is to encourage the rider to use a protective helmet. Head injuries are the major cause of bicycle-related fatalities. The child should always wear a properly fitted helmet approved by the U.S. Consumer Product Safety Commission and should replace the helmet at

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least every 5 years.

PTS: 1 DIF: Cognitive Level: Apply REF: 472 | 474 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 18. When teaching injury prevention during the school-age years, what should the nurse include? a. Teach children to fear strangers. b. Teach basic rules of water safety. c. Avoid letting child cook in microwave ovens. d. Caution child against engaging in competitive sports.

ANS: B Water safety instruction is an important source of injury prevention at this age. The child should be taught to swim, select safe and supervised places to swim, swim with a companion, check for sufficient water depth before diving, and use an approved flotation device. Teach stranger safety, not fear of strangers. This includes instructing children to not go with strangers, not wear personalized clothing in public places, tell parents if anyone makes child feel uncomfortable, and say no in uncomfortable situations. Teach child safe cooking. Caution against engaging in hazardous sports such as those involving trampolines.

PTS: 1 DIF: Cognitive Level: Apply REF: 473 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 19. A nurse is teaching parents of kindergarten children general guidelines to assist their children in school. Which statement by the parents indicates they understand the teaching? a. We will only meet with the teacher if problems occur. b. We will discourage hobbies so our child focuses on school work. c. We will plan a trip to the library as often as possible. d. We will expect our child to make all As in school.

ANS: C General guidelines for parents to help their child in school include sharing an interest in reading.

The library should be used frequently and books the child is reading should be discussed.

Hobbies should be encouraged. The parents should not expect all As. They should focus on growth more than grades.

PTS: 1 DIF: Cognitive Level: Apply REF: 467

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TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 20. A school nurse is teaching dental health practices to a group of sixth-grade children. How often should the nurse recommend the children brush their teeth? a. Twice a day b. Three times a day c. After meals d. After meals, snacks, and bedtime ANS: D Teeth should be brushed after meals, after snacks, and at bedtime. Children who brush their teeth frequently and become accustomed to the feel of a clean mouth at an early age usually maintain the habit throughout life. Twice a day, three times a day or after meals would not be often enough.

Chapter 22. Health Promotion of the Adolescent MULTIPLE CHOICE 1. In girls, the initial indication of puberty is: a. menarche. b. growth spurt. c. growth of pubic hair. d. breast development.

ANS: D In most girls, the initial indication of puberty is the appearance of breast buds, an event known as thelarche. The usual sequence of secondary sex characteristic development in girls is breast changes, rapid increase in height and weight, growth of pubic hair, appearance of axillary hair, menstruation, and abrupt deceleration of linear growth.

PTS: 1 DIF: Cognitive Level: Understand REF: 477 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 2. A school nurse is teaching a group of preadolescent girls about puberty. Which is the mean

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age of menarche for girls in the United States? a. 11 1/2 years b. 12 3/4 years c. 13 1/2 years d. 14 years ANS: B The average age of menarche is 12 years 9.5 months in North American girls, with a normal range of 10 1/2 to 15 years. Ages 11 1/2, 13 1/2, and 14 are within the normal range for menarche, but these are not the average ages.

PTS: 1 DIF: Cognitive Level: Remember REF: 478 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 3. A school nurse is teaching a group of preadolescent boys about puberty. By which age should concerns about pubertal delay be considered? a. 12 to 12 1/2 years b. 12 1/2 to 13 years c. 13 to 13 1/2 years d. 13 1/2 to 14 years ANS: D Concerns about pubertal delay should be considered for boys who exhibit no enlargement of the testes or scrotal changes from 13 1/2 to 14 years. Ages 12 to 13 1/2 years is too young for initial concern.

PTS: 1 DIF: Cognitive Level: Remember REF: 478 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 4. A 14-year-old male mentions that he now has to use deodorant but never had to before. The nurses response should be based on knowledge that which occurs during puberty? a. Eccrine sweat glands in the axillae become fully functional during puberty. b. Sebaceous glands become extremely active during puberty. c. New deposits of fatty tissue insulate the body and cause increased sweat production. d. Apocrine sweat glands reach secretory capacity during puberty.

ANS: D The apocrine sweat glands, nonfunctional in children, reach secretory capacity during puberty.

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They secrete a thick substance as a result of emotional stimulation that, when acted on by surface bacteria, becomes highly odoriferous. They are limited in distribution and grow in conjunction with hair follicles, in the axilla, genital, anal, and other areas. Eccrine sweat glands are present almost everywhere on the skin and become fully functional and respond to emotional and thermal stimulation. Sebaceous glands become extremely active at this time, especially those on the genitalia and the flush areas of the body such as face, neck, shoulders, upper back, and chest.

This increased activity is important in the development of acne. New deposits of fatty tissue is not the etiology of apocrine sweat gland activity.

PTS: 1 DIF: Cognitive Level: Understand REF: 479 | 481 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 5. According to Erikson, the psychosocial task of adolescence is developing: a. intimacy. b. identity. c. initiative. d. independence.

ANS: B Traditional psychosocial theory holds that the developmental crises of adolescence lead to the formation of a sense of identity. Intimacy is the developmental stage for early adulthood.

Independence is not one of Eriksons developmental stages.

PTS: 1 DIF: Cognitive Level: Understand REF: 481 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 6. A nurse is planning a teaching session for a group of adolescents. The nurse understands that by adolescence the individual is in which stage of cognitive development? a. Formal operations b. Concrete operations c. Conventional thought d. Post-conventional thought ANS: A Cognitive thinking culminates with capacity for abstract thinking. This stage, the period of formal operations, is Piagets fourth and last stage. Concrete operations usually occur between ages 7 and 11 years. Conventional and post-conventional thought refer to Kohlbergs stages of

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moral development.

PTS: 1 DIF: Cognitive Level: Understand REF: 482 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Health Promotion and Maintenance 7. Which aspect of cognition develops during adolescence? a. Capability to use a future time perspective b. Ability to place things in a sensible and logical order c. Ability to see things from the point of view of another d. Progress from making judgments based on what they see to making judgments based on what they reason ANS: A Adolescents are no longer restricted to the real and actual. They also are concerned with the possible; they think beyond the present. During concrete operations (between ages 7 and 11 years), children exhibit these characteristic thought processes.

PTS: 1 DIF: Cognitive Level: Remember REF: 482 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 8. Parents are concerned about the number of hours their teenage daughter spends with peers.

The nurse explains that peer relationships are important during adolescence for which reason? a. Adolescents dislike their parents. b. Adolescents no longer need parental control. c. They provide adolescents with a feeling of belonging. d. They promote a sense of individuality in adolescents.

ANS: C The peer group serves as a strong support to teenagers, providing them with a sense of belonging and a sense of strength and power. During adolescence, the parent-child relationship changes from one of protection-dependency to one of mutual affection and quality. Parents continue to play an important role in the personal and health-related decisions. The peer group forms the transitional world between dependence and autonomy.

PTS: 1 DIF: Cognitive Level: Apply REF: 483 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance

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9. An adolescent boy tells the nurse that he has recently had homosexual feelings. The nurses response should be based on knowledge that: a. this indicates the adolescent is homosexual. b. this indicates the adolescent will become homosexual as an adult. c. the adolescent should be referred for psychotherapy. d. the adolescent should be encouraged to share his feelings and experiences.

ANS: D These adolescents are at increased risk for health-damaging behaviors, not because of the sexual behavior itself, but because of societys reaction to the behavior. The nurses first priority is to give the young man permission to discuss his feelings about this topic, knowing that the nurse will maintain confidentiality, appreciate his feelings, and remain sensitive to his need to talk about the topic. In recent studies among self-identified gay, lesbian, and bisexual adolescents, many of the adolescents report changing self-labels one or more times during their adolescence.

An assessment must be made about any risks to himself or others. If these do not exist, the adolescent needs a supportive person to talk with.

PTS: 1 DIF: Cognitive Level: Apply REF: 486 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Health Promotion and Maintenance 10. The school nurse tells adolescents in the clinic that confidentiality and privacy will be maintained unless a life-threatening situation arises. This practice is: a. not appropriate in a school setting. b. never appropriate because adolescents are minors. c. important in establishing trusting relationships. d. suggestive that the nurse is meeting his or her own needs.

ANS: C Health professionals who work with adolescents should consider adolescents increasing independence and responsibility while maintaining privacy and ensuring confidentiality.

However, in some circumstances, such as self-destructive behavior or maltreatment by others, they are not able to maintain confidentiality. Confidentiality and privacy are necessary to build trust with this age group. The nurse must be aware of the limits placed on confidentiality by local jurisdiction.

PTS: 1 DIF: Cognitive Level: Understand REF: 487 TOP: Integrated Process: Communication and Documentation

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MSC: Area of Client Needs: Management of Care 11. A 14-year-old boy seems to be always eating, although his weight is appropriate for his height. What is the best explanation for this? a. This is normal because of increase in body mass. b. This is abnormal and suggestive of future obesity. c. His caloric intake would have to be excessive. d. He is substituting food for unfilled needs.

ANS: A In adolescence, nutritional needs are closely related to the increase in body mass. The peak requirements occur in the years of maximal growth. The caloric and protein requirements are higher than at almost any other time of life. Seemingly always eating describes the expected eating pattern for young adolescents; as long as weight and height are appropriate, obesity is not a concern.

PTS: 1 DIF: Cognitive Level: Understand REF: 478-479 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 12. Which predisposes the adolescent to feel an increased need for sleep? a. An inadequate diet b. Rapid physical growth c. Decreased activity that contributes to a feeling of fatigue d. The lack of ambition typical of this age group ANS: B During growth spurts, the need for sleep increases. Rapid physical growth, the tendency toward overexertion, and the overall increased activity of this age contribute to fatigue.

PTS: 1 DIF: Cognitive Level: Understand REF: 490 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 13. The most common cause of death in the adolescent age group involves: a. drownings. b. firearms. c. drug overdoses. d. motor vehicles.

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ANS: D Forty percent of all adolescent deaths in the United States are the result of motor vehicle accidents. Drownings, firearms, and drug overdoses are major concerns in adolescence but are not the most common cause of death.

PTS: 1 DIF: Cognitive Level: Understand REF: 487 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 14. A young adolescent boy tells the nurse he feels gawky. The nurse should explain that this occurs in adolescents because of: a. growth of the extremities and neck precedes growth in other areas. b. growth is in the trunk and chest. c. the hip and chest breadth increases. d. the growth spurt occurs earlier in boys than it does in girls.

ANS: A Growth in length of the extremities and neck precedes growth in other areas, and, because these parts are the first to reach adult length, the hands and feet appear larger than normal during adolescence. Increases in hip and chest breadth take place in a few months followed several months later by an increase in shoulder width. These changes are followed by increases in length of the trunk and depth of the chest. This sequence of changes is responsible for the characteristic long-legged, gawky appearance of early adolescent children. The growth spurt occurs earlier in girls than in boys.

PTS: 1 DIF: Cognitive Level: Apply REF: 478 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 15. A nurse is reviewing hormone changes that occur during adolescence. The hormone that is responsible for the growth of beard, mustache, and body hair in the male is: a. estrogen. b. pituitary. c. androgen. d. progesterone.

ANS: C Beard, mustache, and body hair on the chest, upward along the linea alba, and sometimes on other areas (e.g., back and shoulders) appears in males and is androgen dependent. Estrogen and

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progesterone are produced by the ovaries in the female and do not contribute to body hair appearance in the male. The pituitary hormone does not have any relationship to body hair appearance in the male.

PTS: 1 DIF: Cognitive Level: Analyze REF: 481 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 16. A nurse is caring for an adolescent hospitalized for cellulitis. The nurse notes that the adolescent experiences many mood swings throughout the day. The nurse interprets this behavior as: a. requiring a referral to a mental health counselor. b. requiring some further lab testing. c. normal behavior. d. related to feelings of depression.

ANS: C Adolescents vacillate in their emotional states between considerable maturity and childlike behavior. One minute they are exuberant and enthusiastic; the next minute they are depressed and withdrawn. Because of these mood swings, adolescents are frequently labeled as unstable, inconsistent, and unpredictable, but the behavior is normal. The behavior would not require a referral to a mental health counselor or further lab testing. The mood swings do not indicate depression.

PTS: 1 DIF: Cognitive Level: Understand REF: 482 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Health Promotion and Maintenance 17. A nurse is conducting parenting classes for parents of adolescents. Which parenting style should the nurse recommend? a. Laissez-faire b. Authoritative c. Disciplinarian d. Confrontational ANS: B Parents should be guided toward an authoritative style of parenting in which authority is used to guide the adolescent while allowing developmentally appropriate levels of freedom and providing clear, consistent messages regarding expectations. The authoritative style of parenting

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has been shown to have both immediate and long-term protective effects toward adolescent risk reduction. The laissez-faire method would not give adolescents enough structure. The disciplinarian and confrontational styles would not allow any autonomy or independence.

PTS: 1 DIF: Cognitive Level: Apply REF: 483 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 18. A 14-year-old adolescent never had chickenpox as a child. Which should the nurse recommend? a. One dose of the varicella vaccination b. Two doses of the varicella vaccination 4 weeks apart c. One dose of the varicella immune globulin d. No vaccinationsthe child is past the age to receive it ANS: B All adolescents should also be assessed for previous history of varicella infection or vaccination.

Vaccination with the varicella vaccine is recommended for those with no previous history; for those with no previous infection or history, the varicella vaccine may be given in two doses 4 or more weeks apart to adolescents 13 years or older. The varicella immune globulin is given to immunosuppressed children exposed to chickenpox to boost immunity; it is only temporary. The varicella vaccination should be given to adolescents, no matter the age, who have not had chickenpox as a child.

PTS: 1 DIF: Cognitive Level: Apply REF: 489 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance MULTIPLE RESPONSE 1. A 13-year-old is being seen in the clinic for a routine health check. The adolescent has not been in the clinic for 3 years but was up to date on immunizations at that time. Which immunizations should the adolescent receive? (Select all that apply.) a. DTaP (tetanus, diphtheria, acellular pertussis) b. MMR (measles, mumps, rubella) c. Hepatitis B d. Influenza e. MCV4 (meningococcal)

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ANS: A, D, E The DTaP (tetanus, diphtheria, acellular pertussis) vaccine is recommended for adolescents 11 to 18 years old who have not received a tetanus booster (Td) or DTaP dose and have completed the childhood DTaP/DTP series. Meningococcal vaccine (MCV4) should be given to adolescents 11 to 12 years of age with a booster dose at age 16 years. Annual influenza vaccination with either the live attenuated influenza vaccine or trivalent influenza vaccine is recommended for all children and adolescents. The adolescent, previously up to date on vaccinations, would have received the MMR and hepatitis B as a child.

PTS: 1 DIF: Cognitive Level: Apply REF: 488-489 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 2. The nurse should teach the adolescent that the long-term effects of tanning can cause which conditions? (Select all that apply.) a. Phototoxic reactions b. Increased number of moles c. Premature aging d. Striae e. Increased risk of skin cancer ANS: A, C, E Long-term effects of tanning include premature aging of the skin, increased risk of skin cancer, and, in susceptible individuals, phototoxic reactions. There has been no correlation to an increase in moles or striae (streaks or stripes on the skin, usually on the abdomen) development.

PTS: 1 DIF: Cognitive Level: Apply REF: 492 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 3. Which screening tests should the school nurse perform for the adolescent? (Select all that apply.) a. Glucose b. Vision c. Hearing d. Cholesterol e. Scoliosis ANS: B, C, E

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The school nurse should perform vision, hearing, and scoliosis screening tests according to the school districts required schedule. Glucose and cholesterol screening would be performed in the medical clinic setting.

PTS: 1 DIF: Cognitive Level: Apply REF: 491 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance COMPLETION 1. The estimated average requirement of calcium for an adolescent is

milligrams. (Record

your answer in a whole number.)

ANS: 1100 The EAR (estimated average requirement) for calcium in adolescents 14 to 18 years of age is 1100 mg.

PTS: 1 DIF: Cognitive Level: Understand REF: 489 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Health Promotion and Maintenance ESSAY 1. Place in order the sequence of maturational changes for girls. Begin with the first change seen, sequencing to the last change. Provide answer in using lowercase letters, separated by commas (e.g., a, b, c, d, e). a. Growth of pubic hair b. Rapid increase in height and weight c. Breast changes d. Menstruation e. Appearance of axillary hair ANS: c, b, a, e, d The usual sequence of maturational changes for girls is breast changes, rapid increase in height and weight, growth of public hair, appearance of axillary hair, and then menstruation, which usually begins 2 years after the first signs.

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Chapter 23. Nursing Care of the Hospitalized Child MULTIPLE CHOICE 1. A nurse is caring for four patients; three are toddlers and one is a preschooler. Which represents the major stressor of hospitalization for these four patients?

a.

Separation anxiety

b.

Loss of control

c.

Fear of bodily injury

d.

Fear of pain

ANS: A The major stressor for children from infancy through the preschool years is separation anxiety, also called anaclitic depression. This is a major stressor of hospitalization. Loss of control, fear of bodily injury, and fear of pain are all stressors associated with hospitalization. However, separation from family is a primary stressor in this age group.

PTS: 1 DIF: Cognitive Level: Analyze REF: 613 TOP:Integrated Process: Nursing Process: Evaluation MSC:Area of Client Needs: Health Promotion and Maintenance 2. During the first 4 days of hospitalization, Eric, age 18 months, cried inconsolably when his parents left him, and he refused the staffs attention. Now the nurse observes that Eric appears to be settled in and unconcerned about seeing his parents. The nurse should interpret this as which statement?

a .

He has successfully adjusted to the hospital environment.

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He has transferred his trust to the nursing staff.

. c

He may be experiencing detachment, which is the third stage of separation

.

anxiety.

d

Because he is at home in the hospital now, seeing his mother frequently will only

.

start the cycle again.

ANS: C Detachment is a behavior manifestation of separation anxiety. Superficially it appears that the child has adjusted to the loss. Detachment is a sign of resignation, not contentment. Parents should be encouraged to be with their child. If parents restrict visits, they may begin a pattern of misunderstanding the childs cues and not meeting his needs.

PTS: 1 DIF: Cognitive Level: Analyze REF: 613 TOP:Integrated Process: Nursing Process: Diagnosis MSC:Area of Client Needs: Health Promotion and Maintenance 3. When a preschool child is hospitalized without adequate preparation, the nurse should recognize that the child may likely see hospitalization as:

a.

punishment.

b.

threat to childs self-image.

c.

an opportunity for regression.

d.

loss of companionship with friends.

ANS: A If a toddler is not prepared for hospitalization, a typical preschooler fantasy is to attribute the hospitalization to punishment for real or imagined misdeeds. Attributing the hospitalization to punishment for real or imagined misdeeds is a reaction typical of toddler and school-age children when threatened with loss of control.

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PTS: 1 DIF: Cognitive Level: Understand REF: 615 TOP:Integrated Process: Nursing Process: Diagnosis MSC:Area of Client Needs: Health Promotion and Maintenance 4. Which age group should the pediatric nurse recognize as being vulnerable to events that lessen their feeling of control and power?

a.

Infants

b.

Toddlers

c.

Preschoolers

d.

School-age children

ANS: D When a child is hospitalized, the altered family role, physical disability, loss of peer acceptance, lack of productivity, and inability to cope with stress usurp individual power and identity. This is especially detrimental to school-age children, who are striving for independence and productivity and are now experiencing events that lessen their control and power. Infants, toddlers, and preschoolers, although affected to different extents by loss of power, are not as significantly affected as are school-age children.

PTS: 1 DIF: Cognitive Level: Understand REF: 615 TOP:Integrated Process: Nursing Process: Diagnosis MSC:Area of Client Needs: Health Promotion and Maintenance 5. A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, Wait a minute and Im not ready. The nurse should recognize this as which description?

a.

This is normal behavior for a school-age child.

b.

The behavior is not seen past the preschool years.

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c.

The child thinks the nurse is punishing her.

d.

The child has successfully manipulated the nurse in the past.

ANS: A The 10-year-old girl is attempting to maintain control. The nurse should provide the girl with structured choices about when the IV will be inserted. Telling the nurse Wait a minute and Im not ready can be characteristic behavior when an individual needs to maintain some control over a situation.

PTS: 1 DIF: Cognitive Level: Analyze REF: 616 TOP:Integrated Process: Nursing Process: Implementation MSC:Area of Client Needs: Health Promotion and Maintenance 6. The most common initial reaction of parents to illness or injury and hospitalization in their child is:

a.

anger.

b.

fear.

c.

depression.

d.

disbelief.

ANS: D Disbelief is the most common initial response of parents. This is especially true if the illness is sudden and serious. Anger or guilt is usually the second reaction stage. Fear, anxiety, and frustrations also are common feelings. Parents may finally react with some form of depression related to the physical and emotional exhaustion associated with a hospitalized child.

PTS: 1 DIF: Cognitive Level: Understand REF: 617 TOP:Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Psychosocial Integrity

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7. Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse overhears her school-age siblings tell her, We are sick of Mom always sitting with you in the hospital and playing with you. It isnt fair that you get everything and we have to stay with the neighbors. Which is the nurses best assessment of this situation?

a

The siblings are immature and probably spoiled.

. b

Jealousy and resentment are common reactions to the illness or hospitalization

.

of a sibling.

c

Family has ineffective coping mechanisms to deal with chronic illness.

. d

The siblings need to better understand their sisters illness and needs.

.

ANS: B Siblings experience loneliness, fear, and worry, as well as anger, resentment, jealousy, and guilt.

The siblings experience stress equal to that of the hospitalized child. There is no evidence that the family has maladaptive coping mechanisms.

PTS: 1 DIF: Cognitive Level: Analyze REF: 617 TOP:Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Psychosocial Integrity 8. An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler would be to:

a.

provide for privacy.

b.

encourage parents to room in.

c.

explain procedures and routines.

d.

encourage contact with children the same age.

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ANS: B A toddler experiences separation anxiety secondary to being separated from the parents. To avoid this, the parents should be encouraged to room in as much as possible. Maintaining routines and ensuring privacy are helpful interventions, but they would not substitute for the parents. Encouraging contact with children the same age would not substitute for having the parents present.

PTS: 1 DIF: Cognitive Level: Apply REF: 628 TOP:Integrated Process: Nursing Process: Implementation MSC:Area of Client Needs: Health Promotion and Maintenance 9. Four-year-old Brian appears to be upset by hospitalization. Which is an appropriate intervention?

a.

Let him know it is all right to cry.

b.

Give him time to gain control of himself.

c.

Show him how other children are cooperating.

d.

Tell him what a big boy he is to be so quiet.

ANS: A Crying is an appropriate behavior for the upset preschooler. The nurse provides support through physical presence. Giving the child time to gain control is appropriate, but the child must know that crying is acceptable. The preschooler does not engage in competitive behaviors.

PTS: 1 DIF: Cognitive Level: Apply REF: 621 TOP:Integrated Process: Nursing Process: Implementation MSC:Area of Client Needs: Health Promotion and Maintenance 10. Latasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. Which will help her most in her adjustment to the hospital?

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a

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Explain hospital schedules to her, such as mealtimes.

. b

Use terms such as honey and dear to show a caring attitude.

. c

Explain when parents can visit and why siblings cannot come to see her.

. d

Orient her parents, because she is young, to her room and hospital facility.

.

ANS: A School-age children need to have control of their environment. The nurse should offer explanations or prepare the child for those experiences that are unavailable. The nurse should refer to the child by the preferred name. Explaining when parents can visit and why siblings cannot come to see her is telling the child all of the limitations, not helping her adjust to the hospital. At the age of 8 years, the child should be oriented to the environment along with the parents.

PTS: 1 DIF: Cognitive Level: Apply REF: 614 TOP:Integrated Process: Nursing Process: Implementation MSC:Area of Client Needs: Health Promotion and Maintenance 11. Samantha, age 5 years, tells the nurse that she needs a Band-Aid where she had an injection.

Which is the best nursing action?

a.

Apply a Band-Aid.

b.

Ask her why she wants a Band-Aid.

c.

Explain why a Band-Aid is not needed.

d.

Show her that the bleeding has already stopped.

ANS: A Children at this age group still fear that their insides may leak out at the injection site. Provide

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the Band-Aid. No explanation should be required. The nurse should be prepared to apply a small Band-Aid after the injection.

PTS: 1 DIF: Cognitive Level: Apply REF: 623 TOP:Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance: Growth and Development 12. Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her a lot of new toys, because she will be in the hospital. The nurses reply should be based on an understanding of which concept?

a

New toys make hospitalization easier.

. b

New toys are usually better than older ones for children of this age.

. c

At this age, children often need the comfort and reassurance of familiar toys

.

from home.

d

Buying new toys for a hospitalized child is a maladaptive way to cope with

.

parental guilt.

ANS: C Parents should bring favorite items from home to be with the child. Young children associate inanimate objects with people who are significant in their lives. The favorite items will comfort and reassure the child. Because the parents left the objects, the preschooler knows the parents will return. New toys will not serve the purpose of familiar toys and objects from home. The parents may experience some guilt as a response to the hospitalization, but there is no evidence that it is maladaptive.

PTS: 1 DIF: Cognitive Level: Apply REF: 621 TOP:Integrated Process: Nursing Process: Implementation MSC:Area of Client Needs: Health Promotion and Maintenance

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13. Matthew, age 18 months, has just been admitted with croup. His parent is tearful and tells the nurse, This is all my fault. I should have taken him to the doctor sooner so he wouldnt have to be here. Which is appropriate in the care plan for this parent who is experiencing guilt?

a.

Clarify misconception about the illness.

b.

Explain to parent that the illness is not serious.

c.

Encourage parent to maintain a sense of control.

d.

Assess further why parent has excessive guilt feelings.

ANS: A Guilt is a common response of parents when a child is hospitalized. They may blame themselves for the childs illness or for not recognizing it soon enough. The nurse should clarify the nature of the problem and reassure parents that the child is being cared for. Croup is a potentially serious illness. The nurse should not minimize the parents feelings. It would be difficult for the parent to maintain a sense of control while the child is seriously ill. No further assessment is indicated at this time; guilt is a common response for parents.

PTS: 1 DIF: Cognitive Level: Analyze REF: 627 TOP:Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Psychosocial Integrity 14. A 14-year-old boy is being admitted to the hospital for an appendectomy. Which roommate should the nurse assign with this patient?

a

A 4-year-old boy with first day post-appendectomy surgery

. b

A 6-year-old boy with pneumonia

. c .

A 15-year-old boy admitted with a vasoocclusive sickle cell crisis

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d

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A 12-year-old boy with cellulitis

.

ANS: C When a child is admitted, nurses follow several fairly universal admission procedures. The minimum considerations for room assignment are age, sex, and nature of the illness. Age grouping is especially important for adolescents. The 14-year-old boy being admitted to the unit after appendectomy surgery should be placed with a noninfectious child of the same sex and age.

The 15-year-old child with sickle cell is the best choice. The 4-year-old post-appendectomy is too young, and the child with pneumonia is too young and possibly has an infectious process.

The 12-year-old boy with cellulitis is the right age, but he has an infection (cellulitis).

PTS: 1 DIF: Cognitive Level: Apply REF: 618 | 621 TOP:Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 15. The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statement by the adolescent should be expected about separation anxiety?

a

I wish my parents could spend the night with me while I am in the hospital.

. b

I think I would like for my siblings to visit me but not my friends.

. c

I hope my friends dont forget about visiting me.

. d

I will be embarrassed if my friends come to the hospital to visit.

.

ANS: C Loss of peer-group contact may pose a severe emotional threat to an adolescent because of loss of group status, so friends visiting are an important aspect of hospitalization for an adolescent.

Most adolescents do not need a parent to spend the night during hospitalization and sometimes

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view the hospitalization as a welcome event. Adolescents would be more concerned about friends visiting than siblings. Adolescents want visitors to keep control and maintain social status among their group of peers.

PTS: 1 DIF: Cognitive Level: Analyze REF: 615 TOP:Integrated Process: Nursing Process: Planning MSC:Area of Client Needs: Health Promotion and Maintenance 16. A nurse is preparing to complete an admission assessment on a 2-year-old child. The child is sitting on the parents lap. Which technique should the nurse implement to complete the physical exam?

a

Ask the parent to place the child in the hospital crib.

. b

Take the child and parent to the exam room.

. c

Perform the exam while the child is on the parents lap.

. d

Ask the child to stand by the parent while completing the exam.

.

ANS: C The nurse should complete the exam while the child is on the parents lap. For young children, particularly infants and toddlers, preserving parentchild contact is the best means of decreasing the need for or stress of restraint. The entire physical examination can be done in a parents lap with the parent hugging the child for procedures such as an otoscopic examination. Placing the child in the crib, taking the child to the exam room, or asking the child to stand by the parent would separate the child from the parent and cause anxiety.

PTS: 1 DIF: Cognitive Level: Apply REF: 622 TOP:Integrated Process: Nursing Process: Implementation

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MSC: Area of Client Needs: Psychosocial Integrity 17. A school-age child, admitted for intravenous antibiotic therapy for osteomyelitis, reports difficulty in going to sleep at night. Which intervention should the nurse implement to assist the child in going to sleep at bedtime?

a

Request a prescription for a sleeping pill.

. b

Allow the child to stay up late and sleep late in the morning.

. c

Create a schedule similar to the one the child follows at home.

. d

Plan passive activities in the morning and interactive activities right before

.

bedtime.

ANS: C Many children obtain significantly less sleep in the hospital than at home; the primary causes are a delay in sleep onset and early termination of sleep because of hospital routines. One technique that can minimize the disruption in the childs routine is establishing a daily schedule. This approach is most suitable for noncritically ill school-age and adolescent children who have mastered the concept of time. It involves scheduling the childs day to include all those activities that are important to the child and nurse, such as treatment procedures, schoolwork, exercise, television, playroom, and hobbies. The school-age child with osteomyelitis would benefit from a schedule similar to the one followed at home. Requesting a prescription for a sleeping pill would be inappropriate and allowing the child to stay up late and sleep late would not be keeping the child in a routine followed at home. Passive activities in the morning and interactive activities at bedtime should be reversed; it would be better to keep the child active in the morning hours and plan quiet activities at bedtime.

PTS: 1 DIF: Cognitive Level: Apply REF: 622 TOP:Integrated Process: Nursing Process: Planning MSC:Area of Client Needs: Health Promotion and Maintenance

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18. A previously potty-trained 30-month-old child has reverted to wearing diapers while hospitalized. The nurse should reassure the parents that this is normal because of which reason?

a

Regression is seen during hospitalization.

. b

Developmental delays occur because of the hospitalization.

. c

The child is experiencing urinary urgency because of hospitalization.

. d

The child was too young to be potty-trained.

.

ANS: A Regression is expected and normal for all age groups when hospitalized. Nurses should assure the parents this is temporary and the child will return to the previously mastered developmental milestone when back home. This does not indicate a developmental delay. The child should not be experiencing urinary urgency because of hospitalization and this would not be normal.

Successful potty-training can be started at 2 years of age if the child is ready.

Chapter 24. Acutely Ill Children and Their Needs MULTIPLE CHOICE 1. Which should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered informed.

ANS: C The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances, such as emancipated minors, the consent

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can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed.

PTS: 1 DIF: Cognitive Level: Understand REF: 636 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 2. The nurse is planning to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include which action? a. Plan for a short teaching session of about 30 minutes. b. Tell the child that procedures are never a form of punishment. c. Keep equipment out of the childs view. d. Use correct scientific and medical terminology in explanations.

ANS: B Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. Teaching sessions for this age group should be 10 to 15 minutes in length. Demonstrate the use of equipment, and allow the child to play with miniature or actual equipment. Explain procedure in simple terms and how it affects the child.

PTS: 1 DIF: Cognitive Level: Apply REF: 639 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 3. Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to: a. allow her to wear her underpants. b. discuss with her mother why this is important to Katie. c. ask her mother to explain to her why she cannot wear them. d. explain in a kind, matter-of-fact manner that this is hospital policy.

ANS: A It is appropriate for the child to leave her underpants on. This allows her some measure of control in this procedure, foot surgery. Further discussions may make the child more upset. Katie is too young to understand what hospital policy means.

PTS: 1 DIF: Cognitive Level: Apply REF: 639-640 TOP: Integrated Process: Nursing Process: Implementation

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MSC: Area of Client Needs: Health Promotion and Maintenance 4. Using knowledge of child development, which is the best approach when preparing a toddler for a procedure? a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for teaching session to last about 20 minutes. d. Show necessary equipment without allowing child to handle it.

ANS: B Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the childs favorite doll because the toddler may think the doll is really feeling the procedure. In preparing a toddler for a procedure, allow the child to participate in care and help whenever possible.

Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment, and allow the child to handle it.

PTS: 1 DIF: Cognitive Level: Apply REF: 639 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Health Promotion and Maintenance 5. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. The girl tells the nurse she wants her mother with her like before. The most appropriate nursing action is to: a. grant her request. b. explain why this is not possible. c. identify an appropriate substitute for her mother. d. offer to provide support to her during the procedure.

ANS: A The parents preferences for assisting, observing, or waiting outside the room should be assessed, along with the childs preference for parental presence. The childs choice should be respected. If the mother and child are agreeable, then the mother is welcome to stay. An appropriate substitute for the mother is necessary only if the mother does not wish to stay. Support is offered to the child regardless of parental presence.

PTS: 1 DIF: Cognitive Level: Apply REF: 638 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 6. The emergency department nurse is cleaning multiple facial abrasions on a 9-year-old child

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whose mother is present. The child is crying and screaming loudly. The nurses action should be to: a. ask the child to be quieter. b. have the childs mother give instructions about relaxation. c. tell the child it is okay to cry and scream. d. remove the mother from the room.

ANS: C The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know it is all right to cry. There is no reason for the child to be quieter and feelings need to be able to be expressed. The mother should stay in the room to provide comfort to the child.

PTS: 1 DIF: Cognitive Level: Apply REF: 641 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Health Promotion and Maintenance 7. In some genetically susceptible children, anesthetic agents can trigger malignant hyperthermia.

The nurse should be alert in observing that, in addition to an increased temperature, an early sign of this disorder is: a. apnea. b. bradycardia. c. muscle rigidity. d. decreased blood pressure.

ANS: C Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia. Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased blood pressure, not decreased blood pressure, is characteristic of malignant hyperthermia.

PTS: 1 DIF: Cognitive Level: Understand REF: 645-646 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 8. The nurse is caring for an unconscious child. Skin care should include which action? a. Avoid use of pressure reduction on bed. b. Massage reddened bony prominences to prevent deep tissue damage. c. Use draw sheet to move child in bed to reduce friction and shearing injuries.

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d. Avoid rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

ANS: C A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms. Pressure-reduction devices should be used to redistribute weight. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices should be used instead. The skin should be cleansed with mild nonalkaline soap or soap-free cleaning agents for routine bathing.

PTS: 1 DIF: Cognitive Level: Apply REF: 648 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 9. An appropriate intervention to encourage food and fluid intake in a hospitalized child is to: a. force child to eat and drink to combat caloric losses. b. discourage participation in noneating activities until caloric intake is sufficient. c. administer large quantities of flavored fluids at frequent intervals and during meals. d. give high-quality foods and snacks whenever child expresses hunger.

ANS: D Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the behavior as a control mechanism. Large quantities of fluid may decrease the childs hunger and further inhibit food intake.

PTS: 1 DIF: Cognitive Level: Apply REF: 649 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 10. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at end of every meal that he eats.

ANS: A Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate

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nutrition, favorite foods should be requested for the child. These foods provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

PTS: 1 DIF: Cognitive Level: Apply REF: 650 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 11. A 3-year-old child has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102 F even though she had acetaminophen 2 hours ago. The nurses action should be based on which statement? a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102 F indicates greater severity of illness. d. Fever over 102 F indicates a probable bacterial infection.

ANS: A Most fevers are of brief duration, with limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection.

PTS: 1 DIF: Cognitive Level: Apply REF: 650 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 12. A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen (Tylenol). The nurse should explain that antipyretics: a. may cause malignant hyperthermia. b. may cause febrile seizures. c. are of no value in treating hyperthermia. d. are of limited value in treating hyperthermia.

ANS: C Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Antipyretics do not cause seizures and are of no value in hyperthermia.

PTS: 1 DIF: Cognitive Level: Apply REF: 650-651

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TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 13. Tepid water or sponge baths are indicated for hyperthermia in children. The nurses action is to: a. add isopropyl alcohol to the water. b. direct a fan on the child in the bath. c. stop the bath if the child begins to chill. d. continue the bath for 5 minutes.

ANS: C Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the bodys way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever. Ice water and isopropyl alcohol are potentially dangerous solutions.

Fans should not be used because of the risk of the child developing vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to the skin surface, and the blood remains primarily in the viscera to become heated. The child is placed in a tub of tepid water for 20 to 30 minutes.

PTS: 1 DIF: Cognitive Level: Apply REF: 651 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 14. The nurse approaches a group of school-age patients to administer medication to Sam Hart.

To identify the correct child, the nurses action is to: a. ask the group, Who is Sam Hart? b. call out to the group, Sam Hart? c. ask each child, Whats your name? d. check the patients identification name band.

ANS: D The child must be correctly identified before the administration of any medication. Children are not totally reliable in giving correct names on request; the identification bracelet should always be checked. Asking children or the group for names is not an acceptable way to identify a child.

Older children may exchange places, give an erroneous name, or choose not to respond to their name as a joke.

PTS: 1 DIF: Cognitive Level: Apply REF: 665

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TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 15. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should: a. wash hands thoroughly. b. check the gloves for leaks. c. rinse gloves in disinfectant solution. d. apply new gloves before touching the next patient.

ANS: A When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of after use. Hands should be thoroughly washed before new gloves are applied.

PTS: 1 DIF: Cognitive Level: Apply REF: 654 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 16. The nurse gives an injection in a patients room. The nurse should perform which intervention with the needle for disposal? a. Dispose of syringe and needle in a rigid, puncture-resistant container in patients room. b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patients room. c. Cap needle immediately after giving injection and dispose of in proper container. d. Cap needle, break from syringe, and dispose of in proper container.

ANS: A All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently, these containers should be installed in the patients room. The uncapped needle should not be transported to an area distant from use. Needles are disposed of uncapped and unbroken.

PTS: 1 DIF: Cognitive Level: Apply REF: 654 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 17. A mother calls the outpatient clinic requesting information on appropriate dosing for overthe-counter medications for her 13-month-old who has symptoms of an upper respiratory tract

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infection and fever. The box of acetaminophen says to give 120 mg q4h when needed. At his 12month visit, the nurse practitioner prescribed 150 mg. The nurses best response is: a. The doses are close enough; it doesnt really matter which one is given. b. It is not appropriate to use dosages based on age because children have a wide range of weights at different ages. c. From your description, medications are not necessary. They should be avoided in children at this age. d. The nurse practitioner ordered the drug based on weight, which is a more accurate way of determining a therapeutic dose.

ANS: D The method most often used to determine childrens dosage is based on a specific dose per kilogram of body weight. The mother should be given correct information. For a therapeutic effect, the dosage should be based on weight, not age. Acetaminophen can be used to relieve discomfort in children at this age group.

PTS: 1 DIF: Cognitive Level: Apply REF: 665 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 18. An 8-month-old infant is restrained to prevent interference with the IV infusion. The nurses action is to: a. remove the restraints once a day to allow movement. b. keep the restraints on constantly. c. keep the restraints secure so infant remains supine. d. remove restraints whenever possible.

ANS: D The nurse should remove the restraints whenever possible. When parents or staff are present, the restraints can be removed and the IV site protected. Restraints must be checked and documented every 1 to 2 hours. They should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.

PTS: 1 DIF: Cognitive Level: Apply REF: 656 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 19. A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. The nurse should recognize that this behavior is:

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a. unsafe. b. helpful to relax the child. c. against hospital policy. d. unnecessary because of childs age.

ANS: B The mothers preference for assisting, observing, or waiting outside the room should be assessed along with the childs preference for parental presence. The childs choice should be respected.

This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care. The child should determine whether parental support is necessary.

PTS: 1 DIF: Cognitive Level: Understand REF: 641 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 20. A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, the nurses best action is to: a. prepare child for conscious sedation during the test. b. set up a tray with equipment the same size as for adults. c. reassure the parents that the test is simple, painless, and risk free. d. apply EMLA to puncture site 15 minutes before procedure.

ANS: A Because of the urgency of the childs condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. Reassuring the parents that the test is simple, painless, and risk free is incorrect information. A spinal tap does have associated risks, and analgesia will be given for the pain. EMLA (a eutectic mixture of anesthetics) should be applied approximately 60 minutes before the procedure. The emergency nature of the spinal tap precludes its use.

PTS: 1 DIF: Cognitive Level: Analyze REF: 641 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 21. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant.

Which is the most appropriate way to collect small amounts of urine for these tests?

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a. Apply a urine-collection bag to perineal area. b. Tape a small medicine cup to inside of diaper. c. Aspirate urine from cotton balls inside diaper with a syringe. d. Aspirate urine from superabsorbent disposable diaper with a syringe.

ANS: C To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the childs skin. It is not feasible to tape a small medicine cup to inside of diaper; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.

PTS: 1 DIF: Cognitive Level: Apply REF: 659 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 22. Which is an important nursing consideration when performing a bladder catheterization on a young boy? a. Clean technique, not standard precautions, is needed. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

ANS: B The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparation of the child and parents, by selection of the correct catheter, and by appropriate technique of insertion. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. Catheterization is a sterile procedure, and standard precautions for body-substance protection should be followed. Water-soluble lubricants do not provide appropriate local anesthesia. Catheterization should be delayed 2 to 3 minutes only. This provides sufficient local anesthesia for the procedure.

PTS: 1 DIF: Cognitive Level: Apply REF: 660 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 23. The Allen test is performed as a precautionary measure before which procedure?

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a. Heel stick b. Venipuncture c. Arterial puncture d. Lumbar puncture ANS: C The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial puncture. The Allen test is used before arterial punctures, not heel sticks, venipunctures, or lumbar punctures.

PTS: 1 DIF: Cognitive Level: Understand REF: 662 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 24. The nurse must do a heel stick on an ill neonate to obtain a blood sample. Which is recommended to facilitate this? a. Apply cool, moist compresses. b. Apply a tourniquet to ankle. c. Elevate foot for 5 minutes. d. Wrap foot in a warm washcloth.

ANS: D Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood collection more difficult. A tourniquet is used to constrict superficial veins. It will have an insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot available for collection.

PTS: 1 DIF: Cognitive Level: Understand REF: 662 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 25. The nurse has just collected blood by venipuncture in the antecubital fossa. Which should the nurse do next? a. Keep arm extended while applying a bandage to the site. b. Keep arm extended, and apply pressure to the site for a few minutes. c. Apply a bandage to the site, and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.

ANS: B

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Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before bandage is applied.

PTS: 1 DIF: Cognitive Level: Apply REF: 662 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 26. A nurse must do a venipuncture on a 6-year-old child. Which is an important consideration in providing atraumatic care? a. Use an 18-gauge needle if possible. b. If not successful after four attempts, have another nurse try. c. Restrain child only as needed to perform venipuncture safely. d. Show child equipment to be used before procedure.

ANS: C Restrain child only as needed to perform the procedure safely; use therapeutic hugging. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Keep all equipment out of sight until used.

PTS: 1 DIF: Cognitive Level: Apply REF: 664 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 27. An appropriate method for administering oral medications that are bitter to an infant or small child would be to mix them with: a. a bottle of formula or milk. b. any food the child is going to eat. c. a small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream. d. large amounts of water to dilute medication sufficiently.

ANS: C Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat in the future.

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PTS: 1 DIF: Cognitive Level: Apply REF: 666 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 28. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administer the medication with a syringe (without needle) placed along the side of the infants tongue. b. Administer the medication as rapidly as possible with the infant securely restrained. c. Mix the medication with the infants regular formula or juice and administer by bottle. d. Keep the child upright with the nasal passages blocked for a minute after administration.

ANS: A Administer the medication with a syringe without needle placed along the side of the infants tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. Holding the childs nasal passages will increase the risk of aspiration.

PTS: 1 DIF: Cognitive Level: Apply REF: 666 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 29. Which is the preferred site for intramuscular injections in infants? a. Deltoid b. Dorsogluteal c. Rectus femoris d. Vastus lateralis ANS: D The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older children and adults. The rectus femoris is not a recommended site.

PTS: 1 DIF: Cognitive Level: Understand REF: 667 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 30. Guidelines for intramuscular administration of medication in school-age children include

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which action? a. Inject medication as rapidly as possible. b. Insert needle quickly, using a dartlike motion. c. Penetrate skin immediately after cleansing site, before skin has dried. d. Have child stand, if possible, and if child is cooperative.

ANS: B The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before skin is penetrated. Place child in lying or sitting position.

PTS: 1 DIF: Cognitive Level: Apply REF: 671 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 31. Several types of long-term central venous access devices are used. Which is considered an advantage of a Hickman-Broviac catheter? a. No need to keep exit site dry b. Easy to use for self-administered infusions c. Heparinized only monthly and after each infusion d. No limitations on regular physical activity, including swimming ANS: B The Hickman-Broviac catheter has several benefits, including that it is easy to use for selfadministered infusions. The exit site must be kept dry to decrease risk of infection. The Hickman-Broviac catheter requires daily heparin flushes. Water sports may be restricted because of risk of infection.

PTS: 1 DIF: Cognitive Level: Understand REF: 675 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 32. When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down b. Carefully under the eye lid while it is gently pulled upward c. On the sclera while the child looks to the side d. Anywhere as long as drops contact the eyes surface ANS: A

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The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball.

PTS: 1 DIF: Cognitive Level: Understand REF: 679 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 33. A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. Which best explains why an intraosseous infusion is started? a. It is less painful for small children. b. Rapid venous access is not possible. c. Antibiotics must be started immediately. d. Long-term central venous access is not possible.

ANS: B In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe, lifesaving alternative. The procedure is painful, and local anesthetics and systemic analgesics are given. Antibiotics could be given when vascular access is obtained.

Long-term central venous access is time-consuming, and intraosseous infusion is used in an emergency situation.

PTS: 1 DIF: Cognitive Level: Analyze REF: 682 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 34. When caring for a child with an intravenous infusion, the nurse should: a. use a macrodropper to facilitate reaching the prescribed flow rate. b. avoid restraining the child to prevent undue emotional stress. c. change the insertion site every 24 hours. d. observe the insertion site frequently for signs of infiltration.

ANS: D The nursing responsibility for IV therapy is to calculate the amount to be infused in a given length of time; set the infusion rate; and monitor the apparatus frequently (at least every 1 to 2 hours) to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. A minidropper (60 drops/ml) is the recommended IV tubing in pediatrics. The IV site should be protected. This may require soft restraints on the child. Insertion sites do not need

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to be changed every 24 hours unless a problem is found with the site. This exposes the child to significant trauma.

PTS: 1 DIF: Cognitive Level: Apply REF: 683 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 35. Nursing considerations related to the administration of oxygen in an infant include to: a. humidify oxygen if infant can tolerate it. b. assess infant to determine how much oxygen should be given. c. ensure uninterrupted delivery of the appropriate oxygen concentration. d. direct oxygen flow so that it blows directly into the infants face in a hood.

ANS: C Oxygen is a prescribed medication. It is the nurses responsibility to ensure that the ordered concentration is delivered and the effects of therapy are monitored. Oxygen is drying to the tissues. Oxygen should always be humidified when delivered to a patient. A child receiving oxygen therapy should have the oxygen saturation monitored at least as frequently as vital signs.

Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage as indicated. Humidified oxygen should not be blown directly into an infants face.

Chapter 25. Adapting to Chronic Illness and Supporting the Family Unit MULTIPLE CHOICE 1. Home care is being considered for a young child who is ventilator-dependent. Which factor is most important in deciding whether home care is appropriate? a. Level of parents education b. Presence of two parents in the home c. Preparation and training of family d. Familys ability to assume all health care costs ANS: C One of the essential elements is the familys training and preparation. The family must be able to demonstrate all aspects of care for the child. In many areas, it cannot be guaranteed that nursing care will be available on a continual basis, and the family will have to care for the child. The amount of formal education reached by the parents is not the important issue. The determinant is

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the familys ability to care adequately for the child in the home. At least two family members should learn and demonstrate all aspects of the childs care in the hospital, but it does not have to be two parents. Few families can assume all health care costs. Creative financial planning, including negotiating arrangements with the insurance company and/or public programs, may be required.

PTS: 1 DIF: Cognitive Level: Analyze REF: 598-599 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control 2. The home health nurse asks a childs mother many questions as part of the assessment. The mother answers many questions, then stops and says, I dont know why you ask me all this. Who gets to know this information? The nurse should take which action? a. Determine why the mother is so suspicious. b. Determine what the mother does not want to tell. c. Explain who will have access to the information. d. Explain that everything is confidential and that no one else will know what is said.

ANS: C Communication with the family should not be invasive. The nurse needs to explain the importance of collecting the information, its applicability to the childs care, and who will have access to the information. The mother is not being suspicious and is not necessarily withholding important information. She has a right to understand how the information she provides will be used. The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals.

PTS: 1 DIF: Cognitive Level: Apply REF: 604 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 3. When communicating with other professionals, it is important for home care nurses to: a. ask others what they want to know. b. share everything known about the family. c. restrict communication to clinically relevant information. d. recognize that confidentiality is not possible.

ANS: C The nurse will need to share, through both oral and written communication, clinically relevant information with other involved health professionals. Asking others what they want to know and

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sharing everything known about the family is inappropriate. Patients have a right to confidentiality. The nurse is not permitted to share information about clients, except clinically relevant information that pertains to the childs care. Confidentiality permits the disclosure of information to other health professionals on a need-to-know basis.

PTS: 1 DIF: Cognitive Level: Apply REF: 604 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 4. The home health nurse is caring for a child who requires complex care. The family expresses frustration related to obtaining accurate information about their childs illness and its management. Which is the best action for the nurse? a. Determine why family is easily frustrated. b. Refer family to childs primary care practitioner. c. Clarify familys request, and provide information they want. d. Answer only questions that family needs to know about.

ANS: C The philosophic basis for family-centered practice is the recognition that the family is the constant in the childs life. It is essential and appropriate that the family have complete and accurate information about their childs illness and management. The nurse may first have to clarify what information the family believes has not been communicated. The familys frustration arises from their perception that they are not receiving information pertinent to their childs care.

Referring the family to the childs primary care practitioner does not help the family. The home health nurse should have access to the necessary information. Questions about what they need and want to know concerning their childs care should be addressed.

PTS: 1 DIF: Cognitive Level: Apply REF: 605 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 5. A family wants to begin oral feeding of their 4-year-old son, who is ventilator-dependent and currently tube-fed. They ask the home health nurse to feed him the baby food orally. The nurse recognizes a high risk of aspiration and an already compromised respiratory status. The most appropriate nursing action is to: a. refuse to feed him orally because the risk is too high. b. explain the risks involved, and then let the family decide what should be done. c. feed him orally because the family has the right to make this decision for their child.

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d. acknowledge their request, explain the risks, and explore with the family the available options.

ANS: D Parents want to be included in the decision making for their childs care. The nurse should discuss the request with the family to ensure this is the issue of concern, and then they can explore potential options together. Merely refusing to feed the child orally does not determine why the parents wish the oral feedings to begin and does not involve them in the problem solving. The decision to begin or not change feedings should be a collaborative one, made in consultation with the family, nurse, and appropriate member of the health care team.

PTS: 1 DIF: Cognitive Level: Analyze REF: 605 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 6. The home health nurse outlines short- and long-term goals for a 10-year-old child with many complex health problems. Who should agree on these goals? a. Family and nurse b. Child, family, and nurse c. All professionals involved d. Child, family, and all professionals involved ANS: D In the home, the family is a partner in each step of the nursing process. Family priorities should guide the planning process. Both short- and long-term goals should be outlined and agreed on by the child, family, and professionals involved. Involvement of the individuals who are essential to the childs care is necessary during this important stage. The elimination of any one of these groups can potentially create a care plan that does not meet the needs of the child and family.

PTS: 1 DIF: Cognitive Level: Analyze REF: 605 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 7. One of the supervisors for a home health agency asks the nurse to give the family a survey evaluating the nurses and other service providers. The nurse should recognize this as: a. inappropriate, unless nurses are able to evaluate family. b. appropriate to improve quality of care. c. inappropriate, unless nurses and other providers agree to participate. d. inappropriate, because family lacks knowledge necessary to evaluate professionals.

ANS: B

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Quality assessment and improvement activities are essential for virtually all organizations.

Family involvement is essential in evaluating a home care plan and can occur on several levels.

The nurse can ask the family open-ended questions at regular intervals to assess their opinion of the effectiveness of care. Families should also be given an opportunity to evaluate the individual home care nurses, the home care agency, and other service providers periodically. The nurse is the care provider. The evaluation is of the provision of care to the patient and family. The nurses role is not to evaluate the family. Quality-monitoring activities are required by virtually all health care agencies. During the evaluation process, the family is requested to provide their perceptions of care.

PTS: 1 DIF: Cognitive Level: Apply REF: 606 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 8. The home care nurse has been visiting an adolescent with recently acquired quadriplegia. The teens mother tells the nurse, Im sick of providing all the care while my husband does whatever he wants to, whenever he wants to do it. Which should be the initial action of the nurse? a. Refer mother for counseling. b. Listen and reflect mothers feelings. c. Ask father, in private, why he does not help. d. Suggest ways the mother can get her husband to help.

ANS: B It is appropriate for the nurse to reflect with the mother about her feelings, exploring issues such as an additional home health aide to help care for the child and provide respite for the mother. It is inappropriate for the nurse to agree with the mother that her husband is not helping enough. It is a judgment beyond the role of the nurse and can undermine the family relationship.

Counseling is not necessary at this time. A support group for caregivers may be indicated.

Asking the father why he does not help and suggesting ways to the mother to get her husband to help are interventions based on the mothers assumption of minimal contribution to the childs care. The father may have a full-time job and other commitments. The parents need to have an involved third person help them through the negotiation of responsibilities for the loss of their normal child and new parenting responsibilities.

PTS: 1 DIF: Cognitive Level: Apply REF: 610 TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Psychosocial Integrity

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9. The home health nurse is planning care for a 3-year-old boy who has Down syndrome and is receiving continuous oxygen. He recently began walking around furniture. He is spoon-fed by his parents and eats some finger foods. Which is the most appropriate goal to promote normal development? a. Encourage mobility. b. Encourage assistance in self-care. c. Promote oral-motor development. d. Provide opportunities for socialization.

ANS: A A major principle for developmental support in children with complex medical issues is that it should be flexible and tailored to the individual childs abilities, interests, and needs. This child is exhibiting readiness for ambulation. It is an appropriate time to provide activities that encourage mobility, for example, longer oxygen tubing. Parents should provide decreasing amounts of assistance with self-care as he is able to develop these skills. He is receiving oral foods and is eating finger foods. He has acquired oral-motor development. Mobility is a new developmental task. Opportunities for socialization should be ongoing.

PTS: 1 DIF: Cognitive Level: Apply REF: 606-607 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 10. A mother of a 5-year-old child, with complex health care needs and cared for at home, expresses anxiety about attending a kindergarten graduation exercise of a neighbors child. The mother says, I wish it could be my child graduating from kindergarten. The nurse recognizes that the mother is experiencing: a. abnormal anxiety. b. ineffective coping. c. chronic sorrow. d. denial.

ANS: C Home care nurses should be aware that parents may experience chronic sorrow as a parental stressor. Chronic sorrow as a normal grief response is associated with a living loss (the loss of a healthy child) that is cyclical in nature. This is a normal response and does not indicate abnormal anxiety, ineffective coping, or denial.

PTS: 1 DIF: Cognitive Level: Understand REF: 597

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TOP: Integrated Process: Communication and Documentation MSC: Area of Client Needs: Psychosocial Integrity 11. A ventilator-dependent child is cared for at home by his parents. Nurses come for 4 hours each day giving the parents some relief. Which other strategy should the nurse recommend to give the parents a break from the responsibilities of caring for a ventilator-dependent child? a. Encourage members from the parents church group to provide some relief care. b. Train a trusted grandparent to provide an occasional break from the responsibilities of care. c. Encourage the parents to pay out of pocket for additional private duty nurses. d. Suggest the parents place the child in a care facility.

ANS: B Respite care provides temporary relief to parents and allows a break from the responsibilities of caring for the ventilator-dependent child on a daily basis. For example, a trusted and trained grandparent or extended family member may be called in to give the family a break from caring for the child. Members of the parents church group would not have the training necessary to care for a ventilator-dependent child. Asking the parents to pay out of pocket for additional care would put a financial burden on the family. Suggesting the family place the child in a care facility is inappropriate.

PTS: 1 DIF: Cognitive Level: Apply REF: 598 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Psychosocial Integrity 12. A nurse manager at a home-care agency is planning a continuing education program for the home-care staff nurses. Which type of continuing education program should the nurse manager plan? a. On-line training modules b. A structured written teaching module each nurse completes individually c. A workshop training day, with a professional speaker, where nurses can interact with each other d. One-on-one continuing education training with each nurse ANS: C Because of the unique practice environment of home care nurses, it is important for an agency to facilitate sharing among peers to decrease work-related stress, increase job satisfaction, and support high-quality patient care. On-line training, written teaching modules, and one-on-one training would not allow for any sharing with peers.

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PTS: 1 DIF: Cognitive Level: Apply REF: 602 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Safe and Effective Care Environment: Management of Care 13. A priority intervention the home-care nurse should teach parents to do to maintain infection control is: a. sterilize equipment. b. reuse equipment to decrease costs. c. use proper hand hygiene. d. use gloves when repositioning the child.

ANS: B Hand hygiene is the cornerstone of infection control, and the nurse should teach parents the practice and help identify appropriate areas in the home setting for hand hygiene to be carried out with ease. Equipment can be cleaned in the home setting, but there is no means to sterilize equipment and because the child is exposed to fewer organisms in the home setting use of sterile equipment on a daily basis is not warranted. Some medical equipment may be washed with an appropriate disinfectant and reused to decrease cost of care; however, appropriate infection control practices should not be compromised to save money. It is not necessary to wear gloves when repositioning the child. Gloves would be worn only when protective personal equipment (PPE) is required.

PTS: 1 DIF: Cognitive Level: Apply REF: 608 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. Which behaviors by the nurse indicate therapeutic nurse-family boundaries? (Select all that apply.) a. Nurse visits family on days off. b. House rules are negotiated. c. Nurse buys child expensive gifts. d. Communication is open and two-way.

ANS: B, D A home care nurse can establish therapeutic nurse-family boundaries by negotiating house rules and ensuring that communication is open and two-way. Visiting the family of off-duty days and

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buying expensive gifts for the child would be boundary crossing and nontherapeutic.

PTS: 1 DIF: Cognitive Level: Analyze REF: 606 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 2. A child dependent on medical technology is preparing to be discharged from the hospital to home. Which predischarge assessments should the nurse ensure? (Select all that apply.) a. Emergency care and transport plan b. Reliance on private duty nurses to teach the family infection control practices c. Financial arrangements d. Individualized home plan to be completed within the first month of the childs discharge ANS: A, C The predischarge plan for a child dependent on medical technology going home should include emergency care and transport plan and financial arrangements. The infection control practices and individualized home plan should be completed before discharge, not after the child goes home.

Chapter 26. The Abused Child

1

The nurse is presenting a class at a local community health center on violence

.

during pregnancy. Which of the following would the nurse include as a possible complication?

A

Hypertension of pregnancy

) B

Chorioamnionitis

) C

Placenta previa

) D )

Postterm labor

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2

Which approach would be most appropriate when counseling a woman who is a

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suspected victim of violence?

A

Offer her a pamphlet about the local battered womens shelter.

) B

Call her at home to ask her some questions about her marriage.

) C

Wait until she comes in a few more times to make a better assessment.

) D

Ask, Have you ever been physically hurt by your partner?

)

3

When describing an episode, the victim reports that she attempted to calm her

.

partner down to keep things from escalating. This behavior reflects which phase of the cycle of violence?

A

Battering

) B

Honeymoon

) C

Tension-building

) D

Reconciliation

)

4

A battered pregnant woman reports to the nurse that her husband has stopped

.

hitting her and promises never to hurt her again. Which of the following is an appropriate response?

A )

Thats great. I wish you both the best.

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The cycle of violence often repeats itself.

) C

He probably didnt mean to hurt you.

) D

You need to consider leaving him.

)

5

Which of the following nursing actions would be least helpful for a client who is

.

a victim of violence?

A

Assist the client to project her anger.

) B

Provide information about a safe home and crisis line.

) C

Teach her about the cycle of violence.

) D

Discuss her legal and personal rights.

)

6

When describing the cycle of violence to a community group, the nurse explains

.

that the first phase usually is:

A

Somehow triggered by the victims behavior

) B

Characterized by tension-building and minor battery

) C

Associated with loss of physical and emotional control

) D )

Like a honeymoon that lulls the victim

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7

Which of the following statements would be most appropriate to empower

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victims of violence to take action?

A

Give your partner more time to come around.

) B

Rememberchildren do best in two-parent families.

) C

Change your behavior so as not to trigger the violence.

) D

You are a good person and you deserve better than this.

)

8

When a nurse suspects that a client may have been abused, the first action

.

should be to:

A

Ask the client about the injuries and if they are related to abuse.

) B

Encourage the client to leave the batterer immediately.

) C

Set up an appointment with a domestic violence counselor.

) D

Ask the suspected abuser about the victims injuries.

)

9

Which of the following would the nurse describe as a characteristic of the

.

second phase of the cycle of violence?

A

The batterer is contrite and attempts to apologize for the behavior.

) B )

The physical battery is abrupt and unpredictable.

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Verbal assaults begin to escalate toward the victim.

) D

The victim accepts the anger as legitimately directed at her.

)

1

In addition to providing privacy, which of the following would be most

0

appropriate initially in situations involving suspected abuse?

.

A

Allow the client to have a good cry over the situation.

) B

Tell the client, Injuries like these dont usually happen by accident.

) C

Call the police immediately so they can question the victim.

) D

Ask the abuser to describe his side of the story first.

)

1

When the nurse is alone with a client, the client says, It was all my fault. The

1

house was so messy when he got home and I know he hates that. Which

.

response would be most appropriate?

A

It is not your fault. No one deserves to be hurt.

) B

What else did you do to make him so angry with you?

) C

You need to start to clean the house early in the day.

) D )

Remember, he works hard and you need to meet his needs.

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1

When developing a presentation for a local community organization on

2

violence, the nurse is planning to include statistics on intimate partner abuse and

.

its effects on children. In what percentage of the cases in which a parent is abused are the children battered also?

A

50% to 75%

) B

25% to 50%

) C

10% to 25%

) D

Less than 5%

)

1

The primary goal when working with victims of intimate partner violence is

3

to:

.

A

Convince them to leave the abuser soon

) B

Help them cope with their life as it is

) C

Empower them to regain control of their life

) D

Arrest the abuser so he or she cant abuse again

)

1

Teaching for victims who are recovering from abusive situations must focus on

4

ways to:

.

A )

Enhance their personal appearance and hairstyle

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Develop their creativity and work ethic

) C

Improve their communication skills and assertiveness

) D

Plan more nutritious meals to improve their own health

)

1

During a follow-up visit to the clinic, a victim of sexual assault reports that she

5

has changed her job and moved to another town. She tells the nurse, I pretty

.

much stay to myself at work and at home. The nurse interprets these findings to indicate that the client is in which phase of rape recovery?

A

Disorganization

) B

Denial

) C

Reorganization

) D

Integration

)

1

A nurse is assessing a rape survivor for post-traumatic stress disorder. The nurse

6

asks the woman, Do you feel as though you are reliving the trauma? The nurse

.

is assessing for which of the following?

A

Physical symptoms

) B

Intrusive thoughts

) C )

Avoidance

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D

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Hyperarousal

)

1

A group of students are preparing a class discussion about rape and sexual

7

assault. Which of the following would the students include as being most

.

accurate? (Select all that apply.)

A

Most victims of rape tell someone about it.

) B

Few women falsely cry rape.

) C

Women have rape fantasies desiring to be raped.

) D

A rape victim feels vulnerable and betrayed afterwards.

) E

Medication and counseling can help a rape victim cope.

)

1

After teaching a class on date rape, the instructor determines that the teaching

8

was successful when the class identifies which of the following as the most

.

common date rape drug?

A

Gamma hydroxybutyrate

) B

Liquid ecstasy

) C

Ketamine

) D )

Rohypnol

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1

A nurse is caring for a woman who was recently raped. The nurse would expect

9

this woman to experience which of the following first?

.

A

Denial

) B

Disorganization

) C

Reorganization

) D

Integration

)

2

A group of nurses are researching information about risk factors for intimate

0

partner violence in men. Which of the following would the nurses expect to find

.

related to the individual person? (Select all that apply.)

A

Dysfunctional family system

) B

Low academic achievement

) C

Victim of childhood violence

) D

Heavy alcohol consumption

) E

Economic stress

)

2

A nurse is working with a victim of intimate partner violence and helping her

1

develop a safety plan. Which of the following would the nurse suggest that the

.

woman take with her? (Select all that apply.)

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A

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Drivers license

) B

Social security number

) C

Cash

) D

Phone cards

) E

Health insurance cards

)

2

A nurse is presenting a discussion on sexual violence at a local community

2

college. When describing the incidence of sexual violence, the nurse would

.

identify that a woman has which chance of experiencing a sexual assault in her lifetime?

A

One in three

) B

One in six

) C

Two in 15

) D

Three in 20

)

2

After teaching a class on sexual violence, the instructor determines that the

3

teaching was successful when the class identifies which of the following as a

.

type of sexual violence. (Select all that apply.)

A

Female genital cutting

)

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B

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Bondage

) C

Infanticide

) D

Human trafficking

) E

Rape

)

2

A nurse is reading a journal article about sexual abuse. Which age range would

4

the nurse expect to find as the peak age for such abuse?

.

A

710 years

) B

812 years

) C

1418 years

) D

1822 years

)

2

After teaching a group of students about sexual abuse and violence, the

5

instructor determines that the teaching was successful when the students

.

describe incest as involving which of the following?

A

Sexual exploitation by blood or surrogate relatives

) B )

Sexual abuse of individuals over age 18

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C

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Violent aggressive assault on a person

) D

Consent between perpetrator and victim.

) Answer Key

1.

B

2.

D

3.

C

4.

B

5.

A

6.

B

7.

D

8.

A

9.

B

10.

B

11.

A

12.

A

13.

C

14.

C

15.

C

16.

B

17.

B, D, E

18.

D

19.

B

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20.

B, C, D

21.

A, B, C, E

22.

B

23.

A, B, C, D, E

24.

B

25.

A

Chapter 27. Child With a Neurological Condition MULTIPLE CHOICE 1. The nurse is planning a staff in-service on childhood spastic cerebral palsy. Spastic cerebral palsy is characterized by: a. hypertonicity and poor control of posture, balance, and coordinated motion. b. athetosis and dystonic movements. c. wide-based gait and poor performance of rapid, repetitive movements. d. tremors and lack of active movement.

ANS: A Hypertonicity and poor control of posture, balance, and coordinated motion are part of the classification of spastic cerebral palsy. Athetosis and dystonic movements are part of the classification of dyskinetic (athetoid) cerebral palsy. Wide-based gait and poor performance of rapid, repetitive movements are part of the classification of ataxic cerebral palsy. Tremors and lack of active movement may indicate other neurologic disorders.

PTS: 1 DIF: Cognitive Level: Understand REF: 1092 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. The parents of a child with cerebral palsy ask the nurse whether any drugs can decrease their childs spasticity. The nurses response should be based on which statement? a. Anticonvulsant medications are sometimes useful for controlling spasticity. b. Medications that would be useful in reducing spasticity are too toxic for use with children.

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c. Many different medications can be highly effective in controlling spasticity. d. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.

ANS: D Baclofen, given intrathecally, is best suited for children with severe spasticity that interferes with activities of daily living and ambulation. Anticonvulsant medications are used when seizures occur in children with cerebral palsy. The intrathecal route decreases the side effects of the drugs that reduce spasticity. Few medications are currently available for the control of spasticity.

PTS: 1 DIF: Cognitive Level: Understand REF: 1094 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 3. The nurse is preparing to admit a newborn with myelomeningocele to the neonatal intensive care nursery. Which describes this newborns defect? a. Fissure in the spinal column that leaves the meninges and the spinal cord exposed b. Herniation of the brain and meninges through a defect in the skull c. Hernial protrusion of a saclike cyst of meninges with spinal fluid but no neural elements d. Visible defect with an external saclike protrusion containing meninges, spinal fluid, and nerves ANS: D A myelomeningocele is a visible defect with an external saclike protrusion, containing meninges, spinal fluid, and nerves. Rachischisis is a fissure in the spinal column that leaves the meninges and the spinal cord exposed. Encephalocele is a herniation of brain and meninges through a defect in the skull, producing a fluid-filled sac. Meningocele is a hernial protrusion of a saclike cyst of meninges with spinal fluid, but no neural elements.

PTS: 1 DIF: Cognitive Level: Understand REF: 1098 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 4. The nurse is conducting a staff in-service on common problems associated with myelomeningocele. Which common problem is associated with this defect? a. Hydrocephalus b. Craniosynostosis c. Biliary atresia d. Esophageal atresia

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ANS: A Hydrocephalus is a frequently associated anomaly in 80% to 90% of children. Craniosynostosis is the premature closing of the cranial sutures and is not associated with myelomeningocele.

Biliary and esophageal atresia is not associated with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Understand REF: 1100 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 5. The nurse is teaching a group of nursing students about newborns born with the congenital defect of myelomeningocele. Which common problem is associated with this defect? a. Neurogenic bladder b. Mental retardation c. Respiratory compromise d. Cranioschisis ANS: A Myelomeningocele is one of the most common causes of neuropathic (neurogenic) bladder dysfunction among children. Risk of mental retardation is minimized through early intervention and management of hydrocephalus. Respiratory compromise is not a common problem in myelomeningocele. Cranioschisis is a skull defect through which various tissues protrude. It is not associated with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Understand REF: 1101 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. The nurse is reviewing prenatal vitamin supplements with an expectant client. Which supplement should be included in the teaching? a. Vitamin A throughout pregnancy b. Multivitamin preparations as soon as pregnancy is suspected c. Folic acid for all women of childbearing age d. Folic acid during the first and second trimesters of pregnancy ANS: C The widespread use of folic acid among women of childbearing age has decreased the incidence of spina bifida significantly. Vitamin A is not related to the prevention of spina bifida. Folic acid supplementation is recommended for the preconception period and during the pregnancy. Only

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42% of women actually follow these guidelines.

PTS: 1 DIF: Cognitive Level: Understand REF: 1102 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 7. How much folic acid is recommended for women of childbearing age? a. 1.0 mg b. 0.4 mg c. 1.5 mg d. 2.0 mg ANS: B It has been estimated that a daily intake of 0.4 mg of folic acid in women of childbearing age will prevent 50% to 70% of cases of neural tube defects; 1.0 mg is too low a dose; 1.5 to 2.0 mg are not the recommended dosages of folic acid.

PTS: 1 DIF: Cognitive Level: Remember REF: 1102 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 8. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. The most appropriate way to position and feed this neonate is which position? a. Prone and tube-fed b. Prone, head turned to side, and nipple-fed c. Supine in an infant carrier and nipple-fed d. Supine, with defect supported with rolled blankets, and nipple-fed ANS: B In the prone position, feeding is a problem. The infants head is turned to one side for feeding. If the child is able to nipple-feed, tube feeding is not needed. Before surgery, the infant is kept in the prone position to minimize tension on the sac and risk of trauma.

PTS: 1 DIF: Cognitive Level: Apply REF: 1103 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 9. The nurse is talking to a parent with a child who has a latex allergy. Which statement by the parent would indicate a correct understanding of the teaching?

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a. My child will have an allergic reaction if he comes in contact with yeast products. b. My child may have an upset stomach if he eats a food made with wheat or barley. c. My child will probably develop an allergy to peanuts. d. My child should not eat bananas or kiwis.

ANS: D There are cross-reactions between latex allergies and a number of foods such as bananas, avocados, kiwi, and chestnuts. Children with a latex allergy will not develop allergies to other food products such as yeast, wheat, barley, or peanuts.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1104 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 10. Latex allergy is suspected in a child with spina bifida. Appropriate nursing interventions include which action? a. Avoid using any latex product. b. Use only nonallergenic latex products. c. Administer medication for long-term desensitization. d. Teach family about long-term management of asthma.

ANS: A Care must be taken that individuals who are at high risk for latex allergies do not come in direct or secondary contact with products or equipment containing latex at any time during medical treatment. There are no nonallergenic latex products. At this time, desensitization is not an option. The child does not have asthma. The parents must be taught about allergy and the risk of anaphylaxis.

PTS: 1 DIF: Cognitive Level: Apply REF: 1104 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 11. The nurse is admitting a child with Werdnig-Hoffmann disease (spinal muscular atrophy type 1). Which signs and symptoms are associated with this disease? a. Spinal muscular atrophy b. Neural atrophy of muscles c. Progressive weakness and wasting of skeletal muscle d. Pseudohypertrophy of certain muscle groups ANS: C

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Werdnig-Hoffmann disease (spinal muscular atrophy type 1) is the most common paralytic form of floppy infant syndrome (congenital hypotonia). It is characterized by progressive weakness and wasting of skeletal muscle caused by degeneration of anterior horn cells. KugelbergWelander disease is a juvenile spinal muscular atrophy with a later onset. Charcot-Marie-Tooth disease is a form of progressive neural atrophy of muscles supplied by the peroneal nerves.

Progressive weakness is found of the distal muscles of the arms and feet. Duchenne muscular dystrophy is characterized by muscles, especially in the calves, thighs, and upper arms, which become enlarged from fatty infiltration and feel unusually firm or woody on palpation. The term pseudohypertrophy is derived from this muscular enlargement.

PTS: 1 DIF: Cognitive Level: Understand REF: 1105 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 12. Which clinical manifestations in an infant would be suggestive of spinal muscular atrophy (Werdnig-Hoffmann disease)? a. Hyperactive deep tendon reflexes b. Hypertonicity c. Lying in the frog position d. Motor deficits on one side of body ANS: C The infant lies in the frog position with the legs externally rotated, abducted, and flexed at knees.

The deep tendon reflexes are absent. The child has hypotonia and inactivity as the most prominent features. The motor deficits are bilateral.

PTS: 1 DIF: Cognitive Level: Understand REF: 1105 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. A 4-year-old child has just been diagnosed with pseudohypertrophic (Duchenne) muscular dystrophy. The management plan should include which action? a. Recommend genetic counseling. b. Explain that the disease is easily treated. c. Suggest ways to limit use of muscles. d. Assist family in finding a nursing facility to provide his care.

ANS: A Pseudohypertrophic (Duchenne) muscular dystrophy is inherited as an X-linked recessive gene.

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Genetic counseling is recommended for parents, female siblings, maternal aunts, and their female offspring. No effective treatment exists at this time for childhood muscular dystrophy.

Maintaining optimal function of all muscles for as long as possible is the primary goal. It has been found that children who remain as active as possible are able to avoid wheelchair confinement for a longer time. Assisting the family in finding a nursing facility to provide his care is inappropriate at the time of diagnosis. When the child becomes increasingly incapacitated, the family may consider home-based care, a skilled nursing facility, or respite care to provide the necessary care.

PTS: 1 DIF: Cognitive Level: Understand REF: 1109 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 14. Therapeutic management of a child with tetanus includes the administration of: a. nonsteroidal anti-inflammatory drugs (NSAIDs) to reduce inflammation. b. muscle stimulants to counteract muscle weakness. c. bronchodilators to prevent respiratory complications. d. tetanus immunoglobulin therapy.

ANS: D Tetanus immunoglobulin therapy, to neutralize toxins, is the most specific therapy for tetanus.

Tetanus toxin acts at the myoneural junction to produce muscular stiffness and lowers the threshold for reflex excitability. NSAIDs are not routinely used. Sedatives or muscle relaxants are used to help reduce titanic spasm and prevent seizures. Respiratory status is carefully evaluated for any signs of distress because muscle relaxants, opioids, and sedatives that may be prescribed may cause respiratory depression. Bronchodilators would not be used unless specifically indicated.

PTS: 1 DIF: Cognitive Level: Understand REF: 1112 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 15. The nurse is conducting reflex testing on infants at a well-child clinic. Which reflex finding should be reported as abnormal and considered as a possible sign of cerebral palsy? a. Tonic neck reflex at 5 months of age b. Absent Moro reflex at 8 months of age c. Moro reflex at 3 months of age d. Extensor reflex at 7 months of age

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ANS: D Establishing a diagnosis of cerebral palsy (CP) may be confirmed with the persistence of primitive reflexes: (1) either the asymmetric tonic neck reflex or persistent Moro reflex (beyond 4 months of age) and (2) the crossed extensor reflex. The tonic neck reflex normally disappears between 4 and 6 months of age. The crossed extensor reflex, which normally disappears by 4 months, is elicited by applying a noxious stimulus to the sole of one foot with the knee extended.

Normally, the contralateral foot responds with extensor, abduction, and then adduction movements. The possibility of CP is suggested if these reflexes occur after 4 months.

PTS: 1 DIF: Cognitive Level: Apply REF: 1091 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 16. The nurse is caring for an infant with myelomeningocele scheduled for surgical closure in the morning. Which interventions should the nurse plan for the care of the myelomeningocele sac? a. Open to air b. Covered with a sterile moist nonadherent dressing c. Reinforcement of the original dressing if drainage noted d. A diaper secured over the dressing ANS: B Before surgical closure, the myelomeningocele is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. The moistening solution is usually sterile normal saline. Dressings are changed frequently (every 2 to 4 hours), and the sac is closely inspected for leaks, abrasions, irritation, and any signs of infection. The sac must be carefully cleansed if it becomes soiled or contaminated. The original dressing would not be reinforced but changed as needed. A diaper is not placed over the dressing because stool contamination can occur.

PTS: 1 DIF: Cognitive Level: Apply REF: 1102 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 17. The nurse is admitting a school-age child with suspected Guillain-Barr syndrome (GBS).

Which is a priority in the care for this child? a. Monitoring intake and output b. Assessing respiratory efforts c. Placing on a telemetry monitor

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d. Obtaining laboratory studies ANS: B Treatment of GBS is primarily supportive. In the acute phase, patients are hospitalized because respiratory and pharyngeal involvement may require assisted ventilation, sometimes with a temporary tracheotomy. Treatment modalities include aggressive ventilatory support in the event of respiratory compromise, intravenous (IV) administration of immunoglobulin (IVIG), and sometimes steroids; plasmapheresis and immunosuppressive drugs may also be used. Intake and output, telemetry monitoring and obtaining laboratory studies may be part of the plan of care but are not the priority.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1110 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 18. The nurse is caring for an intubated infant with botulism in the pediatric intensive care unit.

Which health care provider prescriptions should the nurse clarify with the health care provider before implementing? a. Administer 250 mg botulism immune globulin intravenously (BIG-IV) one time. b. Provide total parenteral nutrition (TPN) at 25 ml/hr intravenously. c. Titrate oxygen to keep pulse oximetry saturations greater than 92. d. Administer gentamicin sulfate (Garamycin) 10 mg per intravenous piggyback every 12 hours.

ANS: D The nurse should clarify the administration of an aminoglycoside antibiotic. Antibiotic therapy is not part of the management of infant botulism because the botulinum toxin is an intracellular molecule, and antibiotics would not be effective; aminoglycosides in particular should not be administered because they may potentiate the blocking effects of the neurotoxin. Treatment consists of immediate administration of botulism immune globulin intravenously (BIG-IV) without delaying for laboratory diagnosis. Early administration of BIG-IV neutralizes the toxin and stops the progression of the disease. The human-derived botulism antitoxin (BIG-IV) has been evaluated and is now available nationwide for use only in infant botulism. Approximately 50% of affected infants require intubation and mechanical ventilation; therefore, respiratory support is crucial, as is nutritional support because these infants are unable to feed.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1113-1114 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy

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19. A home care nurse is caring for an adolescent with a T1 spinal cord injury. The adolescent suddenly becomes flushed, hypertensive, and diaphoretic. Which intervention should the nurse perform first? a. Place the adolescent in a flat right side-lying position. b. Place a cool washcloth on the adolescents forehead and continue to monitor the blood pressure. c. Implement a standing prescription to empty the bladder with a sterile in and out Foley catheter. d. Take a full set of vital signs and notify the health care provider.

ANS: C The adolescent is experiencing an autonomic dysreflexia episode. The paralytic nature of autonomic function is replaced by autonomic dysreflexia, especially when the lesions are above the mid-thoracic level. This autonomic phenomenon is caused by visceral distention or irritation, particularly of the bowel or bladder. Sensory impulses are triggered and travel to the cord lesion, where they are blocked, which causes activation of sympathetic reflex action with disturbed central inhibitory control. Excessive sympathetic activity is manifested by a flushing face, sweating forehead, pupillary constriction, marked hypertension, headache, and bradycardia. The precipitating stimulus may be merely a full bladder or rectum or other internal or external sensory input. It can be a catastrophic event unless the irritation is relieved. Placing a cool washcloth on the adolescents forehead, continuing to monitor blood pressure and vital signs, and notifying the healthcare provider would not reverse the sympathetic reflex situation.

PTS: 1 DIF: Cognitive Level: Apply REF: 1115 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Nursing care for this child includes which action(s)? (Select all that apply.) a. Monitoring and maintaining systemic blood pressure b. Administering corticosteroids c. Minimizing environmental stimuli d. Discussing long-term care issues with the family e. Monitoring for respiratory complications ANS: A, B, E Spinal cord injury patients are physiologically labile, and close monitoring is required. They may

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be unstable for the first few weeks after the injury. Corticosteroids are administered to minimize the inflammation present with the injury. It is not necessary to minimize environmental stimuli for this type of injury. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

PTS: 1 DIF: Cognitive Level: Apply REF: 1115-1116 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. Which assessment findings should the nurse note in a school-age child with Duchenne muscular dystrophy (DMD)? (Select all that apply.) a. Lordosis b. Gower sign c. Kyphosis d. Scoliosis e. Waddling gait ANS: A, B, E Difficulties in running, riding a bicycle, and climbing stairs are usually the first symptoms noted in Duchenne muscular dystrophy. Typically, affected boys have a waddling gait and lordosis, fall frequently, and develop a characteristic manner of rising from a squatting or sitting position on the floor (Gower sign). Lordosis occurs as a result of weakened pelvic muscles, and the waddling gait is a result of weakness in the gluteus medius and maximus muscles. Kyphosis and scoliosis are not assessment findings with DMD. PTS: 1 DIF: Cognitive Level: Apply REF: 1107 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. The nurse is conducting discharge teaching to parents of a preschool child with myelomeningocele, repaired at birth, being discharged from the hospital after a urinary tract infection (UTI). Which should the nurse include in the discharge instructions related to management of the childs genitourinary function? (Select all that apply.) a. Continue to perform the clean intermittent catheterizations (CIC) at home. b. Administer the oxybutynin chloride (Ditropan) as prescribed. c. Reduce fluid intake in the afternoon and evening hours. d. Monitor for signs of a recurrent urinary tract infection.

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e. Administer furosemide (Lasix) as prescribed.

ANS: A, B, D Discharge teaching to prevent renal complications in a child with myelomeningocele include: (1) regular urologic care with prompt and vigorous treatment of infections; (2) a method of regular emptying of the bladder, such as clean intermittent catheterization (CIC) taught to and performed by parents and self-catheterization taught to children; (3) medications to improve bladder storage and continence, such as oxybutynin chloride (Ditropan) and tolterodine (Detrol). Fluids should not be limited and Lasix is not used to improve renal function for children with myelomeningocele.

PTS: 1 DIF: Cognitive Level: Apply REF: 1101 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. Which should the nurse expect to find in the cerebral spinal fluid (CSF) results of a child with Guillain-Barr syndrome (GBS)? (Select all that apply.) a. Decreased protein concentration b. Normal glucose c. Fewer than 10 white blood cells (WBCs/mm3) d. Elevated red blood cell (RBC) count ANS: B, C Diagnosis of GBS is based on clinical manifestations, CSF analysis, and EMG findings. CSF analysis reveals an abnormally elevated protein concentration, normal glucose, and fewer than 10 WBCs/mm3. CSF fluid should not contain RBCs. PTS: 1 DIF: Cognitive Level: Understand REF: 1110 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 5. The nurse in the neonatal intensive care unit is caring for an infant with myelomeningocele scheduled for surgical repair in the morning. Which early signs of infection should the nurse monitor on this infant? (Select all that apply.) a. Temperature instability b. Irritability c. Lethargy d. Bradycardia e. Hypertension

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ANS: A, B, C The nurse should observe an infant with unrepaired myelomeningocele for early signs of infection, such as temperature instability (axillary), irritability, and lethargy. Bradycardia and hypertension are not early signs of infection in infants.

Chapter 28. Child With a Sensory Impairment MULTIPLE CHOICE 1. A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media? a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure. c. They have increased susceptibility to upper respiratory tract infections. d. The eustachian tube is short, straight, and wide.

ANS: D An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.

DIF: Cognitive Level: Knowledge REF: Page 525 OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. What statement by a patients mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media? a. I will continue using the medication until symptoms are relieved. b. I will share the medicine with siblings if their symptoms are the same. c. I will give the medication with a glass of milk. d. I will administer prescribed doses until all the medication is used.

ANS: D Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.

DIF: Cognitive Level: Application REF: Page 527, Nursing Tip OBJ: 2 TOP: Otitis Media KEY: Nursing Process Step: Evaluation

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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. Which situation would cause the nurse to suspect a hearing impairment? a. 3-month-old infant with a positive Moro reflex b. 15-month-old toddler who is babbling c. 18-month-old toddler who is speaking one-syllable words d. 24-month-old toddler who communicates by pointing ANS: D The child who is not making verbal attempts by 18 months should undergo a complete physical examination.

DIF: Cognitive Level: Analysis REF: Page 527-528 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment? a. Use gestures and signs as much as possible. b. Let the childs parents communicate for her. c. Face the child and speak clearly in short sentences. d. Recognize that the childs ability to communicate will be on a 6-year-old childs level.

ANS: C The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.

DIF: Cognitive Level: Application REF: Page 528, Nursing Tip OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 5. What would the nurse include when planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes? a. Keeping the infant flat after feeding b. Giving over-the-counter decongestants c. Avoiding getting water in the ears d. Cleaning the ear canal with cotton-tipped applicators

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ANS: C After a tympanostomy, care should be taken to avoid getting water in the ears.

DIF: Cognitive Level: Comprehension REF: Page 527 OBJ: 2 TOP: Postoperative Care of Tympanostomy KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 6. What assessment made by the school nurse would lead to the suspicion of strabismus? a. Reddened sclera in one eye b. Child covers one eye to read the chalkboard c. Child complains of a headache d. Copious tears while watching TV ANS: B Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder.

DIF: Cognitive Level: Analysis REF: Page 530-531 OBJ: 4 TOP: Strabismus KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. What might the nurse explain as a common treatment for amblyopia? a. Patching the good eye to force the brain to use the affected eye b. Patching the affected eye to allow the refractory muscles to rest c. Using glasses that will slightly blur the image for the good eye d. Using corticosteroids to treat inflammation of the optic nerve ANS: A Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.

DIF: Cognitive Level: Knowledge REF: Page 530 OBJ: 4 TOP: Amblyopia KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. What assessment does the school nurse recognize as the cardinal sign of a hyphema? a. Opacity of the lens b. A yellow-white reflex on the pupil

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c. A dark-red spot in front of the iris d. Inflamed mucous membranes of the eyelids ANS: C A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.

DIF: Cognitive Level: Knowledge REF: Page 532 OBJ: N/A TOP: Hyphema KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching? a. Use aspirin instead of acetaminophen for children with viral illness. b. Advise parents to have their children immunized against Reyes syndrome. c. Avoid giving salicylate-containing medications to a child who has viral symptoms. d. Get the child tested for Reyes syndrome if the child exhibits fever, vomiting, and lethargy.

ANS: C Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms.

DIF: Cognitive Level: Application REF: Page 533 OBJ: 8 TOP: Reyes Syndrome KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. What symptom leads the nurse caring for a 5-month-old with viral influenza to suspect the development of Reyes syndrome? a. Respirations drop from 18 to 14 breaths/min b. Falling asleep after feeding c. Sudden vomiting without effort d. Development of a macular rash ANS: C A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal.

DIF: Cognitive Level: Application REF: Page 533 OBJ: 8 TOP: Reyes Syndrome KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. What does the nurse explains to parents of a child with febrile seizures? a. They occur when the body temperature exceeds 38.3 C (101 F). b. They can be prevented by anticonvulsant medication. c. They usually lead to the development of epilepsy. d. They occur when the temperature rises quickly.

ANS: D Febrile seizures occur in response to a rapid rise in temperature, often above 38.8 C (102 F).

DIF: Cognitive Level: Comprehension REF: Page 539 OBJ: 10 TOP: Febrile Seizures KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic? a. Absence b. Akinetic c. Myoclonic d. Complex partial ANS: A Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.

DIF: Cognitive Level: Comprehension REF: Page 540, Table 23-2 OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. An adolescent has just had a generalized seizure and collapsed in the school nurses office.

When should the nurse should call 911? a. The seizure lasts more than 5 minutes. b. The child is sleepy and lethargic after the seizure. c. The child fell at the onset of the seizure. d. The child is confused and has slurred speech after the seizure.

ANS: A If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are

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indicators of possible status epilepticus, a medical emergency.

DIF: Cognitive Level: Application REF: Page 540, Table 23-2 OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure? a. Guide the child to the floor if the child is standing, and then go for help. b. Move objects out of the childs immediate area. c. Stick a padded tongue blade between the childs teeth. d. Manually restrain the child.

ANS: B During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

DIF: Cognitive Level: Application REF: Page 540, Table 23-2 OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 15. A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds.

What would the nurse expect to assess after a generalized tonic-clonic seizure? a. Restlessness b. Sleepiness c. Nausea d. Anxiety ANS: B Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.

DIF: Cognitive Level: Comprehension REF: Page 540, Table 23-2 OBJ: 10 | 11 TOP: Epilepsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)? a. The medication should be given on an empty stomach. b. Insomnia can be a significant side effect.

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c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored.

ANS: C Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day.

DIF: Cognitive Level: Comprehension REF: Page 543, Figure 23-10 OBJ: 10 TOP: Epilepsy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed ANS: C Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

DIF: Cognitive Level: Comprehension REF: Page 544, Table 23-4 OBJ: 12 TOP: Cerebral Palsy KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. Which assessment finding in a child with meningitis should be reported immediately? a. Irregular respirations b. Tachycardia c. Slight drop in blood pressure d. Elevated temperature ANS: A Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure.

DIF: Cognitive Level: Application REF: Page 536 OBJ: 9 TOP: Meningitis KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Physiological Integrity 19. The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture? a. Correct anatomical position b. Decorticate c. Decerebrate d. Opisthotonos ANS: C In decerebrate posturing, arms are extended along the side of the body and hands are pronated.

This posture indicates brainstem function only.

DIF: Cognitive Level: Application REF: Page 550, Figure 23-13 OBJ: 15 TOP: Posturing KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. What will the nurse teach parents when giving instructions for acute conjunctivitis? a. Apply cool compresses to the affected eye several times a day. b. Instill topical steroid eye drops for 1 week. c. Clear drainage from the inner to the outer aspect of the eye. d. Keep the eye patched until the inflammation resolves.

ANS: C Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).

DIF: Cognitive Level: Application REF: Page 532 OBJ: N/A TOP: Conjunctivitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 21. A child is brought to the emergency department after he fell and hit his head on the ground.

Which nursing assessment suggests the child has a concussion? a. Sleepy but easily arousable b. Complaining of a stiff neck c. Cannot remember what happened to him d. Pupils react sluggishly to light ANS: C A concussion is a temporary disturbance of the brain that is immediately followed by a period of

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unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

DIF: Cognitive Level: Analysis REF: Page 548-552 OBJ: 16 | 17 TOP: Head Injury KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect? a. Meningitis b. Reyes syndrome c. Brain tumor d. Encephalitis ANS: C The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

DIF: Cognitive Level: Analysis REF: Page 538 OBJ: 10 TOP: Brain Tumor KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against? a. Encephalitis b. Influenza c. Bacterial meningitis d. Otitis media ANS: C H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.

DIF: Cognitive Level: Knowledge REF: Page 536-537 OBJ: N/A TOP: Prevention of Meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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24. The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)? a. Temperature increase from 37.2 C (99 F) to 37.7 C (100 F) b. Increase in blood pressure with an attendant decrease in pulse c. Increase in respirations d. Equilateral pupils ANS: B Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP. DIF: Cognitive Level: Comprehension REF: Page 552 OBJ: 14 | 17 TOP: ICP KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 25. A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected? a. Patching the unaffected eye b. Corrective lenses c. Laser treatment d. Surgery ANS: B In nonparalytic strabismus the refractory error is usually corrected with eyeglasses.

DIF: Cognitive Level: Comprehension REF: Page 531-532 OBJ: 5 TOP: Strabismus KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 26. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which of the following a statements by the parents alerts the nurse that they need further instruction? a. We dress our son every morning for school. b. Our son participates in the Special Olympics every year. c. Our son attends play therapy at a center close to home. d. We attend a support group once a week.

ANS: A The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should

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not take over projects because of their own need to assist or speed up the process.

DIF: Cognitive Level: Application REF: Page 548 OBJ: 13 TOP: Cognitive Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Therapeutic Environment 27. What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants? a. Using ear plugs during takeoff b. Omitting the meal just before takeoff c. Letting the infant nurse during descent d. Applying ear drops before takeoff ANS: C Encouraging an infant to swallow reduces the pressure in the ears during descent.

DIF: Cognitive Level: Comprehension REF: Page 529 OBJ: 1 TOP: Barotrauma KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 28. Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.) a. Hypersensitivity to noise b. Irritability c. Reddened ear canal d. Rolls head from side to side e. Temperature of 39.4 C (103 F) ANS: B, D, E Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.

DIF: Cognitive Level: Comprehension REF: Page 526, Nursing Tip OBJ: 2 TOP: Indications of Ear Infection KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 29. Which aspect(s) of a childs development does the nurse caution parents that hearing

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impairment can affect? (Select all that apply.) a. Speech clarity b. Language development c. Immunity to disease d. Personality development e. Academic achievement ANS: A, B, D, E All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.

DIF: Cognitive Level: Comprehension REF: Page 527 OBJ: 3 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 30. What intervention(s) would the nurse caring for a child with infectious meningitis include?

(Select all that apply.) a. Isolation precautions b. Provision of brightly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions ANS: A, C, D, E All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive care of a child with meningitis.

DIF: Cognitive Level: Application REF: Page 537 OBJ: 9 TOP: Nursing Care of Child with Meningitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 31. What will the nurse include then documenting a grand mal seizure? (Select all that apply.) a. Presence of incontinence b. Current dose of antispasmodic medication c. Activity level prior to and following seizure d. Level of consciousness following seizure e. Length of seizure ANS: A, C, D, E

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Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.

DIF: Cognitive Level: Application REF: Page 539 OBJ: 10 TOP: Documentation of Seizure KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 32. The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.) a. Encourage books with large type. b. Words in books should be closely spaced. c. Provide adequate lighting without glare. d. Be sure desks and chairs are adequate height. e. Instruct child to squint when reading.

ANS: A, C, D Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height.

DIF: Cognitive Level: Comprehension REF: Page 532 OBJ: 6 TOP: Decorticate Posturing KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention 33. The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow Coma Scale. What score will the nurse give if the child is babbling? a. 1 b. 2 c. 3 d. 4 ANS: D If babbling, the 10-month-old infant receives a score of 4 for responses.

DIF: Cognitive Level: Application REF: Page 553, Table 23-6 OBJ: 18 TOP: Neurological Monitoring/Infants KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Health Promotion/Disease Prevention

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34. An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.) a. Parental education regarding prevention b. Respiratory support c. Cardiovascular support d. Controlled rewarming e. Adequate cerebral oxygenation ANS: B, C, D, E Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up.

DIF: Cognitive Level: Comprehension REF: Page 553-554 OBJ: 19 TOP: Near-drowning KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 35. The sign that suggests possible damage to the cortex of the brain is

posturing.

ANS: decorticate Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet. This posture suggests injury to the brain cortex.

DIF: Cognitive Level: Comprehension REF: Page 550 OBJ: 15 TOP: Decorticate Posturing KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 36. The nurse records the finding of

when the child with

meningitis cries out in pain when his head is flexed toward his chest.

ANS: nuchal rigidity Stiffness of the neck resulting from inflamed meninges is a sign of meningitis called nuchal

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rigidity.

DIF: Cognitive Level: Comprehension REF: Page 536 OBJ: 9 TOP: Nuchal Rigidity KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 37. The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle is the

nerve.

ANS: hypoglossal The hypoglossal (XII) nerve allows the infant to be able to suck and swallow. It is also responsible for tongue movement.

DIF: Cognitive Level: Knowledge REF: Page 535, Figure 23-7 | Page 536, Table 23-1 OBJ: 7 TOP: Cranial Nerves KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 38.

occurs when there is a change in the atmospheric pressure between the

internal body systems and the surrounding environment.

ANS: Barotrauma Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.

Chapter 29. Child With a Mental Health Condition MULTIPLE CHOICE 1. A parent asks the nurse to describe what is meant by a learning disability. Which is the nurses most helpful response? a. A child may have difficulty with perception, language, comprehension, or memory. b. It is characterized by inattention, impulsiveness, and hyperactivity.

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c. The childs intellectual ability limits his learning. d. The child has difficulty learning because of brain damage.

ANS: A Learning disability is an educational term. Children with learning disabilities may have average to above-average intelligence, but they may experience difficulties in perception, language, comprehension, and conceptualization.

DIF: Cognitive Level: Comprehension REF: Page 749 OBJ: N/A TOP: Learning Disability KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. What would be the appropriate response to an adolescent who states, This has been the worst day of my life? a. You should focus your mind on positive thoughts. b. Everybody has a bad day now and then. c. Youre young. What could be so terrible? d. Tell me about the worst day of your life.

ANS: D The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and giving the adolescent full attention.

DIF: Cognitive Level: Application REF: Page 754, Nursing Tip OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse asks, Do your parents drink every day? The adolescent suddenly shouts, Im not going to talk about that! Its none of your business, anyway! Leave me alone! How does the nurse interpret the adolescents behavior? a. The adolescent is acting out and needs to be brought under control so the conference can continue. b. The adolescent is trying to shift the focus of the conference away from himself, and the nurse needs to refocus. c. The adolescent is demonstrating that this problem requires the assistance of a psychiatrist. d. The adolescent is responding to the discrediting of his parents, which causes anxiety.

ANS: D Discrediting parents threatens the childs security and creates anxiety.

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DIF: Cognitive Level: Analysis REF: Page 757-758 OBJ: 10 TOP: Children of Alcoholics KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. The nurse is answering phone calls at a local suicide prevention hotline. Which statement would be recognized as the greatest risk of suicide? a. I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself. b. My parents arent home and wont be back for 4 hours. That should be enough time for the pills to work. Ive got a hundred of them. c. My dad will be home first, so hell find me. So I think Ill use his gun. I hope he didnt lock the cabinet. d. My girlfriend is here with me. She told me to call because I was talking crazy about killing myself.

ANS: B The risk of death increases when there is a definite plan of action, the means are readily available, and the person has few resources for help and support.

DIF: Cognitive Level: Analysis REF: Page 752-753, NCP 33-1 OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. A 15-year-old boy was previously active in a band and saved money to buy a special guitar.

What would a nurse assess as an early sign of depression in this boy? a. He gives up the band to spend time with his girlfriend. b. He spends all of his time at the library studying to qualify for the honor society. c. He gives his guitar away and spends his time listening to music in his room. d. He withdraws all of his money out of the bank to buy an expensive leather jacket.

ANS: C A major depression is characterized by a prolonged behavioral change from baseline that interferes with school, family life, and age-specific activities, frequently signaled by giving prized possessions away.

DIF: Cognitive Level: Analysis REF: Page 751-752 OBJ: 6 TOP: Depression KEY: Nursing Process Step: Data Collection

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. A mother is concerned because her adolescent son is always in trouble for fighting at school and always seems to be angry. She mentions that her husband drinks a bit. Which understanding will guide the nurses response? a. The boy is displaying antisocial behavior and should be evaluated for mental illness. b. The boy is displaying one of the typical defense patterns of children of alcoholics and should receive immediate treatment. c. The mother is displaying her own anger with her husbands drinking, and she needs immediate intervention. d. The boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention.

ANS: D Early recognition of and intervention for children of alcoholics are paramount. This adolescent is using the coping pattern of acting-out behaviors to deal with the family situation.

DIF: Cognitive Level: Comprehension REF: Page 757-758 OBJ: 10 TOP: Children of Alcoholics KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 7. What is the most appropriate classroom intervention for a child with attention deficit hyperactivity disorder (ADHD) for the school nurse to suggest? a. Seat the child in the back of the room to prevent distractions for other children. b. Pair the child with a student buddy to offer reminders to pay attention. c. Divide work assignments into shorter periods with breaks in between. d. Separate the child from others to increase his focus on schoolwork.

ANS: C The child with ADHD needs breaks between periods of work and study.

DIF: Cognitive Level: Application REF: Page 750, Health Promotion Box OBJ: 12 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 8. How does the nurse describe a person who is bulimic? a. Severely underweight

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b. Alternates binge eating with purging c. Introverted perfectionist d. Has extremely close family relationships ANS: B Bulimia is characterized by alternating binge eating and purge behavior.

DIF: Cognitive Level: Comprehension REF: Page 751-752 OBJ: 13 TOP: Bulimia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 9. A 14-year-old girl with obsessive-compulsive disorder (OCD) tells the nurse other adolescents tease her because she washes her hands many times during the school day. For what does this disorder put the adolescent at greater risk? a. Anorexia nervosa b. Depression c. ADHD d. A learning disability ANS: B OCD is related to depression and other psychiatric disorders. Suicidal behavior is a high risk for adolescents with OCD. DIF: Cognitive Level: Comprehension REF: Page 748-749 OBJ: 5 TOP: Obsessive-Compulsive Disorder KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. Which statement made by a parent of an adolescent with anorexia nervosa indicates an understanding of this condition? a. There really isnt anything to worry about. Dont they say you can never be too thin? b. My daughter just doesnt have much of an appetite. c. She is just trying to punish me for divorcing her father. d. She seems to see herself as fat, even though her weight is below normal.

ANS: D Individuals with anorexia nervosa have a disturbed body image, which this parent correctly recognizes.

DIF: Cognitive Level: Comprehension REF: Page 750, Figure 33-3

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OBJ: 13 TOP: Anorexia Nervosa KEY: Nursing Process Step: Evaluation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 11. What is an appropriate nursing intervention for a hospitalized child who is autistic? a. Place the child in a location where she can watch all of the activity on the unit. b. Use the childs chronological age as a guide for communication. c. Keep the childs room free of toys or objects that she might want to take home with her. d. Organize care to provide as few disruptions to the routine as possible.

ANS: D During hospitalization, the nurse should provide a highly structured environment with few distractions for a child who is autistic.

DIF: Cognitive Level: Application REF: Page 748 OBJ: 4 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 12. A nurse is planning to speak with a parent support group about childhood autism. What will the nurse include? a. Significant signs of the disorder manifest by 1 year of age. b. The earliest signs of autism are impulsivity and overactivity. c. Autism is usually diagnosed when the child goes to elementary school. d. Medications can cure childhood autism.

ANS: A Failure to use eye contact and look at others, poor attention span, and poor orienting to ones name are significant signs of dysfunction by 1 year of age.

DIF: Cognitive Level: Comprehension REF: Page 748 OBJ: 4 TOP: Autism KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. An adolescent is brought to the emergency department after an automobile accident. When the nurse approaches the adolescent, he becomes combative. The nurse notes his speech is slurred and his gait is ataxic. What does the nurse suspect the adolescent has used? a. Alcohol b. Cocaine c. Amphetamines

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d. PCP ANS: A Behavioral signs of alcohol ingestion include slurred speech, short attention span, drowsiness, combativeness, and violence.

DIF: Cognitive Level: Analysis REF: Page 755, Table 33-1 OBJ: 8 TOP: Substance Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 14. When the nurse is collecting a nursing history, an adolescent states that she has tried speed.

For what does the nurse recognize this as the street name? a. Barbiturates b. Cocaine c. Methamphetamine d. Marijuana ANS: C Speed is the street name for methamphetamine.

DIF: Cognitive Level: Knowledge REF: Page 755, Table 33-2 OBJ: 8 TOP: Substance Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. How would the nurse identify a member of the child guidance team who is a medical doctor with special training in psychoanalytic theory? a. Psychiatrist b. Psychoanalyst c. Psychologist d. Counselor ANS: A The psychiatrist is a medical doctor; the psychoanalyst may be a medical doctor or a psychologist. The psychologist is not a medical doctor, and neither is the counselor.

DIF: Cognitive Level: Knowledge REF: Page 747 OBJ: 2 TOP: Psychoanalytic Professional KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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16. A young child on the pediatric unit cannot express himself well. What therapeutic intervention might the nurse implement that allows children to act out their feelings? a. Art therapy b. Play therapy c. Music therapy d. Bibliotherapy ANS: B Play therapy allows a young child to act out with dolls or figures concerns that the child may be unable to adequately express verbally.

DIF: Cognitive Level: Comprehension REF: Page 747 OBJ: 5 TOP: Play Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 17. The nurse explains that use of stimulants will decrease hyperactivity in the autistic child.

What is a negative aspect of stimulants? a. Sedating the child b. Impairing cognition c. Causing hypotension d. Creating fluid retention ANS: B Stimulants that decrease the hyperactivity in the autistic child also impair cognition and may increase the potential of self-injuring behavior.

DIF: Cognitive Level: Comprehension REF: Page 748 OBJ: 4 TOP: Autism KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. A 9-year-old has been admitted to the hospital after huffing lighter fluid and is in a high euphoric state. For what should the nurse assess? a. Depressed respirations b. Severe vomiting c. Frightening hallucinations d. Elevation of temperature ANS: A Inhaling hydrocarbons depresses the central nervous system, including respiratory rate and

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general sensorium.

DIF: Cognitive Level: Application REF: Page 756 OBJ: 8 TOP: Substance Abuse KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. The pediatric nurse listens to a 9-year-old child read to his 6-year-old roommate. What action by 9-year-old child leads the nurse to question possible dyslexia? a. Becomes hyperactive and ceases to read b. Reads the word dog as God c. Makes up a story rather than reading the text d. Stutters as he reads ANS: B Dyslexics often transpose a word as they read; for example, the word is dog, but it appears to the dyslexic child as the word God. DIF: Cognitive Level: Comprehension REF: Page 749 OBJ: N/A TOP: Dyslexia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. How is a gateway substance defined? a. Recreational drug used occasionally b. Nonaddictive drug used daily c. Drug used to wean from stronger drugs d. Substance that can lead to use of stronger drugs ANS: D A gateway drug is a substance that creates a high that can lead to the use of stronger drugs.

DIF: Cognitive Level: Knowledge REF: Page 754, Nursing Tip OBJ: 8 TOP: Gateway Drugs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 21. Which substance puts a person at the greatest risk for HIV and hepatitis B? a. Alcohol b. Opiates c. Cocaine d. Marijuana

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ANS: B The use of opiates coupled with sharing needles put the user at risk for HIV and hepatitis B. DIF: Cognitive Level: Comprehension REF: Page 755, Table 33-1 OBJ: 8 TOP: Opiate Use KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 22. What role has the child of an alcoholic assumed if he tries to do everything perfectly? a. Perfect child b. Super coper c. Flight d. Helper ANS: B Of the four roles for the child of the alcoholic, the super coper is one who tries to do everything perfectly and feels overly responsible. The perfect child is the child who tries to earn love by never causing any trouble.

DIF: Cognitive Level: Comprehension REF: Page 757-758 OBJ: 10 TOP: Child of an Alcoholic KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation MULTIPLE RESPONSE 23. The nurse working with children from dysfunctional families must be prepared to address what associated problem(s)? (Select all that apply.) a. Lack of trust b. Acting out c. Exaggerated self-confidence d. Blaming others for problems e. Depression ANS: A, B, E Children from dysfunctional families exhibit lack of trust, act out, and show signs of depression.

DIF: Cognitive Level: Comprehension REF: Page 747 OBJ: 3 TOP: Dysfunctional Families KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

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24. The nurse counsels parents that the early school years create nervous tension in the child manifested by which abnormal behavior(s)? (Select all that apply.) a. Masturbation b. Food fads c. Stuttering d. Aggressive behavior e. Nonnutritive sucking ANS: C, D, E Stuttering, aggressive behavior, and finger or thumb sucking that appear suddenly with no previous history are a clue to increased nervous tension in the young school-age child.

Masturbation and food fads are normal behavioral phenomena for the early school-age child.

DIF: Cognitive Level: Comprehension REF: Page 748 OBJ: 3 TOP: Nervous Tension KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 25. The nurse states that the members of a mental health team for child guidance include which member(s)? (Select all that apply.) a. Psychiatrist b. Pediatrician c. Psychologist d. Dietitian e. Social worker ANS: A, B, C, E The traditional members of the child guidance team are the psychiatrist, pediatrician, psychologist, and social worker. The dietitian is not usually on the treatment team.

DIF: Cognitive Level: Knowledge REF: Page 747 OBJ: 2 TOP: Members of the Child Guidance Team KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 26. The school nurse cautions a group of parents about the prevalence of children who get high by inhaling hydrocarbons and fluorocarbons. Which products contain these substances? (Select all that apply.) a. Glue b. Chlorine

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c. Cleaning fluid d. Copy machine toner e. Aerosol sprays ANS: A, C, E Although there are many products that could be inhaled, the most frequently used products are glue, cleaning fluid, aerosol sprays, Freon, shoe polish, and gasoline products.

DIF: Cognitive Level: Knowledge REF: Page 755, Table 33-1 OBJ: 8 TOP: Inhaling Hydrocarbons KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 27. The nurse is planning the care of an adolescent with anorexia nervosa. What characteristic(s) cause this disorder? (Select all that apply.) a. Discomfort relative to emerging sexuality b. Fear of intimacy c. Pervasive high self-esteem d. Egocentricity e. Inability to meet developmental needs ANS: A, B, D, E All options except pervasive high self-esteem are considered to be a cause of anorexia nervosa.

Pervasive low self-esteem also is considered a cause of anorexia nervosa.

DIF: Cognitive Level: Comprehension REF: Page 750 OBJ: 13 TOP: Anorexia Nervosa KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 28. The nurse is assessing a 16-year-old female for characteristics of anorexia nervosa. Which assessment finding(s) would lead the nurse to suspect the possibility of this diagnosis? (Select all that apply.) a. Amenorrhea b. Severe weight loss c. Oily skin d. Hypertension e. Lanugo on back ANS: A, B, E The primary symptom of anorexia nervosa is severe weight loss. Adolescents who wish to be

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fashion models or actresses or who participate in sports, dance, or gymnastics activities may be at risk for developing an eating disorder. On physical examination, some of the following conditions may be evident: dry skin, amenorrhea, lanugo hair over the back and extremities, cold intolerance, low blood pressure, abdominal pain, and constipation.

DIF: Cognitive Level: Comprehension REF: Page 750 OBJ: 13 TOP: Anorexia Nervosa KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. A nurse is hired to work in a psychiatric facility on a unit specializing in obsessive compulsive disorders (OCD). Which diagnoses might the nurse expect to encounter? (Select all that apply.) a. Trichotillomania b. Hoarding disorder c. Excoriation disorder d. Body dysmorphic disorder e. Oppositional defiant disorder ANS: A, B, C, D Oppositional defiant disorder is described as an ongoing pattern of anger-guided disobedience, a hostile or defiant response to authority and is not considered a form of OCD. DIF: Cognitive Level: Knowledge REF: Page 749 OBJ: 5 TOP: Obsessive Compulsive Disorder KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 30. A child is diagnosed with attention deficit hyperactivity disorder (ADHD). Which characteristics would the nurse assess in this child? (Select all that apply.) a. Social anxiety b. Impulsivity c. Hyperactivity d. Distractability e. Inattention ANS: B, C, D, E ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility.

DIF: Cognitive Level: Knowledge REF: Page 749 OBJ: 11 TOP: Attention Deficit Hyperactivity Disorder

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KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 31. The nurse documents that every time the child is directed to discuss the relationship with her brother, she complains of shortness of breath and begins to have asthma-like symptoms. The nurse assesses this behavior as a(n)

reaction.

ANS: psychosomatic A psychosomatic reaction is one in which a dysfunction of the body has an emotional or mental cause.

DIF: Cognitive Level: Comprehension REF: Page 748 OBJ: 1 TOP: Psychosomatic Reaction KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 32. The nurse assists with the intervention of

therapy, which provides a physical

and social environment that is stable and therapeutic.

ANS: milieu Milieu therapy is a modality of treatment offered to troubled children, in which they are placed in an environment that is stable and therapeutic so that their problems might be better expressed or identified.

DIF: Cognitive Level: Knowledge REF: Page 747 OBJ: 1 TOP: Milieu Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 33. Early childhood experiences are critical to personality formation. Situations that disrupt family patterns can have a lasting impact on the child. These families are known as and can make children feel negatively about themselves and the world.

ANS: dysfunctional

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Early childhood experiences are critical to personality formation. Situations that disrupt family patterns can have a lasting impact on the child. Children who come from these dysfunctional families may experience any of the following: failure to develop a sense of trust (in their caregivers and environment), excessive fears, misdirected anger manifested as behavioral problems, depression, low self-esteem, lack of confidence, and feelings of lack of control over themselves and their environment.

Chapter 30. Child With a Respiratory Condition MULTIPLE CHOICE 1. The nurse is teaching nursing students about normal physiologic changes in the respiratory system of toddlers. Which best describes why toddlers have fewer respiratory tract infections as they grow older? a. The amount of lymphoid tissue decreases. b. Repeated exposure to organisms causes increased immunity. c. Viral organisms are less prevalent in the population. d. Secondary infections rarely occur after viral illnesses.

ANS: B Children have increased immunity after exposure to a virus. The amount of lymphoid tissue increases as children grow older. Viral organisms are not less prevalent, but older children have the ability to resist invading organisms. Secondary infections after viral illnesses include Mycoplasma pneumoniae and group A b-hemolytic streptococcal infections.

PTS: 1 DIF: Cognitive Level: Understand REF: 707 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. A nurse is charting that a hospitalized child has labored breathing. Which describes labored breathing? a. Dyspnea b. Tachypnea c. Hypopnea d. Orthopnea ANS: A

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Dyspnea is labored breathing. Tachypnea is rapid breathing. Hypopnea is breathing that is too shallow. Orthopnea is difficulty breathing except in upright position.

PTS: 1 DIF: Cognitive Level: Remember REF: 709 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 3. Which explains why cool-mist vaporizers rather than steam vaporizers are recommended in home treatment of childhood respiratory tract infections? a. They are safer. b. They are less expensive. c. Respiratory secretions are dried. d. A more comfortable environment is produced.

ANS: A Cool-mist vaporizers are safer than steam vaporizers, and little evidence exists to show any advantages to steam. The cost of cool-mist and steam vaporizers is comparable. Steam loosens secretions, not dries them. Both may promote a more comfortable environment, but cool-mist vaporizers present decreased risk for burns and growth of organisms.

PTS: 1 DIF: Cognitive Level: Understand REF: 708 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include which action? a. Avoid using for more than 3 days. b. Keep drops to use again for nasal congestion. c. Administer drops until nasal congestion subsides. d. Administer drops after feedings and at bedtime.

ANS: A Vasoconstrictive nose drops such as phenylephrine (Neo-Synephrine) should not be used for more than 3 days to avoid rebound congestion. Drops should be discarded after one illness because they may become contaminated with bacteria. Vasoconstrictive nose drops can have a rebound effect after 3 days of use. Drops administered before feedings are more helpful.

PTS: 1 DIF: Cognitive Level: Apply REF: 709 TOP: Integrated Process: Nursing Process: Implementation

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MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 5. Which is an appropriate nursing intervention when caring for an infant with an upper respiratory tract infection and elevated temperature? a. Give tepid water baths to reduce fever. b. Encourage food intake to maintain caloric needs. c. Have child wear heavy clothing to prevent chilling. d. Give small amounts of favorite fluids frequently to prevent dehydration.

ANS: D Preventing dehydration by small frequent feedings is an important intervention in the febrile child. Tepid water baths may induce shivering, which raises temperature. Food should not be forced; it may result in the child vomiting. The febrile child should be dressed in light, loose clothing.

PTS: 1 DIF: Cognitive Level: Apply REF: 710 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. The parent of an infant with nasopharyngitis should be instructed to notify the health professional if the infant displays which clinical manifestation? a. Fussiness b. Coughing c. A fever over 99 F d. Signs of an earache ANS: D If an infant with nasopharyngitis shows signs of an earache, it may mean a secondary bacterial infection is present and the infant should be referred to a practitioner for evaluation. Irritability is common in an infant with a viral illness. Cough can be a sign of nasopharyngitis. Fever is common in viral illnesses.

PTS: 1 DIF: Cognitive Level: Apply REF: 714 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 7. It is generally recommended that a child with acute streptococcal pharyngitis can return to school: a. when sore throat is better.

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b. if no complications develop. c. after taking antibiotics for 24 hours. d. after taking antibiotics for 3 days.

ANS: C After children have taken antibiotics for 24 hours, they are no longer contagious to other children. Sore throat may persist longer than 24 hours after beginning antibiotic therapy, but the child is no longer considered contagious. Complications may take days to weeks to develop.

PTS: 1 DIF: Cognitive Level: Understand REF: 715 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 8. A child is diagnosed with influenza, probably type A disease. Management includes which recommendation? a. Clear liquid diet for hydration b. Aspirin to control fever c. Amantadine hydrochloride (Symmetrel) to reduce symptoms d. Antibiotics to prevent bacterial infection ANS: C Amantadine hydrochloride may reduce symptoms related to influenza A if administered within 24 to 48 hours of onset. It is ineffective against type B or C. A clear liquid diet is not necessary for influenza, but maintaining hydration is important. Aspirin is not recommended in children because of increased risk of Reye syndrome. Acetaminophen or ibuprofen is a better choice.

Preventive antibiotics are not indicated for influenza unless there is evidence of a secondary bacterial infection.

PTS: 1 DIF: Cognitive Level: Apply REF: 717 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 9. Chronic otitis media with effusion (OME) is differentiated from acute otitis media (AOM) because it is usually characterized by: a. a fever as high as 40 C (104 F). b. severe pain in the ear. c. nausea and vomiting. d. a feeling of fullness in the ear.

ANS: D

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OME is characterized by feeling of fullness in the ear or other nonspecific complaints. Fever is a sign of AOM. OME does not cause severe pain. This may be a sign of AOM. Nausea and vomiting are associated with otitis media.

PTS: 1 DIF: Cognitive Level: Understand REF: 718 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 10. Parents have understood teaching about prevention of childhood otitis media if they make which statement? a. We will only prop the bottle during the daytime feedings. b. Breastfeeding will be discontinued after 4 months of age. c. We will place the child flat right after feedings. d. We will be sure to keep immunizations up to date.

ANS: D Parents have understood the teaching about preventing childhood otitis media if they respond they will keep childhood immunizations up to date. The child should be maintained upright during feedings and after. Otitis media can be prevented by exclusively breastfeeding until at least 6 months of age. Propping bottles is discouraged to avoid pooling of milk while the child is in the supine position.

PTS: 1 DIF: Cognitive Level: Analyze REF: 719 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 11. An 18-month-old child is seen in the clinic with AOM. Trimethoprim-sulfamethoxazole (Bactrim) is prescribed. Which statement made by the parent indicates a correct understanding of the instructions? a. I should administer all the prescribed medication. b. I should continue medication until the symptoms subside. c. I will immediately stop giving medication if I notice a change in hearing. d. I will stop giving medication if fever is still present in 24 hours.

ANS: A Antibiotics should be given for their full course to prevent recurrence of infection with resistant bacteria. Symptoms may subside before the full course is given. Hearing loss is a complication of AOM. Antibiotics should continue to be given. Medication may take 24 to 48 hours to make

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symptoms subside. It should be continued.

PTS: 1 DIF: Cognitive Level: Apply REF: 718 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 12. An infants parents ask the nurse about preventing OM. Which should be recommended? a. Avoid tobacco smoke. b. Use nasal decongestant. c. Avoid children with OM. d. Bottle-feed or breastfeed in supine position.

ANS: A Eliminating tobacco smoke from the childs environment is essential for preventing OM and other common childhood illnesses. Nasal decongestants are not useful in preventing OM. Children with uncomplicated OM are not contagious unless they show other upper respiratory tract infection (URI) symptoms. Children should be fed in an upright position to prevent OM. PTS: 1 DIF: Cognitive Level: Apply REF: 719 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 13. The nurse is assessing a child with acute epiglottitis. Examining the childs throat by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction c. Sore throat d. Respiratory tract infection ANS: B If a child has acute epiglottitis, examination of the throat may cause complete obstruction and should be performed only when immediate intubation can take place. Stridor is aggravated when a child with epiglottitis is supine. Sore throat and pain on swallowing are early signs of epiglottitis. Epiglottitis is caused by H. influenzae in the respiratory tract.

PTS: 1 DIF: Cognitive Level: Understand REF: 721 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 14. Which type of croup is always considered a medical emergency?

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a. Laryngitis b. Epiglottitis c. Spasmodic croup d. Laryngotracheobronchitis (LTB) ANS: B Epiglottitis is always a medical emergency needing antibiotics and airway support for treatment.

Laryngitis is a common viral illness in older children and adolescents, with hoarseness and URI symptoms. Spasmodic croup is treated with humidity. LTB may progress to a medical emergency in some children.

PTS: 1 DIF: Cognitive Level: Understand REF: 721 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 15. The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. The nurses rationale for this action is described primarily in which statement? a. Mothers of hospitalized toddlers often experience guilt. b. The mothers presence will reduce anxiety and ease childs respiratory efforts. c. Separation from mother is a major developmental threat at this age. d. The mother can provide constant observations of the childs respiratory efforts.

ANS: B The familys presence will decrease the childs distress. It is true that mothers of hospitalized toddlers often experience guilt but this is not the best answer. The main reason to keep parents at the childs bedside is to ease anxiety and therefore respiratory effort. The child should have constant monitoring by cardiorespiratory monitor and noninvasive oxygen saturation monitoring, but the parent should not play this role in the hospital.

PTS: 1 DIF: Cognitive Level: Apply REF: 723 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Adaptation 16. A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. The cough has become productive in the past 24 hours. This is most suggestive of which diagnosis? a. Bronchitis b. Bronchiolitis

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c. Viral-induced asthma d. Acute spasmodic laryngitis ANS: A Bronchitis is characterized by these symptoms and occurs in children older than 6 years.

Bronchiolitis is rare in children older than 2 years. Asthma is a chronic inflammation of the airways that may be exacerbated by a virus. Acute spasmodic laryngitis occurs in children between 3 months and 3 years.

PTS: 1 DIF: Cognitive Level: Understand REF: 723 TOP: Integrated Process: Nursing Process: Diagnosis MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 17. Which frequency is recommended for childhood skin testing for tuberculosis (TB) using the Mantoux test? a. Every year for all children older than 2 years b. Every year for all children older than 10 years c. Every 2 years for all children starting at age 1 year d. Periodically for children who reside in high-prevalence regions ANS: D Children who reside in high-prevalence regions for TB should be tested every 2 to 3 years.

Annual testing is not necessary. Testing is not necessary unless exposure is likely or an underlying medical risk factor is present.

PTS: 1 DIF: Cognitive Level: Remember REF: 729 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 18. Which consideration is the most important in managing tuberculosis (TB) in children? a. Skin testing annually b. Pharmacotherapy c. Adequate nutrition d. Adequate hydration ANS: B Drug therapy for TB includes isoniazid, rifampin, and pyrazinamide daily for 2 months and two or three times a week for the remaining 4 months. Pharmacotherapy is the most important intervention for TB.

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PTS: 1 DIF: Cognitive Level: Apply REF: 730 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 19. The mother of a toddler yells to the nurse, Help! He is choking to death on his food. The nurse determines that lifesaving measures are necessary based on which symptom? a. Gagging b. Coughing c. Pulse over 100 beats/min d. Inability to speak ANS: D The inability to speak is indicative of a foreign-body airway obstruction of the larynx.

Abdominal thrusts are needed for treatment of the choking child. Gagging indicates irritation at the back of the throat, not obstruction. Coughing does not indicate a complete airway obstruction. Tachycardia may be present for many reasons.

PTS: 1 DIF: Cognitive Level: Apply REF: 732 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 20. The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include: a. forcing fluids. b. monitoring pulse oximetry. c. instituting seizure precautions. d. encouraging a high-protein diet.

ANS: B Monitoring cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a highprotein diet is not helpful.

PTS: 1 DIF: Cognitive Level: Apply REF: 734 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 21. The nurse is caring for a child with carbon monoxide poisoning associated with smoke

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inhalation. Which is essential in this childs care? a. Monitor pulse oximetry. b. Monitor arterial blood gases. c. Administer oxygen if respiratory distress develops. d. Administer oxygen if childs lips become bright, cherry red.

ANS: B Arterial blood gases are the best way to monitor carbon monoxide poisoning. Pulse oximetry is contraindicated in the case of carbon monoxide poisoning because the PaO2 may be normal. The child should receive 100% oxygen as quickly as possible, not only if respiratory distress or other symptoms develop.

PTS: 1 DIF: Cognitive Level: Apply REF: 735 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. A nurse is admitting an infant with asthma. The nurse understands that asthma in infants is usually triggered by: a. medications. b. a viral infection. c. exposure to cold air. d. allergy to dust or dust mites.

ANS: B Viral illnesses cause inflammation that causes increased airway reactivity in asthma. Medications such as aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and antibiotics may aggravate asthma, but not frequently in infants. Exposure to cold air may exacerbate already existing asthma. Allergy is associated with asthma, but 20% to 40% of children with asthma have no evidence of allergic disease.

PTS: 1 DIF: Cognitive Level: Understand REF: 737 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 23. A nurse is conducting an in-service on asthma. Which statement is the most descriptive of bronchial asthma? a. There is heightened airway reactivity. b. There is decreased resistance in the airway. c. The single cause of asthma is an allergic hypersensitivity.

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d. It is inherited.

ANS: A In bronchial asthma, spasm of the smooth muscle of the bronchi and bronchioles causes constriction, producing impaired respiratory function. In bronchial asthma, there is increased resistance in the airway. There are multiple causes of asthma, including allergens, irritants, exercise, cold air, infections, medications, medical conditions, and endocrine factors. Atopy or development of an immunoglobulin E (IgE)mediated response is inherited but is not the only cause of asthma.

PTS: 1 DIF: Cognitive Level: Understand REF: 737 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 24. A child is admitted to the hospital with asthma. Which assessment findings support this diagnosis? a. Nonproductive cough, wheezing b. Fever, general malaise c. Productive cough, rales d. Stridor, substernal retractions ANS: A Asthma presents with a nonproductive cough and wheezing. Pneumonia appears with an acute onset, fever, and general malaise. A productive cough and rales would be indicative of pneumonia. Stridor and substernal retractions are indicative of croup.

PTS: 1 DIF: Cognitive Level: Understand REF: 738 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 25. It is now recommended that children with asthma who are taking long-term inhaled steroids should be assessed frequently because which disease or assessment findings may develop? a. Cough b. Osteoporosis c. Slowed growth d. Cushing syndrome ANS: C The growth of children on long-term inhaled steroids should be assessed frequently to assess for systemic effects of these drugs. Cough is prevented by inhaled steroids. No evidence exists that

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inhaled steroids cause osteoporosis. Cushing syndrome is caused by long-term systemic steroids.

PTS: 1 DIF: Cognitive Level: Understand REF: 739-740 TOP: Integrated Process: Nursing Process: Problem Identification MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 26. b-Adrenergic agonists and methylxanthines are often prescribed for a child with an asthma attack. Which describes their action? a. Liquefy secretions. b. Dilate the bronchioles. c. Reduce inflammation of the lungs. d. Reduce infection.

ANS: B b-Adrenergic agonists and methylxanthines work to dilate the bronchioles in acute exacerbations.

These medications do not liquefy secretions or reduce infection. Corticosteroids and mast cell stabilizers reduce inflammation in the lungs.

PTS: 1 DIF: Cognitive Level: Understand REF: 740 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 27. Parents of two school-age children with asthma ask the nurse, What sports can our children participate in? The nurse should recommend which sport? a. Soccer b. Running c. Swimming d. Basketball ANS: C Swimming is well tolerated in children with asthma because they are breathing air fully saturated with moisture and because of the type of breathing required in swimming. Exercise-induced bronchospasm is more common in sports that involve endurance, such as soccer. Prophylaxis with medications may be necessary.

PTS: 1 DIF: Cognitive Level: Apply REF: 740 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 28. Which drug is usually given first in the emergency treatment of an acute, severe asthma

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episode in a young child? a. Ephedrine b. Theophylline c. Aminophylline d. Short-acting b2 agonists ANS: D Short-acting b2 agonists are the first treatment in an acute asthma exacerbation. Ephedrine is not helpful in acute asthma exacerbations. Theophylline is unnecessary for treating asthma exacerbations. Aminophylline is not helpful for acute asthma exacerbation.

PTS: 1 DIF: Cognitive Level: Apply REF: 741 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 29. Parents of a child with cystic fibrosis ask the nurse about genetic implications of the disorder.

Which statement, made by the nurse, expresses accurately the genetic implications? a. If it is present in a child, both parents are carriers of this defective gene. b. It is inherited as an autosomal dominant trait. c. It is a genetic defect found primarily in non-Caucasian population groups. d. There is a 50% chance that siblings of an affected child also will be affected.

ANS: A CF is an autosomal recessive gene inherited from both parents and is inherited as an autosomal recessive, not autosomal dominant, trait. CF is found primarily in Caucasian populations. An autosomal recessive inheritance pattern means that there is a 25% chance a sibling will be infected but a 50% chance a sibling will be a carrier.

PTS: 1 DIF: Cognitive Level: Understand REF: 747 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 30. A nurse is teaching nursing students about clinical manifestations of cystic fibrosis (CF).

Which is/are the earliest recognizable clinical manifestation(s) of CF? a. Meconium ileus b. History of poor intestinal absorption c. Foul-smelling, frothy, greasy stools d. Recurrent pneumonia and lung infections ANS: A

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The earliest clinical manifestation of CF is a meconium ileus, which is found in about 10% of children with CF. Clinical manifestations include abdominal distention, vomiting, failure to pass stools, and rapid development of dehydration. History of malabsorption is a later sign that manifests as failure to thrive. Foul-smelling stools are a later manifestation of CF. Recurrent respiratory tract infections are a later sign of CF. PTS: 1 DIF: Cognitive Level: Understand REF: 747 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 31. A child is being admitted to the hospital to be tested for cystic fibrosis (CF). Which tests should the nurse expect? a. Sweat chloride test, stool for fat, chest radiograph films b. Stool test for fat, gastric contents for hydrochloride, chest radiograph films c. Sweat chloride test, bronchoscopy, duodenal fluid analysis d. Sweat chloride test, stool for trypsin, biopsy of intestinal mucosa ANS: A A sweat test result of greater than 60 mEq/L is diagnostic of CF, a high level of fecal fat is a gastrointestinal (GI) manifestation of CF, and a chest radiograph showing patchy atelectasis and obstructive emphysema indicates CF. Gastric contents contain hydrochloride normally; it is not diagnostic. Bronchoscopy and duodenal fluid are not diagnostic. Stool test for trypsin and intestinal biopsy are not helpful in diagnosing CF. PTS: 1 DIF: Cognitive Level: Understand REF: 748-749 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 32. Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? a. Bronchoscopy b. Serum calcium c. Urine creatinine d. Sweat chloride test ANS: D A sweat chloride test result greater than 60 mEq/L is diagnostic of CF. Bronchoscopy, although helpful for identifying bacterial infection in children with CF, is not diagnostic. Serum calcium is

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normal in children with CF. Urine creatinine is not diagnostic of CF. PTS: 1 DIF: Cognitive Level: Understand REF: 749 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 33. A child with cystic fibrosis (CF) receives aerosolized bronchodilator medication. When should this medication be administered? a. Before chest physiotherapy (CPT) b. After CPT c. Before receiving 100% oxygen d. After receiving 100% oxygen ANS: A Bronchodilators should be given before CPT to open bronchi and make expectoration easier.

Aerosolized bronchodilator medications are not helpful when used after CPT. Oxygen administration is necessary only in acute episodes with caution because of chronic carbon dioxide retention.

PTS: 1 DIF: Cognitive Level: Apply REF: 750 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 34. A child with cystic fibrosis (CF) is receiving recombinant human deoxyribonuclease (DNase). Which is an adverse effect of this medication? a. Mucus thickens b. Voice alters c. Tachycardia d. Jitteriness ANS: B One of the only adverse effects of DNase is voice alterations and laryngitis. DNase decreases viscosity of mucus, is given in an aerosolized form, and is safe for children younger than 12 years. b2 agonists can cause tachycardia and jitteriness.

PTS: 1 DIF: Cognitive Level: Apply REF: 750 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 35. Pancreatic enzymes are administered to the child with cystic fibrosis (CF). Nursing

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considerations should include to: a. not administer pancreatic enzymes if child is receiving antibiotics. b. decrease dose of pancreatic enzymes if child is having frequent, bulky stools. c. administer pancreatic enzymes between meals if at all possible. d. pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.

ANS: D Enzymes may be administered in a small amount of cereal or fruit at the beginning of a meal or swallowed whole. Pancreatic enzymes are not a contraindication for antibiotics. The dosage of enzymes should be increased if child is having frequent, bulky stools. Enzymes should be given just before meals and snacks.

PTS: 1 DIF: Cognitive Level: Apply REF: 751 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 36. In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? a. Diet should be high in carbohydrates and protein. b. Diet should be high in easily digested carbohydrates and fats. c. Most fruits and vegetables are not well tolerated. d. Fats and proteins must be greatly curtailed.

ANS: A Children with CF require a well-balanced, high-protein, high-calorie diet because of impaired intestinal absorption. Enzyme supplementation helps digest foods; other modifications are not necessary. A well-balanced diet containing fruits and vegetables is important. Fats and proteins are a necessary part of a well-balanced diet.

PTS: 1 DIF: Cognitive Level: Understand REF: 751 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 37. Cardiopulmonary resuscitation (CPR) is begun on a toddler. Which pulse is usually palpated because it is the most central and accessible? a. Radial b. Carotid c. Femoral

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d. Brachial ANS: B In a toddler, the carotid pulse is palpated. The radial pulse is not considered a central pulse. The femoral pulse is not the most central and accessible. Brachial pulse is felt in infants younger than 1 year.

PTS: 1 DIF: Cognitive Level: Understand REF: 757 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 38. Which drug is considered the most useful in treating childhood cardiac arrest? a. Bretylium tosylate (Bretylium) b. Lidocaine hydrochloride (Lidocaine) c. Epinephrine hydrochloride (Adrenaline) d. Naloxone (Narcan) ANS: C Epinephrine works on alpha and beta receptors in the heart and is the most useful drug in childhood cardiac arrest. Bretylium is no longer used in pediatric cardiac arrest management.

Lidocaine is used for ventricular arrhythmias only. Naloxone is useful only to reverse effects of opioids.

PTS: 1 DIF: Cognitive Level: Understand REF: 758 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 39. Effective lone-rescuer CPR on a 5-year-old child should include a. two breaths to every 30 chest compressions. b. two breaths to every 15 chest compressions. c. reassessment of child after 50 cycles of compression and ventilation. d. reassessment of child every 10 minutes that CPR continues.

ANS: A Lone-rescuer CPR is two breaths to 30 compressions for all ages until signs of recovery occur.

Reassessment of the child should take place after 20 cycles or 1 minute.

PTS: 1 DIF: Cognitive Level: Apply REF: 758 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

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40. The Heimlich maneuver is recommended for airway obstruction in children older than year(s). a. 1 b. 4 c. 8 d. 12 ANS: A The Heimlich maneuver is recommended for airway obstruction in children older than 1 year.

Younger than 1 year, back blows and chest thrusts are administered. The Heimlich maneuver can be used in children older than 1 year.

PTS: 1 DIF: Cognitive Level: Understand REF: 759 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 41. A nurse is caring for a child in acute respiratory failure. Which blood gas analysis indicates the child is still in respiratory acidosis? a. pH 7.50, CO2 48 b. pH 7.30, CO2 30 c. pH 7.32, CO2 50 d. pH 7.48, CO2 33 ANS: C Respiratory failure is a process that involves pulmonary dysfunction generally resulting in impaired alveolar gas exchange, which can lead to hypoxemia or hypercapnia. Acidosis indicates the pH is less than 7.35 and the CO2 is greater than 45. If the pH is less than 7.35 but the CO2 is low, it is metabolic acidosis. Alkalosis is when the pH is greater than 7.45. If the pH is high and the CO2 is high, it is metabolic alkalosis. When the pH is high and the CO2 is low, it is respiratory alkalosis.

PTS: 1 DIF: Cognitive Level: Analyze REF: 754 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 42. A nurse is teaching an adolescent how to use the peak expiratory flowmeter. The adolescent has understood the teaching if which statement is made? a. I will record the average of the readings. b. I should be sitting comfortably when I perform the readings.

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c. I will record the readings at the same time every day. d. I will repeat the routine two times.

ANS: C Instructions for use of a peak flowmeter include standing up straight before performing the reading, recording the highest of the three readings (not the average), measuring the peak expiratory flow rate (PEFR) close to the same time each day, and repeating the entire routine three times, waiting 30 seconds between each routine.

PTS: 1 DIF: Cognitive Level: Apply REF: 744 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 43. A school-age child has been admitted with an acute asthma episode. The child is receiving oxygen by nasal prongs at 2 liters. How often should the nurse plan to monitor the childs pulse oximetry status? a. Continuous b. Every 30 minutes c. Every hour d. Every 2 hours ANS: A The child on supplemental oxygen requires intermittent or continuous oxygenation monitoring, depending on severity of respiratory compromise and initial oxygenation status. The child in status asthmaticus should be placed on continuous cardiorespiratory (including blood pressure) and pulse oximetry monitoring.

PTS: 1 DIF: Cognitive Level: Apply REF: 743 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 44. A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV positive. Which induration size indicates a positive result for this child 4872 hours after the test? a. 5 mm b. 10 mm c. 15 mm d. 20 mm ANS: A Clinical evidence of a positive TST in children receiving immunosuppressive therapy, including

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immunosuppressive doses of steroids or who have immunosuppressive conditions, including HIV infection is an induration of 5 mm. Children younger than 4 years of age with: (a) other medical risk conditions, including Hodgkin disease, lymphoma, diabetes mellitus, chronic renal failure, or malnutrition; (b) born or whose parents were born in high-prevalence (TB) regions of the world; (c) frequently exposed to adults who are HIV infected, homeless, users of illicit drugs, residents of nursing homes, incarcerated or institutionalized, or migrant farm workers; and (d) who travel to high-prevalence (TB) regions of the world are positive when the induration is 10 mm. Children 4 years of age or older without any risk factors are positive when the induration is 20 mm.

PTS: 1 DIF: Cognitive Level: Understand REF: 729 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential MULTIPLE RESPONSE 1. An infant has developed staphylococcal pneumonia. Nursing care of the child with pneumonia includes which interventions? (Select all that apply.) a. Cluster care to conserve energy b. Round-the-clock administration of antitussive agents c. Strict intake and output to avoid congestive heart failure d. Administration of antibiotics ANS: A, D Antibiotics are indicated for a bacterial pneumonia. Often the child will have decreased pulmonary reserve, and the clustering of care is essential. Antitussive agents are used sparingly.

It is desirable for the child to cough up some of the secretions. Fluids are essential to kept secretions as liquefied as possible.

PTS: 1 DIF: Cognitive Level: Apply REF: 726 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 2. The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention should be included in the childs care? (Select all that apply.) a. Place in a mist tent. b. Administer antibiotics. c. Administer cough syrup.

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d. Encourage to drink 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring.

ANS: D, E, F Hydration is important in children with RSV bronchiolitis to loosen secretions and prevent shock. Clustering of care promotes periods of rest. The use of noninvasive oxygen monitoring is recommended. Mist tents are no longer used. Antibiotics do not treat illnesses with viral causes.

Cough syrup suppresses clearing of respiratory secretions and is not indicated for young children.

Chapter 31. Child With a Cardiac Condition MULTIPLE CHOICE 1. A chest radiograph film is ordered for a child with suspected cardiac problems. The childs parent asks the nurse, What will the radiograph show about the heart? The nurses response should be based on knowledge that the x-ray film will show: a. bones of chest but not the heart. b. measurement of electrical potential generated from heart muscle. c. permanent record of heart size and configuration. d. computerized image of heart vessels and tissues.

ANS: C A chest radiograph will provide information on the heart size and pulmonary blood-flow patterns. It will provide a baseline for future comparisons. The heart will be visible, as well as the sternum and ribs. Electrocardiography (ECG) measures the electrical potential generated from heart muscle. Echocardiography will produce a computerized image of the heart vessels and tissues by using sound waves.

PTS: 1 DIF: Cognitive Level: Understand REF: 835 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for? a. Cardiac arrhythmia

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b. Hypostatic pneumonia c. Heart failure d. Rapidly increasing blood pressure ANS: A Because a catheter is introduced into the heart, a risk exists of catheter-induced dysrhythmias occurring during the procedure. These are usually transient. Hypostatic pneumonia, heart failure, and rapidly increasing blood pressure are not risks usually associated with cardiac catheterization.

PTS: 1 DIF: Cognitive Level: Apply REF: 853 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. Jos is a 4-year-old child scheduled for a cardiac catheterization. Preoperative teaching should be: a. directed at his parents because he is too young to understand. b. detailed in regard to the actual procedures so he will know what to expect. c. done several days before the procedure so that he will be prepared. d. adapted to his level of development so that he can understand.

ANS: D Preoperative teaching should always be directed at the childs stage of development. The caregivers also benefit from the same explanations. The parents may ask additional questions, which should be answered, but the child needs to receive the information based on developmental level. Preschoolers will not understand in-depth descriptions and should be prepared close to the time of the cardiac catheterization.

PTS: 1 DIF: Cognitive Level: Apply REF: 822 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 4. Which explanation regarding cardiac catheterization is appropriate for a preschool child? a. Postural drainage will be performed every 4 to 6 hours after the test. b. It is necessary to be completely asleep during the test. c. The test is short, usually taking less than 1 hour. d. When the procedure is done, you will have to keep your leg straight for at least 4 hours.

ANS: D The childs leg will have to be maintained in a straight position for approximately 4 hours.

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Younger children can be held in the parents lap with the leg maintained in the correct position.

Postural drainage will not be performed unless the child has corresponding pulmonary problems.

The child should be sedated to lie still, but being completely asleep is not necessary. The test will vary in length of time from start to finish.

PTS: 1 DIF: Cognitive Level: Apply REF: 823 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 5. The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is too wet. The nurse finds the bandage and bed soaked with blood. The most appropriate initial nursing action is to: a. notify physician. b. apply new bandage with more pressure. c. place the child in Trendelenburg position. d. apply direct pressure above catheterization site.

ANS: D If bleeding occurs, direct continuous pressure is applied 2.5 cm (1 inch) above the percutaneous skin site to localize pressure over the vessel puncture. Notifying a physician and applying a new bandage can be done after pressure is applied. The nurse can have someone else notify the physician while the pressure is being maintained. It is not a helpful intervention to place the girl in the Trendelenburg position. It would increase the drainage from the lower extremities.

PTS: 1 DIF: Cognitive Level: Apply REF: 823 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching? a. I should avoid tub baths but may shower. b. I have to stay on strict bed rest for 3 days. c. I should remove the pressure dressing the day after the procedure. d. I may attend school but should avoid exercise for several days.

ANS: B The child does not need to be on strict bed rest for 3 days. Showers are recommended; children should avoid a tub bath. The pressure dressing is removed the day after the catheterization and replaced by an adhesive bandage to keep the area clean. Strenuous activity must be avoided for

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several days, but the child can return to school.

PTS: 1 DIF: Cognitive Level: Analyze REF: 823 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 7. Surgical closure of the ductus arteriosus would: a. stop the loss of unoxygenated blood to the systemic circulation. b. decrease the edema in legs and feet. c. increase the oxygenation of blood. d. prevent the return of oxygenated blood to the lungs.

ANS: D The ductus arteriosus allows blood to flow from the higher-pressure aorta to the lower-pressure pulmonary artery, causing a right-to-left shunt. If this is surgically closed, no additional oxygenated blood (from the aorta) will return to the lungs through the pulmonary artery. The aorta carries oxygenated blood to the systemic circulation. Because of the higher pressure in the aorta, blood is shunted into the pulmonary artery and the pulmonary circulation. Edema in the legs and feet is usually a sign of heart failure. This repair would not directly affect the edema.

Increasing the oxygenation of blood would not interfere with the return of oxygenated blood to the lungs.

PTS: 1 DIF: Cognitive Level: Analyze REF: 825 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries ANS: C Atrial septal defect results in increased pulmonary blood flow. Blood flows from the left atrium (higher pressure) into the right atrium (lower pressure) and then to the lungs via the pulmonary artery. Pulmonic stenosis is an obstruction to blood flowing from the ventricles. Tricuspid atresia results in decreased pulmonary blood flow. Transposition of the great arteries results in mixed blood flow.

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PTS: 1 DIF: Cognitive Level: Understand REF: 825 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy ANS: A Tetralogy of Fallot has these four characteristics: pulmonic stenosis, ventricular septal defect, overriding aorta, and right ventricular hypertrophy. There is pulmonic stenosis but not atrial stenosis in tetralogy of Fallot. Right ventricular hypertrophy, not left ventricular hypertrophy, is present in tetralogy of Fallot. Tetralogy of Fallot has right ventricular hypertrophy, not left ventricular hypertrophy, and an atrial septal defect, not aortic hypertrophy.

PTS: 1 DIF: Cognitive Level: Understand REF: 830 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 10. A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? a. Atrial septal defect b. Tetralogy of Fallot c. Ventricular septal defect d. Patent ductus arteriosus ANS: B Tetralogy of Fallot results in decreased blood flow to the lungs. The pulmonic stenosis increases the pressure in the right ventricle, causing the blood to go from right to left across the ventricular septal defect. Atrial and ventricular septal defects and patent ductus arteriosus result in increased pulmonary blood flow.

PTS: 1 DIF: Cognitive Level: Understand REF: 830 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

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11. Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures? a. Pulmonary congestion b. Congenital heart defect c. Heart failure d. Systemic venous congestion ANS: C The definition of heart failure is the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures to meet the bodys metabolic demands.

Pulmonary congestion is an excessive accumulation of fluid in the lungs. Congenital heart defect is a malformation of the heart present at birth. Systemic venous congestion is an excessive accumulation of fluid in the systemic vasculature.

PTS: 1 DIF: Cognitive Level: Understand REF: 830 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 12. Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure? a. Tachypnea b. Tachycardia c. Peripheral edema d. Pale, cool extremities ANS: C Peripheral edema, especially periorbital edema, is a clinical manifestation of systemic venous congestion. Tachypnea is a manifestation of pulmonary congestion. Tachycardia and pale, cool extremities are clinical manifestations of impaired myocardial function.

PTS: 1 DIF: Cognitive Level: Understand REF: 835 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)? a. It decreases edema. b. It decreases cardiac output. c. It increases heart size.

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d. It increases venous pressure.

ANS: A Digoxin has a rapid onset and is useful for increasing cardiac output, decreasing venous pressure, and, as a result, decreasing edema. Cardiac output is increased by digoxin. Heart size and venous pressure are decreased by digoxin.

PTS: 1 DIF: Cognitive Level: Understand REF: 835 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 14. A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse be administering? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril) ANS: A Captopril is an ACE inhibitor. Furosemide is a loop diuretic. Spironolactone blocks the action of aldosterone. Chlorothiazide works on the distal tubules.

PTS: 1 DIF: Cognitive Level: Remember REF: 835 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 15. An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than

beats/min.

a. 60 b. 70 c. 90 d. 100 ANS: B If a 1-minute apical pulse is less than 70 beats/min for an older child, the digoxin is withheld; 60 beats/min is the cut-off for holding the digoxin dose in an adult. A pulse below 90 to 110 beats/ min is the determination for not giving a digoxin dose to infants and young children.

PTS: 1 DIF: Cognitive Level: Apply REF: 836 TOP: Integrated Process: Nursing Process: Assessment

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MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 16. A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than

beats/min.

a. 60 b. 70 c. 90 to 110 d. 110 to 120 ANS: C If the 1-minute apical pulse is below 90 to 110 beats/min, the digoxin should not be given to a 6month-old. 60 beats/min is the cut-off for holding the digoxin dose in an adult. 70 beats/min is the determining heart rate to hold a dose of digoxin for an older child. 110 to 120 beats/min is an acceptable heart rate to administer digoxin to a 6-month-old.

PTS: 1 DIF: Cognitive Level: Apply REF: 836 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 17. The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity? a. Seizures b. Vomiting c. Bradypnea d. Tachycardia ANS: B Vomiting is a common sign of digoxin toxicity. Seizures are not associated with digoxin toxicity.

The child will have a slower heart rate, not respiratory rate. The heart rate will be slower, not faster.

PTS: 1 DIF: Cognitive Level: Understand REF: 839 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 18. The parents of a young child with heart failure tell the nurse that they are nervous about giving digoxin (Lanoxin). The nurses response should be based on which statement? a. It is a safe, frequently used drug. b. It is difficult to either overmedicate or undermedicate with digoxin.

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c. Parents lack the expertise necessary to administer digoxin. d. Parents must learn specific, important guidelines for administration of digoxin.

ANS: D Digoxin has a narrow therapeutic range. The margin of safety between therapeutic, toxic, and lethal doses is very small. Specific guidelines are available for parents to learn how to administer the drug safely and to monitor for side effects. Digoxin is a frequently used drug, but it has a narrow therapeutic range. Small amounts of the liquid are given to infants, making it easy to overmedicate or undermedicate. Parents may lack the necessary expertise to administer the drug at first, but with discharge preparation, they should be prepared to administer the drug safely.

PTS: 1 DIF: Cognitive Level: Apply REF: 839 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 19. The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct? a. You may need to increase the caloric density of your infants formula. b. You should feed your baby every 2 hours. c. You may need to increase the amount of formula your infant eats with each feeding. d. You should place a nasal oxygen cannula on your infant during and after each feeding.

ANS: A The metabolic rate of infants with heart failure is greater because of poor cardiac function and increased heart and respiratory rates. Their caloric needs are greater than those of the average infants, yet their ability to take in the calories is diminished by their fatigue. Infants with heart failure should be fed every 3 hours; a 2-hour schedule does not allow for enough rest, and a 4hour schedule is too long. Fluids must be carefully monitored because of the heart failure. Infants do not require supplemental oxygen with feedings.

PTS: 1 DIF: Cognitive Level: Apply REF: 838-839 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 20. As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in: a. chlorides. b. potassium.

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c. sodium. d. vitamins.

ANS: B Diuretics that work on the proximal and distal renal tubules contribute to increased losses of potassium. The childs diet should be supplemented with this electrolyte. With this type of diuretic, potassium must be monitored and supplemented as needed.

PTS: 1 DIF: Cognitive Level: Understand REF: 840 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 21. An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurses first action should be to: a. assess for neurologic defects. b. place the child in the knee-chest position. c. begin cardiopulmonary resuscitation. d. prepare family for imminent death.

ANS: B The first action is to place the infant in the knee-chest position. Blow-by oxygen may be indicated. Neurologic defects are unlikely. The child should be assessed for airway, breathing, and circulation. Often, calming the child and administering oxygen and morphine can alleviate the hypercyanotic spell.

PTS: 1 DIF: Cognitive Level: Apply REF: 841-842 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk? a. Minimize seizures. b. Prevent dehydration. c. Promote cardiac output. d. Reduce energy expenditure.

ANS: B In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting

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cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.

PTS: 1 DIF: Cognitive Level: Analyze REF: 841 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurses reply should be based on which statement? a. Child needs opportunities to play with peers. b. Child needs to understand that peers activities are too strenuous. c. Parents can meet all of the childs needs. d. Constant parental supervision is needed to avoid overexertion.

ANS: A The child needs opportunities for social development. Children usually limit their activities if allowed to set their own pace. The child will limit activities as necessary. Parents must be encouraged to seek appropriate social activities for the child, especially before kindergarten. The child needs to have activities that foster independence. The child will be able to regulate activities.

PTS: 1 DIF: Cognitive Level: Analyze REF: 843 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity 24. Which should the nurse consider when preparing a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Let child hear the sounds of an ECG monitor. c. Avoid mentioning postoperative discomfort and interventions. d. Explain that an endotracheal tube will not be needed if the surgery goes well.

ANS: B The child and family should be exposed to the sights and sounds of the intensive care unit (ICU).

All positive, nonfrightening aspects of the environment are emphasized. The child should be shown unfamiliar equipment and its use demonstrated on a doll. Carefully prepare the child for the postoperative experience, including intravenous (IV) lines, incision, and endotracheal tube.

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PTS: 1 DIF: Cognitive Level: Analyze REF: 845 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 25. Seventy-two hours after cardiac surgery, a young child has a temperature of 101 F. Which action should the nurse take? a. Keep child warm with blankets. b. Apply a hypothermia blanket. c. Record temperature on nurses notes. d. Report findings to physician.

ANS: D In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7 C (100 F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated.

Blankets should be removed from the child to keep the temperature from increasing.

Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.

PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 26. Which is an important nursing consideration when suctioning a young child who has had heart surgery? a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Administer supplemental oxygen before and after suctioning. d. Expect symptoms of respiratory distress when suctioning.

ANS: C If suctioning is indicated, supplemental oxygen is administered with a manual resuscitation bag before and after the procedure to prevent hypoxia. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time.

Symptoms of respiratory distress are avoided by using appropriate technique.

PTS: 1 DIF: Cognitive Level: Apply REF: 846

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TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. The nurse is caring for a child after heart surgery. Which should the nurse do if evidence is found of cardiac tamponade? a. Increase analgesia. b. Apply warming blankets. c. Immediately report this to physician. d. Encourage child to cough, turn, and breathe deeply.

ANS: C If evidence is noted of cardiac tamponade, which is blood or fluid in the pericardial space constricting the heart, the physician is notified immediately of this life-threatening complication.

Increasing analgesia may be done before the physician drains the fluid, but the physician must be notified. Warming blankets are not indicated at this time. Encouraging the child to cough, turn, and breathe deeply should be deferred till after the evaluation by the physician.

PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 28. Which is an important nursing consideration when chest tubes will be removed from a child? a. Explain that it is not painful. b. Explain that only a Band-Aid will be needed. c. Administer analgesics before procedure. d. Expect bright red drainage for several hours after removal.

ANS: C It is appropriate to prepare the child for the removal of chest tubes with analgesics. Short-acting medications can be used that are administered through an existing IV line. A sharp, momentary pain is felt. This should not be misrepresented to the child. A petroleum gauze, air-tight dressing will be needed, but it is not a pain-free procedure. Little or no drainage should be found on removal.

PTS: 1 DIF: Cognitive Level: Apply REF: 846 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 29. Which is the most common causative agent of bacterial endocarditis?

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a. Staphylococcus albus b. Streptococcus hemolyticus c. Staphylococcus albicans d. Streptococcus viridans ANS: D S. viridans is the most common causative agent in bacterial (infective) endocarditis.

Staphylococcus albus, Streptococcus hemolyticus, and Staphylococcus albicans are not common causative agents.

PTS: 1 DIF: Cognitive Level: Remember REF: 848 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 30. Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? a. Osler nodes b. Janeway lesions c. Subcutaneous nodules d. Aschoff nodes ANS: A Osler nodes are red, painful, intradermal nodes found on pads of the phalanges in bacterial endocarditis. Janeway lesions are painless hemorrhagic areas on palms and soles in bacterial endocarditis. Subcutaneous nodules are nontender swellings, located over bony prominences, commonly found in rheumatic fever. Aschoff nodules are small nodules composed of cells and leukocytes found in the interstitial tissues of the heart in rheumatic myocarditis.

PTS: 1 DIF: Cognitive Level: Understand REF: 848 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 31. The primary nursing intervention to prevent bacterial endocarditis is to: a. institute measures to prevent dental procedures. b. counsel parents of high-risk children about prophylactic antibiotics. c. observe children for complications, such as embolism and heart failure. d. encourage restricted mobility in susceptible children.

ANS: B The objective of nursing care is to counsel the parents of high-risk children about both the need

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for prophylactic antibiotics for dental procedures and the necessity of maintaining excellent oral health. The childs dentist should be aware of the childs cardiac condition. Dental procedures should be done to maintain a high level of oral health. Prophylactic antibiotics are necessary.

Children should be observed for complications such as embolism and heart failure and restricted mobility should be encouraged in susceptible children, but maintaining good oral health and prophylactic antibiotics is important.

PTS: 1 DIF: Cognitive Level: Apply REF: 848 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 32. Which is a common, serious complication of rheumatic fever? a. Seizures b. Cardiac arrhythmias c. Pulmonary hypertension d. Cardiac valve damage ANS: D Cardiac valve damage is the most significant complication of rheumatic fever. Seizures, cardiac arrhythmias, and pulmonary hypertension are not common complications of rheumatic fever.

PTS: 1 DIF: Cognitive Level: Understand REF: 849 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 33. The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever? a. Polyarthritis b. Osler nodes c. Janeway spots d. Splinter hemorrhages of distal third of nails ANS: A Polyarthritis, which is swollen, hot, red, and painful joints, is a major clinical manifestation of rheumatic fever. The affected joints will change every 1 to 2 days. Primarily the large joints are affected. Osler nodes, Janeway spots, and splinter hemorrhages are characteristic of infective endocarditis.

PTS: 1 DIF: Cognitive Level: Apply REF: 850

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TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 34. The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement? a. Administering penicillin b. Avoiding salicylates (aspirin) c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops ANS: A The goal of medical management is the eradication of the hemolytic streptococci. Penicillin is the drug of choice. Salicylates can be used to control the inflammatory process, especially in the joints, and reduce the fever and discomfort. Bed rest is recommended for the acute febrile stage, but it does not need to be strict. The chorea is transient and will resolve without treatment.

PTS: 1 DIF: Cognitive Level: Apply REF: 849 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 35. Which action by the school nurse is important in the prevention of rheumatic fever? a. Encourage routine cholesterol screenings. b. Conduct routine blood pressure screenings. c. Refer children with sore throats for throat cultures. d. Recommend salicylates instead of acetaminophen for minor discomforts.

ANS: C Nurses have a role in preventionprimarily in screening school-age children for sore throats caused by group A b-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A b-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.

Chapter 32. Child With a Metabolic Condition

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MULTIPLE CHOICE 1. Which postoperative order does the nurse clarify with the surgeon before discharging the client who just had arthroscopic surgery on the right knee?

a .

Keep the right leg elevated on a soft pillow for 12 hours.

b .

Maintain nonweight bearing by right leg for 48 hours.

c .

Use ice on the knee for 24 hours.

d .

Administer two tablets of oxycodone/APAP (Tylox) every 4 hours for pain.

ANS: D Each tablet of Tylox has 5 mg oxycodone with 500 mg acetaminophen. If the client took two tablets every 4 hours, the client would ingest a total of 6000 mg of acetaminophen, well over the safe maximum dose of 4000 mg in 24 hours. The rest of the orders are appropriate.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Pharmacological and Parenteral TherapiesAdverse Effects/Contraindications/Interactions/Side Effects) MSC: Integrated Process: Nursing Process (Planning) 2. An occupational therapist is treating a client with rheumatoid arthritis. Which assessment finding in the client does the nurse share with the occupational therapist?

a .

Difficulty sleeping because of pain in the knees and elbows

b .

Difficulty tying shoelaces and doing zippers on clothing

c .

Swollen knees with crepitus and limited range of motion

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Generalized joint stiffness that is worse in the early morning

ANS: B The functional assessment helps nurses and therapists measure how functional the client is with activities of daily living, including dressing. The occupational therapist can assist the client to explore clothing options that are easier to manage with arthritic fingers. The other findings would not necessarily need to be shared with the occupational therapist for the treatment plan.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Management of CareCollaboration with Interdisciplinary Team) MSC: Integrated Process: Nursing Process (Assessment) 3. The nurse is caring for a client who is to have a computed tomography (CT) scan of the leg.

Which assessment question does the nurse ask the client before the procedure?

a .

Do you have any metal clips, plates, or pins in your body?

b .

Have you had anything to eat or drink in the last 6 hours?

c .

Do you have someone to drive you home after the procedure?

d .

Do you have any allergies to shrimp, scallops, or other seafood?

ANS: D IV contrast that contains iodine may be required for CT scans to rule out malignancy. The client should be assessed for allergy to shellfish, which contain high amounts of iodine. The other questions are not relevant when a CT scan is to be obtained.

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DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care Environment (Safety and Infection ControlError Prevention) MSC: Integrated Process: Nursing Process (Assessment) 4. The nurse is assessing a client who reports severe knee pain after a fall. Which question does the nurse ask to determine the radiation of the pain?

a .

What makes the pain better or worse?

b .

Are you able to bear any weight on the knee at all?

c .

Does the pain move to another area from your knee?

d .

How would you rate the pain on a scale of 1 to 10?

ANS: C To determine radiation of the pain, the nurse asks the client if the pain moves to another area from the knee. The other questions address the amount, functional impact, and alleviating or aggravating factors of the pain.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1111 TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationIllness Management) MSC: Integrated Process: Nursing Process (Assessment) 5. Which instruction does the nurse give to the client before he or she has electromyography (EMG)?

a .

Make sure that you have someone to drive you home after the test.

b .

Do not eat or drink anything for at least 6 hours before the test.

c .

You will have to avoid heavy lifting for 24 hours following the test.

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Do not take your cyclobenzaprine (Flexeril) on the 2 days before the test.

ANS: D Electromyography (EMG) testing measures nerve signal transmission to and through muscles.

Skeletal muscle relaxants such as Flexeril can affect test results and should be avoided for at least 2 days before the test. The other instructions are not relevant before EMG testing.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Health Promotion and Maintenance (Health Screening) MSC: Integrated Process: Teaching/Learning 6. The nurse is caring for a client with prostate cancer. Which laboratory finding indicates to the nurse that the cancer has metastasized to the bone?

a .

Serum calcium, 21.6 mg/dL

b .

Creatine kinase, 55 U/mL

c .

Alkaline phosphatase, 45 IU/mL

d .

Lactate dehydrogenase, 120 U/L

ANS: A Metastasis of tumor to bone results in release of calcium into the bloodstream, causing an elevation of the serum calcium level (normal range, 9 to 10.5 mg/dL). The other laboratory values are within normal limits and do not indicate metastasis to the bone.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialLaboratory

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Values) MSC: Integrated Process: Nursing Process (Assessment) 7. The nurse is caring for a client who presents with achy jaw pain. Which assessment technique does the nurse use to determine whether the client has inflammation of the temporomandibular joint (TMJ)?

a .

Checking for decayed, fractured, loose, or missing teeth

b .

Observing the jaw joint as the client chews a piece of food

c .

Palpating the joint during movement for tenderness or crepitus

d .

Observing for asymmetric joint protrusion when the clients mouth is closed

ANS: C The temporomandibular joints are best assessed by palpation while the client opens his or her mouth. The other assessment techniques are not effective for assessing possible TMJ inflammation.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 8. The nurse is caring for a client who is able to flex the right arm forward without difficulty or pain but is unable to abduct the arm because of pain and muscle spasms. Which condition does the nurse suspect based on these assessment findings?

a .

Dislocated elbow

b .

Lesion in the rotator cuff

c .

Osteoarthritis of the shoulder

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Atrophy of the supraspinatus muscle

ANS: B Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The assessment findings are not consistent with the other conditions.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Physiological AdaptationAlterations in Body Systems) MSC: Integrated Process: Nursing Process (Assessment) 9. The nurse is assessing a client who is suspected of having muscular dystrophy. Which statement by the client indicates that more teaching may be needed about the creatine kinase (CK) test that the health care provider has ordered?

a .

The Lasix that I took this morning may affect the test results.

b .

The CK test is 90% accurate in demonstrating muscle trauma or injury.

c .

The level of CK will be decreased with skeletal muscle disease.

d .

When muscle is damaged, CK isoenzymes are released over time.

ANS: C All of the statements are correct, except that the level of creatine kinase will increase with any skeletal muscle damage.

DIF: Cognitive Level: Comprehension/Understanding REF: p. 1114 TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic

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Tests) MSC: Integrated Process: Teaching/Learning 10. A client has cancer and a pacemaker, and suffers from claustrophobia. Which diagnostic test is the best indicator of the clients bone metastasis?

a .

Magnetic resonance imaging (MRI)

b .

Arthrogram

c .

Ultrasound

d .

Thallium bone scan

ANS: D Because the client has a pacemaker and claustrophobia, MRI would not be an option as a diagnostic test. The arthrogram is an x-ray used to visualize bone chips and torn ligaments within a joint. Ultrasound is used to assess soft tissue disorders, traumatic joint injuries, and osteomyelitis. The thallium bone scan is ideal for obtaining information about the extent of bone cancer such as osteosarcoma or bony metastases.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Physiological Integrity (Reduction of Risk PotentialDiagnostic Tests) MSC: Integrated Process: Nursing Process (Assessment) 11. Which client does the nurse assess first at the start of the nursing shift?

a .

Client wanting to know information about a magnetic resonance imaging (MRI) test scheduled in 3 hours

b .

Client who is verbalizing mild discomfort after an electromyography (EMG)

c .

Client who reports increased pain and swelling after an arthroscopy

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Client who refuses to drink more fluids after a nuclear medicine scan

ANS: C The client who should be the first priority is the one who is reporting increased pain and swelling after arthroscopy; this could indicate complications from the surgery. The client with mild discomfort after an EMG should be assessed for pain, but mild discomfort is common for this procedure. Pain medication can then be administered. After a nuclear medicine scan, the client must increase fluids to flush out the radioisotope used in the scan. The nurse could then visit with the client who had questions about the upcoming MRI.

DIF: Cognitive Level: Application/Applying or higher REF: N/A TOP: Client Needs Category: Safe and Effective Care (Establishing Priorities) MSC: Integrated Process: Nursing Process (Assessment) MULTIPLE RESPONSE 1. The nurse is performing a medical history and physical assessment on an older client. Which common findings in the older client are related to the musculoskeletal system? (Select all that apply.)

a .

Decrease in bone density

b .

Decrease in falls due to lack of activity

c .

Atrophy of the muscle tissue

d .

Decrease in bone prominence

e .

Degeneration of cartilage

f .

Reduced range of motion of the joints

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ANS: A, C, E, F In the older adult, common findings include a decrease in bone density, atrophy of muscle tissue, cartilage degeneration, and a decrease in range of motion. In addition, falls increase as the result of kyphotic posture, widened gait, and an alteration in the center of gravity, creating an unsteady walking pattern. Increased bony prominences are observed in the older adult because less soft tissue is present to cushion the bone, and pressure ulcers are a threat.

Chapter 33. Child With a Musculoskeletal Condition MULTIPLE CHOICE 1. The nurse is caring for a 4-year-old child immobilized by a fractured hip. Which complication should the nurse monitor related to the childs immobilization status? a. Metabolic rate increases b. Increased joint mobility leading to contractures c. Bone calcium increases, releasing excess calcium into the body (hypercalcemia) d. Venous stasis leading to thrombi or emboli formation ANS: D The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. The metabolic rate decreases with immobilization. Loss of joint mobility leads to contractures. Bone demineralization with osteoporosis and hypercalcemia occur with immobilization.

PTS: 1 DIF: Cognitive Level: Apply REF: 1051 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. The nurse is caring for a preschool child immobilized by a spica cast. Which effect on metabolism should the nurse monitor on this child related to the immobilized status? a. Hypocalcemia b. Decreased metabolic rate c. Positive nitrogen balance d. Increased production of stress hormones ANS: B Immobilization causes a decreased metabolic rate with slowing of all systems and a decreased

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food intake. Immobilization leads to hypercalcemia and causes a negative nitrogen balance secondary to muscle atrophy. A decreased production of stress hormones occurs with decreased physical and emotional coping capacity.

PTS: 1 DIF: Cognitive Level: Understand REF: 1051 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. The nurse should monitor for which effect on the cardiovascular system when a child is immobilized? a. Venous stasis b. Increased vasopressor mechanism c. Normal distribution of blood volume d. Increased efficiency of orthostatic neurovascular reflexes ANS: A The physiologic effects of immobilization, as a result of decreased muscle contraction, include venous stasis. This can lead to pulmonary emboli or thrombi. A decreased vasopressor mechanism results in orthostatic hypotension, syncope, hypotension, decreased cerebral blood flow, and tachycardia. An altered distribution of blood volume is found with decreased cardiac workload and exercise tolerance. Immobilization causes a decreased efficiency of orthostatic neurovascular reflexes with an inability to adapt readily to the upright position and with pooling of blood in the extremities in the upright position.

PTS: 1 DIF: Cognitive Level: Understand REF: 1051 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. Which can result from the bone demineralization associated with immobility? a. Osteoporosis b. Urinary retention c. Pooling of blood d. Susceptibility to infection ANS: A Bone demineralization leads to a negative calcium balance, osteoporosis, pathologic fractures, extraosseous bone formation, and renal calculi. Urinary retention is secondary to the effect of immobilization on the urinary tract. Pooling of blood is a result of the cardiovascular effects of immobilization. Susceptibility to infection can result from the effects of immobilization on the

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respiratory and renal systems.

PTS: 1 DIF: Cognitive Level: Understand REF: 1051 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. A young girl has just injured her ankle at school. In addition to calling the childs parents, the most appropriate, immediate action by the school nurse is to: a. apply ice. b. observe for edema and discoloration. c. encourage child to assume a position of comfort. d. obtain parental permission for administration of acetaminophen or aspirin.

ANS: A Soft-tissue injuries should be iced immediately. In addition to ice, the extremity should be rested, be elevated, and have compression applied. Observing for edema and discoloration, encouraging the child to assume a position of comfort, and obtaining parental permission for administration of acetaminophen or aspirin are not immediate priorities. The application of ice can reduce the severity of the injury.

PTS: 1 DIF: Cognitive Level: Apply REF: 1056 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 6. Which term is used to describe a type of fracture that does not produce a break in the skin? a. Simple b. Compound c. Complicated d. Comminuted ANS: A If a fracture does not produce a break in the skin, it is called a simple, or closed, fracture. A compound, or open, fracture is one with an open wound through which the bone protrudes. A complicated fracture is one in which the bone fragments damage other organs or tissues. A comminuted fracture occurs when small fragments of bone are broken from the fractured shaft and lie in the surrounding tissue. These are rare in children.

PTS: 1 DIF: Cognitive Level: Understand REF: 1057 TOP: Integrated Process: Nursing Process: Assessment

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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 7. Kristin, age 10 years, sustained a fracture in the epiphyseal plate of her right fibula when she fell off of a tree. When discussing this injury with her parents, the nurse should consider which statement? a. Healing is usually delayed in this type of fracture. b. Growth can be affected by this type of fracture. c. This is an unusual fracture site in young children. d. This type of fracture is inconsistent with a fall.

ANS: B Detection of epiphyseal injuries is sometimes difficult, but fractures involving the epiphysis or epiphyseal plate present special problems in determining whether bone growth will be affected.

Healing of epiphyseal injuries is usually prompt. The epiphysis is the weakest point of the long bones. This is a frequent site of damage during trauma.

PTS: 1 DIF: Cognitive Level: Apply REF: 1057 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. The nurse is conducting a staff in-service on casts. Which is an advantage to using a fiberglass cast instead of a plaster of Paris cast? a. Cheaper b. Dries rapidly c. Molds closely to body parts d. Smooth exterior ANS: B A synthetic casting material dries in 5 to 30 minutes as compared with a plaster cast, which takes 10 to 72 hours to dry. Synthetic casts are more expensive and have a rough exterior, which may scratch surfaces. Plaster casts mold closer to body parts.

PTS: 1 DIF: Cognitive Level: Apply REF: 1060 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. The nurse is conducting teaching to parents of a 7-year-old child who fractured an arm and is being discharged with a cast. Which instruction should be included in the teaching? a. Swelling of the fingers is to be expected for the next 48 hours.

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b. Immobilize the shoulder to decrease pain in the arm. c. Allow the affected limb to hang down for 1 hour each day. d. Elevate casted arm when resting and when sitting up.

ANS: D The injured extremity should be kept elevated while resting and in a sling when upright. This will increase venous return. Swelling of the fingers may indicate neurovascular damage and should be reported immediately. Permanent damage can occur within 6 to 8 hours. Joints above and below the cast on the affected extremity should be moved. The affected limb should not hang down for any length of time.

PTS: 1 DIF: Cognitive Level: Apply REF: 1060 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 10. The nurse uses the palms of the hands when handling a wet cast for which reason? a. To assess dryness of the cast b. To facilitate easy turning c. To keep the patients limb balanced d. To avoid indenting the cast ANS: D Wet casts should be handled by the palms of the hands, not the fingers, to avoid creating pressure points. Assessing dryness, facilitating easy turning, and keeping the patients limb balanced are not reasons for using the palms of the hand rather than the fingers when handling a wet cast.

PTS: 1 DIF: Cognitive Level: Understand REF: 1060 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 11. Which should cause a nurse to suspect that an infection has developed under a cast? a. Complaint of paresthesia b. Cold toes c. Increased respirations d. Hot spots felt on cast surface ANS: D If hot spots are felt on the cast surface, they usually indicate infection beneath the area. This should be reported so that a window can be made in the cast to observe the site. The five Ps of ischemia from a vascular injury are pain, pallor, pulselessness, paresthesia, and paralysis.

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Paresthesia is an indication of vascular injury, not infection. Cold toes may be indicative of too tight a cast and need further evaluation. Increased respirations may be indicative of a respiratory tract infection or pulmonary emboli. This should be reported, and child should be evaluated.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1060 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 12. A child is upset because, when the cast is removed from her leg, the skin surface is caked with desquamated skin and sebaceous secretions. Which should the nurse suggest to remove this material? a. Soak in a bathtub. b. Vigorously scrub leg. c. Apply powder to absorb material. d. Carefully pick material off leg.

ANS: A Simple soaking in the bathtub is usually sufficient for the removal of the desquamated skin and sebaceous secretions. It may take several days to eliminate the accumulation completely. The parents and child should be advised not to scrub the leg vigorously or forcibly remove this material because it may cause excoriation and bleeding. Oil or lotion, but not powder, may provide comfort for the child.

PTS: 1 DIF: Cognitive Level: Apply REF: 1062 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 13. An adolescent with a fractured femur is in Russells traction. Surgical intervention to correct the fracture is scheduled for the morning. Nursing actions should include which action? a. Maintaining continuous traction until 1 hour before the scheduled surgery b. Maintaining continuous traction and checking position of traction frequently c. Releasing traction every hour to perform skin care d. Releasing traction once every 8 hours to check circulation ANS: B When the muscles are stretched, muscle spasm ceases and permits realignment of the bone ends.

The continued maintenance of traction is important during this phase because releasing the traction allows the muscles normal contracting ability to again cause malpositioning of the bone ends. Continuous traction must be maintained to keep the bone ends in satisfactory realignment.

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Releasing at any time, either 1 hour before surgery, once every hour for skin care, or once every 8 hours would not keep the fracture in satisfactory alignment.

PTS: 1 DIF: Cognitive Level: Apply REF: 1063 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 14. Which is a type of skin traction with legs in an extended position? a. Dunlop b. Bryant c. Russell d. Buck extension ANS: D Buck extension traction is a type of skin traction with the legs in an extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calv-Perthes disease. Dunlop traction is an upper-extremity traction used for fractures of the humerus. Bryant traction is skin traction with the legs flexed at a 90-degree angle at the hip. Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position.

PTS: 1 DIF: Cognitive Level: Understand REF: 1063 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 15. Which type of traction uses skin traction on the lower leg and a padded sling under the knee? a. Dunlop b. Bryant c. Russell d. Buck extension ANS: C Russell traction uses skin traction on the lower leg and a padded sling under the knee. The combination of longitudinal and perpendicular traction allows realignment of the lower extremity and immobilizes the hips and knees in a flexed position. Dunlop traction is an upper-extremity traction used for fractures of the humerus. Bryant traction is skin traction with the legs flexed at a 90-degree angle at the hip. Buck extension traction is a type of skin traction with the legs in an

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extended position. It is used primarily for short-term immobilization, preoperatively with dislocated hips, for correcting contractures, or for bone deformities such as Legg-Calv-Perthes disease.

PTS: 1 DIF: Cognitive Level: Understand REF: 1063 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 16. Four-year-old David is placed in Buck extension traction for Legg-Calv-Perthes disease. He is crying with pain as the nurse assesses that the skin of his right foot is pale with an absence of pulse.

Which action should the nurse take first? a. Notify the practitioner of the changes noted. b. Give the child medication to relieve the pain. c. Reposition the child and notify physician. d. Chart the observations and check the extremity again in 15 minutes.

ANS: A The absence of a pulse and change in color of the foot must be reported immediately for evaluation by the practitioner. Pain medication should be given after the practitioner is notified.

Legg-Calv-Perthes disease is an emergency condition; immediate reporting is indicated. The findings should be documented with ongoing assessment.

PTS: 1 DIF: Cognitive Level: Apply REF: 1065 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 17. Which is an appropriate nursing intervention when caring for a child in traction? a. Remove adhesive traction straps daily to prevent skin breakdown. b. Assess for tightness, weakness, or contractures in uninvolved joints and muscles. c. Provide active range-of-motion exercises to affected extremity three times a day. d. Keep the child in one position to maintain good alignment.

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only.

Movement is expected with children. Each time the child moves, the nurse should check to

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ensure that proper alignment is maintained.

PTS: 1 DIF: Cognitive Level: Apply REF: 1065 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 18. The nurse is teaching a family how to care for their infant in a Pavlik harness to treat developmental dysplasia of the hip. Which should be included? a. Apply lotion or powder to minimize skin irritation. b. Remove harness several times a day to prevent contractures. c. Return to clinic every 1 to 2 weeks. d. Place diaper over harness, preferably using a superabsorbent disposable diaper that is relatively thin.

ANS: C Infants have a rapid growth pattern. The child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness. The harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

PTS: 1 DIF: Cognitive Level: Apply REF: 1071 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 19. A neonate is born with bilateral mild talipes equinovarus (clubfoot). When the parents ask the nurse how this will be corrected, the nurse should give which explanation? a. Traction is tried first. b. Surgical intervention is needed. c. Frequent, serial casting is tried first. d. Children outgrow this condition when they learn to walk.

ANS: C Serial casting is begun shortly after birth before discharge from nursery. Successive casts allow for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are repeated frequently (every week) to accommodate the rapid growth of early infancy. Serial casting is the preferred treatment. Surgical intervention is done only if serial casting is not successful. Children do not improve without intervention.

PTS: 1 DIF: Cognitive Level: Apply REF: 1072

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TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 20. A 4-year-old child is newly diagnosed with Legg-Calv-Perthes disease. Nursing considerations should include which action? a. Encouraging normal activity for as long as is possible b. Explaining the cause of the disease to the child and family c. Preparing the child and family for long-term, permanent disabilities d. Teaching the family the care and management of the corrective appliance ANS: D The family needs to learn the purpose, function, application, and care of the corrective device and the importance of compliance to achieve the desired outcome. The initial therapy is rest and nonweight bearing, which helps reduce inflammation and restore motion. Legg-Calv-Perthes is a disease with an unknown etiology. A disturbance of circulation to the femoral capital epiphysis produces an ischemic aseptic necrosis of the femoral head. The disease is self-limiting, but the ultimate outcome of therapy depends on early and efficient therapy and the childs age at onset.

PTS: 1 DIF: Cognitive Level: Apply REF: 1075 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 21. The nurse is taking care of an adolescent diagnosed with kyphosis. Which describes this condition? a. Lateral curvature of the spine b. Immobility of the shoulder joint c. Exaggerated concave lumbar curvature of the spine d. Increased convex angulation in the curve of the thoracic spine ANS: D Kyphosis is an abnormally increased convex angulation in the curve of the thoracic spine.

Scoliosis is a complex spinal deformity usually involving lateral curvature, spinal rotation causing rib asymmetry, and thoracic hypokyphosis. Ankylosis is the immobility of a joint.

Lordosis is an exaggerated concave lumbar curvature of the spine.

PTS: 1 DIF: Cognitive Level: Understand REF: 1076 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation

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22. A school nurse is conducting a staff in-service to other school nurses on idiopathic scoliosis.

During which period of child development does idiopathic scoliosis become most noticeable? a. Newborn period b. When child starts to walk c. Preadolescent growth spurt d. Adolescence ANS: C Idiopathic scoliosis is most noticeable during the preadolescent growth spurt. Idiopathic scoliosis is seldom apparent before age 10 years. Diagnosis usually occurs during the preadolescent growth spurt.

PTS: 1 DIF: Cognitive Level: Understand REF: 1076-1077 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 23. The nurse is preparing an adolescent with scoliosis for a Luque-rod segmental spinal instrumentation procedure. Which consideration should the nurse include? a. Nasogastric intubation and urinary catheter may be required. b. Ambulation will not be allowed for up to 3 months. c. Surgery eliminates the need for casting and bracing. d. Discomfort can be controlled with nonpharmacologic methods.

ANS: A Luque-rod segmental spinal instrumentation is a surgical procedure. Nasogastric intubation and urinary catheterization may be required. Ambulation is allowed as soon as possible. Depending on the instrumentation used, most patients walk by the second or third postoperative day. Casting and bracing are required postoperatively. The child usually has considerable pain for the first few days after surgery. Intravenous opioids should be administered on a regular basis.

PTS: 1 DIF: Cognitive Level: Apply REF: 1078 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 24. The nurse is taking care of a 10-year-old child who has osteomyelitis. Which treatment plan is considered the primary method of treating osteomyelitis? a. Joint replacement b. Bracing and casting c. Intravenous antibiotic therapy

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d. Long-term corticosteroid therapy ANS: C Osteomyelitis is an infection of the bone, most commonly caused by Staphylococcus aureus. The treatment of choice is antibiotics. Joint replacement, bracing and casting, and long-term corticosteroid therapy are not indicated for infectious processes.

PTS: 1 DIF: Cognitive Level: Understand REF: 1080 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 25. A nurse is conducting a staff in-service on childhood cancers. Which is the primary site of osteosarcoma? a. Femur b. Humerus c. Pelvis d. Tibia ANS: A Osteosarcoma is the most frequently encountered malignant bone cancer in children. The peak incidence is between ages 10 and 25 years. More than half occur in the femur. After the femur, most of the remaining sites are the humerus, tibia, pelvis, jaw, and phalanges.

PTS: 1 DIF: Cognitive Level: Understand REF: 1081 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 26. The nurse is taking care of an adolescent with osteosarcoma. The parents ask the nurse about treatment. The nurse should make which accurate response about treatment for osteosarcoma? a. Treatment usually consists of surgery and chemotherapy. b. Amputation of affected extremity is rarely necessary. c. Intensive irradiation is the primary treatment. d. Bone marrow transplantation offers the best chance of long-term survival.

ANS: A The optimal therapy for osteosarcoma is a combination of surgery and chemotherapy. Intensive irradiation and bone marrow transplantation are usually not part of the therapeutic management.

PTS: 1 DIF: Cognitive Level: Understand REF: 1081 TOP: Integrated Process: Nursing Process: Implementation

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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. An adolescent with osteosarcoma is scheduled for a leg amputation in 2 days. The nurses approach should include which action? a. Answering questions with straightforward honesty b. Avoiding discussing the seriousness of the condition c. Explaining that, although the amputation is difficult, it will cure the cancer d. Assisting the adolescent in accepting the amputation as better than a long course of chemotherapy ANS: A Honesty is essential to gain the childs cooperation and trust. The diagnosis of cancer should not be disguised with falsehoods. The adolescent should be prepared for the surgery so he or she has time to reflect on the diagnosis and subsequent treatment. This allows questions to be answered.

To accept the need for radical surgery, the child must be aware of the lack of alternatives for treatment. Amputation is necessary, but it will not guarantee a cure. Chemotherapy is an integral part of the therapy with surgery. The child should be informed of the need for chemotherapy and its side effects before surgery.

PTS: 1 DIF: Cognitive Level: Apply REF: 1082 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 28. Which medication is usually tried first when a child is diagnosed with juvenile idiopathic arthritis (JIA)? a. Aspirin b. Corticosteroids c. Cytotoxic drugs such as methotrexate d. Nonsteroidal anti-inflammatory drugs (NSAIDs) ANS: D NSAIDs are the first drugs used in JIA. Naproxen, ibuprofen, and tolmetin are approved for use in children. Aspirin, once the drug of choice, has been replaced by the NSAIDs because they have fewer side effects and easier administration schedules. Corticosteroids are used for lifethreatening complications, incapacitating arthritis, and uveitis. Methotrexate is a second-line therapy for JIA. PTS: 1 DIF: Cognitive Level: Understand REF: 1085 TOP: Integrated Process: Nursing Process: Implementation

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MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 29. The nurse is caring for a school-age child diagnosed with juvenile idiopathic arthritis (JIA).

Which intervention should be a priority? a. Apply ice packs to relieve stiffness and pain. b. Administer acetaminophen to reduce inflammation. c. Teach the child and family correct administration of medications. d. Encourage range-of-motion exercises during periods of inflammation.

ANS: C The management of JIA is primarily pharmacologic. The family should be instructed regarding administration of medications and the value of regular schedule of administration to maintain a satisfactory blood level in the body. They need to know that NSAIDs should not be given on an empty stomach and to be alert for signs of toxicity. Warm moist heat is best for relieving stiffness and pain. Acetaminophen does not have antiinflammatory effects. Range-of-motion exercises should not be done during periods of inflammation.

Chapter 34. Child With a Gastrointestinal Condition MULTIPLE CHOICE 1. Which condition in a child should alert a nurse for increased fluid requirements? a. Fever b. Mechanical ventilation c. Congestive heart failure d. Increased intracranial pressure (ICP) ANS: A Fever leads to great insensible fluid loss in young children because of increased body surface area relative to fluid volume. Respiratory rate influences insensible fluid loss and should be monitored in the mechanically ventilated child. Congestive heart failure is a case of fluid overload in children. Increased ICP does not lead to increased fluid requirements in children.

PTS: 1 DIF: Cognitive Level: Understand REF: 763 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

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2. A nurse is conducting an in-service on gastrointestinal disorders. The nurse includes that melena, the passage of black, tarry stools, suggests bleeding from which area? a. Perianal or rectal area b. Hemorrhoids or anal fissures c. Upper gastrointestinal (GI) tract d. Lower GI tract ANS: C Melena is denatured blood from the upper GI tract or bleeding from the right colon. Blood from the perianal or rectal area, hemorrhoids, or lower GI tract would be bright red.

PTS: 1 DIF: Cognitive Level: Apply REF: 792 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. Which type of dehydration is defined as dehydration that occurs in conditions in which electrolyte and water deficits are present in approximately balanced proportion? a. Isotonic dehydration b. Hypotonic dehydration c. Hypertonic dehydration d. All types of dehydration in infants and small children ANS: A Isotonic dehydration is the correct term for this definition and is the most frequent form of dehydration in children. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic. Hypertonic dehydration results from water loss in excess of electrolyte loss and is usually caused by a proportionately larger loss of water or a larger intake of electrolytes. This definition is specific to isotonic dehydration.

PTS: 1 DIF: Cognitive Level: Understand REF: 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. A nurse is admitting an infant with dehydration caused from water loss in excess of electrolyte loss. Which type of dehydration is this infant experiencing? a. Isotonic b. Isosmotic c. Hypotonic d. Hypertonic

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ANS: D Hypertonic dehydration results from water loss in excess of electrolyte loss. This is the most dangerous type of dehydration. It is caused by feeding children fluids with high amounts of solute. Isotonic dehydration occurs in conditions in which electrolyte and water deficits are present in balanced proportion and is another term for isotonic dehydration. Hypotonic dehydration occurs when the electrolyte deficit exceeds the water deficit, leaving the serum hypotonic.

PTS: 1 DIF: Cognitive Level: Understand REF: 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. An infant is brought to the emergency department with dehydration. Which physical assessment finding does the nurse expect? a. Weight gain b. Bradycardia c. Poor skin turgor d. Brisk capillary refill ANS: C Clinical manifestations of dehydration include poor skin turgor, weight loss, lethargy, and tachycardia. The infant would have prolonged capillary refill, not brisk.

PTS: 1 DIF: Cognitive Level: Understand REF: 767 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 6. Parents call the clinic and report that their toddler has had acute diarrhea for 24 hours. The nurse should further ask the parents if the toddler has which associated factor that is causing the acute diarrhea? a. Celiac disease b. Antibiotic therapy c. Immunodeficiency d. Protein malnutrition ANS: B Acute diarrhea is a sudden increase in frequency and change in consistency of stools and may be associated with antibiotic therapy. Celiac disease is a problem with gluten intolerance and may cause chronic diarrhea if not identified and managed appropriately. Immunodeficiency would

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occur with chronic diarrhea. Protein malnutrition or kwashiorkor causes chronic diarrhea from lowered resistance to infection.

PTS: 1 DIF: Cognitive Level: Apply REF: 772 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 7. Which pathogen is the viral pathogen that frequently causes acute diarrhea in young children? a. Giardia organisms b. Shigella organisms c. Rotavirus d. Salmonella organisms ANS: C Rotavirus is the most frequent viral pathogen that causes diarrhea in young children. Giardia (parasite) and Salmonella are bacterial pathogens that cause diarrhea. Shigella is a bacterial pathogen that is uncommon in the United States.

PTS: 1 DIF: Cognitive Level: Understand REF: 772 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. Which is a parasite that causes acute diarrhea? a. Shigella organisms b. Salmonella organisms c. Giardia lamblia d. Escherichia coli ANS: C G. lamblia is a parasite that represents 10% of non-dysenteric illness in the United States.

Shigella, Salmonella, and E. coli are bacterial pathogens.

PTS: 1 DIF: Cognitive Level: Understand REF: 775 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. A child is admitted with bacterial gastroenteritis. Which lab results of a stool specimen confirm this diagnosis? a. Eosinophils b. Occult blood

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c. pH less than 6 d. Neutrophils and red blood cells ANS: D Neutrophils and red blood cells in stool indicate bacterial gastroenteritis. Protein intolerance and parasitic infections are suspected in the presence of eosinophils. Occult blood may indicate pathogens such as Shigella, Campylobacter, or hemorrhagic Escherichia coli strains. A pH of less than 6 may indicate carbohydrate malabsorption or secondary lactase insufficiency.

PTS: 1 DIF: Cognitive Level: Understand REF: 775 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 10. Which therapeutic management should the nurse prepare to initiate first for a child with acute diarrhea and moderate dehydration? a. Clear liquids b. Adsorbents, such as kaolin and pectin c. Oral rehydration solution (ORS) d. Antidiarrheal medications such as paregoric ANS: C ORS is the first treatment for acute diarrhea. Clear liquids are not recommended because they contain too much sugar, which may contribute to diarrhea. Adsorbents are not recommended.

Antidiarrheals are not recommended because they do not get rid of pathogens.

PTS: 1 DIF: Cognitive Level: Apply REF: 775 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 11. A school-age child with diarrhea has been rehydrated. The nurse is discussing the childs diet with the family. Which statement by the parent would indicate a correct understanding of the teaching? a. I will keep my child on a clear liquid diet for the next 24 hours. b. I should encourage my child to drink carbonated drinks but avoid food for the next 24 hours. c. I will offer my child bananas, rice, applesauce, and toast for the next 48 hours. d. I should have my child eat a normal diet with easily digested foods for the next 48 hours.

ANS: D Easily digested foods such as cereals, cooked vegetables, and meats should be provided for the child. Early reintroduction of nutrients is desirable. Continued feeding or reintroduction of a

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regular diet has no adverse effects and actually lessens the severity and duration of the illness.

Clear liquids and carbonated drinks have high carbohydrate content and few electrolytes.

Caffeinated beverages should be avoided because caffeine is a mild diuretic. The BRAT diet has little nutritional value and is high in carbohydrates.

PTS: 1 DIF: Cognitive Level: Apply REF: 775-776 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 12. A young child is brought to the emergency department with severe dehydration secondary to acute diarrhea and vomiting. Therapeutic management of this child should begin with: a. intravenous (IV) fluids. b. ORS. c. clear liquids, 1 to 2 ounces at a time. d. administration of antidiarrheal medication.

ANS: A In children with severe dehydration, IV fluids are initiated. ORS is acceptable therapy if the dehydration is not severe. Diarrhea is not managed by using clear liquids by mouth. These fluids have a high carbohydrate content, low electrolyte content, and high osmolality. Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

PTS: 1 DIF: Cognitive Level: Apply REF: 776 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. A mother calls the clinic nurse about her 4-year-old son who has acute diarrhea. She has been giving him the antidiarrheal drug loperamide (Imodium A-D). The nurses response should be based on knowledge that this drug is: a. not indicated. b. indicated because it slows intestinal motility. c. indicated because it decreases diarrhea. d. indicated because it decreases fluid and electrolyte losses.

ANS: A Antidiarrheal medications are not recommended for the treatment of acute infectious diarrhea.

These medications have adverse effects and toxicity, such as worsening of the diarrhea because of slowing of motility and ileus, or a decrease in diarrhea with continuing fluid losses and

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dehydration. Antidiarrheal medications are not recommended in infants and small children.

PTS: 1 DIF: Cognitive Level: Analyze REF: 777 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 14. Constipation has recently become a problem for a school-age girl. She is healthy except for seasonal allergies that are being treated with antihistamines. The nurse should suspect that the constipation is most likely caused by: a. diet. b. allergies. c. antihistamines. d. emotional factors.

ANS: C Constipation may be associated with drugs such as antihistamines, antacids, diuretics, opioids, antiepileptics, and iron. Because this is the only known change in her habits, the addition of antihistamines is most likely the cause of the diarrhea. With a change in bowel habits, the role of any recently prescribed medications should be assessed.

PTS: 1 DIF: Cognitive Level: Analyze REF: 778 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 15. Which is a high-fiber food that the nurse should recommend for a child with chronic constipation? a. Popcorn b. Pancakes c. Muffins d. Ripe bananas ANS: A Popcorn is a high-fiber food. Pancakes and muffins do not have significant fiber unless made with fruit or bran. Raw fruits, especially those with skins and seeds, other than ripe bananas, have high fiber.

PTS: 1 DIF: Cognitive Level: Apply REF: 779-780 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort

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16. Which therapeutic management treatment is implemented for children with Hirschsprung disease? a. Daily enemas b. Low-fiber diet c. Permanent colostomy d. Surgical removal of affected section of bowel ANS: D Most children with Hirschsprung disease require surgical rather than medical management.

Surgery is done to remove the aganglionic portion of the bowel, relieve obstruction, and restore normal bowel motility and function of the internal anal sphincter. Preoperative management may include enemas and low-fiber, high-calorie, high-protein diet, until the child is physically ready for surgery. The colostomy that is created in Hirschsprung disease is usually temporary.

PTS: 1 DIF: Cognitive Level: Understand REF: 781 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 17. Enemas are ordered to empty the bowel preoperatively for a child with Hirschsprung disease.

The enema solution should be: a. tap water. b. normal saline. c. oil retention. d. phosphate preparation.

ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oilretention enemas will not achieve the until clear result. Phosphate enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the phosphate enema can result in diarrhea, which can lead to metabolic acidosis.

PTS: 1 DIF: Cognitive Level: Apply REF: 781 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 18. A 3-year-old child with Hirschsprung disease is hospitalized for surgery. A temporary colostomy will be necessary. The nurse should recognize that preparing this child psychologically is:

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a. not necessary because of childs age. b. not necessary because colostomy is temporary. c. necessary because it will be an adjustment. d. necessary because the child must deal with a negative body image.

ANS: C The childs age dictates the type and extent of psychological preparation. When a colostomy is performed, the child who is at least preschool age is told about the procedure and what to expect in concrete terms, with the use of visual aids. It is necessary to prepare a 3-year-old child for procedures. The preschooler is not yet concerned with body image.

PTS: 1 DIF: Cognitive Level: Understand REF: 781 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity: Coping and Adaptation 19. The nurse is explaining to a parent how to care for a school-age child with vomiting associated with a viral illness. Which action should the nurse include? a. Avoid carbohydrate-containing liquids. b. Give nothing by mouth for 24 hours. c. Brush teeth or rinse mouth after vomiting. d. Give plain water until vomiting ceases for at least 24 hours.

ANS: C It is important to emphasize the need for the child to brush the teeth or rinse the mouth after vomiting to dilute the hydrochloric acid that comes in contact with the teeth. Ad libitum administration of glucose-electrolyte solution to an alert child will help restore water and electrolytes satisfactorily. It is important to include carbohydrate to spare body protein and avoid ketosis.

PTS: 1 DIF: Cognitive Level: Apply REF: 782 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 20. A 4-month-old infant has gastroesophageal reflux (GER) but is thriving without other complications. Which should the nurse suggest to minimize reflux? a. Place in Trendelenburg position after eating. b. Thicken formula with rice cereal. c. Give continuous nasogastric tube feedings. d. Give larger, less frequent feedings.

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ANS: B Small, frequent feedings of formula combined with 1 teaspoon to 1 tablespoon of rice cereal per ounce of formula has been recommended. Milk-thickening agents have been shown to decrease the number of episodes of vomiting and to increase the caloric density of the formula. This may benefit infants who are underweight as a result of GER disease. Placing the child in a Trendelenburg position would increase the reflux. Continuous nasogastric feedings are reserved for infants with severe reflux and failure to thrive.

PTS: 1 DIF: Cognitive Level: Apply REF: 783 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 21. A histamine-receptor antagonist such as cimetidine (Tagamet) or ranitidine (Zantac) is ordered for an infant with GER. The purpose of this is to: a. prevent reflux. b. prevent hematemesis. c. reduce gastric acid production. d. increase gastric acid production.

ANS: C The mechanism of action of histamine-receptor antagonists is to reduce the amount of acid present in gastric contents and perhaps prevent esophagitis. Preventing reflux or hematemesis and increasing gastric acid production are not the modes of action of histamine-receptor antagonists.

PTS: 1 DIF: Cognitive Level: Understand REF: 783 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 22. Which clinical manifestation would be the most suggestive of acute appendicitis? a. Rebound tenderness b. Bright red or dark red rectal bleeding c. Abdominal pain that is relieved by eating d. Abdominal pain that is most intense at McBurney point ANS: D Pain is the cardinal feature. It is initially generalized, usually periumbilical. The pain localizes to the right lower quadrant at McBurney point. Rebound tenderness is not a reliable sign and is extremely painful to the child. Bright red or dark red rectal bleeding and abdominal pain that is

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relieved by eating are not signs of acute appendicitis.

PTS: 1 DIF: Cognitive Level: Understand REF: 785 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. When caring for a child with probable appendicitis, the nurse should be alert to recognize that which condition or symptom is a sign of perforation? a. Bradycardia b. Anorexia c. Sudden relief from pain d. Decreased abdominal distention ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation.

Tachycardia, not bradycardia, is a manifestation of peritonitis. Anorexia is already a clinical manifestation of appendicitis. Abdominal distention usually increases.

PTS: 1 DIF: Cognitive Level: Understand REF: 786 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 24. The nurse is caring for a child admitted with acute abdominal pain and possible appendicitis.

Which is appropriate to relieve the abdominal discomfort? a. Place in Trendelenburg position. b. Allow to assume position of comfort. c. Apply moist heat to the abdomen. d. Administer a saline enema to cleanse bowel.

ANS: B The child should be allowed to take a position of comfort, usually with the legs flexed. The Trendelenburg position will not help with the discomfort. In any instance in which appendicitis is a possibility, there is a danger in administering a laxative or enemas or applying heat to the area. Such measures stimulate bowel motility and increase the risk of perforation.

PTS: 1 DIF: Cognitive Level: Apply REF: 787 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 25. A nurse is conducting an in-service on childhood gastrointestinal disorders. Which statement

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is most descriptive of Meckel diverticulum? a. It is more common in females than in males. b. It is acquired during childhood. c. Intestinal bleeding may be mild or profuse. d. Medical interventions are usually sufficient to treat the problem.

ANS: C Bloody stools are often a presenting sign of Meckel diverticulum. It is associated with mild to profuse intestinal bleeding. It is twice as common in males as in females, and complications are more frequent in males. Meckel diverticulum is the most common congenital malformation of the GI tract and is present in 1% to 4% of the general population. The standard therapy is surgical removal of the diverticulum.

PTS: 1 DIF: Cognitive Level: Apply REF: 788 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 26. A nurse is admitting a child with Crohn disease. Parents ask the nurse, How is this disease different from ulcerative colitis? Which statement should the nurse make when answering this question? a. With Crohns the inflammatory process involves the whole GI tract. b. There is no difference between the two diseases. c. The inflammation with Crohns is limited to the colon and rectum. d. Ulcerative colitis is characterized by skip lesions.

ANS: A The chronic inflammatory process of Crohn disease involves any part of the GI tract from the mouth to the anus but most often affects the terminal ileum. Crohn disease involves all layers of the bowel wall in a discontinuous fashion, meaning that between areas of intact mucosa, there are areas of affected mucosa (skip lesions). The inflammation found with ulcerative colitis is limited to the colon and rectum, with the distal colon and rectum the most severely affected.

Inflammation affects the mucosa and submucosa and involves continuous segments along the length of the bowel with varying degrees of ulceration, bleeding, and edema.

PTS: 1 DIF: Cognitive Level: Apply REF: 789 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. Which is used to treat moderate to severe inflammatory bowel disease?

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a. Antacids b. Antibiotics c. Corticosteroids d. Antidiarrheal medications ANS: C Corticosteroids, such as prednisone and prednisolone, are used in short bursts to suppress the inflammatory response in inflammatory bowel disease. Antacids and antidiarrheal medications are not drugs of choice in the treatment of inflammatory bowel disease. Antibiotics may be used as an adjunctive therapy to treat complications.

PTS: 1 DIF: Cognitive Level: Understand REF: 790 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 28. Bismuth subsalicylate, clarithromycin, and metronidazole are prescribed for a child with a peptic ulcer to: a. eradicate Helicobacter pylori. b. coat gastric mucosa. c. treat epigastric pain. d. reduce gastric acid production.

ANS: A The drug therapy combination of bismuth subsalicylate, clarithromycin, and metronidazole is effective in the treatment of H. pylori and is prescribed to eradicate it.

PTS: 1 DIF: Cognitive Level: Understand REF: 793 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 29. Which statement best characterizes hepatitis A? a. Incubation period is 6 weeks to 6 months. b. Principal mode of transmission is through the parenteral route. c. Onset is usually rapid and acute. d. There is a persistent carrier state.

ANS: C Hepatitis A is the most common form of acute hepatitis in most parts of the world. It is characterized by a rapid and acute onset. The incubation period is approximately 3 weeks for hepatitis A and the principal mode of transmission for it is the fecal-oral route. Hepatitis A does

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not have a carrier state.

PTS: 1 DIF: Cognitive Level: Understand REF: 795 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 30. Which vaccine is now recommended for the immunization of all newborns? a. Hepatitis A vaccine b. Hepatitis B vaccine c. Hepatitis C vaccine d. Hepatitis A, B, and C vaccines ANS: B Universal vaccination for hepatitis B is now recommended for all newborns. A vaccine is available for hepatitis A, but it is not yet universally recommended. No vaccine is currently available for hepatitis C. Only hepatitis B vaccine is recommended for newborns.

PTS: 1 DIF: Cognitive Level: Understand REF: 797 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 31. The best chance of survival for a child with cirrhosis is: a. liver transplantation. b. treatment with corticosteroids. c. treatment with immune globulin. d. provision of nutritional support.

ANS: A The only successful treatment for end-stage liver disease and liver failure may be liver transplantation, which has improved the prognosis for many children with cirrhosis. Liver transplantation has revolutionized the approach to cirrhosis. Liver failure and cirrhosis are indications for transplantation. Liver transplantation reflects the failure of other medical and surgical measures to prevent or treat cirrhosis.

PTS: 1 DIF: Cognitive Level: Understand REF: 798 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 32. A nurse is admitting an infant with biliary atresia. Which is the earliest clinical manifestation of biliary atresia the nurse should expect to assess?

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a. Jaundice b. Vomiting c. Hepatomegaly d. Absence of stooling ANS: A Jaundice is the earliest and most striking manifestation of biliary atresia. It is first observed in the sclera, may be present at birth, but is usually not apparent until age 2 to 3 weeks. Vomiting is not associated with biliary atresia. Hepatomegaly and abdominal distention are common but occur later. Stools are large and lighter in color than expected because of the lack of bile.

PTS: 1 DIF: Cognitive Level: Understand REF: 798-799 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 33. A newborn was admitted to the nursery with a complete bilateral cleft lip and palate. The physician explained the plan of therapy and its expected good results. However, the mother refuses to see or hold her baby. Initial therapeutic approach to the mother should be: a. restating what the physician has told her about plastic surgery. b. encouraging her to express her feelings. c. emphasizing the normalcy of her baby and the babys need for mothering. d. recognizing that negative feelings toward the child continue throughout childhood.

ANS: B For parents, cleft lip and cleft palate deformities are particularly disturbing. The nurse must place emphasize not only the infants physical needs but also the parents emotional needs. The mother needs to be able to express her feelings before she can accept her child. Although the nurse will restate what the physician has told the mother about plastic surgery, it is not part of the initial therapeutic approach. As the mother expresses her feelings, the nurses actions should convey to the parents that the infant is a precious human being. The nurse emphasizes the childs normalcy and helps the mother recognize the childs uniqueness. Maternal-infant attachment was not negatively affected at age 1 year.

PTS: 1 DIF: Cognitive Level: Apply REF: 800 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 34. Caring for the newborn with a cleft lip and palate before surgical repair includes: a. gastrostomy feedings.

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b. keeping infant in near-horizontal position during feedings. c. allowing little or no sucking. d. providing satisfaction of sucking needs.

ANS: D Using special or modified nipples for feeding techniques helps meet the infants sucking needs.

Gastrostomy feedings are usually not indicated. Feeding is best accomplished with the infants head in an upright position. The child requires both nutritive and nonnutritive sucking.

PTS: 1 DIF: Cognitive Level: Apply REF: 801 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 35. A mother who intended to breastfeed has given birth to an infant with a cleft palate. Nursing interventions should include: a. giving medication to suppress lactation. b. encouraging and helping mother to breastfeed. c. teaching mother to feed breast milk by gavage. d. recommending use of a breast pump to maintain lactation until infant can suck.

ANS: B The mother who wishes to breastfeed may need encouragement and support because the defect does present some logistical issues. The nipple must be positioned and stabilized well back in the infants oral cavity so that the tongue action facilitates milk expression. Because breastfeeding is an option, if the mother wishes to breastfeed, medications should not be given to suppress lactation. Because breastfeeding can usually be accomplished, gavage feedings are not indicated.

The suction required to stimulate milk, absent initially, may be useful before nursing to stimulate the let-down reflex.

PTS: 1 DIF: Cognitive Level: Apply REF: 801 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 36. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infants postoperative care include: a. arm restraints, postural drainage, mouth irrigations. b. cleansing the suture line, supine and side-lying positions, arm restraints. c. mouth irrigations, prone position, cleansing suture line. d. supine and side-lying positions, postural drainage, arm restraints.

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ANS: B The suture line should be cleansed gently after feeding. The child should be positioned on the back, on the side, or in an infant seat. Elbows are restrained to prevent the child from accessing the operative site. Postural drainage is not indicated. This would increase the pressure on the operative site when the child is placed in different positions. There is no reason to perform mouth irrigations, and the child should not be placed in the prone position where injury to the suture site can occur.

PTS: 1 DIF: Cognitive Level: Apply REF: 802 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 37. During the first few days after surgery for cleft lip, which intervention should the nurse do? a. Leave infant in crib at all times to prevent suture strain. b. Keep infant heavily sedated to prevent suture strain. c. Remove restraints periodically to cuddle infant. d. Alternate position from prone to side-lying to supine.

ANS: C Remove restraints periodically, while supervising the infant, to allow him or her to exercise arms and to provide cuddling and tactile stimulation. The infant should not be left in the crib, but should be removed for appropriate holding and stimulation. Analgesia and sedation are administered for pain. Heavy sedation is not indicated. The child should not be placed in the prone position.

PTS: 1 DIF: Cognitive Level: Apply REF: 802 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 38. The nurse is caring for a neonate with a suspected tracheoesophageal fistula. Nursing care should include: a. elevating the head but give nothing by mouth. b. elevating the head for feedings. c. feeding glucose water only. d. avoiding suctioning unless infant is cyanotic.

ANS: A When a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that

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any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having tracheoesophageal fistulas. The oral pharynx should be kept clear of secretion by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

PTS: 1 DIF: Cognitive Level: Apply REF: 803-804 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 39. Which type of hernia has an impaired blood supply to the herniated organ? a. Hiatal hernia b. Incarcerated hernia c. Omphalocele d. Strangulated hernia ANS: D A strangulated hernia is one in which the blood supply to the herniated organ is impaired. Hiatal hernia is the intrusion of an abdominal structure, usually the stomach, through the esophageal hiatus. Incarcerated hernia is a hernia that cannot be reduced easily. Omphalocele is the protrusion of intra-abdominal viscera into the base of the umbilical cord. The sac is covered with peritoneum, not skin.

PTS: 1 DIF: Cognitive Level: Understand REF: 805 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 40. Pyloric stenosis can best be described as: a. dilation of the pylorus. b. hypertrophy of the pyloric muscle. c. hypotonicity of the pyloric muscle. d. reduction of tone in the pyloric muscle.

ANS: B Hypertrophic pyloric stenosis occurs when the circumferential muscle of the pyloric sphincter becomes thickened, resulting in elongation and narrowing of the pyloric channel. Dilation of the pylorus, hypotonicity of the pyloric muscle, and reduction of tone in the pyloric muscle are not the definition of pyloric stenosis.

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Chapter 35. Child With a Genitourinary Condition MULTIPLE CHOICE 1. The nurse is conducting a staff in-service on renal ultrasounds. Which statement describes this diagnostic test? a. Computed tomography uses external radiation to visualize the renal system. b. Visualization of the renal system is accomplished without exposure to radiation or radioactive isotopes. c. Contrast medium and x-rays allow for visualization of the renal system. d. External radiation for x-ray films is used to visualize the renal system, before, during, and after voiding.

ANS: A A renal ultrasound transmits ultrasonic waves through the renal parenchyma allowing for visualization of the renal system without exposure to external beam radiation or radioactive isotopes. Computed tomography uses external radiation and sometimes contrast media to visualize the renal system. An intravenous pyelogram uses contrast medium and external radiation for x-ray films. The voiding cystourethrogram visualizes the renal system with injection of a contrast media into the bladder through the urethral opening and use of x-ray before, during, and after voiding.

PTS: 1 DIF: Cognitive Level: Understand REF: 908 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. The nurse is admitting a school-age child in acute renal failure with reduced glomerular filtration rate. Which urine test is the most useful clinical indication of glomerular filtration rate? a. pH b. Osmolality c. Creatinine d. Protein level ANS: C The most useful clinical indication of glomerular filtration is the clearance of creatinine. It is a substance that is freely filtered by the glomerulus and secreted by the renal tubule cells. The pH

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and osmolality are not estimates of glomerular filtration. Although protein in the urine demonstrates abnormal glomerular permeability, it is not a measure of filtration rate.

PTS: 1 DIF: Cognitive Level: Understand REF: 904 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. The nurse is conducting an assessment on a school-age child with urosepsis. Which assessment finding should the nurse expect? a. Fever with a positive blood culture b. Proteinuria and edema c. Oliguria and hypertension d. Anemia and thrombocytopenia ANS: A Symptoms of urosepsis include a febrile UTI coexisting with systemic signs of bacterial illness; blood culture reveals presence of urinary pathogen. Proteinuria and edema are symptoms of minimal change nephrotic syndrome (MCNS). Oliguria and hypertension are symptoms of acute glomerulonephritis (AGN). Anemia and thrombocytopenia are symptoms of hemolytic uremic syndrome (HUS).

PTS: 1 DIF: Cognitive Level: Analyze REF: 906 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 4. The nurse is teaching parents about prevention of urinary tract infections in children. Which factor predisposes the urinary tract to infection? a. Increased fluid intake b. Short urethra in young girls c. Prostatic secretions in males d. Frequent emptying of the bladder ANS: B The short urethra in females provides a ready pathway for invasion of organisms. Increased fluid intake and frequent emptying of the bladder offer protective measures against urinary tract infections. Prostatic secretions have antibacterial properties that inhibit bacteria.

PTS: 1 DIF: Cognitive Level: Understand REF: 908 TOP: Integrated Process: Teaching/Learning

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MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. Which should the nurse recommend to prevent urinary tract infections in young girls? a. Wear cotton underpants. b. Limit bathing as much as possible. c. Increase fluids; decrease salt intake. d. Cleanse perineum with water after voiding.

ANS: A Cotton underpants are preferable to nylon underpants. No evidence exists that limiting bathing, increasing fluids/decreasing salt intake, or cleansing the perineum with water after voiding decrease urinary tract infections in young girls.

PTS: 1 DIF: Cognitive Level: Apply REF: 910 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 6. The nurse is admitting a newborn with hypospadias to the nursery. The nurse expects which finding in this newborn? a. Absence of a urethral opening is noted. b. Penis appears shorter than usual for age. c. The urethral opening is along the dorsal surface of the penis. d. The urethral opening is along the ventral surface of the penis.

ANS: D Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis. The urethral opening is present, but not at the glans.

Hypospadias refers to the urethral opening, not to the size of the penis. Urethral opening along ventral surface of penis is known as epispadias.

PTS: 1 DIF: Cognitive Level: Understand REF: 912 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 7. The nurse is conducting a staff in-service on newborn defects of the genitourinary system.

Which describes the narrowing of the preputial opening of the foreskin? a. Chordee b. Phimosis c. Epispadias

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d. Hypospadias ANS: B Phimosis is the narrowing or stenosis of the preputial opening of the foreskin. Chordee is the ventral curvature of the penis. Epispadias is the meatal opening on the dorsal surface of the penis. Hypospadias is a congenital condition in which the urethral opening is located anywhere along the ventral surface of the penis.

PTS: 1 DIF: Cognitive Level: Remember REF: 912 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 8. Which is an objective of care for a 10-year-old child with minimal change nephrotic syndrome? a. Reduce blood pressure. b. Reduce excretion of urinary protein. c. Increase excretion of urinary protein. d. Increase ability of tissues to retain fluid.

ANS: B The objectives of therapy for the child with minimal change nephrotic syndrome include reduction of the excretion of urinary protein, reduction of fluid retention, prevention of infection, and minimization of complications associated with therapy. Blood pressure is usually not elevated in minimal change nephrotic syndrome. Excretion of urinary protein and fluid retention are part of the disease process and must be reversed.

PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 9. Which is instituted for the therapeutic management of minimal change nephrotic syndrome? a. Corticosteroids b. Antihypertensive agents c. Long-term diuretics d. Increased fluids to promote diuresis ANS: A Corticosteroids are the first line of therapy for minimal change nephrotic syndrome. Response is usually seen within 7 to 21 days. Antihypertensive agents and long-term diuretic therapy are

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usually not necessary. A diet that has fluid and salt restrictions may be indicated.

PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 10. Which is a common side effect of short-term corticosteroid therapy? a. Fever b. Hypertension c. Weight loss d. Increased appetite ANS: D Side effects of short-term corticosteroid therapy include an increased appetite. Fever is not a side effect of therapy. It may be an indication of infection. Hypertension is not usually associated with initial corticosteroid therapy. Weight gain, not weight loss, is associated with corticosteroid therapy.

PTS: 1 DIF: Cognitive Level: Understand REF: 914 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 11. The nurse closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication? a. Infection b. Hypertension c. Encephalopathy d. Edema ANS: A Infection is a constant source of danger to edematous children and those receiving corticosteroid therapy. An increased temperature could be an indication of an infection. Temperature is not an indication of hypertension or edema. Encephalopathy is not a complication usually associated with minimal change nephrotic syndrome. The child will most likely have neurologic signs and symptoms.

PTS: 1 DIF: Cognitive Level: Understand REF: 914 TOP: Integrated Process: Nursing Process: Assessment

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MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 12. A hospitalized child with minimal change nephrotic syndrome is receiving high doses of prednisone. Which is an appropriate nursing goal related to this? a. Prevent infection. b. Stimulate appetite. c. Detect evidence of edema. d. Ensure compliance with prophylactic antibiotic therapy.

ANS: A High-dose steroid therapy has an immunosuppressant effect. These children are particularly vulnerable to upper respiratory tract infections. A priority nursing goal is to minimize the risk of infection by protecting the child from contact with infectious individuals. Appetite is increased with prednisone therapy. The amount of edema should be monitored as part of the disease process, not necessarily related to the administration of prednisone. Antibiotics would not be used as prophylaxis.

PTS: 1 DIF: Cognitive Level: Apply REF: 914 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 13. Which is included in the diet of a child with minimal change nephrotic syndrome? a. High protein b. Salt restriction c. Low fat d. High carbohydrate ANS: B Salt is usually restricted (but not eliminated) during the edema phase. The child has little appetite during the acute phase. Favorite foods are provided (with the exception of high-salt ones) in an attempt to provide nutritionally complete meals.

PTS: 1 DIF: Cognitive Level: Understand REF: 914 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 14. Which best describes acute glomerulonephritis? a. Occurs after a urinary tract infection b. Occurs after a streptococcal infection

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c. Associated with renal vascular disorders d. Associated with structural anomalies of genitourinary tract ANS: B Acute glomerulonephritis is an immune-complex disease that occurs after a streptococcal infection with certain strains of the group A -hemolytic streptococcus. Acute glomerulonephritis usually follows streptococcal pharyngitis and is not associated with renal vascular disorders or genitourinary tract structural anomalies.

PTS: 1 DIF: Cognitive Level: Understand REF: 915 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 15. A child is admitted with acute glomerulonephritis. The nurse should expect the urinalysis during this acute phase to show: a. bacteriuria, hematuria. b. hematuria, proteinuria. c. bacteriuria, increased specific gravity. d. proteinuria, decreased specific gravity.

ANS: B Urinalysis during the acute phase characteristically shows hematuria and proteinuria. Bacteriuria and changes in specific gravity are not usually present during the acute phase.

PTS: 1 DIF: Cognitive Level: Understand REF: 915 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 16. A mother asks the nurse what would be the first indication that acute glomerulonephritis is improving. The nurses best response should be that the: a. blood pressure will stabilize. b. the child will have more energy. c. urine will be free of protein. d. urinary output will increase.

ANS: D An increase in urinary output may signal resolution of the acute glomerulonephritis. If blood pressure is elevated, stabilization usually occurs with the improvement in renal function. The child having more energy and the urine being free of protein are related to the improvement in

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urinary output.

PTS: 1 DIF: Cognitive Level: Apply REF: 916 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 17. The nurse notes that a child has lost 8 pounds after 4 days of hospitalization for acute glomerulonephritis. This is most likely the result of: a. poor appetite. b. increased potassium intake. c. reduction of edema. d. restriction to bed rest.

ANS: C This amount of weight loss in this period is a result of the improvement of renal function and mobilization of edema fluid. Poor appetite and bed rest would not result in a weight loss of 8 pounds in 4 days. Foods with substantial amounts of potassium are avoided until renal function is normalized.

PTS: 1 DIF: Cognitive Level: Understand REF: 916 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 18. The nurse is teaching the parent about the diet of a child experiencing severe edema associated with acute glomerulonephritis. Which information should the nurse include in the teaching? a. You will need to decrease the number of calories in your childs diet. b. Your childs diet will need an increased amount of protein. c. You will need to avoid adding salt to your childs food. d. Your childs diet will consist of low-fat, low-carbohydrate foods.

ANS: C For most children, a regular diet is allowed, but it should contain no added salt. The child should be offered a regular diet with favorite foods. Severe sodium restrictions are not indicated.

PTS: 1 DIF: Cognitive Level: Apply REF: 916 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 19. Which is the most appropriate nursing diagnosis for the child with acute glomerulonephritis?

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a. Risk for Injury related to malignant process and treatment b. Fluid Volume Deficit related to excessive losses c. Fluid Volume Excess related to decreased plasma filtration d. Fluid Volume Excess related to fluid accumulation in tissues and third spaces ANS: C Glomerulonephritis has a decreased filtration of plasma, which results in an excessive accumulation of water and sodium that expands plasma and interstitial fluid volumes, leading to circulatory congestion and edema. No malignant process is involved in acute glomerulonephritis.

A fluid volume excess is found. The fluid accumulation is secondary to the decreased plasma filtration.

PTS: 1 DIF: Cognitive Level: Analyze REF: 915 TOP: Integrated Process: Nursing Process: Nursing Diagnosis MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 20. The nurse is admitting a child with a Wilms tumor. Which is the initial assessment finding associated with this tumor? a. Abdominal swelling b. Weight gain c. Hypotension d. Increased urinary output ANS: A The initial assessment finding with a Wilms (kidney) tumor is abdominal swelling. Weight loss, not weight gain, may be a finding. Hypertension occasionally occurs with a Wilms tumor.

Urinary output is not increased, but hematuria may be noted.

PTS: 1 DIF: Cognitive Level: Understand REF: 917 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 21. Which is the most common cause of acute renal failure in children? a. Pyelonephritis b. Tubular destruction c. Urinary tract obstruction d. Severe dehydration ANS: D The most common cause of acute renal failure in children is dehydration or other causes of poor

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perfusion that may respond to restoration of fluid volume. Pyelonephritis and tubular destruction are not common causes of acute renal failure. Obstructive uropathy may cause acute renal failure, but it is not the most common cause.

PTS: 1 DIF: Cognitive Level: Understand REF: 919 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. The nurse is conducting an admission assessment on a school-age child with acute renal failure. Which are the primary clinical manifestations the nurse expects to find with this condition? a. Oliguria and hypertension b. Hematuria and pallor c. Proteinuria and muscle cramps d. Bacteriuria and facial edema ANS: A The principal feature of acute renal failure is oliguria; hypertension is a nonspecific clinical manifestation. Hematuria and pallor, proteinuria and muscle cramps, and bacteriuria and facial edema are not principal features of acute renal failure.

PTS: 1 DIF: Cognitive Level: Understand REF: 919 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. The nurse is caring for a child with acute renal failure. Which clinical manifestation should the nurse recognize as a sign of hyperkalemia? a. Dyspnea b. Seizure c. Oliguria d. Cardiac arrhythmia ANS: D Hyperkalemia is the most common threat to the life of the child. Signs of hyperkalemia include electrocardiograph anomalies such as prolonged QRS complex, depressed ST segments, peaked T waves, bradycardia, or heart block. Dyspnea, seizure, and oliguria are not manifestations of hyperkalemia.

PTS: 1 DIF: Cognitive Level: Apply REF: 920

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TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 24. When a child has chronic renal failure, the progressive deterioration produces a variety of clinical and biochemical disturbances that eventually are manifested in the clinical syndrome known as: a. uremia. b. oliguria. c. proteinuria. d. pyelonephritis.

ANS: A Uremia is the retention of nitrogenous products, producing toxic symptoms. Oliguria is diminished urinary output. Proteinuria is the presence of protein, usually albumin, in the urine.

Pyelonephritis is an inflammation of the kidney and renal pelvis.

PTS: 1 DIF: Cognitive Level: Remember REF: 921 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 25. Which is a major complication in a child with chronic renal failure? a. Hypokalemia b. Metabolic alkalosis c. Water and sodium retention d. Excessive excretion of blood urea nitrogen ANS: C Chronic renal failure leads to water and sodium retention, which contributes to edema and vascular congestion. Hyperkalemia, metabolic acidosis, and retention of blood urea nitrogen are complications of chronic renal failure.

PTS: 1 DIF: Cognitive Level: Understand REF: 921 TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 26. Which clinical manifestation would be seen in a child with chronic renal failure? a. Hypotension b. Massive hematuria c. Hypokalemia

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d. Unpleasant uremic breath odor ANS: D Children with chronic renal failure have a characteristic breath odor resulting from the retention of waste products. Hypertension may be a complication of chronic renal failure. With chronic renal failure, little or no urinary output occurs. Hyperkalemia is a concern in chronic renal failure.

PTS: 1 DIF: Cognitive Level: Understand REF: 922 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 27. One of the clinical manifestations of chronic renal failure is uremic frost. Which best describes this term? a. Deposits of urea crystals in urine b. Deposits of urea crystals on skin c. Overexcretion of blood urea nitrogen d. Inability of body to tolerate cold temperatures ANS: B Uremic frost is the deposition of urea crystals on the skin. The urea crystals are present on the skin, not in the urine. The kidneys are unable to excrete blood urea nitrogen, leading to elevated levels. There is no relation between cold temperatures and uremic frost.

PTS: 1 DIF: Cognitive Level: Understand REF: 922 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 28. Calcium carbonate is given with meals to a child with chronic renal disease. The purpose of this is to: a. prevent vomiting. b. bind phosphorus. c. stimulate appetite. d. increase absorption of fat-soluble vitamins.

ANS: B Oral calcium carbonate preparations combine with phosphorus to decrease gastrointestinal absorption and the serum levels of phosphate. Serum calcium levels are increased by the calcium carbonate, and vitamin D administration is necessary to increase calcium absorption. Calcium carbonate does not prevent vomiting, stimulate appetite, or increase the absorption of fat-soluble

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vitamins.

PTS: 1 DIF: Cognitive Level: Apply REF: 922 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapy 29. Which should the nurse recommend for the diet of a child with chronic renal failure? a. High in protein b. Low in vitamin D c. Low in phosphorus d. Supplemented with vitamins A, E, and K ANS: C Dietary phosphorus is controlled by the reduction of protein and milk intake to prevent or control the calcium-phosphorus imbalance. Protein should be limited in chronic renal failure to decrease intake of phosphorus. Vitamin D therapy is administered in chronic renal failure to increase calcium absorption. Supplementation of vitamins A, E, and K is not part of dietary management in chronic renal disease.

PTS: 1 DIF: Cognitive Level: Apply REF: 922 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 30. The nurse is caring for an adolescent who has just started dialysis. The child seems always angry, hostile, or depressed. The nurse should recognize that this is most likely related to: a. neurologic manifestations that occur with dialysis. b. physiologic manifestations of renal disease. c. adolescents having few coping mechanisms. d. adolescents often resenting the control and enforced dependence imposed by dialysis.

ANS: D Older children and adolescents need control. The necessity of dialysis forces the adolescent into a dependent relationship, which results in these behaviors. These are a function of the childs age, not neurologic or physiologic manifestations of the dialysis. Feelings of anger, hostility, and depression are functions of the childs age, not neurologic or physiologic manifestations of the dialysis. Adolescents do have coping mechanisms, but they need to have some control over their disease management.

PTS: 1 DIF: Cognitive Level: Analyze REF: 923

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TOP: Integrated Process: Nursing Process: Evaluation MSC: Area of Client Needs: Health Promotion and Maintenance 31. Which is an advantage of peritoneal dialysis? a. Treatments are done in hospitals. b. Protein loss is less extensive. c. Dietary limitations are not necessary. d. Parents and older children can perform treatments.

ANS: D Peritoneal dialysis is the preferred form of dialysis for parents, infants, and children who wish to remain independent. Parents and older children can perform the treatments themselves.

Treatments can be done at home. Protein loss is not significantly different. The dietary limitations are necessary, but they are not as stringent as those for hemodialysis.

PTS: 1 DIF: Cognitive Level: Analyze REF: 923 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 32. Which statement is descriptive of renal transplantation in children? a. It is an acceptable means of treatment after age 10 years. b. It is the preferred means of renal replacement therapy in children. c. Children can receive kidneys only from other children. d. The decision for transplantation is difficult because a relatively normal lifestyle is not possible.

ANS: B Renal transplant offers the opportunity for a relatively normal life and is the preferred means of renal replacement therapy in end-stage renal disease. Renal transplantation can be done in children as young as age 6 months. Both children and adults can serve as donors for renal transplant purposes. Renal transplantation affords the child a more normal lifestyle than dependence on dialysis.

PTS: 1 DIF: Cognitive Level: Understand REF: 925 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 33. A preschool child is being admitted to the hospital with dehydration and a urinary tract infection (UTI). Which urinalysis result should the nurse expect with these conditions?

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a. WBC <1; specific gravity 1.008 b. WBC <2; specific gravity 1.025 c. WBC >2; specific gravity 1.016 d. WBC >2; specific gravity 1.030 ANS: D WBC count in a routine urinalysis should be <1 or 2. Over that amount indicates a urinary tract inflammatory process. The urinalysis specific gravity for children with normal fluid intake is 1.016 to 1.022. When the specific gravity is high, dehydration is indicated. A low specific gravity is seen with excessive fluid intake, distal tubular dysfunction, or insufficient antidiuretic hormone secretion.

PTS: 1 DIF: Cognitive Level: Analyze REF: 907 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 34. The nurse is conducting teaching for an adolescent being discharged to home after a renal transplant. The adolescent needs further teaching if which statement is made? a. I will report any fever to my primary health care provider. b. I am glad I only have to take the immunosuppressant medication for two weeks. c. I will observe my incision for any redness or swelling. d. I wont miss doing kidney dialysis every week.

ANS: B The immunosuppressant medications are taken indefinitely after a renal transplant, so they should not be discontinued after two weeks. Reporting a fever and observing an incision for redness and swelling are accurate statements. The adolescent is correct in indicating dialysis will not need to be done after the transplant.

Chapter 36. Child With a Skin Condition MULTIPLE CHOICE 1. The nurse is taking care of a 7-year-old child with a skin rash called a papule. Which clinical finding should the nurse expect to assess with this type of skin rash? a. A lesion that is elevated, palpable, firm and circumscribed; less than 1 cm in diameter b. A lesion that is elevated, flat-topped, firm, rough and superficial; greater than 1 cm in diameter

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c. An elevated lesion, firm, circumscribed, palpable; 1 to 2 cm in diameter d. An elevated lesion, circumscribed, filled with serous fluid; less than 1 cm in diameter ANS: A A papule is elevated; palpable; firm; circumscribed; less than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A plaque is an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be coalesced papules. A nodule is elevated, 1 to 2 cm in diameter, firm, circumscribed, palpable, and deeper in the dermis than a papule. A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with serous fluid.

PTS: 1 DIF: Cognitive Level: Understand REF: 1011 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 2. The nurse is teaching nursing students about childhood skin lesions. Which is an elevated, circumscribed skin lesion that is less than 1 cm in diameter and filled with serous fluid? a. Cyst b. Papule c. Pustule d. Vesicle ANS: D A vesicle is elevated, circumscribed, superficial, less than 1 cm in diameter, and filled with serous fluid. A cyst is elevated, circumscribed, palpable, encapsulated, and filled with liquid or semisolid material. A papule is elevated; palpable; firm; circumscribed; less than 1 cm in diameter; and brown, red, pink, tan, or bluish red. A pustule is elevated, superficial, and similar to a vesicle but filled with purulent fluid.

PTS: 1 DIF: Cognitive Level: Remember REF: 1011 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 3. The nurse is taking care of a 2-year-old child with a macule skin lesion. Which clinical finding should the nurse expect to assess with this type of lesion? a. Flat, nonpalpable, and irregularly shaped lesion that is greater than 1 cm in diameter b. Heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size c. Flat, brown mole less than 1 cm in diameter d. Elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter

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ANS: C A macule is flat; nonpalpable; circumscribed; less than 1 cm in diameter; and brown, red, purple, white, or tan. A patch is a flat, nonpalpable, and irregularly shaped macule that is greater than 1 cm in diameter. Scale is heaped-up keratinized cells, flaky exfoliation, irregular, thick or thin, dry or oily, varied in size, and silver white or tan. A plaque is an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter. It may be coalesced papules.

PTS: 1 DIF: Cognitive Level: Understand REF: 1011 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 4. A school-age child falls on the playground and has a small laceration on the forearm. The school nurse should do which to cleanse the wound? a. Slowly pour hydrogen peroxide over wound. b. Soak arm in warm water and soap for at least 30 minutes. c. Gently cleanse with sterile pad and a nonstinging povidone-iodine solution. d. Wash wound gently with mild soap and water for several minutes.

ANS: D Lacerations should be washed gently with mild soap and water or normal saline. A sterile pad is not necessary, and hydrogen peroxide and povidone-iodine should not be used because they have a cytotoxic effect on healthy cells and minimal effect on controlling infection. Soaking the arm will not effectively clean the wound.

PTS: 1 DIF: Cognitive Level: Apply REF: 1015 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 5. A child steps on a nail and sustains a puncture wound of the foot. Which is the most appropriate method for cleansing this wound? a. Wash wound thoroughly with chlorhexidine. b. Wash wound thoroughly with povidone-iodine. c. Soak foot in warm water and soap. d. Soak foot in solution of 50% hydrogen peroxide and 50% water.

ANS: C Puncture wounds should be cleansed by soaking the foot in warm water and soap. Chlorhexidine, hydrogen peroxide, and povidone-iodine should not be used because they have a cytotoxic effect

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on healthy cells and minimal effect on controlling infection.

PTS: 1 DIF: Cognitive Level: Apply REF: 1016 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 6. Which nursing consideration is important when caring for a child with impetigo contagiosa? a. Apply topical corticosteroids to decrease inflammation. b. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris. c. Carefully wash hands and maintain cleanliness when caring for an infected child. d. Examine child under a Wood lamp for possible spread of lesions.

ANS: C A major nursing consideration related to bacterial skin infections, such as impetigo contagiosa, is to prevent the spread of the infection and complications. This is done by thorough hand washing before and after contact with the affected child. Corticosteroids are not indicated in bacterial infections. Dressings are usually not indicated. The undermined skin, crusts, and debris are carefully removed after softening with moist compresses. A Wood lamp is used to detect fluorescent materials in the skin and hair. It is used in certain disease states, such as tinea capitis.

PTS: 1 DIF: Cognitive Level: Understand REF: 1017 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 7. The nurse is caring for a 5-year-old child with impetigo contagiosa. The parents ask the nurse what will happen to their childs skin after the infection has subsided and healed. Which answer should the nurse give? a. There will be no scarring. b. There may be some pigmented spots. c. It is likely there will be some slightly depressed scars. d. There will be some atrophic white scars.

ANS: A Impetigo contagiosa tends to heal without scarring unless a secondary infection occurs.

PTS: 1 DIF: Cognitive Level: Apply REF: 1018 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 8. Cellulitis is often caused by:

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a. herpes zoster. b. Candida albicans. c. human papillomavirus. d. Streptococcus or Staphylococcus organisms.

ANS: D Streptococci, staphylococci, and Haemophilus influenzae are the organisms usually responsible for cellulitis. Herpes zoster is the virus associated with varicella and shingles. C. albicans is associated with candidiasis, or thrush. Human papillomavirus is associated with various types of human warts.

PTS: 1 DIF: Cognitive Level: Remember REF: 1018 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 9. The nurse is conducting a staff in-service on appearance of childhood skin conditions.

Lymphangitis (streaking) is frequently seen in which condition? a. Cellulitis b. Folliculitis c. Impetigo contagiosa d. Staphylococcal scalded skin ANS: A Lymphangitis is frequently seen in cellulitis. If it is present, hospitalization is usually required for parenteral antibiotics. Lymphangitis is not associated with folliculitis, impetigo, or staphylococcal scalded skin.

PTS: 1 DIF: Cognitive Level: Understand REF: 1018 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 10. The nurse should expect to assess which causative agent in a child with warts? a. Bacteria b. Fungus c. Parasite d. Virus ANS: D Human warts are caused by the human papillomavirus. Infection with bacteria, fungus, and

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parasites does not result in warts.

PTS: 1 DIF: Cognitive Level: Understand REF: 1019 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 11. The nurse should implement which prescribed treatment for a child with warts? a. Vaccination b. Local destruction c. Corticosteroids d. Specific antibiotic therapy ANS: B Local destructive therapy individualized according to location, type, and numberincluding surgical removal, electrocautery, curettage, cryotherapy, caustic solutions, x-ray treatment, and laser therapiesis used. Vaccination is prophylaxis for warts and is not a treatment.

Corticosteroids and specific antibiotic therapy are not effective in the treatment of warts.

PTS: 1 DIF: Cognitive Level: Apply REF: 1019 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 12. Herpes zoster is caused by the varicella virus and has an affinity for: a. sympathetic nerve fibers. b. parasympathetic nerve fibers. c. posterior root ganglia and posterior horn of the spinal cord. d. lateral and dorsal columns of the spinal cord.

ANS: C The herpes zoster virus has an affinity for posterior root ganglia, the posterior horn of the spinal cord, and skin. The zoster virus does not involve sympathetic or parasympathetic nerve fibers and the lateral and dorsal columns of the spinal cord.

PTS: 1 DIF: Cognitive Level: Understand REF: 1019 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 13. The nurse is taking care of a 7-year-old child with herpes simplex virus (type 1 or 2). Which prescribed medication should the nurse expect to be included in the treatment plan? a. Corticosteroids

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b. Oral griseofulvin c. Oral antiviral agent d. Topical and/or systemic antibiotic ANS: C Oral antiviral agents are effective for viral infections such as herpes simplex. Corticosteroids are not effective for viral infections. Griseofulvin is an antifungal agent and not effective for viral infections. Antibiotics are not effective in viral diseases.

PTS: 1 DIF: Cognitive Level: Apply REF: 1019 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 14. Tinea capitis (ringworm), frequently found in schoolchildren, is caused by a(n): a. virus. b. fungus. c. allergic reaction. d. bacterial infection.

ANS: B Ringworm is caused by a group of closely related filamentous fungi that invade primarily the stratum corneum, hair, and nails. They are superficial infections that live on, not in, the skin.

Virus and bacterial infection are not the causative organisms for ringworm. Ringworm is not an allergic response.

PTS: 1 DIF: Cognitive Level: Understand REF: 1020 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 15. The nurse is caring for a school-age child with a tinea capitis (ringworm) infection. The nurse should expect that therapeutic management for this child includes: a. administering oral griseofulvin. b. administering topical or oral antibiotics. c. applying topical sulfonamides. d. applying Burow solution compresses to affected area.

ANS: A Treatment with the antifungal agent griseofulvin is part of the treatment for the fungal disease ringworm. Oral griseofulvin therapy frequently continues for weeks or months. Antibiotics,

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sulfonamides, and Burow solution are not effective in fungal infections.

PTS: 1 DIF: Cognitive Level: Understand REF: 1020 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 16. Parents tell the nurse that their child keeps scratching the areas where he has poison ivy. The nurses response should be based on which knowledge? a. Poison ivy does not itch and needs further investigation. b. Scratching the lesions will not cause a problem. c. Scratching the lesions will cause the poison ivy to spread. d. Scratching the lesions may cause them to become secondarily infected.

ANS: D Poison ivy is a contact dermatitis that results from exposure to the oil urushiol in the plant. Every effort is made to prevent the child from scratching because the lesions can become secondarily infected. The poison ivy produces localized, streaked or spotty, oozing, and painful impetiginous lesions. Itching is a common response. Scratching the lesions can result in secondary infections.

The lesions do not spread by contact with the blister serum or by scratching.

PTS: 1 DIF: Cognitive Level: Apply REF: 1022 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 17. The nurse is taking care of a child with scabies. Which primary clinical manifestation should the nurse expect to assess with this disease? a. Edema b. Redness c. Pruritus d. Maceration ANS: C Scabies is caused by the scabies mite. The inflammatory response and intense itching occur after the host has become sensitized to the mite. This occurs approximately 30 to 60 days after initial contact. Edema, redness, and maceration are not observed in scabies.

PTS: 1 DIF: Cognitive Level: Understand REF: 1024 | 1026 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

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18. Which is usually the only symptom of pediculosis capitis (head lice)? a. Itching b. Vesicles c. Scalp rash d. Localized inflammatory response ANS: A Itching is generally the only manifestation of pediculosis capitis (head lice). Diagnosis is made by observation of the white eggs (nits) on the hair shaft. Vesicles, scalp rash, and localized inflammatory response are not symptoms of head lice.

PTS: 1 DIF: Cognitive Level: Understand REF: 1027 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 19. The nurse is talking to the parents of a child with pediculosis capitis. Which should the nurse include when explaining how to manage pediculosis capitis? a. You will need to cut the hair shorter if infestation and nits are severe. b. You can distinguish viable from nonviable nits, and remove all viable ones. c. You can wash all nits out of hair with a regular shampoo. d. You will need to remove nits with an extra-fine tooth comb or tweezers.

ANS: D Treatment consists of the application of pediculicide and manual removal of nit cases. An extrafine tooth comb facilitates manual removal. Parents should be cautioned against cutting the childs hair short; lice infest short hair as well as long. It increases the childs distress and serves as a continual reminder to peers who are prone to tease children with a different appearance. It is not possible to differentiate between viable and nonviable eggs. Regular shampoo is not effective; a pediculicide is necessary.

PTS: 1 DIF: Cognitive Level: Apply REF: 1027 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 20. The management of a child who has just been stung by a bee or wasp should include the application of: a. cool compresses. b. warm compresses. c. antibiotic cream.

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d. corticosteroid cream.

ANS: A Bee or wasp stings are initially treated by carefully removing stinger, cleansing with soap and water, applying cool compresses, and using common household agents such as lemon juice or a paste made with aspirin and baking soda. Warm compresses are avoided. Antibiotic cream is unnecessary unless a secondary infection occurs. Corticosteroid cream is not part of the initial therapy. If a severe reaction occurs, systemic corticosteroids may be indicated.

PTS: 1 DIF: Cognitive Level: Apply REF: 1025 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 21. A father calls the clinic nurse because his 2-year-old child was bitten by a black widow spider. The nurse should advise which to the father? a. Apply warm compresses. b. Carefully scrape off stinger. c. Take child to emergency department. d. Apply a thin layer of corticosteroid cream.

ANS: C The venom of the black widow spider has a neurotoxic effect. The father should take the child to the emergency department for treatment with antivenin and muscle relaxants as needed. Warm compresses increase the circulation to the area and facilitate the spread of the venom. The black widow spider does not have a stinger. Corticosteroid cream will have no effect on the venom.

PTS: 1 DIF: Cognitive Level: Apply REF: 1025 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 22. A mother calls the emergency department nurse because her child was stung by a scorpion.

The nurse should recommend: a. administering an antihistamine. b. cleansing area with soap and water. c. keeping the child quiet and coming to the emergency department. d. removing the stinger and applying cool compresses.

ANS: C Venomous species of scorpions inject venom that contains hemolysins, endotheliolysins, and neurotoxins. The absorption of the venom is delayed by keeping the child quiet and the involved

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area in a dependent position. Antihistamines are not effective against scorpion venom. The wound will have intense local pain. Transport to the emergency department is indicated.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1026 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 23. Rocky Mountain spotted fever is caused by the bite of a: a. flea. b. tick. c. mosquito. d. mouse or rat.

ANS: B Rocky Mountain spotted fever is caused by a tick. The tick must attach and feed for at least 1 to 2 hours to transmit the disease. The usual habitat of the tick is in heavily wooded areas. Fleas, mosquitoes, and mice or rats do not transmit Rocky Mountain spotted fever.

PTS: 1 DIF: Cognitive Level: Understand REF: 1026 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 24. The school nurse is conducting a class for school-age children on Lyme disease. Which is characteristic of Lyme disease? a. Difficult to prevent b. Treated with oral antibiotics in stages 1, 2, and 3 c. Caused by a spirochete that enters the skin through a tick bite d. Common in geographic areas where the soil contains the mycotic spores that cause the disease ANS: C Lyme disease is caused by Borrelia burgdorferi, a spirochete spread by ticks. The early characteristic rash is erythema migrans. Tick bites should be avoided by entering tick-infested areas with caution. Light-colored clothing should be worn to identify ticks easily. Long-sleeved shirts and long pants tucked into socks should be the attire. Early treatment of the erythema migrans (stage 1) can prevent the development of Lyme disease. Lyme disease is caused by a spirochete, not mycotic spores.

PTS: 1 DIF: Cognitive Level: Understand REF: 1029 TOP: Integrated Process: Teaching/Learning

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MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 25. The nurse is examining 12-month-old Amy, who was brought to the clinic for persistent diaper rash. The nurse finds perianal inflammation with satellite lesions that cross the inguinal folds. This is most likely caused by: a. impetigo. b. Candida albicans. c. urine and feces. d. infrequent diapering.

ANS: B C. albicans infection produces perianal inflammation and a maculopapular rash with satellite lesions that may cross the inguinal folds. Impetigo is a bacterial infection that spreads peripherally in sharply marginated, irregular outlines. Eruptions involving the skin in contact with the diaper, but sparing the folds, are likely to be caused by chemical irritation, especially urine and feces.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1032 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 26. The nurse is teaching a class on preventing diaper rash in newborns to a group of new parents. Which statement made by a parent indicates a correct understanding of the teaching? a. I should cleanse my infants skin with a commercial diaper wipe every time I change the diaper. b. If my infants buttocks become slightly red, I will expose the skin to air. c. I should wash my infants buttocks with soap before applying a thin layer of oil. d. I will apply baby oil and powder to the creases in my infants buttocks.

ANS: B Slightly irritated skin can be exposed to air, not heat, to dry completely. Overwashing or cleansing the skin every diaper change with commercial wipes should be avoided. The skin should be thoroughly dried after washing. Application of oil does not create an effective barrier.

Baby powder should not be used because of the danger of aspiration.

PTS: 1 DIF: Cognitive Level: Apply REF: 1032-1033 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential

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27. Which prescribed treatment should the nurse plan to implement for a child with psoriasis? a. Antihistamines b. Oral antibiotics c. Topical application of calamine lotion d. Tar and exposure to sunlight and ultraviolet light ANS: D Psoriasis is treated with tar preparations and exposure to ultraviolet B light or natural sunlight.

Antihistamines, oral antibiotics, and topical application of calamine lotion are not effective in psoriasis.

PTS: 1 DIF: Cognitive Level: Apply REF: 1031 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Basic Care and Comfort 28. Atopic dermatitis (eczema) in the infant is: a. easily cured. b. worse in humid climates. c. associated with upper respiratory tract infections. d. associated with allergy with a hereditary tendency.

ANS: D Atopic dermatitis is a type of pruritic eczema that usually begins during infancy and is associated with allergy with a hereditary tendency. Atopic dermatitis can be controlled but not cured.

Manifestations of the disease are worse when environmental humidity is lower. Atopic dermatitis is not associated with respiratory tract infections.

PTS: 1 DIF: Cognitive Level: Understand REF: 1032 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 29. Nursing care of the infant with atopic dermatitis focuses on: a. feeding a variety of foods. b. keeping lesions dry. c. preventing infection. d. using fabric softener to avoid rough cloth.

ANS: C The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection. The infants nails should be kept short and clean and have no

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sharp edges. In periods of irritability, these children tend to have a decreased appetite. The restriction of hyperallergenic foods, such as milk, dairy products, peanuts, and eggs, may make adequate nutrition a challenge with these children. Wet soaks and compresses are used to keep the lesions moist and minimize the pruritus. Fabric softener should be avoided because of the irritant effects of some of its components.

PTS: 1 DIF: Cognitive Level: Apply REF: 1033 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 30. Tretinoin (Retin-A) is a topical agent commonly used to treat acne. Nursing considerations with this drug should include: a. teaching to avoid use of sunscreen agents. b. applying generously to the skin. c. explaining that medication should not be applied until at least 20 to 30 minutes after washing. d. explaining that erythema and peeling are indications of toxicity.

ANS: C The medication should not be applied for at least 20 to 30 minutes after washing to decrease the burning sensation. The avoidance of sun and the use of sunscreen agents must be emphasized because sun exposure can result in severe sunburn. The agent should be applied sparingly to the skin. Erythema and peeling are common local manifestations.

PTS: 1 DIF: Cognitive Level: Apply REF: 1036 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 31. When is isotretinoin (Accutane) indicated for the treatment of acne during adolescence? a. The acne has not responded to other treatments. b. The adolescent is or may become pregnant. c. The adolescent is unable to give up foods causing acne. d. Frequent washing with antibacterial soap has been unsuccessful.

ANS: A Isotretinoin is reserved for severe cystic acne that has not responded to other treatments.

Isotretinoin has teratogenic effects and should never be used when there is a possibility of pregnancy. No correlation exists between foods and acne. Antibacterial soaps are ineffective.

Frequent washing with antibacterial soap is not a recommended therapy for acne.

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PTS: 1 DIF: Cognitive Level: Understand REF: 1037 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Pharmacologic and Parenteral Therapies 32. A child experiences frostbite of the fingers after prolonged exposure to the cold. Which intervention should the nurse implement first? a. Rapid rewarming of the fingers by placing in warm water b. Placing the hand in cool water c. Slow rewarming by wrapping in warm cloth d. Using an ice pack to keep cold until medical intervention is possible ANS: A Rapid rewarming is accomplished by immersing the part in well-agitated water at 37.8 to 42.2 C (100 to 108 F). The frostbitten area should be rewarmed as soon as possible to avoid further tissue damage. Rapid rewarming results in less tissue necrosis than slow thawing.

PTS: 1 DIF: Cognitive Level: Apply REF: 1048 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 33. Which best describes a full-thickness (third-degree) burn? a. Erythema and pain b. Skin showing erythema followed by blister formation c. Destruction of all layers of skin evident with extension into subcutaneous tissue d. Destruction injury involving underlying structures such as muscle, fascia, and bone ANS: C A third-degree, or full-thickness, burn is a serious injury that involves the entire epidermis and dermis and extends into the subcutaneous tissues. Erythema and pain are characteristic of a firstdegree, or superficial, burn. Erythema with blister formation is characteristic of a second-degree, or partial-thickness, burn. A fourth-degree burn is a full-thickness burn that also involves underlying structures such as muscle, fascia, and bone.

PTS: 1 DIF: Cognitive Level: Understand REF: 1039 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 34. A child is admitted with extensive burns. The nurse notes that there are burns on the childs lips and singed nasal hairs. The nurse should suspect that the child has a(n):

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a. chemical burn. b. inhalation injury. c. electrical burn. d. hot-water scald.

ANS: B Evidence of an inhalation injury is burns of the face and lips, singed nasal hairs, and laryngeal edema. Clinical manifestation may be delayed for up to 24 hours. Chemical burns, electrical burns, and those associated with hot-water scalds would not cause singed nasal hair.

PTS: 1 DIF: Cognitive Level: Understand REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 35. Which explains physiologically the edema formation that occurs with burns? a. Vasoconstriction b. Decreased capillary permeability c. Increased capillary permeability d. Decreased hydrostatic pressure within capillaries ANS: C With a major burn, an increase in capillary permeability occurs, allowing plasma proteins, fluids, and electrolytes to be lost. Maximal edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximal edema may not occur until 18 to 24 hours.

Vasoconstriction, decreased capillary permeability, and decreased hydrostatic pressure within capillaries are not physiologic mechanisms for edema formation in burn patients.

PTS: 1 DIF: Cognitive Level: Analyze REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 36. The most immediate threat to life in children with thermal injuries is: a. shock. b. anemia. c. local infection. d. systemic sepsis.

ANS: A The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis

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are the primary complications. Respiratory problems, primarily airway compromise, are the primary complications during the acute stage of burn injury.

PTS: 1 DIF: Cognitive Level: Apply REF: 1040 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 37. After the acute stage and during the healing process, the primary complication from burn injury is: a. asphyxia. b. shock. c. renal shutdown. d. infection.

ANS: D During the healing phase, local infection and sepsis are the primary complications. Renal shutdown is not a complication of the burn injury, but may be a result of the profound shock.

PTS: 1 DIF: Cognitive Level: Apply REF: 1040 TOP: Integrated Process: Nursing Process: Planning MSC: Area of Client Needs: Physiologic Integrity: Physiologic Adaptation 38. An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which is important in her immediate care? a. Wrap her in a blanket until help arrives. b. Encourage her to drink clear liquids. c. Place her in a tub of cool water. d. Remove her burned clothing and jewelry.

ANS: D In major burns, burned clothing should be removed to avoid further damage from smoldering fabric and hot beads of melted synthetic materials. Jewelry is also removed to eliminate the transfer of heat from the metal and constriction resulting from edema formation. The burns should be covered, not wrapped with a clean cloth. A blanket can be used initially to stop the burning process. Fluids should not be given by mouth to avoid aspiration and water intoxication.

The child should be kept warm. Placing her in a tub of cool water will exacerbate heat loss.

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Chapter 37. Child With a Communicable Disease MULTIPLE CHOICE 1. Which classification of medication would make a child most susceptible to an opportunistic infection? a. Anticonvulsant b. Beta-adrenergic agent c. Antibiotic d. Corticosteroid ANS: D Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic infections.

DIF: Cognitive Level: Knowledge REF: Page 725 OBJ: 3 TOP: Effect of Steroids KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 2. An 8-year-old asks the nurse how she got the antibodies that kept her from getting whooping cough. What is the nurses best explanation? a. You received borrowed antibodies from another person who had whooping cough. b. You were given a tiny case of whooping cough and then you made your own antibodies. c. An immunization strengthened antibodies you were born with. d. You received only temporary borrowed antibodies and you need to have another shot every 5 years.

ANS: B Vaccines contain live weakened or dead organisms not strong enough to cause disease but they stimulate the body to develop an immune reaction and antibodies. This is active acquired immunity.

DIF: Cognitive Level: Comprehension REF: Page 728, Table 32-1 OBJ: 4 TOP: Vaccines KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. How would the nurse document a rash that has erythematous, circular raised lesions?

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a. Macular b. Papular c. Vesicular d. Pustular ANS: B A papule is a circular, reddened elevated area on the skin.

DIF: Cognitive Level: Knowledge REF: Page 727 OBJ: 2 TOP: Rashes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. Which finding would lead the nurse to delay the administration of DTaP for an infant? a. Diarrhea b. Temperature of 40.5 C (105 F) from the previous inoculation c. Teething d. Traveling to Europe in a week ANS: B A contraindication to giving the DTaP vaccine is a 40.5 C (105 F) temperature following the previous vaccination.

DIF: Cognitive Level: Application REF: Page 731 OBJ: 6 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 5. What type of precautions are necessary when caring for a toddler with varicella? a. Contact b. Protective c. Airborne infection d. Large droplet infection ANS: C Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubella. Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room.

DIF: Cognitive Level: Application REF: Page 722, Health Promotion box OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation

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MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. Which statement assures the nurse that parents understand how long a child who has varicella is contagious? a. My child should stay home from school for 6 days after the pox appear. b. My child can return to school when the rash fades. c. My child must stay away from other children until all of the lesions have healed. d. My child is contagious as long as he has a fever.

ANS: A The child with varicella is contagious for 6 days after the appearance of the rash.

DIF: Cognitive Level: Comprehension REF: Page 722, Health Promotion box OBJ: 2 TOP: Common Varicella KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 7. Which statement made by a sexually active adolescent girl indicates an understanding of the prevention of sexually transmitted diseases? a. I always douche after intercourse. b. I think you can get a vaccination for STDs now. c. I insist that my partner wear a condom. d. I am protected because I take the pill.

ANS: C The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual intercourse.

DIF: Cognitive Level: Comprehension REF: Page 739, Nursing Tip OBJ: 9 TOP: Sexually Transmitted Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. What is the priority nursing diagnosis for a hospitalized infant who is HIV positive? a. Risk for injury b. Altered nutrition c. Impaired skin integrity d. Risk for infection ANS: D

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The infant who is HIV positive has impaired immunologic functioning and is at high risk for infection.

DIF: Cognitive Level: Application REF: Page 742-743, NCP 32-1 OBJ: 10 TOP: Human Immunodeficiency Virus KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. The mother of a newborn asked the nurse, When will my baby get the hepatitis B vaccine?

When will the nurse explain the first dose of Comvax should be given to infants born to a hepatitis B-positive mother? a. Within 12 hours after birth b. Within 2 weeks after birth c. Within 1 month after birth d. Within 2 months after birth ANS: A The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free hepatitis B vaccine, should be used for infants born to HBsAg-positive mothers within 12 hours of birth.

DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6 OBJ: 4 TOP: Immunization Schedule KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 10. A 10-year-old child is diagnosed with Hepatitis A. What is the most likely way the child contracted this disease? a. Came in contact with infected blood b. Came in contact with droplets in the air c. Was bitten by a mosquito or a tick d. Ate shrimp while in Mexico ANS: D Hepatitis A results from ingestion of contaminated water or shellfish.

DIF: Cognitive Level: Comprehension REF: Page 723, Health Promotion box OBJ: 3 TOP: Hepatitis A KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

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11. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse use when caring for the infant? a. Large-droplet infection precautions b. Airborne-infection precautions c. Contact precautions d. Protective precautions ANS: C Contact precautions are used when the condition transmits organisms via skin-to-skin contact or indirect touch of a contaminated fomite.

DIF: Cognitive Level: Application REF: Page 726-727 OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response for the nurse to make when the child asks, Why do you have to wear a gown and mask when you are in my room? a. Nurses and doctors wear gowns and masks because you have a condition that could be spread to others. b. The gown and mask are to protect you because you could get an infection very easily. c. Im wearing this because there are a lot of bacteria in the hospital. d. I might look scary but you wont need this after you have had medication for 24 hours.

ANS: B Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly susceptible to infection.

DIF: Cognitive Level: Application REF: Page 727 OBJ: 3 TOP: Protective Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. The nurse is planning to administer immunizations at a well-child visit when a parent reports the 18-month-old child is allergic to eggs. Which vaccine would be contraindicated? a. Influenza b. Inactivated polio vaccine c. Diphtheria, tetanus, acellular pertussis d. Hepatitis B

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ANS: A The influenza vaccine should not be given to children who are allergic to eggs.

DIF: Cognitive Level: Knowledge REF: Page 729 OBJ: 6 TOP: Nurses Role in ImmunizationsAllergy KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. The nurse is preparing to administer immunizations at a well-child clinic. Which method of administration will the nurse implement? a. DTaP subcutaneously b. Hib vaccine prepared in a separate syringe c. Varicella intramuscularly d. Varicella 1 week after the MMR vaccine ANS: B Hib vaccine must be given in a separate syringe from other vaccines administered at the same time.

DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6 OBJ: 6 TOP: Hib KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. A child was sent to the school nurse because of a rash. The nurse noted the rash was present on the trunk, extremities, and face. The childs cheeks were bright red. With what is the nurse aware this type of rash is consistent? a. Measles b. Roseola c. Varicella d. Fifth disease ANS: D In fifth disease, the child has a generalized rash and the cheeks have a slapped-cheek appearance.

DIF: Cognitive Level: Comprehension REF: Page 722, Health Promotion box OBJ: 2 TOP: Fifth Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 16. What statement leads the nurse to determine that a childs parent understands information

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related to tick bites? a. Ill have my son wear dark clothing on his hike. b. We should all get the Lyme disease vaccine before our trip. c. Ill get a prescription for amoxicillin to take with us. d. We will wear long pants and long-sleeved shirts in the woods.

ANS: D People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites.

DIF: Cognitive Level: Application REF: Page 724, Health Promotion box OBJ: 4 TOP: Prevention of Tick Bites KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 17. An adolescent is taking tetracycline for a sexually transmitted disease. What would the nurse stress when providing instruction about this medication? a. Finish all of the medication. b. Get plenty of fresh air and sunlight. c. Take the medication with food. d. Take an antacid if the medication causes an upset stomach.

ANS: A The nurse would teach the adolescent to take all of the prescribed medication to avoid making the microorganism resistant to tetracyclines.

DIF: Cognitive Level: Comprehension REF: Page 740, Table 32-3 OBJ: 9 TOP: Sexually Transmitted Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. The nurse explains to the parents that their child is in the prodromal stage of varicella. What does this mean? a. The child is now immune to varicella. b. The child has varicella but has not yet broken out. c. The child is infected with varicella but is not contagious. d. The child does not have varicella but has been exposed to it.

ANS: B The prodromal stage is the initial stage of the communicable disease in which the child is

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infected and contagious but does not yet have outward signs of the disease.

DIF: Cognitive Level: Comprehension REF: Page 725 OBJ: 1 TOP: Prodromal Period KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 19. Which is an example of an opportunistic infection? a. Measles b. Pneumocystis jiroveci c. Clostridium difficile d. Smallpox ANS: B Pneumocystis jiroveci is the most common of opportunistic diseases.

DIF: Cognitive Level: Knowledge REF: Page 741 OBJ: 1 TOP: Opportunistic Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 20. A child is admitted to the pediatric unit with a diagnosis of cellulitis on the right upper thigh.

Patient history reveals the child had a 2-cm laceration on the right thigh prior to infection. When explaining the chain of infection, how does the nurse identify this laceration? a. Reservoir b. Portal of entry c. Portal of exit d. Cector ANS: B The chain of infection refers to the way in which organisms spread and infect the individual. A portal of entry is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit is the route by which the organisms exit the body (e.g., feces or urine). A reservoir for infection is a place that supports the growth of organisms (e.g., standing, stagnant water). A vector is an insect or animal that carries and spreads a disease.

DIF: Cognitive Level: Comprehension REF: Page 725 OBJ: 1 TOP: Chain of Infection KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE

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21. Why would a female adolescent with STDs resist reporting the condition? (Select all that apply.) a. She is reluctant to name contacts. b. She is embarrassed. c. She doubts confidentiality. d. She doesnt want to take the medication. e. She dreads the pelvic examination.

ANS: A, B, C, E Adolescents are uncomfortable about the pelvic examination and require a lot of support.

Adolescents doubt the confidentiality of the agency and are reluctant to name contacts.

DIF: Cognitive Level: Comprehension REF: Page 739-740 OBJ: 9 TOP: Reporting STDs KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. What sources are examples of acquired immunity? (Select all that apply.) a. Gamma globulin b. The disease c. Maternal antibodies d. The vaccine e. Immune globulin ANS: B, D Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination. Gamma globulin is simply a support to the immune system. Immune globulin is receiving the antibodies from some other source, giving the person an immediate immunity but one that does not last.

DIF: Cognitive Level: Knowledge REF: Page 726 OBJ: 1 TOP: Acquired Immunity KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 23. The well-child clinic nurse is preparing to give which immunizations to a healthy 2-monthold? (Select all that apply.) a. DTaP b. Hib c. IPV

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d. MMR e. PCV ANS: A, B, C, E All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps, measles, rubella are not expected until the child is 1 year old.

DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6 OBJ: 6 TOP: Inoculations for a 2-Month-Old KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 24. The nurse is explaining to a family about disaster preparedness. What will the nurse instruct the family to prepare in a disaster kit in case of emergency? (Select all that apply.) a. Small television b. Vital documents c. Nonperishable food d. Pet food e. Blankets ANS: B, C, D, E The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or manmade disasters, such as bioterrorist attacks or bombings. The American Medical Association (AMA) office guidelines for preparing a family and community disaster plan state that the family should keep several days supply of food, water, pet food, warm clothing, blankets, copies of vital documents, and toiletries on hand. A battery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential.

DIF: Cognitive Level: Knowledge REF: Page 738-739 OBJ: 8 TOP: Disaster Preparedness KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 25. The nurse is assisting with an admission assessment of a child with scarlet fever. Which actions will the nurse expect to implement? (Select all that apply.) a. Obtain a throat culture. b. Encourage ambulation. c. Assess for desquamation. d. Initiate droplet precautions.

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e. Administer isoniazid.

ANS: A, C A diagnosis of scarlet fever would indicate throat culture and assessment for desquamation. Bed rest with quiet activity is indicated. Droplet precautions would not be implemented for scarlet fever. Isoniazid is administered for tuberculosis.

DIF: Cognitive Level: Application REF: Page 724, Health Promotion box OBJ: 2 TOP: Scarlet Fever KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION 26. The nurse explains that the tuberculosis.

ANS: Mantoux

test determines the childs susceptibility to

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Chapter 38. Child With an Oncological or Hematological Condition MULTIPLE CHOICE 1. The nurse is teaching the parents of a young child with iron deficiency anemia about nutrition.

What food would the nurse emphasize as being a rich source of iron? a. An egg white b. Cream of Wheat c. A banana d. A carrot ANS: B Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried fruits, beans, nuts, and whole-grain breads.

DIF: Cognitive Level: Comprehension REF: Page 622 OBJ: 6 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: ImplementationMSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. Which statement by a mother may indicate a cause for her 9-month-olds iron deficiency anemia? a. Formula is so expensive. We switched to regular milk right away. b. She almost never drinks water. c. She doesnt really like peaches or pears, so we stick to bananas for fruit. d. I give her a piece of bread now and then. She likes to chew on it.

ANS: A Because cows milk contains very little iron, infants should drink iron-fortified formula for the first year of life.

DIF: Cognitive Level: Application REF: Page 622 OBJ: 4 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. What will the nurse administer with ferrous sulfate drops when providing them to a child on the pediatric unit? a. With milk b. With orange juice c. With water d. On a full stomach ANS: B Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.

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DIF: Cognitive Level: Application REF: Page 622 OBJ: 4 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. What is the result of a deficiency of factor IX? a. Thalassemia b. Idiopathic thrombocytopenic purpura c. Hemophilia A d. Christmas disease ANS: D Christmas disease, or hemophilia B, is caused by the deficiency of factor IX.

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DIF: Cognitive Level: Knowledge REF: Page 628 OBJ: 11 TOP: Christmas Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse include in a teaching plan about home care? a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b. Childrens aspirin in lowered doses may be given for joint discomfort. c. A firm, dry toothbrush should be used to clean teeth at least twice a day. d. Do not permit interactive play with other children.

ANS: A When bleeding occurs, the traditional approach is to follow RICErest, ice, compression, and elevation.

DIF: Cognitive Level: Application REF: Page 628 OBJ: 12 TOP: Hemophilia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. What will the nurse teach the parents of a child with a low platelet count to avoid? a. Ibuprofen b. Aspirin c. Caffeine d. Prednisone ANS: B Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding.

DIF: Cognitive Level: Application REF: Page 629 OBJ: N/A TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. What should the nurse closely assess in a child receiving a transfusion? a. Fever b. Lethargy c. Jaundice d. Bradycardia ANS: A

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The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain.

DIF: Cognitive Level: Comprehension REF: Page 632-633 OBJ: 16 TOP: Blood Transfusion KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk 8. On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/ mm3. What is the priority nursing intervention? a. Assessing neurological status b. Inserting an intravenous line c. Monitoring vital signs during platelet transfusions d. Providing family education about how to prevent bleeding ANS: A When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are therefore a priority of care.

DIF: Cognitive Level: Application REF: Page 629 OBJ: 15 TOP: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this? a. I b. II c. III d. IV ANS: C Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage III Hodgkins disease.

DIF: Cognitive Level: Application REF: Page 633, Table 27-2 OBJ: N/A TOP: Hodgkins Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

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10. A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. Which type of crisis is the child most likely experiencing? a. Aplastic b. Hyperhemolytic c. Vaso-occlusive d. Splenic sequestration ANS: C Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm.

DIF: Cognitive Level: Application REF: Page 624, Table 27-1 OBJ: 8 TOP: Sickle Cell Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Which statement made by a parent indicates an understanding of health maintenance of a child with sickle cell disease? a. I should give my child a daily iron supplement. b. It is important for my child to drink plenty of fluids. c. He needs to wear protective equipment if he plays contact sports. d. He shouldnt receive any immunizations until he is older.

ANS: B Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with sickle cell disease.

DIF: Cognitive Level: Application REF: Page 626 OBJ: 9 TOP: Sickle Cell Disease KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 12. A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait. How can the nurse best explain the childrens risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b. All of their children will be carriers, just as they are. c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier. d. The risk levels of their children cannot be determined by this information.

ANS: C

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The sickle cell gene is inherited from both parents; therefore each offspring has a one in four chance of inheriting the disease.

DIF: Cognitive Level: Analysis REF: Page 625, Figure 27-4 OBJ: 7 TOP: Sickle Cell Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. A child with thalassemia major receives blood transfusions frequently. What is a complication of repeated blood transfusions? a. Hemarthrosis b. Hematuria c. Hemoptysis d. Hemosiderosis ANS: D As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues.

DIF: Cognitive Level: Comprehension REF: Page 627 OBJ: 16 TOP: Thalassemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction of immature white blood cells in the bone marrow? a. Decreased T-cell production b. Decreased hemoglobin c. Increased blood clotting d. Increased susceptibility to infection ANS: D An overproduction of immature white blood cells increases the childs susceptibility to infection.

DIF: Cognitive Level: Comprehension REF: Page 630 OBJ: 14 TOP: Leukemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The child receiving a transfusion complains of back pain and itching. What is the best initial action by the nurse? a. Notify the charge nurse.

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b. Disconnect intravenous lines immediately. c. Give diphenhydramine (Benadryl). d. Clamp off blood and keep line open with normal saline.

ANS: D If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse.

DIF: Cognitive Level: Application REF: Page 632 OBJ: 16 TOP: Blood Transfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity 16. What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy? a. Use commercial mouthwash. b. Clean teeth with a soft toothbrush. c. Avoid use of a Water-Pik. d. Inspect the mouth weekly for ulcerations.

ANS: B A soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection.

Water-Pik is useful for toughening gums.

DIF: Cognitive Level: Application REF: Page 632 OBJ: 15 TOP: Leukemia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. A 6-year-old with leukemia asks, Who will take care of me in heaven? What is the best response by the nurse? a. Who do you think will take care of you? b. Your grandparents and God will take care of you. c. Your mom will know more about that than I do. d. Why are you asking me that?

ANS: A This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed responses shut off communication. The asking of a why question is not therapeutic as it calls for justification.

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DIF: Cognitive Level: Application REF: Page 632 OBJ: 18 TOP: Leukemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. The nurse is dealing with a preschool-age child with a life-threatening illness. What should the nurse remember the childs concept of death is at this age? a. That it is final b. Only a fear of separation from her parents c. That a person becomes alive again soon after death d. An understanding based on simple logic ANS: C The preschooler views death as reversible and temporary.

DIF: Cognitive Level: Comprehension REF: Page 638, Health Promotion OBJ: 19 TOP: Nursing Care of the Dying Child KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 19. The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his extremities. Which lab value is consistent with these symptoms? a. Platelet count of 25,000/mm3 b. Hemoglobin level of 8 g/dL c. Hematocrit level of 36% d. Leukocyte count of 14,000/mm3 ANS: A The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential.

DIF: Cognitive Level: Analysis REF: Page 629 OBJ: 14 TOP: Idiopathic Thrombocytopenic Purpura KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 20. The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest? a. Peripheral neuropathy

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b. Stomatitis c. Myelosuppression d. Hemorrhage ANS: A Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel.

DIF: Cognitive Level: Analysis REF: Page 632 OBJ: 14 TOP: Leukemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I am so scared. What is the most appropriate nursing response to this comment? a. I understand how you must feel. b. You shouldnt feel that way. c. Is this the strongest feeling youve had today? d. Tell me whats got you scared.

ANS: D The nurse should encourage the adolescent to express her feelings and concerns.

DIF: Cognitive Level: Application REF: Page 638 OBJ: 18 TOP: Adolescent with CancerFear of Death KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 22. The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is the priority nursing diagnosis for this child? a. Risk for infection b. Risk for hemorrhage c. Altered skin integrity d. Disturbance in body image ANS: A The child with neutropenia is at risk for infection.

DIF: Cognitive Level: Application REF: Page 631-632 OBJ: 15 TOP: Chemotherapy: Neutropenia KEY: Nursing Process Step: Nursing Diagnosis

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MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 23. What important focus of nursing care for the dying child and the family should the nurse implement? a. Nursing care should be organized to minimize contact with the child. b. Adequate oral intake is crucial to the dying child. c. Families should be made aware that hearing is the last sense to stop functioning before death. d. It is best for the family if the nursing staff provides all of the childs care.

ANS: C Hearing is intact even when there is a loss of consciousness.

DIF: Cognitive Level: Analysis REF: Page 638 OBJ: 18 TOP: Dying Child KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 24. The nurse is presenting information on the congentital disorder of hemophilia A. What fact will the nurse include? a. It is seen in males and females equally. b. It is transmitted by symptom-free females. c. It is a sex-linked dominant trait. d. It is a defective gene located on the Y chromosome.

ANS: B Hemophilia A affects mostly males who received the sex-linked recessive trait from a symptomfree female. The defective gene is on the X chromosome.

DIF: Cognitive Level: Comprehension REF: Page 628 OBJ: 11 TOP: Hemophilia A KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 25. A child is diagnosed with iron deficiency anemia. What will the nurse explain can occur if this disorder goes untreated? a. Hemorrhage b. Heart failure c. Infection d. Pulmonary embolism ANS: B Untreated iron deficiency anemias progress slowly, and in severe cases the heart muscle becomes

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too weak to function. If this happens, heart failure follows.

DIF: Cognitive Level: Comprehension REF: Page 622 OBJ: 5 TOP: Iron Deficiency Anemia KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 26. The nurse is caring for a child with a low platelet count. What skin assessments would alert the nurse to bleeding? (Select all that apply.) a. Petichiae b. Purpura c. Ecchymosis d. Hematoma e. Lymphadenopathy ANS: A, B, C, D The reduction or destruction of platelets in the body interferes with the clotting mechanism. Skin lesions that are common to these disorders include petechiae, a bluish, nonblanching, pinpointsized lesion; purpura, groups of adjoining petechiae; ecchymosis, an isolated bluish lesion larger than a petechia; and hematoma, a raised ecchymosis. Lymphadenopathy is an enlargement of lymph nodes that is indicative of infection or disease.

DIF: Cognitive Level: Comprehension REF: Page 629 OBJ: 13 TOP: Manifestations of Bleeding KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 27. Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.) a. She will feel less neglected by the parents. b. She can make amends for past hostilities to her brother. c. She will feel increased helplessness. d. She can express her feelings through care. e. She can experience being supportive of her parents and brother.

ANS: A, B, D, E All options are potential benefits to including the sibling in the care of a dying child except increased helplessness. She would feel less helpless.

DIF: Cognitive Level: Comprehension REF: Page 637-638

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OBJ: 21 | 25 TOP: Siblings KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 28. What should be included in the nursing care of a 12-year-old child receiving radiation therapy for Hodgkins disease? (Select all that apply.) a. Application of sunblock b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger e. Preparation for premature sexual development ANS: A, B, C, D Sun block should be applied to skin after radiation to prevent burning. Low energy levels produce anorexia and anger in many young patients. Radiation delays the development of secondary sex characteristics and menses.

DIF: Cognitive Level: Application REF: Page 633 OBJ: N/A TOP: Effects of Radiation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 29. What are the classic symptoms of thalassemia major (Cooleys anemia)? (Select all that apply.) a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Renal failure ANS: A, B, C, D All of the options are classic signs of thalassemia major except renal failure.

DIF: Cognitive Level: Comprehension REF: Page 627 OBJ: 10 TOP: Thalassemia Major KEY: Nursing Process Step: Data Collection MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 30. How has synthetic recombinant antihemophilic factor improved the management of hemophilia? (Select all that apply.) a. Eliminates the need for frequent transfusions b. Can be administered by family at home

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c. Prevents hemorrhage d. Reduces cost of care of the hemophiliac e. Reduces risk of HIV and hepatitis A and B transmission ANS: A, B, D, E The drug can be given at home by the family. Because it supplies the missing factor, transfusions are not necessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatly reduced because hospitalizations and transfusions are not as frequently required. The drug does not prevent hemorrhage; it makes hemorrhage manageable.

DIF: Cognitive Level: Comprehension REF: Page 628 OBJ: 11 TOP: Hemophilia A KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 31. The family of a child receiving chemotherapy for leukemia should be taught to focus on which aspect(s) of the childs care? (Select all that apply.) a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration d. Continuing with scheduled immunizations e. Reporting exposure to infectious diseases ANS: A, B, C, E Support groups are helpful for emotional support and realistic tips on care. The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the drugs. Because the drugs suppress the bone marrow, children are at risk for infection, and the suppression will not allow the antibody response needed for immunization.

DIF: Cognitive Level: Analysis REF: Page 632 | Page 634-635, Nursing Care Plan 27-2 OBJ: 15 | 21 TOP: Chemotherapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 32. The nurse explains that the COPP medical regimen for the treatment of Hodgkins disease uses a combination of which drugs? (Select all that apply.) a. Vincristine b. Cyclophosphamide c. Methotrexate

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d. Prednisone e. Procarbazine hydrochloride ANS: A, B, D, E The COPP medical regimen includes the combination of cyclophosphamide, vincristine (Oncovin), prednisone, and procarbazine hydrochloride.

DIF: Cognitive Level: Knowledge REF: Page 633 OBJ: N/A TOP: COPP KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 33. A school-aged child is living with a chronic disease process. How would the nurse anticipate chronic illness will effect growth and development? (Select all that apply.) a. Delayed bonding with parents b. Delayed toilet training c. Impaired sense of belonging d. Decreased feelings of independence e. Impaired speech development ANS: C, D A school-age child is in the stage of industry versus inferiority. A chronic illness might experience loss of grade level in school because of illness and inability to participate or compete can lead to sense of inferiority. Sense of independence and accomplishment can be lost. Being different from peers may impede childs sense of belonging.

DIF: Cognitive Level: Comprehension REF: Page 636 OBJ: 17 TOP: Chronic Illness/Growth and Development KEY: Nursing Process Step: Data Collection MSC: NCLEX: Psychosocial Integrity: Grief and Loss COMPLETION 34. The nurse shows slides of red blood cells from a child with sickle cell disease, noting that in addition to their sickle shape, the cells contain the abnormal element of ANS: hemoglobin S Hemoglobin S is the abnormal hemoglobin that makes red blood cells fragile and causes the

.

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walls of the cells to collapse, giving them the characteristic sickle shape.

DIF: Cognitive Level: Knowledge REF: Page 624 OBJ: 7 TOP: Sickle Cell Disease KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 35. The nurse confirms that sickle cell trait can be distinguished from sickle cell disease by a lab test called

.

ANS: electrophoresis The hemoglobin electrophoresis is a blood test to check for different types of hemoglobin in the blood. Hemoglobin is the substance in red blood cells that carries oxygen. Electrophoresis uses an electrical current to separate normal and abnormal types of hemoglobin in the blood.

Hemoglobin types have different electrical charges and move at different speeds. The amount of each hemoglobin type in the current is measured. An abnormal amount of normal hemoglobin or an abnormal type of hemoglobin in the blood may mean that a disease is present. A person with sickle cell disease has abnormal hemoglobin S cells.

DIF: Cognitive Level: Knowledge REF: Page 624 OBJ: 3 TOP: Electrophoresis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 36. To prevent

, the nurse warms the blood that is to be

given as a transfusion through a central line.

ANS: cardiac arrhythmias Cold blood entering the heart via a central line can trigger an irregular heartbeat.

DIF: Cognitive Level: Comprehension REF: Page 632-633 OBJ: 16 TOP: Blood Transfusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 37. The rate of RBC production is regulated by

.

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ANS: erythropoietin Erythropoietin is a glycoprotein hormone that controls erythropoiesis or red blood cell production.

DIF: Cognitive Level: Knowledge REF: Page 620 OBJ: 1 | 2 TOP: Components of Blood KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 38. Place the stages of dying in the usual order as detailed by Kbler-Ross (1975). Put a comma and space between each answer choice (a, b, c, d, etc.) a. Bargaining b. Acceptance c. Denial d. Anger e. Reaching out to help others f. Depression ANS: C, D, A, F, B, E The stages of dying as detailed by Kbler-Ross (1975)denial, anger, bargaining, depression, acceptance, and reaching out to help otherscan be applied to parents and siblings as well as to the sick child. (Nurses may also respond with similar feelings.) It is important to accept and support each participant at whatever stage has been reached and to refrain from directing progress.