Lleifers introduction to maternity and pediatric nursing in canada 1st edition Test Bank

Type:

Test Bank

Leifer's Introduction to Resource: Maternity & Pediatric Nursing in Canada Edition:

1st

Author(s):

Lisa Keenan-Lindsay Gloria Leifer

Chapter 01: Overview of Perinatal and Pediatric Nursing in Canada Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A patient chooses to have a registered midwife (RM) provide care during her pregnancy and for her labour. What does the RM’s scope of practice include? a. Independent comprehensive practice b. Prenatal care only c. Attendance at only low-risk births d. Only present for home births ANS: A The RM provides comprehensive independent prenatal, labour, and postpartum care for up to 6 weeks, for women who are low risk. Births may occur in hospital or at home. RMs are regulated health professions who have a 4-year university degree.

DIF: Cognitive Level: Comprehension TOP: Collaborative Care

REF: 7 OBJ: 3 KEY: Nursing Process Step: N/A

2. Which organization is responsible for the Baby Friendly Initiative (BFI) in Canada? a. World Health Organization (WHO) b. Breastfeeding Committee for Canada (BCC) c. UNICEF d. Public Health Agency of N CU anRaS daI(N PG HT AB C. ) COM ANS: B The BCC is responsible for BFI designation in Canada. The BCC has developed the BFI 10 Steps and WHO Code Outcome Indicators for Hospitals and Community Health Services, which sets the international standards for the WHO/UNICEF global criteria within the Canadian context.

DIF: Cognitive Level: Knowledge REF: 7 TOP: The Past KEY: Nursing Process Step: N/A

OBJ: 3 | 9

3. A pregnant woman who has recently immigrated Canada comments to a nurse, “I am afraid of childbirth. It is so dangerous. I am afraid I will die.” What is the best nursing response reflecting cultural safety? a. “Maternal mortality in Canada is extremely low.” b. “Anesthesia is available to relieve pain during labour and childbirth.” c. “Tell me why you are afraid of childbirth.” d. “Your condition will be monitored during labour and birth.”

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

DIF:

Cognitive Level: Application

REF: 11

OBJ: 7

TOP: Culturally Safe Care

KEY: Nursing Process Step: Implementation

4. An urban area has been reported to have a high perinatal mortality rate. What information does this provide? a. Maternal and infant deaths per 100,000 live births per year b. Deaths of fetuses weighing more than 500 g per 10,000 births per year c. Deaths of infants up to 1 year of age per 1000 live births per year d. Fetal and neonatal deaths per 1000 live births per year ANS: D The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.

DIF: Cognitive Level: Comprehension REF: 8 TOP: Statistics KEY: Nursing Process Step: Assessment

OBJ: 10

5. What is the focus of current perinatal care? a. Hospital births for the majority of women b. The traditional family unit c. Care in a labour room and then a birthing room d. A high-quality family experience for each patient ANS: D Current maternity practice focuses on a high-quality family experience for all families.

DIF: Cognitive Level: Comprehension TOP: Perinatal Care

REF: 7 | 8 OBJ: 2 | 8 KEY: Nursing Process Step: N/A

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6. Which organization offers certification for nurses in specialty areas? a. CNA b. CAPWHN c. CANN d. CAPN ANS: A The Canadian Nurses Association offers certification exams for registered nurses in specialty areas including perinatal, community, neonatal, and pediatric intensive care.

CAPWHN, CANN, and CAPN are specialty organizations for nursing groups in Canada.

DIF: Cognitive Level: Knowledge TOP: Nursing Certification

REF: 10 OBJ: 2 | 3 KEY: Nursing Process Step: N/A

7. Which of the following requires self-reflection and discovery in order to provide care that is culturally appropriate? a. Cultural safety b. Cultural awareness c. Cultural humility d. Cultural competence ANS: C

Cultural humility is the precursor to providing culturally appropriate care. It is a process of self-reflection and discovery to understand one’s own assumptions, biases, and values and how one’s background and social environment have shaped one’s experience DIF: Cognitive Level: Knowledge TOP: Cultural Humility

REF: 4 OBJ: 1 | 7 KEY: Nursing Process Step: Evaluation

8. In 2015, the WHO developed the Sustainable Development Goals (SDGs). What issues do the new SDG’s include that the Millennium Development Goals (MDGs) did not include? a. Climate change and environmental protection b. Combating HIV and malaria c. Eradicating poverty and hunger d. Achieving universal primary education ANS: A Climate change and environmental protection are new goals of the SDGs. All other options are part of the MDGs DIF: Cognitive Level: Knowledge TOP: Sustainable Development Goals

REF: 13 OBJ: 16 KEY: Nursing Process Step: N/A

9. What guidelines define multidisciplinary patient care in terms of expected outcome and timeframe from different areas of care provision? a. Clinical pathways b. Nursing outcome criteria c. Standards of care d. Nursing care plan NURSINGTB.COM 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 TOP: Health Care Delivery Systems

REF: 12 OBJ: 13 KEY: Nursing Process Step: N/A

10. A nursing student has reviewed a hospitalized pediatric patient chart, interviewed her mother, and collected admission data. What is the next step the student will take to develop a nursing care plan for this child? a. Identify measurable outcomes with a timeline. b. Choose specific nursing interventions for the child. c. Determine appropriate nursing diagnoses. d. State nursing actions related to the child’s medical diagnosis.

ANS: C The nurse uses assessment data to develop appropriate nursing diagnoses. Outcomes and interventions are then developed to address the relevant nursing diagnoses.

DIF: Cognitive Level: Application TOP: Nursing Process

REF: 11

OBJ: 10

KEY: Nursing Process Step: Nursing Diagnosis 11. A nursing student on a maternal–newborn rotation questions the floor nurse about the definition of the practical nurse scope of practice. What resource can the nurse suggest to the student? a. Canadian Nurses Association b. Provincial regulatory board c. Federal government d. Canadian Association of Perinatal & Women’s Health Nursing ANS: B The scope of practice of the practical nurse is determined by the provincial board of nursing.

DIF: Cognitive Level: Comprehension TOP: Standards of Practice

REF: 3 OBJ: 2 KEY: Nursing Process Step: Implementation

12. Which social determinant of health (SDOH) is specifically related to Indigenous people’s health? a. Colonization b. Education c. Social support networks d. Employment and working conditions ANS: A All of the SDOH are important but the impact of colonization is related specifically to Indigenous people’s health.

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DIF: Cognitive Level: Knowledge TOP: Social Determinants of Health

REF: 3 OBJ: 6 KEY: Nursing Process Step: N/A

13. 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 TOP: Critical Pathway

REF: 12 OBJ: 13 KEY: Nursing Process Step: Implementation

14. How does electronic charting ensure comprehensive charting more effectively than handwritten charting? a. Provides a uniform style of chart b. Requires certain responses before allowing the user to progress c. All documentation is reflective of the nursing care plan d. Requires a daily audit by the charge nurse ANS: B

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

DIF: Cognitive Level: Comprehension TOP: Computerized Documentation

REF: 12 OBJ: 14 KEY: Nursing Process Step: Implementation

15. The nurse reminds family members that the philosophy of family-centred 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 TOP: Empowerment

REF: 6 OBJ: 13 KEY: Nursing Process Step: Implementation

16. 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 NURSINGTB.COM Critical thinking results in problem prevention in designing nursing care.

DIF: Cognitive Level: Comprehension TOP: Critical Thinking

REF: 12 OBJ: 11 KEY: Nursing Process Step: N/A

17. Practical nursing students are discussing developing nursing diagnosis in post conference on the acute care clinical setting. The students are aware that the role of the practical nurse 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: A The practical nurse is responsible for initiating nursing diagnosis specific to patients.

DIF: Cognitive Level: Comprehension REF: 11 | 12 TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis

OBJ: 11

TRUE/FALSE 1. The term morbidity refers to the rates of illness within a population within a time frame.

ANS: T Morbidity rates show the incidence of disease in a specific population during a certain time frame.

DIF: Cognitive Level: Knowledge REF: 8 OBJ: 1 TOP: Statistics KEY: Nursing Process Step: Data Collection MULTIPLE RESPONSE 1. What are some of the reasons that Indigenous people have poorer health outcomes? (Select all that apply.) a. Residential schools b. Lack of clean water c. Lack of understanding of modern medicine d. Remote geographical locations e. Fragmented healthcare funding ANS: A, B, D, E There are many reasons for poorer health outcomes for Indigenous people although their lack of understanding of modern medicine is not one. Health care providers often have a lack of Indigenous traditional therapies that are used to enhance health.

DIF: Cognitive Level: Knowledge TOP: Indigenous Peoples Health

REF: 6 | 7 OBJ: 6 KEY: Nursing Process Step: Data Collection

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2. What developments in the early 20th century encouraged women to seek hospitalization for childbirth? (Select all that apply.) a. Use of specialized obstetric instruments b. Use of anesthesia c. Physicians’ closer relationships with hospitals d. Focus on family-centred care e. Insurance coverage ANS: A, B, C In the early 1900s, the development of specialized obstetric instruments, better modes of anesthesia, and the physician’s reliance on hospital services were instrumental in encouraging women to seek hospitalization for childbirth.

DIF: Cognitive Level: Comprehension TOP: Hospitalization for Childbirth

REF: 2 OBJ: 2 KEY: Nursing Process Step: N/A

3. What non–family-centred policies were prevalent in the 1960s? (Select all that apply.) a. Waiting room for fathers b. Sedation of mother during labour c. Delay of reunion of mother and infant d. Lenient visiting hours e. Restrictions of visitations by minor children ANS: A, B, C, E

Hospital policies in the 1960s provided a separate waiting room for fathers while the mother went through labour in a sedated state on her own. 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 TOP: Family-centred Care

REF: 2 OBJ: 2 KEY: Nursing Process Step: Implementation

4. A nurse is aware that there is a legal responsibility to report certain diseases and conditions to the public health authorities. Which would be included? (Select all that apply.) a. Tuberculosis b. Child abuse c. Industrial accidents d. Sexually transmitted infections e. Foodborne infections ANS: A, B, D, E The nurse has a legal responsibility to report communicable diseases (such as tuberculosis and sexually transmitted infections), foodborne infections, child abuse, and threats of suicide.

DIF: Cognitive Level: Comprehension TOP: Reportable Diseases

REF: 3 OBJ: 4 KEY: Nursing Process Step: Planning

5. Practical nursing students are using critical-thinking skills to study for an upcoming test.

What will these students include when studying? (Select all that apply.) a. Memorization of facts firN stURSINGTB.COM b. Prioritizing information c. Relating facts to other facts d. Making assumptions e. Reviewing before the test ANS: B, C Using critical thinking when studying involves understanding facts before memorizing, prioritizing information to be memorized, relating facts to other facts, using all five senses, and reading critically. Critical thinking does not involve making assumption as does general thinking.

DIF: Cognitive Level: Comprehension TOP: Critical Thinking

REF: 12 OBJ: 12 KEY: Nursing Process Step: Evaluation

6. What are the pillars of the Medical Care Act of 1968? (Select all that apply.) a. Comprehensive b. Includes dental care c. Able to travel between provinces d. Covers everyone e. Publicly administered ANS: A, C, D, E

All of the options except dental care are part of the Medical Care Act. Some provinces include dental care, but it is not part of the Act. DIF: Cognitive Level: Comprehension TOP: Medical Care Act

REF: 2 OBJ: 2 KEY: Nursing Process Step: N/A

7. A home 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 therapy 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 home health nurse. Family therapy is a specialized form of therapy that requires certification and providing referrals would be care provided by advance practice nurses or physicians.

DIF: Cognitive Level: Application TOP: Community Health

REF: 11 OBJ: 15 KEY: Nursing Process Step: Implementation

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Chapter 02: The Nurse’s Role in Women’s Health Care Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. The nurse is preparing a community education program on preventive health care for women. What common screening test will the nurse plan on explaining to the women attending the program? a. Clinical breast examination (CBE) by a health professional b. Breast self-examination (BSE) c. Breast biopsy d. Mammography ANS: D Mammography is a screening test used to detect breast cancer. CBE by a qualified health care provider can be used to check for abnormalities, although it has not been shown to be an effective screening tool and is not recommended in women with low risk for breast cancer. BSE is not recommended as regular practice. A breast biopsy is a diagnostic test versus a test performed for basic screening purposes.

DIF: Cognitive Level: Comprehension TOP: Mammography

REF: 20 OBJ: 2 KEY: Nursing Process Step: Planning

2. Which of the following strategies is a secondary prevention strategy?

NURSINGTB.COM a. Mammogram b. Smoking cessation c. HPV vaccination d. Learning how to manage diabetes ANS: A Secondary prevention is the early detection of diseases and trying to prevent the disease from developing further. Mammogram screening is an example of secondary prevention.

Vaccinations and smoking cessation are primary prevention and learning how to manage disease is a tertiary strategy.

DIF: Cognitive Level: Knowledge TOP: Health Promotion

REF: 20 OBJ: 2 KEY: Nursing Process Step: Implementation

3. A woman asks the nurse, “How do oral contraceptives prevent pregnancy?” What will the nurse explain about the combination of estrogen and progesterone in oral contraceptives? a. Makes cervical mucus hostile to sperm b. Prevents ovulation c. Prohibits implantation of the egg d. Acts as a barrier by destroying sperm ANS: B Oral contraceptives contain a combination of estrogen and progesterone that suppresses ovulation.

DIF: Cognitive Level: Comprehension TOP: Oral Contraceptives

REF: 29 | 30 OBJ: 6 KEY: Nursing Process Step: Implementation

4. What should a woman expect after insertion of an intrauterine device (IUD)? a. Menstrual flow will be lighter b. Menstrual cramps will be eliminated c. A string should be felt in the vagina d. The device should be changed every 2 years ANS: C A woman should feel for the string every 4 weeks to confirm the presence of the IUD. DIF: Cognitive Level: Comprehension TOP: Intrauterine Contraceptives

REF: 31 OBJ: 6 KEY: Nursing Process Step: Implementation

5. What information will the nurse provide when educating a woman about the correct use of a diaphragm? a. Use of a spermicidal cream or jelly is not recommended b. Leave in place for at least 6 hours after intercourse c. Remove immediately after intercourse for douching d. It is effective for up to 48 hours if positioned properly ANS: B To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to, but no more than 24 hours.

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DIF: Cognitive Level: Comprehension REF: 32 TOP: Diaphragm KEY: Nursing Process Step: Evaluation

OBJ: 6

6. The nurse is providing sexual education to a group of high school students. What will the nurse explain is the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases? a. Abstain from sex b. Use the male condom c. Use the female condom d. Use the barrier method ANS: A Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases.

DIF: Cognitive Level: Comprehension REF: 29 OBJ: 6 TOP: Abstinence KEY: Nursing Process Step: Implementation 7. On day 13 of a 28-day cycle, a woman’s basal body temperature is 36.5° C. What will her temperature measurement most likely be if ovulation takes place on day 14? a. 35.9° C b. 36.3° C c. 36.7° C d. 37.0° C

ANS: D After ovulation, body temperature will increase slightly, about 0.5° C. DIF: Cognitive Level: Analysis TOP: Natural Family Planning

REF: 28 OBJ: 7 KEY: Nursing Process Step: Implementation

8. The nurse teaches a woman who is trying to conceive to check her cervical mucus for changes. What will she expect the characteristic of cervical mucus to be a few days before ovulation? a. Cloudy and tacky b. Scant and thick c. Thin and white d. Clear and slippery ANS: D Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage of sperm into the cervix.

DIF: Cognitive Level: Knowledge TOP: Natural Family Planning

REF: 29 OBJ: 7 KEY: Nursing Process Step: Implementation

9. The nurse is discussing cervical mucus changes with a woman who wishes to use natural family-planning methods. What information about cervical mucus at ovulation will the woman indicate to the nurse, demonstrating that learning has taken place? a. Cervical mucus enhances the motility of the sperm b. Cervical mucus indicates endometrial readiness for implantation UoRvSeI c. Cervical mucus facilitatesNm mN enGt T ofBt. heCoOvMum through the fallopian tube d. Cervical mucus provides vaginal lubrication during intercourse ANS: A Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm.

DIF: Cognitive Level: Comprehension TOP: Natural Family Planning

REF: 29 OBJ: 7 KEY: Nursing Process Step: Evaluation

10. In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty concentrating. What remedy might the nurse suggest to relieve these symptoms? a. Drink tea or hot chocolate before going to bed b. Take a daily folic acid and vitamin C supplement c. Include complex carbohydrates and fibre in the diet d. Avoid exercise when symptoms occur ANS: C A diet rich in complex carbohydrates and fibre is recommended for premenstrual syndrome.

DIF: Cognitive Level: Application TOP: Premenstrual Syndrome

REF: 22 OBJ: 4 KEY: Nursing Process Step: Implementation

11. At her regular gynecological examination, a woman tells the nurse that she is concerned about osteoporosis. What suggestion can the nurse make to this patient? a. Take a vitamin E supplement daily b. Do high impact exercise daily c. Include more dairy products and green, leafy vegetables in her diet d. Try to limit her intake of caffeine ANS: C Foods rich in calcium include milk, dairy products, and green, leafy vegetables.

DIF: Cognitive Level: Application TOP: Prevention of Osteoporosis

REF: 37 | 38 OBJ: 9 | 10 KEY: Nursing Process Step: Implementation

12. A 48-year-old woman tells the nurse, “I missed my period last month. Am I in menopause?”

The nurse knows that at which point is a woman considered to be menopausal? a. Her periods have stopped for 1 year b. Her periods have been irregular and light for 12 months c. She has symptoms of vasomotor instability d. She experiences symptoms of decreased estrogen, such as dyspareunia ANS: A When a woman’s menstrual periods have stopped for 1 year, she is considered menopausal.

DIF: Cognitive Level: Comprehension REF: 36 OBJ: 9 | 10 TOP: Menopause KEY: Nursing Process Step: Implementation 13. The nurse is planning to teachNU aR wS om peOriMmenopause. What would the nurse IaNnGaTboBu.t C include regarding lowered estrogen level? a. It prevents osteoporosis b. It decreases vaginal lubrication c. It raises the level of low-density lipoproteins d. It raises the level of high-density lipoproteins ANS: C Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver for excretion. With lowered levels of estrogen, low-density lipoproteins increase, causing an increase in the incidence of heart attacks and strokes.

DIF: Cognitive Level: Knowledge REF: 36 TOP: Menopause KEY: Nursing Process Step: Planning

OBJ: 9

14. What side effect would the nurse instruct a woman to look for when starting hormone therapy (HT) for management of menopausal symptoms? a. Fatigue b. Headache c. Weight loss d. Amenorrhea ANS: B Patients initiating HT are reminded to have regular follow-up care and report headaches, vision changes, symptoms of thrombophlebitis, and cardiac symptoms.

DIF: Cognitive Level: Comprehension TOP: Hormone Therapy

REF: 37 OBJ: 9 KEY: Nursing Process Step: Implementation

15. What will the nurse advise when a woman asks what she can do to reduce the discomfort of hot flashes? a. “Aerobic exercise helps control hot flashes.” b. “Increase the amount of calcium and vitamin D in your diet.” c. “Dress in layers of cotton clothing.” d. “Drink plenty of fluids, particularly caffeinated beverages.”

ANS: C Cotton allows easier passage of air than synthetic fabrics. Layering allows the woman to take off or put on clothes when symptoms occur.

DIF: Cognitive Level: Application TOP: Physical Changes of Menopause

REF: 39 OBJ: 9 KEY: Nursing Process Step: Implementation

16. Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock syndrome (TSS)? a. “Super-absorbency tampons are effective for overnight absorption.” b. “Tampons should be changed at least every 4 hours.” c. “Gloves should be worn when changing tampons.” d. “TSS can be prevented by using a pad for the first 2 days of menstrual flow.”

ANS: B Tampons should be changed N evUeR ryS4IhNoG urTs Bb. ecC auOsM e a blood-soaked tampon is an excellent environment for bacteria.

DIF: Cognitive Level: Comprehension REF: 23 OBJ: 5 TOP: TSS KEY: Nursing Process Step: Implementation 17. What statement by a man considering a vasectomy indicates a need for further information? a. “Sterility does not occur immediately after the procedure.” b. “We will need to use some form of birth control for about a month afterward.” c. “The procedure involves the use of local anesthesia.” d. “I’ll need to remain in the hospital for a few days.”

ANS: D A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia.

DIF: Cognitive Level: Analysis REF: 35 | 36 TOP: Vasectomy KEY: Nursing Process Step: Evaluation

OBJ: 6

18. At her 6-week postpartum checkup, a woman states, “I am wondering about birth control. I used oral contraceptives before, and I’m breastfeeding now. Can I use the pill again?” What is the nurse’s best response? a. “You should know that oral contraceptives increase your milk production.” b. “Oral contraceptives can be taken once lactation is well established.”

c. “You don’t need to use any form of birth control as long as you are breastfeeding.” d. “Oral contraceptives are contraindicated for the lactating woman.”

ANS: B Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established. Women who breastfeed their infants can use breastfeeding as a method of birth control for up to 6 months, as long as their periods have not returned and the infants are exclusively breastfeeding.

DIF: Cognitive Level: Application TOP: Oral Contraceptives

REF: 30 OBJ: 6 KEY: Nursing Process Step: Implementation

19. A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. With what are these findings consistent? a. Candidiasis b. Trichomoniasis c. Bacterial vaginosis d. Chlamydia ANS: A The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese appearance to the vaginal discharge.

DIF: Cognitive Level: Analysis REF: 24 OBJ: 5 TOP: Candidiasis KEY: Nursing Process Step: Data Collection

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20. The nurse is providing an informational session on oral contraceptives. Which of the following decrease effectiveness of oral contraceptives? a. Antihistamines for seasonal allergies b. Iron preparations for treatment of anemia c. Appetite suppressants for weight reduction d. Anticonvulsants for treatment of epilepsy ANS: D Anticonvulsants decrease the effectiveness of oral contraceptives.

DIF: Cognitive Level: Comprehension TOP: Oral Contraceptives

REF: 30 OBJ: 6 KEY: Nursing Process Step: Implementation

21. The nurse is instructing a man considering a vasectomy. What instruction will the nurse provide to address the postoperative time period? a. Intercourse should be delayed for 6 weeks b. Sperm will still be ejaculated for 1 to 3 months c. Erections will be difficult to maintain d. Monthly sperm counts for a year will be necessary ANS: B

Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for up to 3 months. A sperm count after that period of time should be performed to confirm the absence of sperm. Intercourse does not have to be delayed, but an alternative method of contraception should be used. Erections and sexual pleasure are not affected by a vasectomy.

DIF: Cognitive Level: Comprehension REF: 35 OBJ: 6 TOP: Vasectomy KEY: Nursing Process Step: Implementation 22. A woman diagnosed with endometriosis reports “painful intercourse.” What is the appropriate medical term for the nurse to document when describing this symptom? a. Dyspnea b. Dysmenorrhea c. Dyspareunia d. Dysrhythmia ANS: C Dyspareunia is the term for painful sexual intercourse. Dyspnea is shortness of breath.

Dysmenorrhea is painful menstruation. Dysrhythmia is irregular heart rhythm.

DIF: Cognitive Level: Knowledge REF: 36 OBJ: 1 TOP: Dyspareunia KEY: Nursing Process Step: Data Collection 23. The nurse is educating a woman diagnosed with premenstrual dysphoric disorder (PMDD).

What is the best type of diet for the nurse to recommend? a. High protein, low fat b. High carbohydrate, high fNibUrR e SINGTB.COM c. Low calorie, low fat d. Low carbohydrate, high protein ANS: B Treatment of PMDD includes a diet rich in complex carbohydrates and fibre (to lengthen effects of the carbohydrate meal).

DIF: Cognitive Level: Application REF: 22 OBJ: 4 TOP: PMDD KEY: Nursing Process Step: Implementation 24. Which of the following is the most effective method of screening for breast cancer in a low-risk woman? a. Breast self-examination b. Mammogram c. Clinical breast exam d. Breast ultrasound ANS: B The most reliable way to find breast cancer early is screening mammography. Breast self-examination is not recommended for routine screening.

DIF: Cognitive Level: Comprehension TOP: Breast cancer screening

REF: 20 OBJ: 3 KEY: Nursing Process Step: Implementation

25. Which method of birth control has the highest rate of effectiveness? a. Intrauterine device (IUD) b. Combined oral contraceptive (OC) c. Condoms d. Diaphragm ANS: A The IUD is at least 99% effective.

DIF: Cognitive Level: Knowledge REF: 31 OBJ: 6 TOP: Birth control KEY: Nursing Process Step: Implementation 26. A woman is prescribed to take a bisphosphonate for osteoporosis post menopause. What information will the nurse provide when educating this patient on taking bisphosphonates? a. Drink 240 mL of water following dosage b. Lie down for 30 minutes after taking c. This medication has no known side effects d. Avoid weight-bearing exercises ANS: A Bisphosphonates may be prescribed. Esophageal and gastric irritation are common side effects of these medications, and the woman should be instructed to drink 240 mL of plain water and sit upright for 30 minutes after taking the medication and before eating a meal.

Weight-bearing exercises such as walking, hiking, stair climbing, and dancing are advisable.

High-impact exercises should be avoided.

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DIF: Cognitive Level: Comprehension TOP: Osteoporosis

REF: 38 OBJ: 2 | 8 KEY: Nursing Process Step: Implementation

27. Which herb can a nurse suggest using for discomfort with menopause, such as hot flashes? a. Evening primrose oil b. Echinacea c. Milk thistle d. Black cohosh ANS: D Black cohosh diminishes hot flashes by reducing luteinizing hormone. It also reduces joint pain and other menopausal discomfort.

DIF: Cognitive Level: Knowledge TOP: Herbal Remedies

REF: 37 OBJ: 10 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all that apply.) a. Abdominal pain b. Weight gain c. Headache

d. Eye or visual problems e. Speech disturbances ANS: A, C, D, E The memory aid ACHES is helpful: abdominal pain, chest pain, headaches, eye problems, and speech disturbances. Weight gain is an expected side effect of oral contraceptives.

DIF: Cognitive Level: Comprehension TOP: Oral Contraceptives

REF: 30 OBJ: 6 KEY: Nursing Process Step: Implementation

2. The nurse cautions that women with a history of which disorders are not candidates for hormone therapy (HT)? (Select all that apply.) a. Melanoma b. Estrogen-dependent breast cancer c. Hepatitis C d. Thromboembolic disease e. Hyperthyroidism ANS: A, B, C, D Persons who are absolutely restricted from HT are those with history of malignant melanoma, endometrial cancer, estrogen-dependent breast cancers, chronic liver disorders, thromboembolic disease, severe hypertriglyceridemia, gallbladder disease, and seizure disorders.

DIF: Cognitive Level: Comprehension TOP: Hormone Therapy

REF: 37 OBJ: 10 KEY: Nursing Process Step: Implementation

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3. Which of the following are primary strategies for health promotion? (Select all that apply.) a. HPV vaccination b. Mammograms c. Breast self-examination d. Weight reduction e. Disease management ANS: A, D Primary prevention involves disease prevention through having a healthy lifestyle and decreasing exposure to environmental or other substances that increase the risk of disease.

Immunizations and weight loss help to prevent disease. Mammograms and breast self-examinations are secondary prevention, and disease management is tertiary prevention.

DIF: Cognitive Level: Comprehension TOP: Health Promotion

REF: 19 OBJ: 2 KEY: Nursing Process Step: Implementation

Chapter 03: Fetal Development Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What is the total number of chromosomes contained in a mature sperm or ovum? a. 22 b. 23 c. 44 d. 46 ANS: B Gametes (sex cells) contain 23 chromosomes.

DIF: Cognitive Level: Knowledge TOP: Gametogenesis

REF: 42 OBJ: 2 KEY: Nursing Process Step: N/A

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.”

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

DIF: Cognitive Level: Comprehension TOP: Sex Determination

REF: 44 | 45 OBJ: 3 KEY: Nursing Process Step: Implementation

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: 44 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation 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 9th week and continues until the 40th week of gestation or until birth.

DIF: Cognitive Level: Knowledge REF: 47 TOP: Prenatal Development KEY: Nursing Process Step: Implementation

OBJ: 4

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 TOP: Fetal Circulation

REF: 50 | 51 OBJ: 6 KEY: Nursing Process Step: Implementation

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

NURSINGTB.COM

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

DIF: Cognitive Level: Knowledge REF: 46 TOP: Implantation KEY: Nursing Process Step: N/A

OBJ: 3

7. What is the embryonic membrane that contains fingerlike projections on its surface, which attach to the uterine wall? a. Amnion b. Yolk sac c. Chorion d. Decidua basalis ANS: C The chorion is a thick membrane with fingerlike projections (villi) on its outermost surface.

DIF: Cognitive Level: Knowledge REF: 46 OBJ: 4 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: N/A 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: 47 TOP: Placenta KEY: Nursing Process Step: N/A

OBJ: 6

9. A pregnant patient asks a nurse when her infant’s heart will begin to pump blood. The nurse responds which answer? a. By the end of week 3 b. Beginning in week 8 c. By the end of week 16 d. Beginning in week 24 ANS: A The fetal heart begins to pump by week 3 of gestation.

DIF: Cognitive Level: Knowledge TOP: Prenatal Development KEY: Nursing Process Step: N/A

REF: 51

OBJ: 5

10. What organ does the ductus venosus shunt blood away from in fetal circulation? a. Liver b. Heart c. Lungs NURSINGTB.COM d. Kidneys ANS: A Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.

DIF: Cognitive Level: Knowledge TOP: Prenatal Development KEY: Nursing Process Step: N/A

REF: 51

OBJ: 7

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 TOP: Fetal Circulation

REF: 51 OBJ: 7 KEY: Nursing Process Step: Implementation

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 TOP: Multifetal Pregnancy

REF: 54 OBJ: 8 KEY: Nursing Process Step: Data Collection

13. A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus? a. Lanugo covering the body b. Constant motion c. Skin that is pink and smooth d. Eyes that are closed ANS: A By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus has definite periods of movement and sleeping.

DIF: Cognitive Level: Comprehension REF: 49 TOP: Prenatal Development KEY: Nursing Process StepN : IU mRpS leI mN enGtaTtio n COM B.

OBJ: 5

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 TOP: Prenatal Development KEY: Nursing Process Step: N/A

REF: 49

OBJ: 5

15. A woman missed her menstrual period 2 weeks ago and has come to the doctor’s office for a pregnancy test. Which placental hormone is measured in pregnancy tests? a. Progesterone b. Estrogen c. Human chorionic gonadotropin d. Human placental lactogen ANS: C

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

DIF: Cognitive Level: Knowledge REF: 51 OBJ: 6 TOP: Accessory Structures of Pregnancy KEY: Nursing Process Step: Data Collection 16. When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent? a. Congenital heart defects b. Neural tube defects c. Developmental delays 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 TOP: Prenatal Development KEY: Nursing Process Step: Planning

REF: 47

OBJ: 5

17. The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability? a. 14 weeks b. 22 weeks c. 25 weeks d. 30 weeks NURSINGTB.COM ANS: B By 22 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of viability).

DIF: Cognitive Level: Knowledge TOP: Prenatal Development KEY: Nursing Process Step: N/A

REF: 47

OBJ: 5

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 TOP: Dominant Traits

REF: 45 OBJ: 3 KEY: Nursing Process Step: Implementation

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 TOP: Multifetal Pregnancy

REF: 54 OBJ: 8 KEY: Nursing Process Step: Implementation

20. A nurse is counselling 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 can survive up to 7 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 7 days and cause pregnancy even before ovulation.

DIF: Cognitive Level: ComNpUreRhS enIsN ioG n TBR OBJ: .ECFO:M 44 TOP: Fertilization KEY: Nursing Process Step: Implementation

3

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

DIF: Cognitive Level: Knowledge REF: 44 OBJ: 3 TOP: Fertilization KEY: Nursing Process Step: Implementation 22. The normal umbilical cord has which of the following? a. One artery carrying blood to the fetus and one vein carrying blood away from the fetus b. One artery carrying blood to the fetus and two veins carrying blood away from the fetus c. Two arteries carrying blood away from the fetus and one vein carrying blood to the fetus

d. Two arteries carrying blood to the fetus and two veins carrying blood away from the fetus ANS: C The umbilical cord is comprised of two arteries carrying blood away from the fetus and one vein carrying blood to the fetus.

DIF: Cognitive Level: Knowledge TOP: Fetal Circulation

REF: 51 OBJ: 6 KEY: Nursing Process Step: N/A

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 TOP: Embryonic development

REF: 47 OBJ: 4 KEY: Nursing Process Step: N/A

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 NURSINGTB.COM b. 6 weeks’ gestational age c. 10 weeks’ gestational age d. 16 weeks’ gestational age ANS: C The fetal period begins at the 9th week, and by the 10th week the external genitalia may be visible to ultrasound examination.

DIF: Cognitive Level: Knowledge TOP: Fetal Development

REF: 47 OBJ: 5 KEY: Nursing Process Step: Data Collection

MULTIPLE RESPONSE 1. A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm ANS: A, B, C

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

DIF: Cognitive Level: Knowledge TOP: Primary Germ Layers

REF: 47 OBJ: 4 KEY: Nursing Process Step: Implementation

2. What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus ANS: A, E The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin; allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for the fetus. Although the fetus does swallow amniotic fluid, it has no nutritional value.

DIF: Cognitive Level: Knowledge TOP: Amniotic Fluid

REF: 46 OBJ: 6 KEY: Nursing Process Step: Implementation

3. A patient who has come for a prenatal visit has just learned she is pregnant with dizygotic twins. What facts will a 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 tenNdUtR oS reI peNaG t iTnBfa.mCiO lieMs. 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 TOP: Multifetal Pregnancy

REF: 54 OBJ: 8 KEY: Nursing Process Step: Data Collection

COMPLETION 1. The normal volume of amniotic fluid is approximately 700 to weeks’ gestation.

mL at 37

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 700 to 1000 mL at 37 weeks. In the latter part of pregnancy, the fetus may swallow up to 400 mL of amniotic fluid per day and normally excretes urine into the fluid.

DIF: Cognitive Level: Knowledge TOP: Amniotic Fluid

REF: 46 OBJ: 6 KEY: Nursing Process Step: Data Collection

NURSINGTB.COM

Chapter 04: Prenatal Care and Adaptations to Pregnancy Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son born at 34 weeks’ gestation and had one previous spontaneous abortion. How would the nurse document the patient’s obstetric history using the GTPAL system? a. 2-1-0-0-1 b. 3-1-0-1-1 c. 3-0-1-1-1 d. 2-0-1-1-1 ANS: C Refer to Box 4.1 in the textbook for the GTPAL system for identifying obstetric history.

DIF: Cognitive Level: Application TOP: Definition of Terms

REF: 58 OBJ: 1 KEY: Nursing Process Step: Implementation

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 birth b. Every 4 weeks until the 7th month, after which appointments will become more NURSINGTB.COM frequent c. Monthly until the 8th month d. Every 2 to 3 weeks for the entire pregnancy ANS: B Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 to 3 weeks through 36 weeks. From 36 weeks until birth, visits are weekly.

DIF: Cognitive Level: Application TOP: Prenatal Visits

REF: 60 OBJ: 2 | 3 KEY: Nursing Process Step: Implementation

3. During the physical examination for the first prenatal visit, it is noted that Chadwick sign is present. What is Chadwick sign? a. Bluish or purplish discoloration of the vulva, vagina, and cervix b. Presence of early fetal movements c. Darkening of the areola and breast tenderness d. Palpation of the fetal outline ANS: A Chadwick sign is the purplish or bluish discoloration of the cervix, vulva and vagina.

DIF: Cognitive Level: Knowledge REF: 63 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection

OBJ: 7

4. After an initial physical examination is completed, the woman asks a nurse why Chadwick sign occurs during pregnancy. What would the nurse explain as the cause of Chadwick sign? a. Enlargement of the uterus b. Progesterone action on the breasts c. Increasing activity of the fetus d. Vascular congestion in the pelvic area ANS: D Chadwick sign is caused by increased vascular congestion in the cervical and vaginal area.

DIF: Cognitive Level: Comprehension REF: 63 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Implementation

OBJ: 6 | 7

5. A nurse has explained physiological changes that occur during pregnancy. Which statement indicates that a woman understands the information? a. “Blood pressure goes up toward the end of pregnancy.” b. “My breathing will get deeper and a little faster.” c. “I’ll notice a decreased pigmentation in my skin.” d. “There will be a curvature in my upper spine area.”

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

DIF: Cognitive Level: Comprehension REF: 66 TOP: Normal PhysiologicalNCUhRanSgIeN s iGnTPB re.gC naOnM cy KEY: Nursing Process Step: Implementation

OBJ: 7 | 11

6. A woman reports that her last normal menstrual period began on August 5, 2020. What is this woman’s expected date of birth using Nägele’s rule? a. April 30, 2021 b. May 5, 2021 c. May 12, 2021 d. May 26, 2021 ANS: C To determine the expected date of birth, count forward 7 days from the first day of the last menstrual period, add 9 months and change the year if necessary.

DIF: Cognitive Level: Analysis REF: 59 TOP: Determining Estimated Date of Birth KEY: Nursing Process Step: Data Collection

OBJ: 5

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: 64 TOP: Normal Physiological Changes in Pregnancy KEY: Nursing Process Step: Data Collection

OBJ: 4 | 7

8. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/minute from a rate of 160 beats/minute earlier in the pregnancy. What is the nurse’s first action? a. Ask if the patient has taken a sedative b. Notify the primary health care provider c. Turn the patient to her right side d. Record the rate as a normal finding ANS: D The FHR at term ranges from a low of 110 to 120 beats/minute to a high of 150 to 160 beats/minute. This should be recorded as normal. The FHR drops in the late stages of pregnancy due to hormonal influences.

DIF: Cognitive Level: Application TOP: Assessing Fetal Heart Rate

REF: 64 OBJ: 3 | 7 KEY: Nursing Process Step: Data Collection

9. A woman’s prepregnant weigNhU t iRs S deIteNrG mT inBed.tCoObM e an average BMI. What will the nurse advise the woman regarding recommended weight gain during pregnancy? a. 5 to 9 kg b. 7 to 11.5 kg c. 11.5 to 16 kg d. 12.5 to 18 kg ANS: C The recommended weight gain for a woman of normal BMI before pregnancy is 11.5 to 16 kg.

DIF: Cognitive Level: Knowledge TOP: Nutrition for Pregnancy

REF: 71 OBJ: 9 KEY: Nursing Process Step: Implementation

10. When a nurse tells a pregnant woman that she needs 1000 mg of calcium daily during pregnancy, the woman responds, “I don’t like milk.” What dietary adjustments could the nurse recommend? a. Increase intake of organ meats b. Eat more green leafy vegetables c. Choose more fresh fruits, particularly citrus fruits d. Include molasses and whole-grain breads in the diet ANS: B

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

DIF: Cognitive Level: Application TOP: Nutrition for Pregnancy

REF: 72 OBJ: 8 | 13 KEY: Nursing Process Step: Implementation

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: 78 TOP: Common Discomforts in Pregnancy KEY: Nursing Process Step: Implementation

OBJ: 11

12. A pregnant woman should be counselled regarding the importance of receiving which of the following immunization during pregnancy? a. HPV b. Chicken pox c. MMR NURSINGTB.COM d. Influenza ANS: D The influenza vaccine is recommended for pregnant women as there is higher risk of complications from flu when pregnant and the vaccine is a killed vaccine. The others are live-virus vaccines and are contraindicated during pregnancy.

DIF: Cognitive Level: Application TOP: Immunizations

REF: 76 OBJ: 12 KEY: Nursing Process Step: Implementation

13. The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid–omega 3 fatty acid (DHA) are thought to enhance brain development. What food can the nurse recommend? a. Salmon b. Olive oil c. Red meat d. Leafy green vegetables ANS: A Foods rich in DHA are fatty fish (anchovies, salmon, herring, mackerel, tuna and halibut), eggs, and foods fortified with DHA. DIF:

Cognitive Level: Application

REF: 69

OBJ: 9

TOP: Nutrition for Pregnancy

KEY: Nursing Process Step: Implementation

14. The nurse encourages adequate intake of folic acid for women of child-bearing 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 TOP: Nutrition for Pregnancy

REF: 72 OBJ: 9 KEY: Nursing Process Step: Implementation

15. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. hCG detected in the urine d. Fetal heartbeat ANS: D Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, aNnU dR feS taI lm ovTeB m. enCtO s fMelt by the examiner.

NG DIF: Cognitive Level: Knowledge REF: 64 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection

OBJ: 6 | 7

16. At her initial prenatal visit, a woman asks, “When can I hear the baby’s heartbeat?” At what gestational age can the fetal heartbeat be auscultated with a Doppler? a. 4 weeks b. 10 weeks c. 18 weeks d. 24 weeks ANS: C The fetal heartbeat can be heard with a doppler around 10 weeks of pregnancy.

DIF: Cognitive Level: Knowledge REF: 64 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Data Collection

OBJ: 7

17. A woman pregnant for the first time asks the nurse, “When will I begin to feel the baby move?” What is the nurse’s best response? a. “You may notice the baby moving around the 4th or 5th month.” b. “Quickening varies with every woman.”

c. “You’ll feel something by the end of the first trimester.” d. “The baby will be big enough for you to feel in your 8th month.”

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

DIF: Cognitive Level: Knowledge REF: 64 TOP: Physiological Changes During Pregnancy KEY: Nursing Process Step: Implementation

OBJ: 7

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

ANS: C It is recommended that pregnant women take part in 150 minutes of moderate intensity physical activity per week and should be accumulated over a minimum of 3 days per week, although daily activity is encouraged.

DIF: Cognitive Level: Comprehension TOP: Exercise During Pregnancy

REF: 74 | 75 OBJ: 10 KEY: Nursing Process Step: Planning

19. An ultrasound confirms that aN1U6R-ySeI arN -oGldTgBi. rl C isOpMregnant. How does the need for prenatal care and counselling for adolescents differ from other age populations? a. A pregnant adolescent is experiencing two major life transitions at the same time. b. Adolescents who get pregnant are more likely to have other chronic health problems. c. Adolescents are at greater risk for multifetal pregnancies. d. At this age, a pregnant adolescent will accept the nurse’s advice.

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

DIF: Cognitive Level: Comprehension REF: 82 TOP: Psychological Adaptations to Pregnancy KEY: Nursing Process Step: Planning

OBJ: 15

20. At what age is a woman who becomes pregnant for the first time described as an “elderly primip”? a. After 25 years old b. After 28 years old c. After 30 years old d. After 35 years old ANS: D

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

DIF: Cognitive Level: Knowledge TOP: Elderly Primip

REF: 82 OBJ: 15 KEY: Nursing Process Step: N/A

21. The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the appropriate term for this sign? a. Chadwick b. Hegar c. McDonald d. Goodell ANS: D Goodell sign is one of the probable signs of pregnancy and describes a softened cervix and vagina.

DIF: Cognitive Level: Knowledge TOP: Signs of Pregnancy

REF: 63 OBJ: 1 | 6 | 7 KEY: Nursing Process Step: Implementation

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 HCP will order? a. Endovaginal ultrasound b. Pap test c. Complete blood count d. Hemoglobin electrophoreNsiU s RSINGTB.COM ANS: D Hemoglobin electrophoresis identifies the presence of sickle cell trait or disease (in women of African or Mediterranean descent). It is ordered in the first trimester, if indicated.

DIF: Cognitive Level: Comprehension TOP: Prenatal laboratory tests

REF: 61 OBJ: 3 KEY: Nursing Process Step: Implementation

23. A pregnant woman is attending her second prenatal visit. Prenatal lab work indicates she is not immune to the rubella virus. What is the most appropriate nursing intervention? a. Provide the rubella vaccine as ordered by the HCP immediately b. Teach the woman she should receive the vaccine in the hospital after birth 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 TOP: Immunizations

REF: 76 OBJ: 4 KEY: Nursing Process Step: Implementation

24. A woman who is 8 months pregnant reports feeling dizzy and lightheaded during an ultrasound. What is the priority nursing action? a. Give her an emesis basin b. Turn her on her side c. Put a cool cloth on her forehead d. Assess the woman’s pulse ANS: B Supine hypotension also called aortocaval compression, may occur if the woman lies on her back. Symptoms of supine hypotension include faintness, light-headedness, dizziness, and agitation. Displacing the uterus to one side by turning the patient (preferably to the left) is all that is needed to relieve the pressure.

DIF: Cognitive Level: Application TOP: Physiological Changes

REF: 66 OBJ: 4 KEY: Nursing Process Step: Implementation

25. A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does a nurse explain as the most likely cause of this symptom? a. Supine hypotension b. Gestational diabetes c. Pregnancy-induced hypertension d. Malnutrition ANS: A Supine hypotension also called aortocaval compression, may occur if the woman lies on her back. Symptoms of supine hypotension syndrome include faintness, light-headedness, dizziness, and agitation.

NURSINGTB.COM DIF: Cognitive Level: Comprehension TOP: Physiological Changes

REF: 66 OBJ: 7 KEY: Nursing Process Step: Data Collection

26. A nurse is counselling a pregnant woman on the use of safe herbs to consume during pregnancy. Which of the following herbs would be considered safe? a. Lemon tea b. St. John’s wort c. Feverfew d. Kava ANS: A St. John’s wort, feverfew, and kava are contraindicated in pregnancy. See Table 4.4 for a list of other herbal remedies that are contraindicated during pregnancy.

DIF: Cognitive Level: Knowledge REF: 77 OBJ: 13 TOP: Herbal remedies during Pregnancy KEY: Nursing Process Step: Implementation MULTIPLE RESPONSE 1. A woman who is 36 weeks pregnant tells a nurse she plans to take a 12-hour flight to Africa.

What would the nurse teach the patient to do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return.

b. c. d. e.

Eat a large meal before boarding the flight.

Request a seat with greater leg room.

Drink at least 120 mL of water every hour.

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 TOP: Travel during Pregnancy

REF: 76 OBJ: 11 KEY: Nursing Process Step: Implementation

2. The nurse teaches a patient that the pelvic joints relax due to hormonal changes in late pregnancy. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine ANS: A, B A waddling gait and joint instability are the only signs that relate to joint changes. The other discomforts are related to the enlarging uterus with its attendant weight.

DIF: Cognitive Level: Comprehension REF: 68 OBJ: 7 TOP: Joint Changes EY NURSINGTBK .C O:M Nursing Process Step: Implementation 3. The nurse assesses the progress from the announcement phase of parenthood to the adjustment phase when the woman reports which actions by the partner? (Select all that apply.) a. Goes fishing every afternoon b. Has revised a financial plan c. Spends leisure time with friends d. Trades sports car for a sedan e. Helps in selecting a crib ANS: B, D, E Active planning for an infant is an indication of the adjustment phase. Concentration on a hobby and spending time away from home are indicators of a lack of adjustment.

DIF: Cognitive Level: Comprehension TOP: Stages of Parenthood

REF: 82 OBJ: 14 KEY: Nursing Process Step: Data Collection

4. What nursing interventions are appropriate for the prenatal patient in terms of prenatal care?

(Select all that apply.) a. Offer nutritional counselling b. Teach about tasks of parenthood c. Reduce risk factors d. Improve health practices

e. Make financial arrangements for after the birth ANS: A, B, C, D Nutritional counselling, discussing the roles of parenthood, reducing risk factors for the pregnant woman and the fetus, and improving health practices are all goals of prenatal care.

DIF: Cognitive Level: Comprehension TOP: Goals of Prenatal Care

REF: 58 OBJ: 2 | 3 KEY: Nursing Process Step: Implementation

5. A nurse teaches a woman that which of the following nutrients are important to increase during pregnancy? (Select all that apply.) a. Iron b. Calcium c. Folic acid d. Vitamin A e. Protein ANS: A, C, E Iron, folic acid, and protein are all important nutrients that need to be increased during pregnancy. Calcium and vitamin A intake should be the same as for the non-pregnant woman.

DIF: Cognitive Level: Comprehension TOP: Nutrition for Pregnancy

REF: 71 | 72 | 73 OBJ: 9 KEY: Nursing Process Step: Data Collection

6. A nurse recognizes which behaviour characteristic(s) of women in their first trimester of pregnancy? (Select all that apNpU lyR.)SINGTB.COM a. Showing off her ultrasound photos b. Ambivalence about pregnancy c. Emotional and labile mood d. Focusing on her infant e. Fatigue ANS: A, B, C, E Showing off photos, feeling ambivalence about the pregnancy, fragile emotions, and fatigue and sleepiness are all characteristic behaviours seen in the first trimester. Women are not focused on their infant; they are focused on themselves and the physical changes they are experiencing.

DIF: Cognitive Level: Comprehension TOP: Behaviours of First Trimester

REF: 80 OBJ: 14 KEY: Nursing Process Step: Data Collection

7. A nurse is teaching a pregnant woman who smokes 10 cigarettes per day some of the risks of smoking during pregnancy. The nurse’s teaching includes which of the following topics?

(Select all that apply) a. Increased birth weight in the fetus b. Increased risk of SIDS in the newborn c. Increased chance the pregnancy will go past the due date d. Increased risk of spontaneous abortion in the woman e. Increased rates of asthma in the child

ANS: B, D, E Smoking during pregnancy may increase the risk of premature birth and spontaneous abortion in the mother. The impact on the fetus includes lower birth weight and increased risk of sudden infant death syndrome (SIDS), asthma, and upper and lower respiratory tract illness.

DIF: Cognitive Level: Comprehension TOP: Smoking during Pregnancy

REF: 75 | 76 OBJ: 17 KEY: Nursing Process Step: Implementation

8. Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later stages of pregnancy? (Select all that apply.) a. Leg lifts b. Pelvic rock c. Tailor sitting d. Sit-ups e. Shoulder curling ANS: B, C, E Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial because they both increase intra-abdominal pressure.

DIF: Cognitive Level: Comprehension TOP: Pregnancy Exercises

REF: 75 OBJ: 10 | 11 KEY: Nursing Process Step: Implementation

9. A nurse is obtaining intake information on a new patient being seen for preconception care MTD). What interventions can the nurse and notes a family history of N neUuRraSl I tuN beGdTeBfe.cC tsO(N suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid exposure to high heat. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the first trimester.

ANS: A, C Exposure to high heat in the first trimester can increase the risk of an NTD. The Society of Obstetricians and Gynecologist of Canada (SOGC) recommends that all women of childbearing age who have low risk, take a daily multivitamin that contains 0.4 mg of folic acid throughout pregnancy. Women who have high risk of having a fetus with an NTD (e.g., diabetes, epilepsy, obesity or a family history of NTD) should take 1.0 mg of folic acid prior to pregnancy and for the first 3 months of the pregnancy, at which time this can be decreased to 0.4 mg. Daily exercise and bed rest do not decrease the risk of NTD. DIF: Cognitive Level: Comprehension REF: 72 OBJ: 3 TOP: Prevention of Neural Tube Defects KEY: Nursing Process Step: Planning COMPLETION

1. The nurse reminds the prenatal patient that she should add in the third trimester to nourish the fetus.

kcal to her daily intake

ANS: 450 The recommended dietary intake increase is 450 kcal a day in the third trimester.

DIF: Cognitive Level: Comprehension TOP: Nutrition for Pregnancy

REF: 69 OBJ: 9 KEY: Nursing Process Step: Implementation

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Chapter 05: Nursing Care of Women with Complications During Pregnancy Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness? a. Hyperemesis gravidarum usually lasts for the duration of the pregnancy. b. Hyperemesis gravidarum causes dehydration and electrolyte imbalances. c. Sensitivity to smells is usually the cause of vomiting in hyperemesis gravidarum. d. The woman with hyperemesis gravidarum will have persistent vomiting without weight loss.

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

DIF: Cognitive Level: Comprehension TOP: Hyperemesis

REF: 92 OBJ: 3 KEY: Nursing Process Step: Implementation

2. A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing some tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms? a. Inevitable abortion NURSINGTB.COM b. Incomplete abortion c. Complete abortion d. Missed abortion ANS: B Signs and symptoms of an incomplete abortion are similar to those of an inevitable abortion, but some tissue is passed.

DIF: Cognitive Level: Comprehension REF: 96 | 97 | 98 OBJ: 4 TOP: Abortion KEY: Nursing Process Step: Data Collection 3. A nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse? a. “There is usually something wrong with the fetus when this happens early in pregnancy.” b. “Now there. You can try to conceive on your next cycle.” c. “I’m here if you need to talk.” d. “You are young and strong. I know you can have a healthy pregnancy.”

ANS: C An effective technique when communicating with a woman experiencing pregnancy loss is to say, “I’m here if you need to talk.” The nurse listens and acknowledges the woman’s grief.

DIF: Cognitive Level: Application TOP: Dilation and Evacuation (D&E)

REF: 97 OBJ: 3 KEY: Nursing Process Step: Implementation

4. A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding accompanied by abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman understands the explanation of an ectopic pregnancy? a. “The chorionic villi develop vesicles within the uterus.” b. “The placenta develops in the lower part of the uterus.” c. “The fetus dies in the uterus during the first half of the pregnancy.” d. “The embryo is implanted in the fallopian tube.”

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

DIF: Cognitive Level: Comprehension TOP: Ectopic Pregnancy

REF: 100 OBJ: 3 KEY: Nursing Process Step: Evaluation

5. A woman who is 32 weeks pregnant has an ultrasound that reveals the placenta implanted over the entire cervical os. What does the nurse understand best describes this condition? a. Low-lying placenta b. Marginal placenta previa c. Partial placenta previa d. Total placenta previa ANS: D A total placenta previa descriN beUsRaScI onNdG itT ioB n. inCw OhMich the placenta completely covers the cervical opening.

DIF: Cognitive Level: Comprehension TOP: Placenta Previa

REF: 101 OBJ: 3 KEY: Nursing Process Step: Data Collection

6. What symptom presented by a pregnant woman is indicative of placental abruption? a. Painless vaginal bleeding b. Uterine irritability with contractions c. Vaginal bleeding and back pain d. Premature rupture of membranes ANS: C Bleeding accompanied by abdominal or lower back pain is a typical manifestation of placental abruption.

DIF: Cognitive Level: Knowledge TOP: Placental Abruption

REF: 103 OBJ: 3 KEY: Nursing Process Step: Data Collection

7. What situation would concern the nurse about the presence of Rh incompatibility? a. Rh-negative mother, Rh-positive fetus b. Rh-positive mother, Rh-negative fetus c. Rh-negative mother, Rh-negative fetus d. Rh-positive mother, Rh-positive fetus

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

DIF: Cognitive Level: Analysis TOP: Rh Incompatibility

REF: 108 OBJ: 3 KEY: Nursing Process Step: N/A

8. A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh antibodies from forming? a. Rh immune globulin during labour b. Intrauterine transfusions with O-negative blood c. Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant d. Rh immune globulin now and again in the last trimester ANS: C An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after the birth of an Rh-positive infant or abortion.

DIF: Cognitive Level: Comprehension TOP: Rh Incompatibility

REF: 108 OBJ: 3 KEY: Nursing Process Step: Implementation

9. A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. A nurse recognizes these factors are most likely symptoms of which condition? a. Toxoplasmosis b. Placental abruption c. Hydatidiform mole NURSINGTB.COM d. Diabetes mellitus ANS: D Large (macrosomic) infants over 4000 g are linked to gestational diabetes.

DIF: Cognitive Level: Comprehension TOP: Gestational Diabetes Mellitus

REF: 109 OBJ: 4 KEY: Nursing Process Step: Data Collection

10. A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism in what way. a. Placental hormones increase the resistance of cells to insulin. b. Insulin cells cannot meet the body’s demands as the woman’s weight increases. c. There is a decreased production of insulin during pregnancy. d. The speed of insulin breakdown is decreased during pregnancy.

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

DIF: Cognitive Level: Comprehension TOP: Diabetes Mellitus

REF: 109 OBJ: 4 KEY: Nursing Process Step: Implementation

11. Why does the woman taking oral hypoglycemic agents to control diabetes mellitus need to take insulin during pregnancy?

a. b. c. d.

Insulin can cross the placental barrier to the fetus.

Oral hypoglycemic agents are teratogenic.

Oral agents do not cross the placenta.

Oral agents are not sufficient to meet maternal insulin needs.

ANS: D Oral hypoglycemic agents can be used during pregnancy, but insulin is also required as the oral hypoglycemic are not effective enough.

DIF: Cognitive Level: Comprehension TOP: Diabetes Mellitus

REF: 110 OBJ: 4 KEY: Nursing Process Step: Implementation

12. A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that her infant will also contract hepatitis B. What will a nurse explain to this woman? a. The infant will be given a single dose of hepatitis immune globulin after birth. b. The infant will be able to use the antibodies from the immunizations given to the patient before the birth. c. The infant will not have hepatitis B because the virus does not pass through the placental barrier. d. The infant will be immune to hepatitis B because of the mother’s infection.

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

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DIF: Cognitive Level: Comprehension REF: 116 | 117 OBJ: 4 TOP: Hepatitis B KEY: Nursing Process Step: Implementation 13. What will a nurse begin with when asking a patient about substance use during a prenatal history? a. “Do you smoke, drink alcohol, or use drugs?” b. “Do you ever use prescription or street drugs?” c. “What over-the-counter (OTC) and prescription drugs have you taken in the past 3 months?” d. “We need to know if you take drugs so we can help your baby.”

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

DIF: Cognitive Level: Application REF: 120 TOP: Interviewing Relative to Substance Use KEY: Nursing Process Step: Data Collection

OBJ: 5

14. A nurse assesses a pregnant woman for gestational hypertension. What of the following signs would be most concerning? a. Increased urine output

b. Epigastric pain c. Urine protein 1+ on dipstick d. Swelling of the feet and ankles ANS: B Epigastric pain occurs because of liver edema, ischemia, and necrosis and often precedes a convulsion.

DIF: Cognitive Level: Knowledge TOP: Hypertension

REF: 105 OBJ: 4 KEY: Nursing Process Step: Data Collection

15. A patient with gestational hypertension is exhibiting all of the signs listed. What should the nurse report immediately? a. Diarrhea b. Urticaria c. Blurred vision d. Backache ANS: C Visual disturbances indicate worsening gestational hypertension and must be reported promptly for effective intervention to prevent severe pre-eclampsia and convulsion.

DIF: Cognitive Level: Application TOP: Gestational Hypertension

REF: 105 OBJ: 4 KEY: Nursing Process Step: Planning

16. A patient who is 28 weeks pregnant presents with gestational hypertension. What need would the nurse make the firsNt U prRioSriItyN?GTB.COM a. Bed rest b. Decrease protein intake c. Limiting fluid intake d. Instruction about fetal kick counts ANS: D Fetal kick counts can be reassuring that the fetus remains healthy in the uterus. Bed rest is not recommended for women because of the increased risk of complications it causes.

Activity restriction is recommended.

DIF: Cognitive Level: Application TOP: Gestational Hypertension

REF: 106 OBJ: 4 KEY: Nursing Process Step: Implementation

17. A nurse is caring for a pregnant woman diagnosed with pre-eclampsia. What will the nurse explain is the objective of magnesium sulphate therapy for this patient? a. To prevent seizures b. To promote diaphoresis c. To increase reflex irritability d. To act as a diuretic ANS: A Magnesium sulphate is a central nervous system depressant given to prevent seizures.

DIF:

Cognitive Level: Knowledge

REF: 105

OBJ: 4

TOP: Magnesium Sulphate

KEY: Nursing Process Step: Implementation

18. A nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulphate. What is the highest priority nursing intervention? a. Count respirations and report a rate of less than 12 breaths/minute. b. Count respirations and report a rate of more than 20 breaths/minute. c. Check blood pressure and report a rate of less than 100/60 mm Hg. d. Monitor urinary output and report a rate of less than 100 mL/hr.

ANS: A Excessive magnesium sulphate may cause respiratory depression.

DIF: Cognitive Level: Application TOP: Magnesium Sulphate

REF: 107 OBJ: 4 KEY: Nursing Process Step: Implementation

19. What medication will the nurse plan to have available for immediate IV administration whenever magnesium sulphate is administered to a woman who has pre-eclampsia? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline) ANS: C Calcium gluconate reverses the effects of magnesium sulphate and should be available for immediate use when a woman receives magnesium sulphate.

DIF: Cognitive Level: ComNpUreRhS enIsN ioG n TBR OBJ: 4 .ECFO:M 107 TOP: Magnesium Sulphate KEY: Nursing Process Step: Planning 20. A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, “Will I be able to give birth vaginally?” What explanation by the nurse is the most appropriate? a. “Yes, you can give birth vaginally until 36 weeks.” b. “A vaginal birth can be attempted, but if bleeding occurs, a caesarean section will be done.” c. “A caesarean section is performed when the mother has a total placenta previa.” d. “There is no reason why you cannot have a vaginal birth.”

ANS: C A caesarean birth is done for a total placenta previa.

DIF: Cognitive Level: Application TOP: Placenta Previa

REF: 103 OBJ: 4 KEY: Nursing Process Step: Implementation

21. The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus. What can result from maternal rubella during pregnancy? a. Facial abnormalities b. Developmental delays c. Liver failure d. Limb deformities ANS: B

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

DIF: Cognitive Level: Knowledge REF: 116 OBJ: 4 TOP: Rubella KEY: Nursing Process Step: Implementation 22. What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis? a. Frequency and urgency of urination b. Nausea and weight loss c. Burning sensation when voiding d. Tenderness in the flank area ANS: D Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills, flank pain or tenderness, nausea, and vomiting.

DIF: Cognitive Level: Comprehension TOP: Pyelonephritis

REF: 119 OBJ: 5 KEY: Nursing Process Step: Data Collection

23. The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient? a. Flat on her back with knees flexed to help prevent hemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowler’s position to prevent supine hypotension d. In the knee-chest positionNtU oR reSdI ucNeGpT reB ss. urCeOoM n the placenta ANS: B The prenatal patient with placenta previa is best placed on her side with a pillow for support.

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

DIF: Cognitive Level: Application TOP: Placenta Previa

REF: 103 OBJ: 4 KEY: Nursing Process Step: Implementation

24. The young prenatal patient with gestational diabetes mellitus (GDM) says, “I am frightened that I will have to deal with insulin injections for the rest of my life.” What is the best response by the nurse? a. “After birth your health care provider will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections.” b. “Have you considered an insulin pump?” c. “After a while those insulin injections won’t seem so bad.” d. “It will most likely resolve right after the baby is born.”

ANS: D GDM usually resolves shortly after birth.

DIF: Cognitive Level: Application REF: 109 OBJ: 4 TOP: GDM KEY: Nursing Process Step: Implementation

25. The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks’ gestation.

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

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

DIF: Cognitive Level: Application TOP: Diagnostic Tests

REF: 93 OBJ: 2 KEY: Nursing Process Step: Implementation

26. The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will the nurse assess for in the newborn? a. Meconium ileus b. Diarrhea c. Hypoglycemia d. Muscle tremors ANS: C The fetus responds to the hypNerg aT frB om URlySceImNiG .CthOe Mmother’s blood and produces increased insulin. This insulin may cause hypoglycemia in the infant after it is no longer exposed to the mother’s blood.

DIF: Cognitive Level: Application TOP: Infant of a Diabetic Mother

REF: 109 OBJ: 5 KEY: Nursing Process Step: Data Collection

27. A newly pregnant woman attends the clinic and states that she smokes 15 cigarettes per day.

What should a nurse inform the woman? a. “Smoking can cause the pregnancy to go overdue.” b. “You should not stop smoking completely as it will be difficult on the fetus.” c. “Smoking can cause the fetus to be smaller.” d. “Smoking will not cause any long-term effects to the child.”

ANS: C Smoking can cause fetal growth restriction as well as preterm labour. It is better for the woman and fetus for her to quit during the pregnancy. This will not have a negative impact on the fetus.

DIF: Cognitive Level: Knowledge TOP: Smoking during Pregnancy MULTIPLE RESPONSE

REF: 121 OBJ: 3 KEY: Nursing Process Step: Implementation

1. The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.) a. Toxoplasmosis b. Toxemia c. Cytomegalovirus d. Rubella e. Herpes simplex ANS: A, C, D, E The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.

DIF: Cognitive Level: Knowledge TOP: TORCH Infections

REF: 115 OBJ: 5 KEY: Nursing Process Step: Implementation

2. The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might result in which concerns? (Select all that apply.) a. Disruption of family roles b. Financial pressures c. Excessive attachment to infant d. Frustration with activity restriction e. Alteration in childcare practices ANS: A, B, D, E Women with high-risk pregnancies may have concerns about disruption of family roles, financial pressures, delayed attachment to the infant, alteration in childcare practices, and frustration with activity restriction.

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DIF: Cognitive Level: Comprehension TOP: Impact of High-Risk Pregnancies

REF: 124 OBJ: 8 KEY: Nursing Process Step: Implementation

3. What would the nurse include in a teaching plan for the pregnant patient who has iron deficiency anemia and has been placed on iron supplements? (Select all that apply.) a. Citrus fruits enhance absorption of iron. b. Bran products support iron deficiency. c. Milk will disguise the taste of the iron. d. The iron therapy will continue for about 3 months after the iron levels are corrected. e. Tea should be avoided while taking iron.

ANS: A, D, E Calcium, bran, and milk interfere with the absorption of iron: vitamin C helps with the absorption of iron. The therapy usually lasts 3 months after correction of iron levels. The tannic acid in tea interferes with the absorption of iron.

DIF: Cognitive Level: Application TOP: Iron Deficiency Anemia

REF: 114 OBJ: 4 KEY: Nursing Process Step: Implementation

4. The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection for what reasons? (Select all that apply.) a. Vaginal organisms can reach the placenta more easily.

b. c. d. e.

The undernourished placenta becomes necrotic.

The woman is at increased risk for a postpartum hemorrhage.

The placenta is an excellent growth medium.

The misplaced placenta weakens the uterine wall.

ANS: A, C, D Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the nutrient-rich environment of the placenta. The weak musculature of the lower segment of the uterus may cause postpartum hemorrhage and therefore the blood vessels are open rather than closed with an increased risk for organisms to enter.

DIF: Cognitive Level: Comprehension TOP: Infection with Placenta Previa

REF: 103 OBJ: 4 KEY: Nursing Process Step: Planning

5. The nurse is obtaining history and physical information on a new patient attending her first prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH incompatibility c. Hypertension d. Pre-eclampsia e. Infection ANS: A, C, D The obese woman who is pregnant has a high risk for developing complications during pregnancy such as gestationaN l dUiaRbSetIes, rteCnO siM on, cardiac problems, pre-eclampsia, and NGhyTpBe. respiratory problems.

DIF: Cognitive Level: Comprehension REF: 115 OBJ: 5 TOP: Obesity KEY: Nursing Process Step: Data Collection 6. A woman, G3T2P0A0L2, is attending her fourth prenatal visit and confides in the nurse that she is abused by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.) a. Tell the husband that authorities will be notified immediately. b. Provide privacy for the assessment. c. Determine if children are being hurt. d. Communicate in a nonjudgmental way. e. Determine factors that increase the risk of injury.

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

DIF: Cognitive Level: Application TOP: Intimate Partner Violence

REF: 123 OBJ: 7 KEY: Nursing Process Step: Implementation

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Chapter 06: Nursing Care of Mother and Infant During Labour and Birth Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What does a nurse note when measuring the frequency of a labouring woman’s contractions? a. How long the patient states the contractions last. b. The time between the end of one contraction and the beginning of the next. c. The time between the beginning and the end of one contraction. d. The time between the beginning of one contraction and the beginning of the next.

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

DIF: Cognitive Level: Comprehension TOP: Frequency of Contractions

REF: 132 OBJ: 8 KEY: Nursing Process Step: Data Collection

2. Why is the relaxation phase between contractions important? a. The labouring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward birth at these times.

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ANS: C Blood flow from the mother into the placenta gradually decreases during contractions.

During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

DIF: Cognitive Level: Comprehension REF: 132 TOP: Contractions KEY: Nursing Process Step: N/A

OBJ: 4

3. What contraction duration and interval does a nurse recognize could result in fetal compromise? a. Duration shorter than 30 seconds, interval longer than 75 seconds b. Duration shorter than 90 seconds, interval longer than 120 seconds c. Duration longer than 90 seconds, interval shorter than 60 seconds d. Duration longer than 60 seconds, interval shorter than 90 seconds ANS: C Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

DIF: Cognitive Level: Comprehension TOP: Contraction/Fetal Compromise

REF: 133 OBJ: 4 KEY: Nursing Process Step: Data Collection

4. Vaginal examination reveals the presenting part is the infant’s head, which is well flexed on the chest. What is this presentation? a. Vertex b. Military c. Brow d. Face ANS: A In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

DIF: Cognitive Level: Comprehension TOP: Fetal Position

REF: 135 OBJ: 3 KEY: Nursing Process Step: Data Collection

5. What might meconium-stained amniotic fluid indicate when the infant is in a vertex presentation? a. Fetal distress b. Fetal maturity c. Intact gastrointestinal tract d. Dehydration in the mother ANS: A Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it may be an indicator of fetal compromise. More frequent fetal monitoring will be required.

DIF: Cognitive Level: Comprehension REF: 151 TOP: Meconium-Stained AN mU niRoS ticIFNlG uiT d B.COM KEY: Nursing Process Step: Data Collection

OBJ: 4

6. It is determined that the presenting part of the fetus is the buttocks. At birth the fetus’s hips are flexed and the knees are extended. How would a nurse record this presentation? a. Complete breech b. Frank breech c. Double footling d. Buttocks presentation ANS: B When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.

DIF: Cognitive Level: Application TOP: Fetal Position

REF: 135 OBJ: 3 | 4 KEY: Nursing Process Step: Data Collection

7. At a prenatal visit, a primigravida asks a nurse how she will know her labour has started.

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

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

DIF: Cognitive Level: Application TOP: Initiation of Labour

REF: 143 OBJ: 6 KEY: Nursing Process Step: Implementation

8. While discussing labour and birth during a prenatal visit, a primigravida who is Group B Streptococcus (GBS) positive, asks a nurse when she should go to the hospital. What is the nurse’s most informative response? a. “When you pass the mucous plug.” b. “When your contractions are 7 minutes apart.” c. “When your membranes have ruptured.” d. “When abdominal or groin discomfort occurs.”

ANS: C Ruptured membranes are an indication that the woman should go to the hospital or birthing centre if she is GBS positive.

DIF: Cognitive Level: Application REF: 143 TOP: Admission to the Hospital or Birth Centre KEY: Nursing Process Step: Implementation

OBJ: 5

9. A nurse is caring for a woman in the first stage of labour. What will the nurse remind the patient about contractions during this stage of labour? a. They get the infant positioned for birth. b. They push the infant into the vagina. c. They dilate and efface theNcUeR rvS ixI. NGTB.COM d. They get the mother prepared for true labour.

ANS: C The first stage of labour describes the time from the onset of labour until full dilation of the cervix.

DIF: Cognitive Level: Comprehension TOP: First Stage of Labour

REF: 144 OBJ: 5 KEY: Nursing Process Step: Implementation

10. A woman is 7 cm dilated and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does a nurse assess as the most likely explanation for the woman’s change in behaviour? a. Labour has progressed to the late active phase. b. She lacked adequate preparation for the labour experience. c. The woman would benefit from a different form of analgesia. d. The contractions have increased from mild to moderate intensity.

ANS: A If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the late active phase of labour.

DIF: Cognitive Level: Analysis TOP: Stages of Labour

REF: 144 OBJ: 5 KEY: Nursing Process Step: Data Collection

11. What is the function of contractions during the second stage of labour? a. Align the infant into the proper position for birth b. Dilate and efface the cervix c. Push the infant out of the mother’s body d. Separate the placenta from the uterine wall ANS: C The contractions push the infant out of the mother’s body as the second stage of labour ends with the birth of the infant.

DIF: Cognitive Level: Knowledge TOP: Second Stage of Labour

REF: 144 | 145 OBJ: 5 KEY: Nursing Process Step: Implementation

12. What marks the end of the third stage of labour? a. Full cervical dilation b. Expulsion of the placenta and membranes c. Birth of the infant d. Engagement of the head ANS: B The third stage of labour extends from the birth of the infant until the placenta is detached and expelled.

DIF: Cognitive Level: Knowledge REF: 145 TOP: Third Stage of Labour KEY: Implementation NURSINGTB.COM

OBJ: 5 Nursing Process Step:

13. Why should a nurse encourage the mother to void during the fourth stage of labour? a. A full bladder could interfere with cervical dilation. b. A full bladder could obstruct progress of the infant through the birth canal. c. A full bladder could obstruct the passage of the placenta. d. A full bladder could predispose the mother to uterine hemorrhage.

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

DIF: Cognitive Level: Comprehension REF: 145 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Implementation

OBJ: 5

14. A nurse observes the patient bearing down with contractions and crying out, “The baby is coming!” What is the best nursing intervention? a. Find the primary health care provider. b. Stay with the woman and use the call bell to get help. c. Send the woman’s partner to locate a registered nurse. d. Assist with deep breathing to slow the labour process.

ANS: B

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

DIF: Cognitive Level: Application TOP: Imminent Birth

REF: 153 OBJ: 8 KEY: Nursing Process Step: Implementation

15. A nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate? a. A well-oxygenated fetus b. Compression of the umbilical cord c. Compression of the fetal head d. Uteroplacental insufficiency ANS: A Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

DIF: Cognitive Level: Analysis TOP: Fetal Accelerations

REF: 148 OBJ: 8 KEY: Nursing Process Step: Data Collection

16. What is the most appropriate statement from a nurse when coaching the labouring woman with a fully dilated cervix to push? a. “At the beginning of a contraction, hold your breath and push for 10 seconds.” b. “Take a deep breath and push between contractions.” c. “Begin pushing when a contraction starts and continue for the duration of the contraction.” d. “At the beginning of a contraction, take a deep breath and keep your glottis open while pushing.”

NURSINGTB.COM ANS: D When the cervix is fully dilated, the woman should take a deep breath and then push while exhaling.

DIF: Cognitive Level: Application TOP: Second Stage of Labour

REF: 158 OBJ: 8 KEY: Nursing Process Step: Implementation

17. What is the most important nursing intervention during the fourth stage of labour? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding.

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

DIF: Cognitive Level: Comprehension TOP: Fourth Stage of Labour

REF: 160 OBJ: 8 KEY: Nursing Process Step: Implementation

18. One hour after a birth a nurse notes a new mother has saturated three perineal pads. What is the most appropriate nursing action? a. Check the fundus for position and firmness.

b. Report to the health care provider immediately. c. Change the pads and chart the time. d. Time how long it takes to soak one pad.

ANS: A Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad per hour is an acceptable rate for immediate post birth blood loss.

DIF: Cognitive Level: Application TOP: Postpartum Hemorrhage

REF: 161 OBJ: 8 KEY: Nursing Process Step: Implementation

19. While caring for a labouring woman, a nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse’s initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula.

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

DIF: Cognitive Level: Application TOP: Decelerations

REF: 150 OBJ: 8 KEY: Nursing Process Step: Implementation

20. How should a nurse interveneNtUoRreSliI evNeGpTerBin.eC alObM ruising and edema following birth? a. Use ice packs intermittently on the area for 24 hours. b. Place a warm pack on the perineal area for 24 hours. c. Administer Aspirin to relieve inflammation. d. Change the perineal pad frequently.

ANS: A An ice pack can be placed on the mother’s perineum to reduce bruising and edema for 24 hours followed by warm packs after 24 hours after birth.

DIF: Cognitive Level: Application TOP: Postpartum Comfort

REF: 161 OBJ: 8 KEY: Nursing Process Step: Implementation

21. At 1 and 5 minutes of life, a newborn’s Apgar score is 9. What does the nurse understand that a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in a stable condition.

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

DIF: Cognitive Level: Comprehension TOP: Care of the Infant After Birth

REF: 160 OBJ: 9 KEY: Nursing Process Step: Data Collection

22. A nursing student assisting a woman in labour asks the instructor, “What does it mean when the baby is at minus 1 station?” After being given an explanation by the nursing instructor, what statement by the student indicates an accurate understanding of station? a. “Fetal head is above the ischial spines.” b. “Fetal head is below the ischial spines.” c. “Fetal head is engaged in the mother’s pelvis.” d. “Fetal head is visible at the perineum.”

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

DIF: Cognitive Level: Comprehension TOP: Mechanisms of Labour

REF: 139 OBJ: 5 KEY: Nursing Process Step: Evaluation

23. A nurse formulates a nursing diagnosis for a woman in the fourth stage of labour. What is the most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fear related to the probable need for caesarean birth. c. Dysuria related to prolonged labour and decreased intake. d. Risk for injury related to hemorrhage.

ANS: D In the fourth stage of labour, N aU prRioSriItyNnGuT rsB in.gCaO ctM ion is identifying and preventing hemorrhage.

DIF: Cognitive Level: Application REF: 160 TOP: Nursing Care Immediately After Birth KEY: Nursing Process Step: Nursing Diagnosis

OBJ: 5 | 8

24. A nurse is caring for a patient who is not certain if she is in true labour. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient? a. By offering the patient warm fluids to drink b. By helping the patient to ambulate in the room c. By seating the patient upright in a straight-back chair d. By positioning the patient on her left side ANS: B Ambulation will stimulate effacement and intensify contractions if the patient is in true labour.

DIF: Cognitive Level: Application REF: 143 TOP: Differentiating Between True and False Labour KEY: Nursing Process Step: Implementation

OBJ: 6 | 7 | 8

25. What is the best nursing action to implement when late decelerations occur? a. Turn the patient to lateral position.

b. Decrease flow of intravenous (IV) fluids. c. Increase oxygen to 10 L/minute. d. Prepare to increase oxytocin drip.

ANS: A The major objective of care for late decelerations is to increase maternal blood flow to the uterus. This is done by turning the woman to her side. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped. Administering oxygen will not likely improve blood flow in a woman who has good oxygen saturation.

DIF: Cognitive Level: Application TOP: Late Decelerations

REF: 150 OBJ: 8 KEY: Nursing Process Step: Implementation

26. What is the nurse primarily concerned about maintaining in the initial care of the newborn? a. Fluid intake b. Feeding schedule c. Thermoregulation d. Parental bonding ANS: C Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low.

Hypothermia can cause cold stress, which leads to hypoxia.

DIF: Cognitive Level: Comprehension TOP: Thermoregulation

REF: 163 OBJ: 9 KEY: Nursing Process Step: Planning

27. A pregnant woman, G2T1P0N AU 0LR1S, I teN llsGtT heBn.uCrsOeMshe desires a VBAC (vaginal birth after caesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labour and birth? a. Eclampsia b. Placental abruption c. Congestive heart failure d. Uterine rupture ANS: D Nursing care for women who plan to have a VBAC is similar to that for women who have had no caesarean births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all labouring women, regardless of whether they have had a previous caesarean birth.

DIF: Cognitive Level: Comprehension REF: 158 OBJ: 7 TOP: VBAC KEY: Nursing Process Step: Data Collection 28. The primary health care provider performs an amniotomy on a labouring woman. What will be the nurse’s priority assessment immediately following this procedure? a. Fetal heart rate (FHR) b. Fluid amount c. Maternal blood pressure d. Intensity of contractions

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

Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and intensity of contractions are not priority assessments following rupture of membranes.

DIF: Cognitive Level: Application TOP: Rupture of Membranes

REF: 151 OBJ: 8 KEY: Nursing Process Step: Data Collection

29. What do late decelerations most likely indicate? a. Decreased amniotic fluid volume b. Uteroplacental insufficiency c. Head compression d. Cord compression ANS: B Late decelerations indicate uteroplacental insufficiency. Variable decelerations indicate cord compression and early decelerations indicate head compressions.

DIF: Cognitive Level: Comprehension TOP: Late Decelerations

REF: 150 OBJ: 4 | 5 KEY: Nursing Process Step: Data Collection

30. A woman is admitted to the labour unit. On assessment her cervix is 3 cm dilated and 50% effaced. A nurse knows this woman is in which stage of labour? a. Active phase NURSINGTB.COM b. Latent phase c. Second stage d. Third stage ANS: B Latent (early) labour is defined as 0–3 cm dilation.

DIF: Cognitive Level: Knowledge TOP: Stages of Labour

REF: 144 OBJ: 4 | 5 KEY: Nursing Process Step: Data Collection

31. A woman is having a difficult labour because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief? a. Prone with legs supported b. Lateral position with legs bent at the knee c. Standing with support d. Hands and knees ANS: D Hands and knees position encourages fetal rotation and descent and is helpful for the woman with back labour as there is access to her back for massage.

DIF:

Cognitive Level: Application

REF: 156

OBJ: 8

TOP: Abnormal Labour

KEY: Nursing Process Step: N/A

32. What nursing care should be provided to a woman with a third-degree laceration immediately after the birth? a. Warm compresses to the perineum b. Cold pack to the perineum c. Warm sitz bath d. Elevation of hips to prevent edema ANS: B Ice is applied to the perineum to reduce bruising and edema.

DIF: Cognitive Level: Application REF: 161 OBJ: 3 TOP: Obstetric Procedures—Lacerations KEY: Nursing Process Step: Implementation MULTIPLE RESPONSE 1. Which of the following are true about home births? (Select all that apply.) a. Good alternative for low risk women b. Increased risk for infection c. Lower rates of intervention d. Attended by registered midwives e. Unsafe for most women ANS: A, C, D Home births attended by midwives in a jurisdiction where home birth is well-integrated into the health care system is not N asU soRcS iaI teN dG wT itB h. aC diO ffM erence in serious adverse newborn outcomes but rather associated with fewer intrapartum interventions. There is a decreased risk of exposure to infections.

DIF: Cognitive Level: Comprehension TOP: Birth Alternatives

REF: 131 OBJ: 2 KEY: Nursing Process Step: Implementation

2. A pregnant woman arrives at the emergency department and reports she is in labour. After a thorough examination and diagnostic testing, it is determined to be prelabour (prodromal).

What signs and symptoms would lead the nurse to determine prelabour? (Select all that apply.) a. Leaking of vaginal fluid b. Contractions intensify with ambulation c. Pink spotting d. Discomfort is felt in abdominal muscles e. Cervix thick and not effaced ANS: D, E Discomfort in the abdomen and groin instead of lower back and lower abdomen as well as a thick cervix that is not effaced indicate prelabour. Leaking of vaginal fluid may indicate rupture of membranes and is a sign of true labour. Contractions that intensify with ambulation and pink spotting (bloody show) are signs of true labour.

DIF:

Cognitive Level: Comprehension

REF: 143

OBJ: 6 | 7

TOP: Prelabour

KEY: Nursing Process Step: Data Collection

MATCHING Match the following terms with the appropriate stage of labour for a primigravida patient.

Use each option only one time. a. b. c. d. e.

1.

2.

3.

4.

5.

Longest stage of labour Delivery of the placenta Contractions every 2–3 minutes, lasting 60–90 seconds Full dilation to birth of newborn Assess for fundal tone and bleeding

Latent phase Active phase Second stage Third stage Fourth stage

1. ANS: A DIF: Cognitive Level: Comprehension OBJ: 5 TOP: Stages of Labour KEY: Nursing Process Step: Implementation 2. ANS: C DIF: Cognitive Level: Comprehension OBJ: 5 TOP: Stages of Labour KEY: Nursing Process Step: Health Promotion and Maintenance 3. ANS: D DIF: NCUoR gnSiI tivNeGLTevBe.l:CCOoM mprehension OBJ: 5 TOP: Stages of Labour KEY: Nursing Process Step: Health Promotion and Maintenance 4. ANS: B DIF: Cognitive Level: Comprehension OBJ: 5 TOP: Stages of Labour KEY: Nursing Process Step: Health Promotion and Maintenance 5. ANS: E DIF: Cognitive Level: Comprehension OBJ: 5 TOP: Stages of Labour KEY: Nursing Process Step: Health Promotion and Maintenance

REF: 144 | 145

REF: 144 | 145

REF: 144 | 145

REF: 144 | 145

REF: 144 | 145

Chapter 07: Pain Management During Labour and Birth Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labour pain. What statement is accurate about a patient’s expression of pain? a. It reduces the patient’s perception of pain. b. It is intensified by the vertex position of the fetus. c. It can be influenced by culture. d. It can be completely controlled by nonpharmacological techniques.

ANS: C Culture can influence how women feel about birth and what is an acceptable response to pain.

DIF: Cognitive Level: Comprehension TOP: Cultural Influences on Pain

REF: 175 OBJ: 4 KEY: Nursing Process Step: N/A

2. What chemical substance(s) produced in the body acts as a natural pain reliever? a. Endorphins b. Morphine c. Codeine d. Atropine

NURSINGTB.COM

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

DIF: Cognitive Level: Knowledge REF: 174 TOP: Endorphins KEY: Nursing Process Step: N/A

OBJ: 1 | 4

3. A nurse instructs a woman’s labour coach to comfort her by firmly pressing on her lower back. What is this technique? a. Sacral pressure b. Distraction c. Effleurage d. Conscious relaxation ANS: A Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labour.

DIF: Cognitive Level: Comprehension REF: 174 TOP: Nonpharmacological Pain Management KEY: Nursing Process Step: Implementation

OBJ: 6

4. A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing.

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

DIF: Cognitive Level: Application TOP: Breathing during Labour

REF: 178 OBJ: 3 | 6 KEY: Nursing Process Step: Implementation

5. Several hours into labour, a woman states she has dizziness, numbness, and tingling of her hands and mouth. What does a nurse recognize these symptoms signify? a. Hypertension b. Anxiety c. Anoxia d. Hyperventilation ANS: D Hyperventilation is sometimes a problem if a woman is breathing too rapidly or deeply.

DIF: Cognitive Level: Comprehension TOP: Hyperventilation

REF: 178 OBJ: 4 KEY: Nursing Process Step: Data Collection

NURSINGTB.COM

6. What is the most appropriate nursing action to take when a labouring woman hyperventilates? a. Help her breathe into her cupped hands. b. Place her flat on her back. c. Initiate oxygen at 2 litres via mask. d. Notify the primary health care provider.

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

DIF: Cognitive Level: Application REF: 178 TOP: Nonpharmacological Pain Management KEY: Nursing Process Step: Implementation

OBJ: 4

7. A woman in the late active phase of labour requests an opioid analgesic medication for pain relief. What is the most important thing a nurse should explain to the woman regarding giving an opioid analgesic medication at this stage of labour? a. It can cause medication given at later stages to have more adverse effects. b. It will have no complications for the mother or infant. c. It may result in respiratory depression to the newborn. d. It will slow down labour and decrease pain.

ANS: C

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

DIF: Cognitive Level: Comprehension REF: 180 OBJ: 7 TOP: Opioids KEY: Nursing Process Step: Implementation 8. What should a nurse guide a labour coach to do to comfort a woman tensing her muscles with contractions? a. Offer warm liquids to the patient. b. Use touch and massage. c. Engage the patient in conversation. d. Assist the patient to the knee-chest position.

ANS: B Massage and touch will encourage the woman to relax her muscles. It would not be helpful to offer fluids or to attempt conversation during contractions. Walking intensifies contractions.

DIF: Cognitive Level: Application REF: 176 TOP: Nonpharmacological Pain Management KEY: Nursing Process Step: Implementation

OBJ: 3 | 4

9. A woman is having a booked caesarean section with a general anesthesia. A nurse teaches the patient that food and fluids need to be restricted for several hours prior to the birth in order to prevent? a. Nausea and vomiting b. Vomiting and aspiration NURSINGTB.COM c. Abdominal cramping d. Intestinal obstruction ANS: B The major adverse effect of general anesthesia is aspiration of stomach contents.

DIF: Cognitive Level: Comprehension TOP: General Anesthesia

REF: 184 OBJ: 7 KEY: Nursing Process Step: Implementation

10. What assessment should be taken immediately after the anesthesiologist administers an epidural block to a labouring woman? a. Assess bladder for distention b. Blood pressure c. Sensation in the lower extremities d. Intravenous fluid flow rate ANS: B Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also important but not an initial assessment.

DIF: Cognitive Level: Application TOP: Epidural Block

REF: 182 OBJ: 8 KEY: Nursing Process Step: Implementation

11. A woman in labour has an epidural block for pain relief. A nurse will assess the woman carefully for what associated adverse effect? a. Reduced fetal heart rate b. Long, intense contractions c. Sudden leg cramps d. Bladder distention ANS: D A side effect of an epidural block is urine retention, because the anesthesia interferes with the woman’s ability to have an urge to void. The patient may require catheterization.

DIF: Cognitive Level: Comprehension TOP: Epidural Block

REF: 182 OBJ: 8 KEY: Nursing Process Step: Data Collection

12. Which narcotic antagonist is used to reverse opioid-induced respiratory depression? a. Hydroxyzine (Vistaril) b. Phenobarbital c. Naloxone (Narcan) d. Nitrous oxide ANS: C Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics.

DIF: Cognitive Level: Knowledge REF: 179 TOP: Opioids KEY: Nursing Process Step: N/A

OBJ: 7 | 8

13. A nurse is caring for a womaN nU wR hoSrIeN ceGivTeB d. aC suObM arachnoid (spinal) block for a caesarean birth. What nursing action will the nurse include to assess for the associated adverse effect of this type of anesthesia? a. Assess urine output b. Keep legs flexed c. Walk with assistance as soon as possible d. Restrict oral fluid ANS: A A common adverse effect of a spinal block is urinary retention. A nurse should assess urine output.

DIF: Cognitive Level: Application TOP: Subarachnoid Block

REF: 182 OBJ: 7 | 8 KEY: Nursing Process Step: Planning

14. A woman requests a pudendal block to manage her labour pain. What statement by the woman indicates a need for further explanation about the pudendal block? a. “I’m having a contraction. Can I get the pudendal block now?” b. “I’ll get the pudendal block just before I give birth.” c. “The health care provider will insert the needles into my vagina.” d. “It takes a few minutes after the medicine is administered to make me feel numb.”

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

DIF: Cognitive Level: Comprehension TOP: Pudendal Block

REF: 184 OBJ: 7 | 8 KEY: Nursing Process Step: Evaluation

15. An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, “Please give me something for the pain. I can’t take the pain!” What is the priority nursing diagnosis? a. Pain related to uterine contractions b. Knowledge deficit related to the birth experience c. Ineffective coping related to inadequate preparation for labour d. Risk for injury related to lack of prenatal care ANS: A The most important issue for this woman, at this time, is effective pain management.

DIF: Cognitive Level: Analysis REF: 184 TOP: Pain as a Priority KEY: Nursing Process Step: Nursing Diagnosis

OBJ: 4

16. When a pregnant woman arrives at the labour unit, she tells a nurse that she wants to have an epidural for labour. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous caesarean birth c. History of migraine headaches d. History of diabetes mellitus ANS: A NURSINGTB.COM An epidural block is not used if a woman has abnormal blood clotting.

DIF: Cognitive Level: Comprehension TOP: Epidural Block

REF: 182 OBJ: 7 KEY: Nursing Process Step: Data Collection

17. The nurse coaches the primigravida strategies to not bear down until the cervix is completely dilated. Premature bearing down may cause which of the following complications? a. Increased use of oxygen b. Cervical laceration c. Uterine rupture d. Compression of the cord ANS: B Bearing down against a cervix that is not dilated may cause edema and laceration to the cervix.

DIF: Cognitive Level: Comprehension TOP: Bearing Down

REF: 178 OBJ: 4 KEY: Nursing Process Step: Implementation

18. What is the Dick-Read method of childbirth preparation based on? a. Mild sedation throughout labour b. Relaxation techniques

c. Skin stimulation d. Deep massage ANS: B The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labour.

DIF: Cognitive Level: Knowledge TOP: Childbirth Preparation

REF: 172 | 173 OBJ: 5 KEY: Nursing Process Step: Implementation

19. The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths per minute. What should be the patient’s rate while performing slow breathing? a. 9 b. 11 c. 15 d. 20 ANS: B The range of respirations should be no lower than half of the base rate and no higher than double the baseline rate.

DIF: Cognitive Level: Comprehension TOP: Breathing during Labour

REF: 172 OBJ: 3 KEY: Nursing Process Step: Implementation

20. What is the least amount of sensation that one perceives as pain? a. Tolerance NURSINGTB.COM b. Threshold c. Level d. Abatement ANS: B Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.

DIF: Cognitive Level: Knowledge TOP: Pain Threshold

REF: 173 OBJ: 1 KEY: Nursing Process Step: Implementation

21. The nurse is caring for a labouring patient who is not reporting pain. What sign would alert the nurse of the possible presence of pain? a. Frequently asking for ice chips b. Facial grimacing c. Changing positions in bed d. Covering her face with her hands ANS: B Facial grimacing may be an indicator of unexpressed pain.

DIF: Cognitive Level: Comprehension TOP: Nonverbal Pain Expressing

REF: 178 OBJ: 4 | 6 | 8 KEY: Nursing Process Step: Data Collection

22. A patient who received an epidural block asks why her blood pressure is taken so often.

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

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

DIF: Cognitive Level: Comprehension TOP: Disadvantage of Epidural Block

REF: 182 OBJ: 7 | 8 KEY: Nursing Process Step: Implementation

23. A labouring patient requests hot and cold packs be applied to her abdomen for pain control.

How will this intervention act to control pain? a. By increasing endorphin production b. By facilitating effacement and dilation c. By producing increasing pain tolerance d. By stimulation of large nerve fibres ANS: D The gate control theory explains how pain impulses reach the brain for interpretation. It supports several nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-diameter nerve fibres. However, the stimulation of large-diameter nerve fibres temporarily interferes with the conduction of impulses through small-diameter fibres. TechniNqU ueRsStoIsNtiG mT ula teClaOrgMe-diameter fibres and “close the gate” to B. painful impulses include massage, palm and fingertip pressure, and heat and cold applications.

DIF: Cognitive Level: Comprehension TOP: Nonpharmacological Pain Relief

REF: 174 OBJ: 5 | 6 KEY: Nursing Process Step: Implementation

24. When caring for the labouring patient, the nurse determines that the fetus is in the right occiput posterior (ROP) position. What will the nurse anticipate? a. Urinary retention b. Severe lower back pain c. A shorter labour process d. Nausea ANS: B If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mother’s sacrum, resulting in persistent and poorly relieved back pain (back labour). Labour is often longer with this fetal position.

DIF: Cognitive Level: Application TOP: Fetal Position

REF: 175 OBJ: 4 KEY: Nursing Process Step: Data Collection

25. When a woman is admitted to the labour and birth unit, she tells a nurse that she is anxious about the birth, the welfare of her infant, and how quickly she will recover. How can anxiety affect labour? a. By decreasing a woman’s pain sensitivity b. By reducing blood flow to the uterus c. By increasing the ability to tolerate pain d. By enhancing maternal pushing through greater muscle tension ANS: B Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

DIF: Cognitive Level: Comprehension REF: 175 TOP: Factors That Influence Labour Pain KEY: Nursing Process Step: Data Collection

OBJ: 5

MULTIPLE RESPONSE 1. What topics would be important to teach expectant parents during childbirth preparation classes? (Select all that apply.) a. Infant care b. Breastfeeding c. Gestational diabetes d. Labour support techniques e. Exercises

NURSINGTB.COM ANS: A, B, D, E Prenatal classes include such topics as infant care, breastfeeding, exercising, labour support techniques, and sibling and grandparent preparation. Gestational diabetes is not traditional content for childbirth preparation classes.

DIF: Cognitive Level: Knowledge TOP: Prenatal Classes

REF: 171 OBJ: 2 KEY: Nursing Process Step: Implementation

2. What techniques would the nurse teach the prenatal patient to help her manage pain during labour? (Select all that apply.) a. Breathing b. Changing positions c. Drinking fluids d. Using intradermal water injections e. Listening to music ANS: A, B, D, E Breathing, position changes, intradermal sterile water injections and listening to music are all strategies that can be used to help a woman cope with pain. Drinking fluids is important but not a pain management strategy.

DIF: Cognitive Level: Knowledge REF: 176 | 177 | 178 OBJ: 3 | 5 TOP: Nonpharmacological Pain Strategies KEY: Nursing Process Step: Implementation

3. How does the pain of childbirth differ from other types of pain? (Select all that apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs opioid relief. c. Position changes relieve pain and can facilitate birth. d. Childbirth pain declines following birth. e. Childbirth pain is self-limited.

ANS: A, C, D, E Childbirth pain differs from other types of pain, because it is part of a normal, natural, and expected process, can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with opioids in some cases.

DIF: Cognitive Level: Comprehension TOP: Childbirth Pain

REF: 173 OBJ: 3 | 4 KEY: Nursing Process Step: Planning

4. Which are nonpharmacological forms of pain relief? (Select all that apply.) a. Skin stimulation b. Diversion and distraction c. Breathing techniques d. Exercise e. Yoga ANS: A, B, C Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain conNtrU ol.

AI lthNoGuT ghBe.xC erOciMse and practices such as yoga and Pilates RS are beneficial, they are not means of pain control.

DIF: Cognitive Level: Knowledge REF: 176 | 177 | 178 OBJ: 6 TOP: Nonpharmacological Pain Control KEY: Nursing Process Step: Implementation 5. The nurse is providing a conference on nonpharmacological pain control methods. What major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.) a. They sedate the mother. b. They do not slow labour. c. They do not dull the excitement of the birth experience. d. They do not have the potential to cause allergic reactions. e. They do not have to be delayed until labour is well established.

ANS: B, C, D, E All the options mentioned are benefits of nonpharmacological pain control methods except for sedating the mother.

DIF: Cognitive Level: Knowledge REF: 176 TOP: Advantages of Nonpharmacological Pain Control KEY: Nursing Process Step: Implementation

OBJ: 5 | 6

6. The nurse is caring for a woman with epidural anesthesia for pain control during labour. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.) a. Assess leg movement and sensation before ambulating. b. Administer antibiotic as ordered. c. Observe for signs of impending birth. d. Provide sacral pressure as needed. e. Assess fetal position frequently.

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

DIF: Cognitive Level: Application TOP: Epidural Anesthesia

REF: 186 OBJ: 8 KEY: Nursing Process Step: Implementation

7. The health care provider has ordered fentanyl (Sublimaze) for a woman in labour and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.) a. Onset is slow b. Duration is short c. Oxygen saturation should be monitored d. No known side effects e. It is not the same drug as NsuUfR enStaInN il GTB.COM ANS: B, E Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same drugs. Fentanyl can cause respiratory depression but less than meperidine.

Oxygen saturation should be monitored for 30 minutes.

DIF: Cognitive Level: Comprehension TOP: Narcotic Analgesia

REF: 179 OBJ: 8 KEY: Nursing Process Step: Implementation

8. A nurse who utilizes the gate control theory of pain control would advise a woman in labour and her partner to use which nonpharmacological methods of pain management? (Select all that apply.) a. Slow abdominal breathing b. Guided relaxation c. Hot water bottles d. Massage e. Ice packs to back ANS: D According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage, heat and cold are techniques that stimulates large-diameter fibers and “closes the gate.”

DIF: Cognitive Level: Analysis TOP: Gate Control

REF: 174 OBJ: 6 KEY: Nursing Process Step: Implementation

NURSINGTB.COM

Chapter 08: Nursing Care of Women with Complications During Labour and Birth Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What nursing assessment should be reported immediately after an amniotomy? a. Fetal heart rate is 154 beats/minute. b. Amniotic fluid is clear with flecks of pink. c. Amniotic fluid is watery and pale green. d. Maternal temperature is 37.8° C. ANS: C Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which can be associated with fetal compromise.

DIF: Cognitive Level: Application REF: 193 TOP: Obstetric Procedures—Amniotomy KEY: Nursing Process Step: Implementation

OBJ: 3

2. A woman 10 days past her expected due date is being induced with an oxytocin infusion.

She begins to have contractions every 90 seconds. What is a nurse’s initial action? a. Stop the oxytocin infusion. b. Continue the infusion and report the findings to the health care provider. c. Turn her on her left side and reassess the contractions. d. Administer oxygen by maNsU k.RSINGTB.COM ANS: A Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

DIF: Cognitive Level: Application REF: 194 TOP: Obstetric Procedures—Induction of Labour KEY: Nursing Process Step: Implementation

OBJ: 3

3. A woman with a previous history of preterm labour needs further instruction regarding when to call her health care provider when she states which of the following? a. “If I notice irregular cramping.” b. “If my water breaks.” c. “If I get a fever I will just take some acetaminophen.” d. “If I feel constant low back pain.”

ANS: C Women who have a history of preterm labour need to notify a health care provider if they feel any menstrual cramping, if their water breaks, if they feel back ache, or if they get a fever. They should not treat the fever themselves as infection can cause preterm labour.

DIF: Cognitive Level: Application REF: 208 OBJ: 3 TOP: Obstetric Procedures—Lacerations KEY: Nursing Process Step: Implementation

4. After several hours of labour, a nursing assessment reveals that a woman’s cervix is 5 cm dilated, but contractions are becoming shorter and less frequent. What is this labour pattern considered? a. Normal b. Hypotonic c. Hypertonic d. False ANS: B Hypotonic labour occurs when the woman begins labour normally, but contractions diminish during the active phase (after 4 cm of cervical dilation), when the pace of labour is expected to accelerate.

DIF: Cognitive Level: Comprehension TOP: Abnormal Labour

REF: 202 OBJ: 5 KEY: Nursing Process Step: Data Collection

5. Hypotonic labour due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with intact membranes. What action by the health care provider will a nurse anticipate? a. Perform an amniotomy. b. Initiate tocolytic drugs. c. Order a sedative for the patient. d. Plan to do an emergency caesarean section.

ANS: A Medical treatment for hypotoN nic ouNrGdT ysBfu.nC ctOioMn includes an amniotomy if the URlaSbI membranes are intact.

DIF: Cognitive Level: Comprehension TOP: Abnormal Labour

REF: 202 OBJ: 2 | 5 KEY: Nursing Process Step: Implementation

6. An infant is born with the assistance of forceps. What should a nurse assess for in the newborn? a. Loss of hair from contact with forceps b. Sacral hematoma c. Facial asymmetry d. Shoulder dislocation ANS: C Pressure from forceps may injure the infant’s facial nerve, which is evidenced by facial asymmetry.

DIF: Cognitive Level: Application REF: 196 TOP: Obstetric Procedures—Forceps Delivery KEY: Nursing Process Step: Data Collection

OBJ: 3

7. A new mother is distressed and tearful about the elevated dome over her infant’s posterior fontanelle. The nurse responds, “This condition will resolve itself in a few days.” What is the cause?

a. b. c. d.

An accumulation of blood Small leak of fluid through the posterior fontanelle Pressure of the forceps during birth The effect of the vacuum extractor

ANS: D The vacuum extractor causes a harmless area of circular edema on the infant’s scalp where it was applied.

DIF: Cognitive Level: Comprehension TOP: Risk of Vacuum Extractor

REF: 196 OBJ: 2 KEY: Nursing Process Step: N/A

8. A woman who is 4 days past her due date and is becoming frustrated states, “My doctor won’t induce my labour because of some silly score. He said I was a 4. What kind of magic number do I need?” What is the lowest Bishop score the patient should have prior to induction? a. 6 b. 8 c. 10 d. 12 ANS: A The Bishop score predicts successful labour induction. A minimum score of 6 is recommended by the Society of Obstetricians and Gynecologists of Canada (SOGC).

DIF: Cognitive Level: Comprehension REF: 191 OBJ: 2 TOP: Bishop Score EY NURSINGTBK .C O:M Nursing Process Step: Data Collection 9. A nurse is teaching a prenatal class about the indications for a caesarean birth. Which of the following would be an absolute indication for a caesarean birth? a. Post-term labour b. Preterm labour c. Transverse lie d. Gestational diabetes ANS: C A transverse lie would be a reason for a caesarean birth. All the other options do not require a caesarean unless there are complications during labour.

DIF: Cognitive Level: Comprehension TOP: Indications for Caesarean Birth

REF: 197 OBJ: 2 KEY: Nursing Process Step: Data Collection

10. The initial vaginal examination of a woman admitted to the labour unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, “Please give me something.”

What is the most appropriate pain-relief intervention for a woman in precipitate labour? a. Get an order for an intravenous opioid. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to giving birth.

ANS: C

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

DIF: Cognitive Level: Application TOP: Abnormal Labour

REF: 207 OBJ: 3 | 5 KEY: Nursing Process Step: Implementation

11. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism ANS: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture, because the barrier to the uterine cavity is broken.

DIF: Cognitive Level: Application TOP: Premature Rupture of Membranes

REF: 207 OBJ: 3 | 6 KEY: Nursing Process Step: Data Collection

12. The nurse is administering a prostaglandin synthesis inhibitor (indomethacin) to a pregnant woman as tocolysis for preterm labour. The nurse would assess for which adverse effect? a. Maternal tachycardia b. Decreased amniotic fluid c. Maternal bradycardia NURSINGTB.COM d. Maternal drowsiness ANS: B Decreased amniotic fluid is an adverse effect of indomethacin.

DIF: Cognitive Level: Comprehension TOP: Preterm Labour

REF: 209 OBJ: 6 | 7 KEY: Nursing Process Step: Data Collection

13. Which statement indicates a woman needs further teaching regarding management of her preterm labour? a. “After my shower in the morning, I rest, then I put the laundry in and wait for my partner to get home to finish it.” b. “I pack a picnic basket and put it next to the sofa, so I do not have to get up all day for food.” c. “I have a 2-year-old to care for, so I am very busy.” d. “I get really bored at home, so I invite friends over for coffee. I get them to bring the food.”

ANS: C Complete activity restriction is not recommended for preterm labour management as there is no evidence to support it and the adverse effects of bedrest are significant. Some activity restriction may be prescribed. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

DIF: Cognitive Level: Comprehension TOP: Preterm Labour

REF: 209 OBJ: 7 KEY: Nursing Process Step: Evaluation

14. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative caesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by “walking” fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift.

ANS: B Assessment of the fundus following a caesarean section is done as usual but using especially gentle fundal massage.

DIF: Cognitive Level: Comprehension TOP: Caesarean Postoperative Care

REF: 200 OBJ: 4 KEY: Nursing Process Step: Implementation

15. A pulsating structure is felt during a vaginal examination of a woman in labour. How would a nurse position the woman to prevent compression of a prolapsed cord? a. On her right side with knees flexed b. On her left side with a pillow placed between her legs c. In knee-chest position d. Supine with her legs elevated and bent at the knee

NURSINGTB.COM

ANS: C The knee-chest position displaces the fetus upward to stop compression of the prolapsed cord.

DIF: Cognitive Level: Application REF: 211 OBJ: 6 TOP: Emergencies During Childbirth—Prolapsed Umbilical Cord KEY: Nursing Process Step: Implementation 16. Several hours after birth, a nurse finds a woman crying. The woman says repeatedly, “My baby is beautiful, but I was planning on a vaginal birth. Instead I needed an emergency C-section.” What is the most appropriate nursing diagnosis? a. Anxiety related to the development of postpartum complications b. Ineffective individual coping related to unfamiliarity with procedures c. Risk for ineffective parenting related to emergency caesarean section d. Grieving related to loss of expected birth experience ANS: D Women who have caesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger, because the expected course of birth did not occur.

DIF: Cognitive Level: Application TOP: Caesarean Section

REF: 199

OBJ: 4 | 7

KEY: Nursing Process Step: Nursing Diagnosis 17. A pregnant woman’s membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do? a. Report any increase in fetal activity. b. Notify her health care provider if she has a temperature above 37.8° C (100° F). c. Massage her breasts to promote uterine relaxation. d. Rest in a side-lying Trendelenburg’s position with hips elevated.

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

DIF: Cognitive Level: Application TOP: Premature Rupture of Membranes

REF: 207 OBJ: 7 KEY: Nursing Process Step: Planning

18. A woman who is 28 weeks pregnant and in preterm labour is placed on an intravenous infusion of magnesium sulphate for fetal neuroprotection. What adverse effect should the nurse inform the patient that she might experience? a. Nausea and vomiting b. Headache c. Warm flush d. Urinary frequency

NURSINGTB.COM

ANS: C Magnesium sulphate is the medication of choice for women in preterm labour for neuroprotection for the fetus. The patient will notice a warm flush with the initiation of the drug.

DIF: Cognitive Level: Knowledge TOP: Preterm Labour

REF: 209 OBJ: 6 KEY: Nursing Process Step: Implementation

19. During a rather quick labour, a woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action? a. Give the pain remedy. b. Notify the charge nurse immediately. c. Turn the patient to her back and flex her knees. d. Suggest that the coach give her a back rub.

ANS: B Sudden pain between the scapulae during labour is an indicator of uterine rupture. This should be reported immediately.

DIF: Cognitive Level: Application TOP: Uterine Rupture

REF: 212 OBJ: 6 KEY: Nursing Process Step: Implementation

20. Which of these is a “cervical ripening” agent used to soften the cervix? a. Prostaglandin gel insertion b. Intravenous oxytocin c. Warm saline douches d. Nipple stimulation ANS: A Prostaglandin gel is inserted in the cervix in order to soften the cervix, making labour induction more effective. The woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.

DIF: Cognitive Level: Knowledge TOP: Cervical Ripening

REF: 192 OBJ: 3 KEY: Nursing Process Step: Implementation

21. A nurse is caring for a patient who is threatening preterm labour and has been given a steroid injection. What is the purpose of glucocorticoid administration? a. To prevent infection b. To enhance fetal lung maturity c. To increase blood flow from placenta d. To relax the cervix ANS: B Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

DIF: Cognitive Level: Comprehension TOP: Fetal Lung Maturity

REF: 209 OBJ: 6 KEY: Nursing Process Step: Implementation

NURSINGTB.COM

22. A nurse arrives at the start of a shift on the labour unit to find a census of four patients in active labour. Which labouring patient should the nurse attend to first? a. 18-year-old primigravida with a fetal breech presentation b. 25-year-old multigravida with history of previous caesarean section c. 35-year-old multigravida with history of precipitate birth d. 16-year-old primigravida with a twin pregnancy ANS: C A precipitate birth is completed in less than 3 hours. Labour often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression.

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

DIF: Cognitive Level: Analysis TOP: Priority Setting

REF: 207 OBJ: 7 KEY: Nursing Process Step: Implementation

23. The nurse is caring for a patient diagnosed with hypotonic labour. What will the nurse expect when caring for this patient? a. Elevated uterine resting tone b. Painful and poorly coordinated contractions c. Implementation of fluid restriction

d. Use of frequent position changes ANS: D A woman with hypotonic labour will be encouraged to change position frequently to enhance contractions. With hypotonic labour uterine resting tone is decreased. Painful and poorly coordinated contractions occur with hypertonic labour.

DIF: Cognitive Level: Comprehension TOP: Hypotonic Labour

REF: 203 OBJ: 5 | 6 KEY: Nursing Process Step: Data Collection

24. What sign(s) of infection should the nurse assess for after an amniotomy? a. Oral temperature of 37°C (99.8° F) b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain ANS: B Increase in the FHR above 160 beats/minute frequently precedes a woman’s temperature elevation. All the other options are normal findings for late pregnancy.

DIF: Cognitive Level: Application TOP: Postamniotomy Care

REF: 193 OBJ: 3 KEY: Nursing Process Step: Data Collection

MULTIPLE RESPONSE 1. What are the indications for labour induction? (Select all that apply.)

NURSINGTB.COM a. Placenta previa b. Prolapse of cord c. Pre-eclampsia d. Maternal diabetes e. Placental insufficiency ANS: C, D, E Pre-eclampsia, maternal diabetes and placental insufficiency are rationales for induction.

The other options are contraindications for labour induction.

DIF: Cognitive Level: Comprehension TOP: Rationales for Labour Induction

REF: 190 | 191 OBJ: 2 KEY: Nursing Process Step: Implementation

2. Which interventions could a nurse utilize to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Having the woman stimulate her nipples d. Offering emotional support e. Allowing the patient to vent frustration ANS: A, B, C

Sitting upright, ambulating, and stimulating the nipples may encourage progression of labour. Offering emotional support and allowing the patient to vent frustration are supportive to the patient but do not stimulate more effective labour.

DIF: Cognitive Level: Application TOP: Hypotonic Labour

REF: 191 OBJ: 3 KEY: Nursing Process Step: Implementation

3. What complications of overstimulation of uterine contractions related to oxytocin induction can occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture ANS: A, B, E The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.

DIF: Cognitive Level: Comprehension TOP: Complication of Oxytocin

REF: 193 | 194 OBJ: 6 KEY: Nursing Process Step: Planning

4. How might a midwife instruct a woman to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipplesN.URSINGTB.COM d. Apply suction to the nipples with a breast pump. e. Press the palms of her hands down on her breasts.

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

DIF: Cognitive Level: Application TOP: Nipple Stimulation

REF: 191 OBJ: 5 KEY: Nursing Process Step: Implementation

5. A woman is 37 weeks pregnant and questioning the nurse about possible induction of labour at term. What conditions would contraindicate labour induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal Caesarean incision d. Prolapsed cord e. Gestational diabetes ANS: B, D

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

Gynecoid pelvis is the most favourable shape for vaginal birth. Induction can be attempted as a VBAC after a horizontal Caesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labour induction.

DIF: Cognitive Level: Comprehension REF: 191 OBJ: 2 TOP: Induction KEY: Nursing Process Step: Data Collection 6. A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.) a. Insert an intravenous (IV) line b. Record a baseline fetal heart rate c. Explain procedure to patient d. Instruct patient to ambulate immediately afterward e. Ensure a tocolytic is available ANS: B, C The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An IV line is not required for a woman receiving a cervical ripening agent. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.

DIF: Cognitive Level: Application TOP: Cervical Ripening

REF: 192 OBJ: 3 KEY: Nursing Process Step: Implementation

7. A woman who is undergoingNaU nR oxSyItoNcG inTinBd.uC ctO ioM n shows signs of tachysystole. What would a nurse do in relation to the tachysystole? (Select all that apply.) a. Decrease the oxytocin infusion by half. b. Turn the woman to the lateral position. c. Increase the mainline IV rate. d. Administer a tocolytic if ordered by health care provider. e. Insert a Foley catheter to empty the bladder.

ANS: A, B, C, D Tachysystole occurs when there are more than five contractions in 10 minutes (with or without fetal heart rate changes). A nurse would decrease or stop the oxytocin, turn the woman to her side and increase the IV rate to increase blood flow to the uterus. A tocolytic will be administered if ordered to relax the uterus. Emptying the bladder will not impact the tachysystole.

DIF: Cognitive Level: Application TOP: Oxytocin Induction

REF: 194 OBJ: 3 KEY: Nursing Process Step: Implementation

Chapter 09: Nursing Care of the Woman and Family After Birth Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse assesses a newly postpartum woman’s fundus to be 2 cm above the umbilicus and deviated to the right. What would the nursing action be related to this? a. Encourage the woman to void. b. Massage the uterus to remove any clots. c. Document the findings. d. Call the primary health care provider.

ANS: A A full bladder is often evidenced by the fundus deviated to the right. The woman needs to void to decrease her risk of developing a postpartum hemorrhage.

DIF: Cognitive Level: Analysis TOP: Fundus Assessment

REF: 219 OBJ: 4 | 8 KEY: Nursing Process Step: Implementation

2. What would a nurse expect to find when assessing the fundus of the uterus immediately after birth? 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 Mbilicus c. Relaxed with its upper boNrdUeR r lSeI veNl G wT ithB. thC eO um 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 or slightly below the level of the umbilicus.

DIF: Cognitive Level: Comprehension TOP: Fundus Assessment

REF: 219 OBJ: 4 KEY: Nursing Process Step: Data Collection

3. What statement made by a new mother indicates she needs additional information about breastfeeding? a. “I let the baby feed on the first breast until she comes off and then I offer her the other breast.” b. “The baby needs to breastfeed as long as she wants on the breast to get the hindmilk.” c. “The baby has been nursing every 1 1/2 to 3 hours.” d. “If the baby gets fussy between feedings, I give her a bottle of water.”

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

DIF:

Cognitive Level: Comprehension

REF: 240

OBJ: 10

TOP: Breastfeeding

KEY: Nursing Process Step: Evaluation

4. After birth, a nurse’s assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention? a. Notify the primary health care provider. b. Massage the fundus. c. Initiate measures that encourage voiding. d. Increase the IV rate.

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

DIF: Cognitive Level: Application TOP: Boggy Uterus

REF: 220 OBJ: 8 KEY: Nursing Process Step: Implementation

5. What type of lochia will a nurse assess initially after the birth? a. Serosa b. Rubra c. Alba d. Vaginalis ANS: B The initial vaginal discharge after birth is called lochia rubra. It is red and moderate in amount. Lochia rubra lasts for up to 3 days postpartum.

DIF: Cognitive Level: Knowledge REF: 219 OBJ: 4 TOP: Lochia KEY: NNUuRrsSinIgNPGroTcB es.s C SO teM p: Data Collection 6. A woman will be discharged 24 hours after a vaginal birth. When planning discharge teaching, a nurse would include what information about lochia? a. Lochia should disappear about 2 weeks postpartum. b. It is normal for the lochia to have a slightly foul odour. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity.

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

DIF: Cognitive Level: Application TOP: Postpartum Hemorrhage

REF: 220 OBJ: 18 KEY: Nursing Process Step: Planning

7. What instruction should a nurse teach the postpartum woman who is 36 hours after the birth, about perineal self-care? a. Perform perineal self-care twice a day. b. Cleanse with warm water in a peri-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 TOP: Perineal Care

REF: 222 OBJ: 4 KEY: Nursing Process Step: Implementation

8. A postpartum woman is not immune to rubella. What care will a nurse expect to provide? a. The rubella virus vaccine would be administered before discharge. b. The woman would 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 offered rubella immunization in the immediate postpartum period because there is no danger of her being pregnant.

DIF: Cognitive Level: Comprehension REF: 226 TOP: Rubella KEY: Nursing Process Step: Planning

OBJ: 2

9. Which statement indicates the new mother has good breastfeeding information? a. “I will alternate the breast I offer 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 the end of nipple in the baby’s mouth when I am breastfeeding.”

ANS: A NURSINGTB.COM Alternating breasts for feeding increases milk production.

DIF: Cognitive Level: Comprehension TOP: Breastfeeding

REF: 236 OBJ: 10 KEY: Nursing Process Step: Evaluation

10. A nurse is counselling a breastfeeding mother about diet. What would the nurse include with this information? a. Consume approximately 400 more calories than her usual prepregnancy diet. b. Eat more meat. c. Drink three glasses of fluid daily. d. Increase her calcium intake.

ANS: A To maintain nutrient stores while breastfeeding, the mother needs 400 additional calories each day over her prepregnancy diet. The calcium requirement is the same no matter what the stage of the mother’s life. A woman requires eight glasses of fluid per day.

DIF: Cognitive Level: Comprehension REF: 242 | 243 OBJ: 18 TOP: Breastfeeding—Maternal Nutrition KEY: Nursing Process Step: Implementation 11. A woman asks about resumption of her menstrual cycle after childbirth. How should a 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. A woman does not ovulate until after she has a menstrual period. 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.

Ovulation can occur prior to resumption of menstrual cycle, which means women do need to use a method of birth control.

DIF: Cognitive Level: Comprehension TOP: Return of Menses

REF: 223 | 224 OBJ: 4 | 18 KEY: Nursing Process Step: Implementation

12. In what situation will the health care provider order Rho(D) immune globulin? a. An unsensitized Rh-negative mother has an Rh-positive infant. b. An Rh-negative mother has become 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 Rho(D) immune globulin within 72 hours after the birth of an Rh-positive infant.

DIF: Cognitive Level: Analysis TOP: Rho(D) immune globulin

REF: 226 OBJ: 2 KEY: Nursing Process Step: Implementation

13. Three days after birth a nurse visits a woman at home. The woman is crying and states she feels overwhelmed. What shoNuU ldRtS heInNuG rsT eB do.C atOthMis point? a. Teach her that this is normal. b. Tell her this is abnormal and she needs more help. c. Tell her partner that she needs more support. d. Document the findings in the woman’s chart.

ANS: A The postpartum blues are normal and temporary. The woman needs teaching regarding this.

DIF: Cognitive Level: Application TOP: Postpartum Blues

REF: 228 OBJ: 6 KEY: Nursing Process Step: Implementation

14. A breastfeeding mother of a 1-week-old newborn asks a nurse how she will know the baby is getting enough to drink. What will the nurse teach the woman regarding this? a. The newborn is feeding every 3 to 4 hours. b. The newborn has 4 to 5 wet diapers every day. c. The newborn has frequent audible swallows while feeding. d. The newborn is gaining 10 g per day.

ANS: C Frequent audible swallowing ensures the newborn is feeding well. The newborn should void 6–8 times per day and gain at least 20 g per day. The newborn should feed on demand and not on a timed schedule.

DIF:

Cognitive Level: Application

REF: 238

OBJ: 10

TOP: Breastfeeding

KEY: Nursing Process Step: Evaluation

15. A new mother states her preference to formula feed her newborn. What should the nurse planning discharge 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. Breast stimulation is not encouraged.

DIF: Cognitive Level: Application TOP: Suppression of Lactation

REF: 243 OBJ: 10 | 18 KEY: Nursing Process Step: Planning

16. On the second postpartum day, a mother bathed her newborn for the first time. She tells a nurse, “I don’t think I did it right.” What postpartum psychological stage is this woman most likely in based on this comment? a. Taking in b. Taking hold c. Letting go d. Settling down ANS: B In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, shN eU mR aySbIeN coGmTeBc.riC ticOaM l of her performance.

DIF: Cognitive Level: Analysis TOP: Postpartum Psychological Stages

REF: 229 OBJ: 4 KEY: Nursing Process Step: Data Collection

17. A primipara tells a nurse, “My afterpains get worse when I am breastfeeding.” What is the most appropriate nursing response? a. “I’ll get you some Aspirin to relieve the cramping that you feel.” b. “Afterpains are more intense with your first baby.” c. “Breastfeeding releases a hormone that causes your uterus to contract.” d. “A change of position when you’re breastfeeding might help.”

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

DIF: Cognitive Level: Application REF: 219 OBJ: 2 | 4 TOP: Afterpains KEY: Nursing Process Step: Implementation 18. A new mother has decided not to breastfeed her newborn. What information will a nurse include when planning to teach the mother about formula feeding? a. Feed the baby on demand. b. Heat the infant formula in a microwave. c. Burp the infant after 120 mL and again when the bottle is empty.

d. Prop the bottle for a feeding to make it easier.

ANS: A Formula fed infants should be fed on demand. Propping the bottle and heating the formula in the microwave are unsafe. Infants should be burped when they require it and not based on specific criteria.

DIF: Cognitive Level: Comprehension TOP: Formula Feeding

REF: 244 OBJ: 10 | 16 KEY: Nursing Process Step: Planning

19. In the recovery room, a nurse checks the woman’s fundus following a caesarean 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: 226 OBJ: 5 TOP: Postpartum Caesarean Assessment KEY: Nursing Process Step: Data Collection 20. A nurse instructs 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 breastNmUilR kSinItN heGm ic. roC wO avMe.” TB b. “I’ll put enough breast milk for one day in a container.” c. “Breast milk can be stored in glass containers.” d. “Breast milk can be kept in the refrigerator for up to 3 months.”

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

DIF: Cognitive Level: Comprehension TOP: Storing Breast Milk

REF: 242 OBJ: 13 KEY: Nursing Process Step: Evaluation

21. A nurse is caring for a woman who does not speak English, 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. 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 TOP: Cultural Influences

REF: 217 OBJ: 3 KEY: Nursing Process Step: Evaluation

22. 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 a nurse’s most appropriate action? a. Contact the hospital chaplain. b. Request the couple’s clergy. c. Tell the family it will not be possible at this point. d. Ask the primary health care provider to baptize the newborn.

ANS: A If the condition of a newborn is poor, the parents may wish to have a baptism performed.

The minister or priest is notified. The primary health care provider is attending to the patient’s immediate health needs. Occasionally the nurse may perform this, but the nurse must feel comfortable performing this ritual.

DIF: Cognitive Level: Application TOP: Grieving Parents

REF: 231 | 232 OBJ: 7 KEY: Nursing Process Step: Implementation

NURSINGTB.COM 23. A woman required a Caesarean section for the birth of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by a 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 after breastfeeding.” 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.

DIF: Cognitive Level: Application TOP: Breastfeeding

REF: 237 OBJ: 5 | 12 KEY: Nursing Process Step: Implementation

24. A nurse is caring for an Rh-negative mother on the labour and birth unit. What scenario indicates this patient will require Rh immune globulin administration? a. She has had one Rh-negative child and is pregnant with an Rh-negative child. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative child. d. She is a primipara with an O-negative child.

ANS: B

The only woman with antibodies against the Rh-positive infant is the Rh-negative woman who has had one Rh-positive child and is now pregnant with another.

DIF: Cognitive Level: Analysis TOP: Rh Concerns

REF: 226 OBJ: N/A KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. A patient who is 30 weeks pregnant gives birth to a stillborn child in the emergency department (ED). What should an ED nurse offer the patient? (Select all that apply.) a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) e. A warm beverage ANS: A, B, C, D The patient should be offered privacy, an opportunity to hold the infant, support group information, and a memento. A warm beverage is not a priority at this time.

DIF: Cognitive Level: Application TOP: Stillborn Infant

REF: 232 OBJ: 7 KEY: Nursing Process Step: Planning

2. A woman is having a shower at 24 hours post caesarean birth. What interventions should a nurse include when assisting the woman with the shower? (Select all that apply.) a. Have the mother remove abdominal dressing in the shower if ordered by a health NURSINGTB.COM care provider. b. Provide pain medication after the shower. c. Cover any IV sites with a rubber glove. d. Provide a shower chair. e. Confirm ambulation ability.

ANS: A, C, D, E The patient should be evaluated for ambulatory ability, and the infusion site should be covered with a waterproof cover. Often the abdominal dressing is removed in 24 hours and is easier to remove in the shower. The patient should be provided with a shower chair.

Adequate pain relief should be provided prior to the shower.

DIF: Cognitive Level: Application TOP: Postpartum Caesarean Care

REF: 227 OBJ: 5 KEY: Nursing Process Step: Implementation

3. What postpartum exercises should a nurse teach a patient who had a vaginal birth the previous day? (Select all that apply.) a. Abdominal tightening b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts ANS: A, B, C, D

Exercises for postpartum involution such as abdominal tightening, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.

DIF: Cognitive Level: Comprehension TOP: Postpartum Exercises

REF: 225 | 226 OBJ: 18 KEY: Nursing Process Step: Implementation

4. While instructing a new mother on formula preparations, a nurse would include what types?

(Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cow’s milk e. Canned evaporated milk ANS: A, B, C Formula choices are ready-to-use formula, concentrated liquid formula that will be diluted according to the infant’s needs, and powdered formula that is mixed as needed. Cow’s milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.

DIF: Cognitive Level: Comprehension TOP: Formula Choices

REF: 244 OBJ: 16 KEY: Nursing Process Step: Implementation

5. A nurse is instructing a woman at 6 months postpartum about weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborn’s favouriteNfUeeRdS inIgNfiGrsTt.B.COM 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 feedings.

ANS: B, C, D When weaning a newborn from breastfeeding, the mother should eliminate the favourite 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 feedings, or the breasts will continue to produce milk.

DIF: Cognitive Level: Comprehension REF: 243 OBJ: 14 TOP: Weaning KEY: Nursing Process Step: Implementation

Chapter 10: Nursing Care of Women with Complications After Birth Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What is the first sign of hypovolemic shock from postpartum hemorrhage? a. Cold, clammy skin b. Tachycardia c. Hypotension d. Decreased urinary output ANS: B Tachycardia and tachypnea are usually the first signs of inadequate blood volume.

DIF: Cognitive Level: Knowledge TOP: Hypovolemic Shock

REF: 252 OBJ: 2 KEY: Nursing Process Step: Data Collection

2. Although a nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate? a. Uterine atony b. Uterine dystocia c. Uterine laceration d. Uterine dysfunction ANS: A NURSINGTB.COM Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibres are flaccid and will not compress bleeding vessels.

DIF: Cognitive Level: Comprehension REF: 255 TOP: Atony KEY: Nursing Process Step: N/A

OBJ: 2

3. What should a nurse’s first action be when postpartum hemorrhage from uterine atony is suspected? a. Teach the patient how to massage the fundus and then get help. b. Start IV fluids to prevent hypovolemia and then notify the registered nurse. c. Begin massaging the fundus while another person notifies the primary health care provider. d. Ask the patient to void and reassess fundal tone and location.

ANS: C When the uterus is boggy, the nurse should immediately massage it until it becomes firm and should not leave the patient.

DIF: Cognitive Level: Application REF: 255 OBJ: 6 TOP: Atony KEY: Nursing Process Step: Implementation 4. The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurse’s next assessment be?

a. b. c. d.

Fullness of the bladder Amount of lochia Blood pressure Level of pain

ANS: A Bladder distention can cause uterine atony and pushes the fundus to the side. The bladder is emptied and the uterus is massaged to firmness.

DIF: Cognitive Level: Application TOP: Bladder Distention

REF: 255 OBJ: 6 KEY: Nursing Process Step: Implementation

5. A nurse has massaged the uterus and put the infant to the breast of a postpartum patient but these have been ineffective in controlling a boggy uterus. What would the nurse anticipate will be ordered by the primary health care provider? a. Prepare patient for dilation and curettage b. Magnesium sulphate c. Oxytocin d. Bromocriptine ANS: C Oxytocin is the most common medication ordered to control uterine atony.

DIF: Cognitive Level: Comprehension REF: 255 OBJ: 5 TOP: Oxytocin KEY: Nursing Process Step: Implementation 6. A 4-week postpartum patientNwUitRhSmIaN stG itiT sB as.kC sO thM e nurse if she can continue to breastfeed.

What is the nurse’s most helpful response? a. “Stop breastfeeding until the infection clears.” b. “Pump the breasts to continue milk production, but do not give breast milk to the infant.” c. “Begin all feedings with the affected breast until the mastitis is resolved.” d. “Breastfeeding can continue.”

ANS: D The woman with mastitis can continue to breastfeed.

DIF: Cognitive Level: Application TOP: Mastitis and Breastfeeding

REF: 260 OBJ: 6 KEY: Nursing Process Step: Implementation

7. A woman had a vaginal birth 1 day ago and is preparing for discharge. What would a nurse plan to teach the woman to report to help prevent postpartum complications? a. Fever b. Change in lochia from red to white c. Cramping d. Fatigue and irritability ANS: A Increased temperature is a sign of infection. The other choices are normal in the postpartum period.

DIF: Cognitive Level: Application TOP: Puerperal Infections

REF: 260 OBJ: 4 KEY: Nursing Process Step: Planning

8. One day after discharge, a postpartum patient calls the clinic stating she has symptoms of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-coloured lochia, and sore breasts. What does the nurse suspect from these symptoms? a. Thrombosis b. Puerperal infection c. Late postpartum hemorrhage d. Mastitis ANS: A The symptoms related to the leg are indicative of thrombosis. The other signs are normal in the postpartum patient.

DIF: Cognitive Level: Analysis REF: 257 OBJ: 2 TOP: Phlebitis KEY: Nursing Process Step: Implementation 9. Which statement indicates to a nurse on a postpartum home visit that a patient requires more teaching related to the signs of late postpartum hemorrhage? a. “My discharge would change to red after it has been pink or white.” b. “If I have a postpartum hemorrhage, I will have severe abdominal pain.” c. “I should be alert for an increase in bright red blood.” d. “I would pass a large clot.”

ANS: A Severe abdominal pain does aNcU coRmSpIanNyGsTigBn. sC ofOaMpostpartum hemorrhage, but all the other symptoms are indicative of a PPH. DIF: Cognitive Level: Comprehension TOP: Postpartum Hemorrhage

REF: 252 OBJ: 2 KEY: Nursing Process Step: Evaluation

10. During a postpartum assessment, a woman reports her right calf is painful. A nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve? a. Anticoagulants b. Application of ice to the affected leg c. Gentle massage of the affected leg d. Passive leg exercises twice a day ANS: A Anticoagulant therapy is initiated with heparin for at least 6 weeks after birth to minimize the risk of embolism. Analgesics and heat would help manage the pain. The leg would also be elevated.

DIF: Cognitive Level: Analysis TOP: Anticoagulant Therapy

REF: 258 OBJ: 5 KEY: Nursing Process Step: Implementation

11. What statement by a patient leads a nurse to determine a woman with mastitis understands treatment instructions?

a. b. c. d.

“I will apply cold compresses to the painful areas.”

“I will take a warm shower before nursing the baby.”

“I will nurse first on the affected side.”

“I will empty the affected breast every 8 hours.”

ANS: B Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.

DIF: Cognitive Level: Comprehension REF: 260 TOP: Mastitis KEY: Nursing Process Step: Evaluation

OBJ: 6

12. What is the best response to a postpartum woman who tells a nurse she feels “tired and sick all of the time since I had the baby 3 months ago”? a. “This is a normal response for the body after pregnancy. Try to get more rest.” b. “I’ll bet you will snap out of this funk real soon.” c. “Why don’t you arrange for a babysitter so you and your husband can have a night out?” d. “Let’s talk about this further. I am concerned about how you are feeling.”

ANS: D If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive.

DIF: Cognitive Level: Application TOP: Perinatal Mood Disorder

REF: 261 OBJ: 6 | 7 KEY: Nursing Process Step: Implementation

13. A nurse is caring for a womaN nU wR hoShIaNdGaTcB ae. saCreOaM n birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation? a. Teach the woman to remain in bed with her legs elevated. b. Monitor vital signs every 4 hours and report any changes. c. Teach the woman to use antiembolic stockings when ambulating. d. Assist the woman with ambulation for short periods of time.

ANS: D Early ambulation and antiembolic stockings worn continuously are valuable aids to prevent thrombus formation in the postpartum woman.

DIF: Cognitive Level: Application TOP: Thrombus Prevention

REF: 258 OBJ: 4 KEY: Nursing Process Step: Implementation

14. Five days after a spontaneous vaginal birth, a woman comes to the emergency room because she has had a fever for 2 days and persistent cramping. What does a nurse recognize as the possible cause of these signs and symptoms? a. Dehydration b. Hypovolemic shock c. Endometritis d. Cystitis ANS: C

Fever after 24 hours following birth is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.

DIF: Cognitive Level: Analysis TOP: Puerperal Infections

REF: 259 OBJ: 2 KEY: Nursing Process Step: Data Collection

15. At a 6-week postpartum checkup, a woman mentions to a nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes she is not a good mother. What does the nurse recognize as the most likely reason for this woman’s symptoms? a. Bipolar disorder b. Depression c. Postpartum blues d. Psychosis ANS: B Depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep, and appetite disturbances.

DIF: Cognitive Level: Analysis TOP: Perinatal Mood Disorder

REF: 261 OBJ: 7 KEY: Nursing Process Step: Data Collection

16. Three weeks after giving birth to her first child, a woman tells a nurse, “I waited so long for this baby and now that she is here, I can’t believe how different my life is from what I expected.” What is the best nursing response to the woman’s statement? a. “How is your partner adjusting to the change?” b. “I hear this from a lot of first-time mothers.” c. “Have you told anyone elN seUaRbS ouItNyG ouTr Bfe.eC linOgM s?” d. “Tell me how things are different.”

ANS: D The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mother’s feelings about motherhood and her infant.

DIF: Cognitive Level: Application TOP: Perinatal Mood Disorder

REF: 262 OBJ: 6 | 7 KEY: Nursing Process Step: Implementation

17. After a prolonged labour, a woman gives birth vaginally to a 4600 g infant. What complication should a nurse be alert for in the immediate postpartum period? a. Cervical laceration b. Hematoma c. Endometritis d. Retained placental fragments ANS: B Delivering a large infant and a prolonged labour are risk factors for hematoma formation.

DIF: Cognitive Level: Analysis REF: 256 OBJ: 3 TOP: Hematoma KEY: Nursing Process Step: Data Collection

18. A woman has had persistent lochia rubra for 2 weeks after her birth and is experiencing pelvic discomfort. What does a nurse explain is the usual treatment for subinvolution? a. Uterine massage b. Oxytocin infusion c. Dilation and curettage d. Hysterectomy ANS: C Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall or antibiotics for any infection that might be present.

DIF: Cognitive Level: Knowledge TOP: Subinvolution of the Uterus

REF: 254 OBJ: 2 KEY: Nursing Process Step: Implementation

19. The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms? a. Notify the charge nurse of a possible upper respiratory infection. b. Notify the primary healthcare provider of a possible pulmonary embolism. c. Document expected postpartum mucous membrane congestion. d. Medicate with an antipyretic for elevated temperature.

ANS: B Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication.

DIF: Cognitive Level: AppN liU caRtiS onINGTBR OBJ: 2 | 6 .ECFO:M 257 TOP: Pulmonary Embolus KEY: Nursing Process Step: Implementation 20. While caring for a postpartum patient who had a vaginal birth yesterday, a nurse assesses a firm uterine fundus and a trickle of bright blood. What is the best response to this finding? a. Reports a probable cervical laceration b. Massages the uterus to expel retained clots c. Reports a possible clotting disorder d. Documents the findings ANS: A The bright trickle of blood with a firm uterus suggests a cervical laceration.

DIF: Cognitive Level: Application REF: 256 OBJ: 2 | 6 TOP: Laceration KEY: Nursing Process Step: Implementation 21. A nurse assesses a 4-week postpartum mother. The woman states she has irrational fears, nausea, dyspnea, and insomnia. What does the nurse expect that the woman is most likely experiencing? a. Postpartum blues b. Postpartum anxiety c. Postpartum depression d. Postpartum psychosis ANS: B

These are symptoms of postpartum anxiety.

DIF: Cognitive Level: Knowledge TOP: Perinatal Mood Disorder

REF: 260 OBJ: 2 KEY: Nursing Process Step: Data Collection

22. The new mother who had a vaginal birth yesterday has a white blood cell count of 25  109/L. What action should a nurse implement? a. Notify the charge nurse of a possible infection. b. Prepare to put the patient in isolation. c. Have the infant removed from the room and returned to the nursery. d. Assess the patient further.

ANS: D The patient should be assessed further for other signs of infection because a white blood cell (WBC) count of 20 to 25  109/L is normal in the early postpartum period.

DIF: Cognitive Level: Analysis TOP: Elevated WBC

REF: 258 OBJ: 6 KEY: Nursing Process Step: Data Collection

23. A postpartum patient experiences significant bleeding and is diagnosed with disseminated intravascular coagulation (DIC). What is the most likely cause? a. Pulmonary embolism b. Pre-eclampsia c. Allergy d. Deep vein thrombosis ANS: B NURSINGTB.COM DIC can be caused by pre-eclampsia, stillbirth, infection, or amniotic fluid embolus.

Pulmonary embolism, allergy or deep vein thrombosis do not cause DIC. DIF: Cognitive Level: Comprehension REF: 257 TOP: Disseminated intravascular coagulation KEY: Nursing Process Step: Data Collection

OBJ: 3

24. A postpartum woman is prescribed warfarin (Coumadin) to treat deep vein thrombosis.

What will a nurse instruct this woman is the antidote for warfarin overdose? a. Vitamin A b. Vitamin B c. Vitamin E d. Vitamin K ANS: D The antidote for warfarin overdose is vitamin K. DIF: Cognitive Level: Knowledge TOP: Deep Vein Thrombosis MULTIPLE RESPONSE

REF: 258 OBJ: 5 KEY: Nursing Process Step: Implementation

1. A nursing teacher is discussing risk factors for postpartum hypovolemic shock with a nursing class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage ANS: B, E Blood clotting disorders and a postpartum hemorrhage can cause decrease in blood volume.

DIF: Cognitive Level: Application TOP: Hypovolemic Shock

REF: 252 OBJ: 3 KEY: Nursing Process Step: N/A

2. A nurse assesses the perineal pad placed on a 3-hour postpartum patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus ANS: B, E Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.

NURSINGTB.COM

DIF: Cognitive Level: Analysis TOP: Uterine atony

REF: 255 OBJ: 4 KEY: Nursing Process Step: Data Collection

3. A nurse instructs a postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits d. Rice e. Cantaloupe ANS: A, C, E Legumes (contain proteins) and foods containing vitamin C are conducive to healing.

Starches are not.

DIF: Cognitive Level: Comprehension TOP: Nutrition related to Healing

REF: 259 OBJ: 4 KEY: Nursing Process Step: Implementation

4. What will a nurse teach a breastfeeding mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 litre per day. b. Ensure frequent breastfeeding. c. Take warm showers prior to feeding.

d. Wear a supportive bra. e. Use ice packs prior to breastfeeding.

ANS: B, C, D Nursing mothers should take in about 2 to 3 litres of fluid a day. Warm packs rather than ice packs help to stimulate milk flow. All the other options are interventions to reduce the risk of mastitis.

DIF: Cognitive Level: Comprehension TOP: Reduction of the Risk of Mastitis

REF: 260 OBJ: 4 KEY: Nursing Process Step: Planning

5. A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can a nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples ANS: A, B, C, D Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine.

DIF: Cognitive Level: Comprehension TOP: Urinary Tract Infection

REF: 259 OBJ: 4 KEY: Nursing Process Step: Implementation

6. A postpartum patient is experNieUnR ciS ngIhNyGpT ovBo. leC mOicMshock. What interventions can a nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Administration of a blood transfusion ANS: A, B, C, E Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given.

DIF: Cognitive Level: Application TOP: Hypovolemic Shock

REF: 252 OBJ: 5 KEY: Nursing Process Step: Implementation

7. A nurse is aware that which of the following factors are the causes of a postpartum hemorrhage (PPH)? (Select all that apply) a. Tone b. Tachycardia c. Trauma d. Tissue e. Thromboembolism

ANS: A, C, D PPH is caused by tone, trauma, tissue, and thrombin. Tachycardia and thromboembolism do not cause a PPH. DIF: Cognitive Level: Knowledge TOP: Risk factors for PPH

REF: 251 OBJ: 3 KEY: Nursing Process Step: Data Collection

COMPLETION 1. The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of mL. ANS: 15 The weight of 1 g in a perineal pad is equal to 1 mL of blood loss.

DIF: Cognitive Level: Comprehension TOP: Weighing Perineal Pad

REF: 253 OBJ: 2 KEY: Nursing Process Step: Data Collection

NURSINGTB.COM

Chapter 11: The Term Newborn Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. While inspecting a newborn’s head, a 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. Moulding b. Caput succedaneum c. Cephalohematoma d. Enlarged fontanelle ANS: C A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.

DIF: Cognitive Level: Comprehension TOP: Newborn Assessment—Head

REF: 272 OBJ: 1 | 4 KEY: Nursing Process Step: Implementation

2. What is a nurse’s best response to a mother who is voicing concern about the molding of her 2-day-old infant’s head? a. “Moulding doesn’t cause any problems. Don’t worry about it.” b. “Did you give birth vaginally or by Caesarean?” c. “The baby’s head conformed to the shape of the birth canal. It will go away soon.” d. “A traumatic birth can caN usUeRmSoI ulNdG inT g.B ” .COM ANS: C The newborn’s head may be out of shape from moulding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal.

DIF: Cognitive Level: Application TOP: Newborn Assessment—Head

REF: 272 OBJ: 1 | 4 KEY: Nursing Process Step: Implementation

3. What symptom assessed in the newborn shortly after birth 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: 276 TOP: Newborn Assessment—Respiratory KEY: Nursing Process Step: Implementation

OBJ: 4

4. When a newborn’s crib was moved suddenly, a nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behaviour? a. The Moro reflex b. The grasp reflex c. An abnormality of the musculoskeletal system d. A neurological abnormality ANS: A The Moro reflex is a normal newborn reflex. It is elicited when the infant is startled. 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 TOP: Newborn Reflexes

REF: 271 OBJ: 3 KEY: Nursing Process Step: Data Collection

5. A first-time mother reports that she is experiencing difficulty latching her newborn to the breast. Which newborn reflex would a nurse teach the mother to elicit to facilitate breastfeeding? a. Sucking b. Rooting c. Grasping d. Tonic neck ANS: B The rooting reflex causes the infant’s head to turn in the direction of anything that touches the cheek in anticipation of foNoUdR . SINGTB.COM DIF: Cognitive Level: Application TOP: Newborn Reflexes

REF: 271 OBJ: 3 KEY: Nursing Process Step: Implementation

6. What will a nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn? a. Depressed and sunken b. Triangular shaped c. Smaller than the posterior fontanelle d. Open and diamond shaped ANS: D The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be bulging or sunken, and it closes between 12 and 18 months of age.

DIF: Cognitive Level: Comprehension TOP: Newborn Assessment—Head

REF: 273 OBJ: 2 KEY: Nursing Process Step: Data Collection

7. What statement indicates a parent understands the guidelines for bathing a newborn? a. “I’ll use a mild soap to clean all of the body parts.” b. “I am going to add bath oil to the water to keep the baby’s skin soft.” c. “I should bathe the baby 2 to 3 times per week.”

d. “I’ll wash from the feet upward and change the washcloth for the face.”

ANS: C Bathing only needs to be done 2 to 3 times per week. Soap should not be used on the face; bath oil is not recommended, and bathing should go from head to toe.

DIF: Cognitive Level: Comprehension TOP: Home Care—Bathing the Infant

REF: 289 OBJ: 10 KEY: Nursing Process Step: Evaluation

8. A nurse is measuring the vital signs of a calm, full-term newborn. Which finding is abnormal? a. An axillary temperature of 36.6 C (98 F) b. An apical pulse rate of 178 beats/minute c. Respirations of 35 breaths/minute d. Blood pressure of 80/50 mm Hg ANS: B The normal range for a newborn’s pulse rate is 110 to 160 beats/minute. A pulse rate outside of this range should be reported.

DIF: Cognitive Level: Comprehension REF: 268 TOP: Newborn Assessment—Vital Signs KEY: Nursing Process Step: Data Collection

OBJ: 4

9. A nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool colour to be 3 days after birth? a. Yellow NURSINGTB.COM b. Brown c. Greenish yellow d. Black and tarry ANS: C The stool of a 3-day-old breastfed infant should be greenish yellow, also called transition stools.

DIF: Cognitive Level: Application REF: 282 TOP: Newborn Assessment—Gastrointestinal System KEY: Nursing Process Step: Data Collection

OBJ: 10

10. A mother of a 2-week-old infant tells a nurse, “I think the baby is constipated. I’ve noticed she strains when she has a bowel movement.” What is nurse’s most helpful response? a. “Give the baby one serving of fruit per day.” b. “Increase the amount and frequency of her feedings.” c. “It sounds like the baby is uncomfortable because she is constipated.” d. “Newborns might strain with bowel movements because their muscles aren’t fully developed.”

ANS: D Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.

DIF: Cognitive Level: Application REF: 282 TOP: Newborn Assessment—Gastrointestinal System KEY: Nursing Process Step: Implementation

OBJ: 10

11. A full-term newborn weighs 3600 grams at birth. What would a 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 7 to 10% of their birth weight.

DIF: Cognitive Level: Analysis TOP: Newborn Assessment—Weight

REF: 269 OBJ: 4 KEY: Nursing Process Step: Data Collection

12. Parents of a newborn girl express concern about the infant’s vaginal discharge, which appears to be bloody mucus. What does a 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.

NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: 278 TOP: Newborn Assessment—Genitourinary KEY: Nursing Process Step: Implementation

OBJ: 2

13. The mother of a 2-week-old infant tells a 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 TOP: Discharge Planning

REF: 275 OBJ: 10 KEY: Nursing Process Step: Implementation

14. Which statement indicates parents of a 2-week-old breastfed infant understand when to contact the primary health care provider? a. Infant refuses a feeding. b. Infant has an axillary temperature of 36.1° C (97 F).

c. Infant has three seedy yellow stools in 24 hours. d. Infant’s diaper is not wet after 8 hours.

ANS: D Decreased or lack of voiding by the newborn should be reported to the health care provider to prevent dehydration.

DIF: Cognitive Level: Comprehension TOP: Discharge Planning

REF: 287 OBJ: 8 KEY: Nursing Process Step: Evaluation

15. A mother asks a nurse, “Do you think my baby recognizes my voice?” The nurse should consider which correct information when responding? a. Voice recognition is delayed because the ears are not well developed at birth. b. Infants respond to voice by increasing movements and sucking. c. Infants initially respond to low-pitched voices. d. Newborns can distinguish a mother’s voice from other sounds in the first days of life.

ANS: D The ability to discriminate between a mother’s voice and other voices may occur as early as in the first 3 days of life.

DIF: Cognitive Level: Knowledge TOP: Newborn Assessment—Hearing

REF: 274 OBJ: 4 | 10 KEY: Nursing Process Step: Implementation

16. A nurse compares the birth weight of a 3-day-old with her current weight and determines the infant has lost 8% of the bNiU rthRw ghGt.TW SeIiN Bh.aCt iOsMthe most appropriate intervention by the nurse? a. Assess feeding behaviour. b. Report the discrepancy to the primary health care provider immediately. c. Decrease the interval between the infant’s feedings. d. Try feeding the infant formula between feeds.

ANS: A It is typical for the newborn to lose 7 to 10% of their birth weight in the first 3 to 4 days of life. A nurse would assess the feeding behaviour to determine if newborn is feeding well.

Usually no change in the plan of care is needed.

DIF: Cognitive Level: Application TOP: Newborn Assessment—Weight

REF: 269 OBJ: 4 KEY: Nursing Process Step: Implementation

17. Parents express concern about the milia on the face and nose of their infant. What is a nurse’s most helpful response when instructing the parents? a. “Contact a pediatric dermatologist for topical medication.” b. “Squeeze out the white material after cleansing the face.” c. “Wash the infant’s face with a mild astringent several times a day.” d. “Leave the milia alone; it will disappear spontaneously.”

ANS: D Milia require no treatment. This skin manifestation will disappear spontaneously.

DIF: Cognitive Level: Application TOP: Newborn Assessment—Skin

REF: 279 OBJ: 4 | 6 KEY: Nursing Process Step: Planning

18. A nurse is teaching parents how to use a bulb syringe to clear mucus from a congested newborn’s nose and mouth. What is most important for the nurse to teach the parents? 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 TOP: Discharge Teaching

REF: 287 OBJ: 10 KEY: Nursing Process Step: Implementation

19. A mother of a 4-day-old calls the health care provider’s office because she is concerned about her infant’s skin. Which finding needs to be reported promptly to the child’s health care provider? a. The hands and feet feel cooler than the rest of the body. b. Skin is peeling on several parts of the infant’s body. c. There is a small pink patch on the left eyelid and one on the neck. d. Today, the infant’s skin has a yellowish tinge.

ANS: D Physiological jaundice becomNeU sR evSidIeN ntGbTeB tw.eC enOtM he 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 TOP: Newborn Assessment—Skin

REF: 279 OBJ: 7 KEY: Nursing Process Step: Implementation

20. What action does a nurse implement to protect newborns from infection while in the hospital? a. Keep the newborn dressed warmly. b. Adjust room temperature between 23.8 C (75 F) and 26.6 C (80 F). c. Wash hands before touching each infant. d. Wear a disposable gown when giving infant care.

ANS: C Hand hygiene is the most reliable precaution available to prevent infection. The nurse washes their hands between providing care to any patient.

DIF: Cognitive Level: Application TOP: Preventing Infection

REF: 284 OBJ: 8 KEY: Nursing Process Step: Planning

21. Which assessment of the newborn should a nurse report to the primary health care provider? a. Head circumference is 5 cm greater than the chest circumference. b. Hands and feet are cool with a blue colour. 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 TOP: Newborn Assessment

REF: 270 OBJ: 4 KEY: Nursing Process Step: Data Collection

22. Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does a nurse explain this skin discoloration is called? a. Epstein’s pearls b. Milia c. Stork bites d. Mongolian spot ANS: D Bluish skin discoloration over the sacral area of a newborn is called Mongolian spot. It is benign.

DIF: Cognitive Level: Comprehension TOP: Skin Assessment

REF: 279 OBJ: 6 KEY: Nursing Process Step: Implementation

23. The pediatric clinic nurse receives laboratory results on several newborn patients. Which of the following should be brought to the primary health care provider’s attention first? a. White blood cell count of 18  109/L b. Hemoglobin of 185 g/L NURSINGTB.COM c. Hematocrit of 0.46 d. Bilirubin of 260 mmol/L ANS: D A bilirubin of 260 is elevated and requires further immediate investigation.

DIF: Cognitive Level: Analysis TOP: Normal Lab Values

REF: 282 OBJ: 4 | 7 KEY: Nursing Process Step: Data Collection

24. A nurse is assessing a newborn. Which sign would indicate hypoglycemia? a. Increased nasal mucus b. Increased temperature c. Active muscle movements d. High-pitched cry ANS: D There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.

DIF: Cognitive Level: Comprehension TOP: Signs of Hypoglycemia

REF: 284 OBJ: 4 KEY: Nursing Process Step: Data Collection

25. After birth, a nurse quickly dries and wraps a newborn in a blanket. This action prevents heat loss via which process? 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 TOP: Thermoregulation

REF: 266 OBJ: 5 KEY: Nursing Process Step: Implementation

26. What will a nurse teach a new mother regarding care of the infant’s umbilical cord? 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. Newborns can have a tub bath before the umbilical cord falls off.

DIF: Cognitive Level: Application TOP: Umbilical Cord Care

REF: 289 OBJ: 10 KEY: Nursing Process Step: Implementation

27. What security measure should a nurse implement when bringing an infant from the NICU to the mother? a. Ask, “Is this your band number?” b. Confirm room number ofNmUoRthSeI r. NGTB.COM 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 TOP: Security Identification Procedure

REF: 285 OBJ: 4 KEY: Nursing Process Step: Implementation

28. Which blood glucose level in the newborn is considered hypoglycemic? a. Below 3.0 mmol/L b. Below 2.7 mmol/L c. Below 2.5 mmol/L d. Below 2.2 mmol/L ANS: D A blood glucose level of less than 2.2 mmol/L is considered hypoglycemic. If the level is low the infant is put skin-to-skin and offered the breast.

DIF: Cognitive Level: Comprehension TOP: Hypoglycemia

REF: 283 OBJ: 4 KEY: Nursing Process Step: Planning

29. After birth, a mother asks a nurse about newborn screening tests. The nurse explains that what is the optimal time for testing for phenylketonuria (PKU)? a. In the first 24 hours of life b. After 24 to 48 hours c. At 4 to 6 weeks of age d. At 2 months of age ANS: B Blood tests for PKU should be obtained 24 to 48 hours after birth. The newborn will have had enough time to ingest protein through feedings, and the chance of false-negative results will be reduced.

DIF: Cognitive Level: Comprehension REF: 284 OBJ: 4 TOP: PKU KEY: Nursing Process Step: Implementation MULTIPLE RESPONSE 1. What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Touch b. Skin-to-skin c. Oral sucrose d. Distraction e. Breastfeeding ANS: A, B, C, E Touch, skin-to-skin contact, pNrU ovRidSiI ngNoGraTlBsu.cC roOsM e and breastfeeding are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.

DIF: Cognitive Level: Comprehension TOP: Noninvasive Pain Relief

REF: 275 OBJ: 4 KEY: Nursing Process Step: Implementation

2. A nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborn’s physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts ANS: A, C Newborns have very little subcutaneous fat, which offers little insulation against cold.

Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

DIF: Cognitive Level: Comprehension TOP: Environmental Thermal Stress

REF: 266 | 267 OBJ: 5 KEY: Nursing Process Step: Implementation

3. Which interventions would be included in the nursing care of the newly circumcised infant?

(Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage.

ANS: A, D Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely.

DIF: Cognitive Level: Application TOP: Circumcision Care

REF: 278 OBJ: 10 KEY: Nursing Process Step: Implementation

4. A nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Babinski d. Sucking e. Pincer grasping ANS: A, B, C, D Blinking, sneezing, Babinski, and sucking reflexes are present in the full-term newborn.

Pincer grasp does not occur until between 8 and 12 months.

DIF: Cognitive Level: KnoNwUleRdS geINGTBR OBJ: .ECFO:M 272 TOP: Reflexes KEY: Nursing Process Step: Data Collection

3

5. A nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine ANS: A, B, E The newborn’s glomeruli are small and have only one-third of the blood circulation of an adult, and they are unable to effectively concentrate urine. The GI tract is active. The infant’s sweat glands do not work effectively and allow very little fluid loss through sweat.

DIF: Cognitive Level: Comprehension REF: 277 TOP: Dehydration KEY: Nursing Process Step: Planning

OBJ: 4

6. A nurse is teaching a prenatal class and discussing the risk factors for sudden infant death syndrome (SIDS). Which of the following topics would the nurse include in the class related to the risks? (Select all that apply.) a. Maternal smoking during pregnancy b. Bedsharing

c. Sleeping in supine position d. Use of a pacifier e. Overheating ANS: A, B, E Risk factors for SIDS include exposure to smoke during pregnancy, sharing a bed for infants less than 4 months, and overheating. The use of a pacifier and sleeping in a supine position decreases the risk of SIDS. DIF: Cognitive Level: Knowledge TOP: Sudden Infant Death Syndrome

REF: 289 | 290 OBJ: 9 KEY: Nursing Process Step: Implementation

NURSINGTB.COM

Chapter 12: The High-Risk Newborn Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse is assessing a preterm infant. To what does the infant’s level of maturation refer? a. Actual time the fetus remained in the uterus b. Age on the Dubowitz scoring system c. Infant’s weight as compared to the gestational age d. Ability of the organs to function outside of the uterus ANS: D Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.

DIF: Cognitive Level: Knowledge TOP: Preterm Infant

REF: 295 OBJ: 1 KEY: Nursing Process Step: Data Collection

2. A preterm infant has a yellow skin colour 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

NURSINGTB.COM

ANS: C The higher the bilirubin level and the deeper the jaundice, the greater is the risk for kernicterus (a serious neurological complication that can cause brain damage, which is also known as bilirubin encephalopathy).

DIF: Cognitive Level: Comprehension REF: 306 OBJ: 4 TOP: Jaundice KEY: Nursing Process Step: Data Collection 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 breastmilk by mouth d. Need for a larger quantity of breastmilk at each feeding ANS: A When the preterm infant’s sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

DIF: Cognitive Level: Comprehension TOP: Preterm Infant—Nutrition

REF: 308 OBJ: 4 | 6 KEY: Nursing Process Step: Implementation

4. A nurse is aware that a deficiency in which of the following 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 TOP: Respiratory Distress Syndrome

REF: 298 OBJ: 4 KEY: Nursing Process Step: N/A

5. How will a 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 the pH of the stomach contents.

ANS: D When the preterm infant is gavage fed, the contents of the stomach should be aspirated and the pH checked prior to feeding. The gastric tube is correctly placed in the stomach if the gastric aspirate has a pH  5.5.

DIF: Cognitive Level: Application REF: 304 OBJ: 6 TOP: Preterm Infant—NutrN itiUoR n SINGTBK EY : Nursing Process Step: Implementation .COM 6. A nurse explains to a patient in preterm labour that what treatment may be ordered by the primary health care provider to accelerate fetal lung maturity? a. Prostaglandins b. Oxytocin c. Magnesium sulphate d. Corticosteroids ANS: D Surfactant production can be increased by administering corticosteroids to the mother before birth.

DIF: Cognitive Level: Comprehension TOP: Respiratory Distress Syndrome

REF: 298 OBJ: 4 KEY: Nursing Process Step: Implementation

7. The apnea monitor indicates that a preterm infant is having an apneic episode. What should a nurse do first in this situation? a. Administer oxygen via a nasal cannula. b. Gently rub the infant’s feet or back. c. Ventilate with a bag valve mask. d. Perform nasopharyngeal suctioning.

ANS: B Gently rubbing the infant’s back, ankles, or feet may stimulate the infant to breathe.

DIF: Cognitive Level: Application TOP: Preterm Infant—Apnea

REF: 299 OBJ: 4 KEY: Nursing Process Step: Implementation

8. What would a 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 TOP: Hypocalcemia

REF: 303 OBJ: 4 KEY: Nursing Process Step: Data Collection

9. What is the rationale for placing a preterm infant born at 34 weeks of gestation under a radiant warmer? a. The infant has a small body surface-to-weight ratio. b. Heat increases the flow of oxygen to the extremities. c. The infant’s temperature control mechanism is immature. d. The heat 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 centre in the brainNisUiR mS mIatNuG reT . B.COM DIF: Cognitive Level: Comprehension TOP: Thermoregulation

REF: 300 OBJ: 5 KEY: Nursing Process Step: Implementation

10. What nursing action is most important to prevent possible retinopathy in a preterm infant requiring oxygen therapy? a. Monitor oxygen levels with a pulse oximeter. b. Position the head slightly lower than the body. c. Administer low concentrations of oxygen. d. Keep the infant’s eyes covered at all times.

ANS: A Use of a pulse oximeter to carefully monitor oxygen saturation in high-risk infants continues to be a priority in the neonatal intensive care unit.

DIF: Cognitive Level: Application TOP: Retinopathy of Prematurity

REF: 304 OBJ: 4 KEY: Nursing Process Step: Implementation

11. When assessing a preterm infant, a nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate? a. Respiratory distress syndrome b. Postmaturity syndrome c. Apneic episode

d. Cold stress ANS: A Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.

DIF: Cognitive Level: Analysis TOP: Respiratory Distress Syndrome

REF: 298 OBJ: 4 KEY: Nursing Process Step: Data Collection

12. What nursing action will a 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 TOP: Necrotizing Enterocolitis

REF: 305 OBJ: 4 KEY: Nursing Process Step: Implementation

13. Parents of a preterm infant come to the NICU every day to see their infant. The infant is being fed through a gavage tube. What will a nurse teach the parents regarding how to stimulate the infant?

NURSINGTB.COM a. Bring in colourful pictures and toys to place in the isolette. b. Stimulate the infant during feedings to intake. c. Stroke the infant during feedings to increase intake. d. Do not disturb the infant between feedings.

ANS: C During gavage feedings, stroking the infant gently can provide stimulation.

DIF: Cognitive Level: Application TOP: Developmental Care

REF: 308 OBJ: 6 | 8 KEY: Nursing Process Step: Implementation

14. A 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 which of the following? a. Respiratory distress syndrome b. Hypoglycemia c. Necrotizing enterocolitis d. Renal failure ANS: B Signs of hypoglycemia in the preterm infant include tremors or jitteriness, weak cry, lethargy, and convulsions DIF: Cognitive Level: Analysis TOP: Hypoglycemia

REF: 303 OBJ: 4 KEY: Nursing Process Step: Data Collection

15. A mother of a 4-month-old infant, born prematurely, asks a 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 2 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 TOP: Preterm Infant

REF: 307 OBJ: 8 KEY: Nursing Process Step: Implementation

16. A 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: KnoNwUleRdS geINGTBR OBJ: 4 .ECFO:M 305 TOP: Immature Kidneys KEY: Nursing Process Step: Data Collection 17. A nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit? a. Thin, long extremities b. Large genitals for its size c. Minimal vernix caseosa d. Loose, transparent skin ANS: D The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.

DIF: Cognitive Level: Comprehension TOP: Preterm Infant

REF: 298 OBJ: 2 KEY: Nursing Process Step: Data Collection

18. The woman in labour with a post-term pregnancy asks the nurse why the fetus is being monitored so closely. What is a nurse’s best response? a. “The placenta does not function adequately as it ages.” b. “Infants born postmaturely are generally large.” c. “The birth of the post-term infant can be more difficult.” d. “There is less amniotic fluid.”

ANS: A

Fetal distress may occur in the post-term fetus because placental functioning becomes inadequate with maturity.

DIF: Cognitive Level: Comprehension TOP: Post-term Infant

REF: 308 OBJ: 9 KEY: Nursing Process Step: Implementation

19. What symptoms of cold stress might a nurse recognize in a preterm infant? a. Tremors and weak cry b. Plasma glucose level below 2.6 mmol/L 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 TOP: Preterm Infant

REF: 301 OBJ: 5 KEY: Nursing Process Step: Data Collection

20. A nurse is caring for an infant born at 42 weeks. What would the physical assessment reveal? a. Dry, peeling skin b. Minimal hair on the head c. Short, rough nails d. Abundant lanugo on the body ANS: A NURSINGTB.COM Loss of vernix caseosa leaves the skin dry, causing peeling.

DIF: Cognitive Level: Comprehension TOP: Post-term Infant

REF: 309 OBJ: 9 KEY: Nursing Process Step: Data Collection

21. Why is the post-term newborn 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 TOP: Post-term Cold Stress

REF: 300 OBJ: 9 KEY: Nursing Process Step: Implementation

22. When assessing a 38-week gestation newborn, a nurse records the weight as 4050 g. What will the nurse consider this newborn? a. Term b. Small for gestational age c. Large for gestational age (LGA) d. Late preterm

ANS: C Term infants over 4000 g may be classified as LGA. DIF: Cognitive Level: Analysis TOP: Large for Gestational Age

REF: 294 OBJ: 13 KEY: Nursing Process Step: Data Collection

23. An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will a nurse anticipate seeing improvement of lung function? a. Immediately b. Within 72 hours 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 TOP: Respiratory Distress Syndrome

REF: 298 OBJ: 4 KEY: Nursing Process Step: Evaluation

24. A nurse is advising parents about feeding their infant who has phenylketonuria. What formula and/or diet should the nurse suggest? a. Lifelong high-protein diet b. A formula that is low in the amino acid leucine c. A soy-based formula d. Substitute Lofenalac for sNoU mR eS prIoN teG inTfB oo.dC s OM ANS: D A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted for natural protein foods.

DIF: Cognitive Level: Comprehension REF: 319 OBJ: 15 TOP: PKU KEY: Nursing Process Step: Implementation 25. Parents of a 2-month-old infant with Down syndrome are attending a well-baby visit at the pediatric clinic. What should they be instructed to provide special attention to regarding the generalized hypotonicity of the child? a. Preventing hyperthermia b. Respiratory care c. Prevention of diarrhea d. Incontinence care ANS: B The child with Down syndrome has generalized hypotonicity, which causes mucus accumulation and respiratory problems.

DIF: Cognitive Level: Application TOP: Down Syndrome

REF: 318 OBJ: 14 KEY: Nursing Process Step: Implementation

26. A nurse is caring for an Rh-negative mother on the labour and birth unit. What scenario indicates this woman will require Rho(D) immune globulin administration after the birth? a. She has had one Rh-negative child and is pregnant with an Rh-negative fetus. b. She has had an Rh-positive infant and is pregnant with an Rh-positive fetus. c. She has had an O-negative child and is pregnant with a B-negative fetus. d. She is a primigravida with an O-negative fetus.

ANS: B The only woman with antibodies against the Rh-positive infant is the Rh-negative woman who has had one Rh-positive child and is now pregnant with another.

DIF: Cognitive Level: Analysis TOP: Rh Concerns

REF: 310 OBJ: 10 KEY: Nursing Process Step: Implementation

27. Parents ask what the phototherapy light does for their jaundiced infant. What is a nurse’s best response? a. “The light increases the infant’s metabolism.” b. “The light stimulates liver function.” c. “The light dilates blood vessels.” d. “The light breaks down bilirubin.”

ANS: D Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted.

DIF: Cognitive Level: AppN liU caRtiS onINGTBR .ECFO:M 306 TOP: Hemolytic Disease of the Newborn KEY: Nursing Process Step: Implementation

OBJ:

10

28. Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy? a. Cover the infant’s head with a hat. b. Dress the infant lightly in a T-shirt. c. Keep the infant’s eyes covered. d. Reposition the infant at least every 4 to 6 hours.

ANS: C The infant’s eyes are protected with patches to prevent damage from the high-intensity lights.

DIF: Cognitive Level: Application TOP: Phototherapy

REF: 306 OBJ: 11 KEY: Nursing Process Step: Implementation

29. A nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess for in this newborn? a. Hypoglycemia b. Hemolytic disease of the newborn c. Intracranial hemorrhage d. Pancreatic failure

ANS: A The newborn of a mother with diabetes is prone to hypoglycemia.

DIF: Cognitive Level: Application TOP: Infant of a Diabetic Mother

REF: 315 OBJ: 13 KEY: Nursing Process Step: Data Collection

MULTIPLE RESPONSE 1. A nurse knows that a post-term 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 post-term infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.

DIF: Cognitive Level: Comprehension REF: 308 | 309 TOP: Potential Problems of the Post-term Infant KEY: Nursing Process Step: Implementation

OBJ: 9

2. A nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm birth? (Select all that apply.)

NURSINGTB.COM 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: Knowledge TOP: Preterm Birth

REF: 295 OBJ: 3 KEY: Nursing Process Step: Data Collection

3. A nurse assesses a preterm infant in the NICU. What signs should be reported to the primary health care provider? (Select all that apply.) a. Paleness

b. c. d. e.

Transparent skin Superficial scalp veins Vomiting 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: 304 TOP: Potential Problems of the Preterm Infant KEY: Nursing Process Step: Data Collection

OBJ: 4

4. What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.) a. Close-set eyes b. Simian creases c. Wide-spaced front teeth d. Protruding tongue e. Curved, small fingers ANS: A, B, D, E Children with Down syndrome have close-set, upturned eyes; simian creases in the palms of the hands; a protruding tongue; and curved, small fingers. They also have a wide space between their first and second toe and a high incidence of heart defects.

DIF: Cognitive Level: KnoNwUleRdS geINGTBR OBJ: 14 .ECFO:M 317 TOP: Features of Down Syndrome KEY: Nursing Process Step: Data Collection 5. What will a nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.) a. Keep positioned in slight Fowler’s position. b. Assess for poor feeding. c. Stimulate often to maintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe for increased intracranial pressure.

ANS: A, B, E These children should be kept positioned with the head slightly elevated, assessed for poor feeding, and monitored for increased intracranial pressure. Children with intracranial hemorrhages are not stimulated and are kept in a quiet environment.

DIF: Cognitive Level: Comprehension TOP: Topic: Intracranial Hemorrhage

REF: 304 OBJ: 4 KEY: Nursing Process Step: Planning

6. A nurse is observing for neonatal opioid withdrawal syndrome (NOWS) in the newborn of a mother who took opioids during pregnancy. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing

c. Hyperirritability d. Drowsiness e. Excessive appetite ANS: A, B, C The newborn with NOWS will have tremors, be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite.

DIF: Cognitive Level: Knowledge TOP: Neonatal Opioid Withdrawal

REF: 315 OBJ: 16 KEY: Nursing Process Step: Data Collection

7. A nurse is providing care immediately after birth for a macrosomic newborn whose mother had gestational diabetes. What assessment findings can the nurse anticipate? (Select all that apply.) a. High blood glucose levels b. Weight of 4000 g or more c. Decreased subcutaneous fat d. Hypocalcemia e. Hyperbilirubinemia ANS: B, D, E Many newborn infants of diabetic mothers have serious complications. When the mother is hyperglycemic, large amounts of glucose are transferred to the fetus. After birth the infant often has low blood glucose levels because of the abrupt loss of maternal glucose and hypertrophy of the pancreatic islet cells, which results in a temporary overproduction of insulin. Hyperinsulinism, along with excess production of protein and fatty acids, often results in a newborn infant thN atUwReS igIhN sm orBe . thCaO nM 4000 g. These infants also may have GT hypoglycemia, hypocalcemia, and hyperbilirubinemia.

DIF: Cognitive Level: Comprehension TOP: Macrosomic Newborn

REF: 315 OBJ: 13 KEY: Nursing Process Step: Data Collection

8. 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 TOP: Gestational Age Assessment

REF: 298 OBJ: 2 KEY: Nursing Process Step: Data Collection

COMPLETION 1. A nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of weeks.

ANS: 34 Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.

DIF: Cognitive Level: Knowledge REF: 298 TOP: Surfactant KEY: Nursing Process Step: N/A

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OBJ: 4

Chapter 13: An Overview of Growth, Development, and Nutrition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What type of development is the nurse assessing when an infant can lift his or her head before he or she can sit? a. Specific to general b. Proximodistal c. Cephalocaudal d. General to specific ANS: C Cephalocaudal development proceeds from head to toe.

DIF: Cognitive Level: Comprehension TOP: Cephalocaudal Development

REF: 325 OBJ: 1 KEY: Nursing Process Step: Data Collection

2. What is a unique organization of characteristics that determines an individual’s pattern of behaviour? a. Environment b. Heredity c. Personality d. Experience

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ANS: C One definition of personality states that it is a unique organization of characteristics that determines the individual’s typical or recurrent pattern of behaviour.

DIF: Cognitive Level: Knowledge TOP: Personality Development

REF: 332 OBJ: 1 KEY: Nursing Process Step: N/A

3. An infant’s birth weight is 3.5 kg. What can a nurse project the weight to be at 6 months? a. 6 kg b. 7 kg c. 8 kg d. 10 kg ANS: B An infant usually doubles their birth weight by 6 months.

DIF: Cognitive Level: Analysis TOP: Weight Prediction

REF: 326 OBJ: 2 KEY: Nursing Process Step: Data Collection

4. A nurse understands which of the following is most correct about development? a. It is only an increase in physical size. b. It refers to progressive increase in the function of the body. c. It is the total way the body matures.

d. It is not impacted by environmental factors.

ANS: B Development refers to a progressive increase in the function of the body (e.g., infant’s increasing ability to digest solids). Increase in size is growth. Maturation refers to the total way in which a person grows and develops, as dictated by genetics. Environmental factors impact the development of a child.

DIF: Cognitive Level: Knowledge TOP: Growth and Development

REF: 325 OBJ: 3 KEY: Nursing Process Step: N/A

5. The mother of a 7-month-old infant reports that the first lower central incisor has erupted.

She asks a nurse, “How many teeth will he have by his first birthday?” The nurse explains that the infant will have approximately 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 six teeth, four above and two below.

DIF: Cognitive Level: Knowledge REF: 345 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Implementation 6. At a well-baby visit, parents of a 6-month-old infant ask when to take the infant for the first dental visit. What is a nurse’sNbUeR stSreIsN poGnT seB?.COM 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 Canadian Dental Association.”

ANS: D The Canadian Dental Association recommends that the first dental visit occur by 1 year of age.

DIF: Cognitive Level: Application REF: 345 OBJ: 10 TOP: Dentition KEY: Nursing Process Step: Implementation 7. A 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: 345 TOP: Dentition KEY: Nursing Process Step: Planning

OBJ: 10

8. A nurse encourages an Inuit family who are from northern Labrador to bring food to a child because he is not eating the food served on his hospital tray. What can the nurse most likely expect the child to eat? a. Wild berries, fish, corn b. Crisp vegetables c. Spaghetti and meatballs d. Raw fish, mushrooms, rice ANS: A Inuit people tend to eat lots of fish, wild meat, wild berries, root vegetables, and corn.

DIF: Cognitive Level: Comprehension TOP: Feeding the Ill Child

REF: 342 | 343 OBJ: 7 KEY: Nursing Process Step: Implementation

9. A nurse observes that a 2-year-old toddler is able to use a spoon steadily at mealtime. What does self-feeding help to develop in the toddler? a. Good nutrition b. A sense of independence c. Adequate height and weight d. Healthy teeth ANS: B By the end of the second year, most toddlers can feed themselves. This helps them to develop a sense of independeN ncUeR . SINGTB.COM DIF: Cognitive Level: Comprehension TOP: Feeding the Healthy Child

REF: 336 OBJ: 5 KEY: Nursing Process Step: Data Collection

10. What activity would the nurse choose to meet Erikson’s developmental task of industry when caring for a 7-year-old child? a. Completing a 50-piece jigsaw puzzle b. Looking at a comic book c. Playing a game of “I Spy” with the nurse d. Colouring a picture in a colouring 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 TOP: Personality Development

REF: 340 OBJ: 11 KEY: Nursing Process Step: Planning

11. What does a nurse recognize as an example of Piaget’s concrete operational thinking? a. A 2-year-old child says, “It’s nighttime” when his room is darkened. b. A 4-year-old child refers to the hospital as “my house.” c. A 5-year-old child colouring a picture of a puppy says, “This is my puppy.” d. A 7-year-old child says, “I am sick because I have germs in my chest.”

ANS: D The 7-year-old child’s remark reflecting the cause and effect of germs and illness is an example of operational thinking. All other options are examples of preoperational thought, which is egocentric and symbolic.

DIF: Cognitive Level: Analysis TOP: Cognitive Development

REF: 335 OBJ: 8 KEY: Nursing Process Step: Data Collection

12. A nurse has discussed with a mother the process of introducing solid foods to her 6-month-old infant. What statement by the mother leads the nurse to determine that learning has taken place? a. “I will give my infant iron-rich food first.” b. “I will give my infant yellow vegetables first.” c. “I will give my infant citrus fruit.” d. “I will give my infant pureed fruits first.”

ANS: A Solid foods are usually introduced at about 6 months of age, starting with food high in iron.

DIF: Cognitive Level: Comprehension TOP: Feeding the Healthy Child

REF: 334 OBJ: 9 KEY: Nursing Process Step: Evaluation

13. 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 cleanNtiU ssRuS e.INGTB.COM 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 TOP: Loss of Tooth

REF: 341 OBJ: 10 KEY: Nursing Process Step: Implementation

14. The mother of a 7-month-old infant states, “The baby is eating food now. Should I give him regular milk, too?” What is a nurse’s best response? a. “You should give the baby low-fat milk.” b. “Try the milk. See if he has any digestive problems.” c. “Continue breast milk or iron-fortified formula until 9 months of age.” d. “At this age, infants can tolerate lactose-free or soy-based milk.”

ANS: C Whole milk should not be introduced at 9 to 12 months of age. Low-fat milk should not be introduced before 2 years of age.

DIF: Cognitive Level: Application TOP: Nutrition and Health

REF: 347 OBJ: 9 KEY: Nursing Process Step: Implementation

15. 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: 339 OBJ: 11 TOP: Play KEY: Nursing Process Step: Data Collection 16. A nurse is providing parenting information to parents of a toddler. What information is most important for the nurse to include in the teaching? a. “It is helpful to learn your child’s cues so you can anticipate their needs.” b. “Give them opportunities to try new things within their capabilities. Expect them to make a mess sometimes.” c. “It is appropriate to provide the child with chores to do.” d. “Understand that the child is trying to develop their own identity so try not to interfere with this.”

ANS: B Toddlers are in the stage of developing autonomy but still need support and love from parents. Learning cues are for the infancy stage when they are learning to develop trust with their caregiver. School-age chNiU ldR reS nIshNoGuT ldBb. eC giOvM en chores, and identity develops in an adolescent.

DIF: Cognitive Level: Analysis TOP: Development of a Parent

REF: 349 OBJ: 7 KEY: Nursing Process Step: Implementation

17. A mother tells a nurse, “My 11-month-old son is not as active as my other children were at this age. He is the youngest of four, and the older children love to dote on him.” Which factor is influencing this child’s motor development? a. Heredity b. Sex c. Mother’s health during pregnancy d. Ordinal position ANS: D Motor development of the youngest child may be prolonged if the child has their needs met by others in the family.

DIF: Cognitive Level: Analysis TOP: Factors Influencing Development

REF: 335 OBJ: 5 | 7 KEY: Nursing Process Step: Data Collection

18. 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 the 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 caregivers for fear of punishment.

DIF: Cognitive Level: Comprehension TOP: Moral Development

REF: 331 OBJ: 8 KEY: Nursing Process Step: N/A

19. A nurse would teach a family who have a child with a gluten intolerance that the child should not eat flours made from which of the following? a. Corn b. Wheat c. Rice d. Soybean ANS: B Gluten is in wheat flour but not in any of the other options.

DIF: Cognitive Level: Comprehension TOP: Gluten-free diet

REF: 333 OBJ: 9 KEY: Nursing Process Step: Implementation

20. What does a nurse calculate the basal metabolic index (BMI) of an 8-year-old child who is 1.2 metres tall and weighs 45.4 kg to be? a. 28.9 NURSINGTB.COM b. 32.4 c. 34.8 d. 37.6 ANS: B The formula for BMI calculation is weight in kg divided by height in metres (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 TOP: Calculation of BMI

REF: 337 OBJ: 9 KEY: Nursing Process Step: Implementation

21. What toy is developmentally appropriate for a 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 TOP: Play Activities

REF: 343 OBJ: 11 KEY: Nursing Process Step: Implementation

22. A nurse caring for a 4-year-old postoperative patient instructs him to blow bubbles. What nursing intervention is the nurse most likely implementing by using this form of therapeutic play? a. Providing pain relief b. Encouraging deep breathing c. Decreasing risk of infection d. Maintaining body temperature ANS: B Play can also be therapeutic and aid in the recovery process. An example of therapeutic play is the game of having the child blow bubbles to promote deep breathing.

DIF: Cognitive Level: Application TOP: Therapeutic Play

REF: 349 OBJ: 14 KEY: Nursing Process Step: Implementation

23. The mother of a 7-year-old pediatric patient asks a nurse about her child’s sleep requirement. What is the most accurate response by the nurse? a. “7 to 10 hours a night.” b. “5 to 7 hours a night with 1 daytime nap.” c. “11 to 13 hours a night.” d. “4 to 6 hours a night with 2 daytime naps.”

ANS: C Sleep patterns vary with age. The newborn sleeps up to 18 hours per day for 3 to 4 hours at a time. The 2-year-old child may sleep 10 hours during the night and have only one short daytime nap. The 7-year-old N chUilR dSuI suNalGlyTrBeq.uCirO esM11 to 13 hours of sleep and rarely has a daytime nap. These patterns may be altered by cultural practices.

DIF: Cognitive Level: Comprehension REF: 348 OBJ: 5 TOP: Sleep KEY: Nursing Process Step: Implementation 24. A nurse is preserving a tooth that was knocked out on the school playground. What should the nurse be especially careful to do? a. Wrap the tooth loosely in a clean cloth. b. Rinse the tooth with alcohol. c. Handle the tooth only by the crown. d. Place the tooth in a warm environment.

ANS: C When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage to the root and placed in milk until the child can be examined by a dentist.

DIF: Cognitive Level: Application REF: 328 OBJ: 10 TOP: Safety KEY: Nursing Process Step: Implementation TRUE/FALSE

1. Catch-up growth refers to the process of a preterm growing more quickly to meet their developmental stage.

ANS: F Catch-up growth refers to the process by which a child who has been sick or malnourished and whose growth has slowed or stopped, experiences a period of more rapid growth after recovery as the body attempts to compensate.

DIF: Cognitive Level: Knowledge TOP: Catch-up Growth

REF: 347 OBJ: 5 KEY: Nursing Process Step: Data Collection

MULTIPLE RESPONSE 1. How do children differ from adults? (Select all that apply.) a. Higher metabolic rate b. Greater surface area in relation to their weight c. Less mature organ systems d. More fluid reserves e. Continuously changing growth and development pattern ANS: A, B, C, E Children are in a continuous growth and development pattern. Children have a greater surface area and a higher metabolic rate. All their organ systems are not mature.

DIF: Cognitive Level: Comprehension TOP: Adult Versus Child

REF: 329 OBJ: 3 EY NURSINGTBK .C O:M Nursing Process Step: Implementation

2. What approaches should a nurse suggest for introducing a 6-month old infant to new foods?

(Select all that apply.) a. Serve one food at a time. b. Provide food with different textures. c. Offer foods in small amounts, less than a teaspoon. d. Offer fruit first. e. Eat together as a family.

ANS: A, B, C, E Foods should be introduced in small servings, one food at a time. Providing different textures early are important. Families should eat together as much as possible. Sweets and milk should not be offered until after solid food.

DIF: Cognitive Level: Comprehension REF: 323 OBJ: 9 TOP: Solid Food KEY: Nursing Process Step: Implementation 3. Which healthy snack foods would a 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 TOP: Healthy Snacks

REF: 340 OBJ: 9 KEY: Nursing Process Step: Implementation

4. A nurse teaches parents of school-age children ways to decrease obesity in children. What content does the nurse include in the class? (Select all that apply.) a. Eat five fruits and vegetables daily. b. Limit screen time to 2 hours per day. c. Encourage 30 minutes of physical activity each day. d. Provide juice when thirsty. e. Provide a quarter of each meal as a protein source.

ANS: A, B, E In order to decrease obesity, it is recommended that children eat five fruits and vegetables daily, have screen time limited to 2 hours per day, get 1 hour of physical activity per day, and avoid sugary drinks like juice. Eating Well with Canada’s Food Guide recommends each plate has half fruit and vegetables, a quarter protein and a quarter whole grains.

DIF: Cognitive Level: Comprehension TOP: Decreasing Obesity

REF: 341 OBJ: 9 KEY: Nursing Process Step: Implementation

5. An educational program is beNinUgRpSreIseNnGteTdBto.pCeO diMatric nurses on the relationship of play to childhood development. What information should be included in this presentation? (Select all that apply.) a. Art play should be used sparingly. b. Use of computer/video games is detrimental. c. Understanding of child–parent relationships can be gained by observing play. d. Play encourages self-expression. e. Play provides a sense of accomplishment.

ANS: C, D, E Art is an appropriate play activity at almost any age and provides an avenue for experimentation as well as for creative expression and a feeling of accomplishment in the child. Observing the child at play can aid in assessing growth and development and understanding the child’s relationships with family members. Any plan of care for a hospitalized child of any age should include a play activity that either encourages growth and development or encourages the expression of thoughts and feelings. Computer programs are popular with all age groups, providing opportunities to develop problem-solving skills, manipulative skills, and new learning.

DIF: Cognitive Level: Comprehension REF: 342 OBJ: 11 | 15 TOP: Play KEY: Nursing Process Step: Data Collection

6. Parents attending a well-child visit for their 11-year-old son verbalize concern over his computer use. When asked about it, the boy states, “I play games on my computer for 1 hour a day.” The nurse knows that computer games can provide what opportunities to childhood development? (Select all that apply.) a. Problem-solving skills b. Gross motor development c. Manipulative skills d. Learning opportunities e. Increased self-worth ANS: A, C, D Computer programs are popular with all age groups, providing opportunities to develop problem-solving skills, manipulative skills, and new learning.

DIF: Cognitive Level: Comprehension TOP: Computer Play

REF: 348 OBJ: 13 KEY: Nursing Process Step: Implementation

7. Which of the following aspects of the family are assessed as part of the family APGAR? (Select all that apply.) a. How well the family helps and shares resources b. What type of communication occurs in the family? c. Where the family lives d. How much money the family has e. What type of emotions are shown among family members?

ANS: A, B, E The family APGAR assessesNhU ow elO psMand shares resources (adaptation), the RSthIeNfaGmTilBy.hC lines of communication in the family (partnership), who is responsible for growth and development of a child (growth), how emotional interactions are shown among family members (affection) and how time, money and space are allocated to prevent and solve problems (resolve). How much money the family has or where they live are not part of the assessment.

DIF: Cognitive Level: Analysis TOP: Family APGAR

REF: 348 OBJ: 7 KEY: Nursing Process Step: Data Collection

8. A nurse is caring for a child who lives in northern Saskatchewan on a remote reserve. The nurse is aware that the social determinants of health have an impact on this child and acknowledges that which of the following determinants may influence this particular child’s life? (Select all that apply.) a. Racism b. Social identity c. Geographical location d. Living conditions e. Weather conditions ANS: A, B, C, D

Indigenous people have additional determinants of health that can impact their life including kinship and support networks, racism, and the loss of traditional language, land and social identity, and these unique determinants must be considered in addition to the 12 social determinants.

DIF: Cognitive Level: Comprehension TOP: Social determinants of health

REF: 331 OBJ: 7 KEY: Nursing Process Step: N/A

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Chapter 14: The Infant Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A mother calls the pediatric health care provider’s office because her infant is “colicky.”

What is the most helpful measure a nurse can suggest to the mother? a. Sing songs to the infant in a soft voice. b. Place the infant in a well-lit room. c. Hold supporting the abdomen. d. Rock the fussy infant quickly.

ANS: C One technique the nurse can offer parents of a fussy infant is to hold using the “colic carry”.

Holding the infant face down and close to the body while supporting the abdomen and providing a gentle slow rocking motion of the pelvis, often soothes the colicky infant.

DIF: Cognitive Level: Application REF: 361 OBJ: 7 TOP: Colic KEY: Nursing Process Step: Implementation 2. When does the posterior fontanelle close? a. 3 months b. 6 months c. 9 months NURSINGTB.COM d. 12 months ANS: A The posterior fontanelle closes by 3 months of age.

DIF: Cognitive Level: Knowledge REF: 369 OBJ: 5 TOP: Fontanelles KEY: Nursing Process Step: Data Collection 3. At what age does an infant’s birth weight triple? a. 9 months b. 1 year c. 18 months d. 2 years ANS: B The infant usually triples his or her birth weight by about 12 months of age.

DIF: Cognitive Level: Knowledge TOP: Development and Care

REF: 369 OBJ: 5 KEY: Nursing Process Step: Data Collection

4. What is the earliest age at which an infant is able to sit steadily alone? a. 4 months b. 5 months c. 8 months

d. 15 months ANS: C The infant can sit alone without support at about 8 months of age.

DIF: Cognitive Level: Knowledge TOP: Sitting Alone

REF: 358 OBJ: 5 KEY: Nursing Process Step: Data Collection

5. What is the earliest age at which the infant is usually able to walk independently? a. 8 to 10 months b. 12 to 15 months c. 15 to 18 months d. 18 to 21 months ANS: B For the majority of children, the milestone of walking alone is achieved between 12 and 15 months.

DIF: Cognitive Level: Knowledge TOP: Walk Independently

REF: 360 OBJ: 4 KEY: Nursing Process Step: Data Collection

6. The parent of a 3-month-old infant asks a nurse, “At what age do infants usually begin drinking from a cup?” What is the nurse’s most accurate response? a. 6 months b. 9 months c. 1 year d. 2 years NURSINGTB.COM ANS: A The infant can usually drink from a cup when it is offered at about 6 months.

DIF: Cognitive Level: Comprehension TOP: Drink from Cup

REF: 357 OBJ: 9 | 14 KEY: Nursing Process Step: Implementation

7. What would a nurse expect a 4-month-old infant to be able to accomplish? a. Hold a cup. b. Stand with assistance. c. Lift head and shoulders. d. Sit with back straight.

ANS: C Because development is cephalocaudal; of these choices, lifting the head and shoulders is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months.

DIF: Cognitive Level: Comprehension REF: 357 | 358 OBJ: 4 TOP: Development and Care KEY: Nursing Process Step: Data Collection 8. What is an abnormal finding in an evaluation of growth and development for a 6-month-old infant? a. Weight gain of 120 to 200 g per week

b. Length increase of 2.5 cm in 2 months c. Head lag present d. Can sit alone for a few seconds ANS: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.

DIF: Cognitive Level: Analysis TOP: Head Control

REF: 357 OBJ: 4 KEY: Nursing Process Step: Data Collection

9. A parent brings a 6-month-old infant to the pediatric clinic for a well-baby examination. The birth weight was 3800 g. What will the nurse weighing the infant today expect her weight to be? a. At least 6.5 kg b. At least 7.5 kg c. At least 9 kg d. At least 10 kg ANS: B Birth weight is usually doubled by 6 months of age.

DIF: Cognitive Level: Application TOP: Development and Care

REF: 357 OBJ: 4 KEY: Nursing Process Step: Data Collection

10. What will the nurse advise a parent to do when introducing solid foods? a. Begin with 1 to 2 teaspooNnU fuR lsSoI fN foG odT.B.COM b. Mix foods together. c. Eliminate a refused food from the diet. d. Introduce each new food 4 to 7 days apart.

ANS: A Offer 1 to 2 teaspoonfuls in the beginning. Let the child determine the amount they want based on responsive feeding cues. New foods that are possible allergens should only be offered every 1 to 2 days.

DIF: Cognitive Level: Comprehension REF: 366 OBJ: 9 | 13 TOP: Solid Food KEY: Nursing Process Step: Implementation 11. A nurse is talking with a parent about tooth eruption. What teeth will the nurse explain are the first deciduous teeth to erupt? a. Lower central incisors b. Upper central incisors c. Lower lateral incisors d. Upper lateral incisors ANS: A The first teeth to erupt, usually at about 7 months, are the lower central incisors.

DIF: Cognitive Level: Knowledge REF: 358 OBJ: 5 TOP: Teething KEY: Nursing Process Step: Implementation

12. A nurse is assessing development in a 9-month-old infant. What would the nurse expect to observe? a. Speaking in two-word sentences b. Grasping objects with palmar grasp c. Creeping along the floor d. Beginning to use a spoon rather sloppily ANS: C The 9-month-old infant tries to creep, has developed pincer movement, and can grasp a spoon without keeping food on it.

DIF: Cognitive Level: Analysis TOP: Development and Care

REF: 359 OBJ: 4 KEY: Nursing Process Step: Data Collection

13. What statement made by a parent indicates correct understanding of infant feeding? a. “I’ve been mixing rice cereal and formula in the baby’s bottle.” b. “I switched the baby to low-fat milk at 9 months.” c. “The baby really likes little pieces of chocolate.” d. “I give the baby new foods before he takes his bottle.”

ANS: D New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.

DIF: Cognitive Level: Comprehension REF: 367 OBJ: 9 TOP: Nutrition CounsellingNURSINGTBK EY .C O:M Nursing Process Step: Evaluation 14. A nurse teaches a mother that the grasp reflex of the newborn should disappear at which age? a. 1 month b. 3 months c. 6 months d. 9 months ANS: B The grasp reflex disappears at approximately 3 months.

DIF: Cognitive Level: Knowledge REF: 353 OBJ: 4 TOP: Reflexes KEY: Nursing Process Step: Data Collection 15. A nurse discusses child-proofing the home for safety with the mother of a 9-month-old infant. Which statement made by the mother would indicate an unsafe behaviour? a. “I put covers on all of the electrical outlets.” b. “In the car, she rides in a front-facing car seat.” c. “There are locks on all of the cabinets in the house.” d. “I have a gate at the top and bottom of the stairs.”

ANS: B A rear-facing infant car seat should be used for infants who weighs less than 10 kg (usually about 1 year of age or more).

DIF: Cognitive Level: Analysis REF: 368 TOP: Infant Safety KEY: Nursing Process Step: Evaluation

OBJ: 15

16. A nurse observes a 10-month-old infant using the index finger and thumb to pick up pieces of cereal. What does this behaviour indicate the infant has developed? a. The pincer grasp b. A grasp reflex c. Prehension ability d. The parachute reflex ANS: A By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

DIF: Cognitive Level: Comprehension TOP: General Characteristics

REF: 359 OBJ: 4 KEY: Nursing Process Step: Data Collection

17. A mother is concerned because her infant has a diaper rash. What is the best action a nurse would advise the parent to implement? a. Use commercial diaper wipes to clean the area. b. Expose the diaper area to air frequently. c. Change the infant’s diaper less frequently. d. Keep the diaper area covered all of the time.

ANS: B Exposing the skin to air can help dry the area and decrease diaper rash symptoms.

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DIF: Cognitive Level: Application REF: 361 OBJ: 6 TOP: Diaper Rash KEY: Nursing Process Step: Implementation 18. A mother of an infant born prematurely tells a nurse, “The baby is irritable. She cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe her?” What is the most appropriate recommendation to help this parent? a. Play the radio or TV while you feed the infant. b. Put the infant in a room with sunlight. c. Wrap the infant snugly when you hold them. d. Change the infant’s position quickly.

ANS: C A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face.

DIF: Cognitive Level: Application REF: 361 OBJ: 7 TOP: Infant Care KEY: Nursing Process Step: Implementation 19. What is the most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old infant? a. Ride a tricycle. b. Spend time in an infant swing. c. Play with push-pull toys.

d. Read large picture books.

ANS: C Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old infant.

DIF: Cognitive Level: Analysis REF: 369 OBJ: 17 TOP: Infant Safety KEY: Nursing Process Step: Implementation 20. Which statement indicates the mother of an 8-month-old infant understands infant sleep patterns? a. “I put the baby in my bed until she falls asleep, then I put her in her crib.” b. “I let the baby skip an afternoon nap so that she will fall asleep earlier.” c. “I feed the baby before putting her into the crib to sleep.” d. “I rock the baby back to sleep if she wakes up at night.”

ANS: C Babies should be fed prior to being put to sleep and should not be put into the crib with a bottle.

DIF: Cognitive Level: Analysis TOP: Sleep Patterns

REF: 362 OBJ: 8 KEY: Nursing Process Step: Evaluation

21. How might a nurse demonstrate the parachute reflex with an infant? a. Lifting the infant high in the air above her head b. Holding the infant in a football hold, cradling the head c. Seating the infant in a stroller in an upright position d. Placing the infant downwNarUdRinStoIN thG eT crB ib.COM ANS: D The infant, when placed downward in a prone position, will protectively extend the arms.

DIF: Cognitive Level: Comprehension TOP: Parachute Reflex

REF: 353 OBJ: 4 KEY: Nursing Process Step: Implementation

22. Parents of a 6-month-old infant ask a nurse why it is necessary to offer iron-rich formula to their child. What is the correct response? a. “The infant has limited ability to produce red blood cells.” b. “The infant has ineffective digestive enzymes.” c. “The infant has exhausted maternal iron stores.” d. “The infant has need of the iron to support dentition.”

ANS: C At birth a newborn has iron stores that are from the mother but these are used up by the age of 6 months so an infant requires food that is iron rich.

DIF: Cognitive Level: Comprehension TOP: Infant Feeding

REF: 366 OBJ: 12 KEY: Nursing Process Step: Implementation

23. A nurse is assessing a 1-year-old infant in the pediatric office. What finding should the nurse report to the pediatric health care provider immediately? a. Respiratory rate of 60 breaths/minute

b. Pulse rate of 100 beats/minute c. Minimal verbalization d. Fussy behaviour ANS: A Respirations of a 1-year-old infant should be 20 to 40 breaths/minute. Increased respiratory rate can lead to distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal verbalization and fussy behaviour are not emergency situations or abnormal for this age.

DIF: Cognitive Level: Application REF: 353 TOP: 12-Month-Old Physical Characteristics KEY: Nursing Process Step: Data Collection

OBJ: 3

24. A new mother is voicing concern she is breastfeeding her newborn too frequently. How often does a nurse instruct this mother she should expect her newborn to feed? a. Every 2 to 3 hours b. Every 3 to 4 hours c. Every 4 to 6 hours d. On demand ANS: D Breastfed infants should be fed on demand whenever the infant shows feeding cues.

DIF: Cognitive Level: Application TOP: Infant Feeding

REF: 364 OBJ: 12 KEY: Nursing Process Step: Intervention

NURSINGTB.COM TRUE/FALSE 1. A nurse teaches parents of a 6-month old that they should not pick their baby up every time he cries because he will become spoiled.

ANS: F Infants learn to develop trust with their caregivers when their needs are met and the only way they can express needs is by crying.

DIF: Cognitive Level: Analysis TOP: Development of Trust

REF: 353 OBJ: 6 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)? (Select all that apply.) a. Irritability b. Adequate weight gain c. No predictable sleep–wake cycle d. Distrust e. Effective parent bonding

ANS: A, C, D Children who experience frequent hunger do not have effective parental bonding and will have inadequate weight gain. All other options are probable outcomes for a child who has unmet hunger needs.

DIF: Cognitive Level: Comprehension REF: 359 OBJ: 9 TOP: Hunger KEY: Nursing Process Step: Implementation 2. A nurse is preparing to outline principles of discipline for parents of an infant. What information should the nurse include? (Select all that apply.) a. Firmly say “No.” b. Distract the child to another activity. c. Bribe the child with a sweet treat. d. Remain consistent. e. Ignore the child until behaviour improves.

ANS: A, B, D Parental approval is important to the infant, and setting limits early is essential. Principles of discipline at this age include the following: lowering the voice to say no firmly, removing the child from the situation, distraction, and consistency.

DIF: Cognitive Level: Comprehension REF: 355 OBJ: 4 | 6 TOP: Discipline KEY: Nursing Process Step: Implementation 3. What should the teaching plan include about infant fall precautions? (Select all that apply.) a. Remove all unsteady furniture.

Bh.eCnOwMalking. b. Use a baby walker to impNroUvR eS baIlaNnG ceTw c. Steady infant with hand when on changing table. d. Use tray attachment on high chair as restraint. e. Keep infant seat on the floor while indoors.

ANS: A, C, E The tray attachment to a high chair is an inadequate restraint. Infant walkers are illegal as they increase the risk of falling down stairs. The other options are good precautions to prevent an infant from falling.

DIF: Cognitive Level: Comprehension TOP: Fall Prevention

REF: 368 | 369 OBJ: 15 KEY: Nursing Process Step: Planning

4. A nurse is aware that a 7-month-old infant can signal feeding readiness by which action(s)?

(Select all that apply.) a. Pulling spoon toward mouth b. Biting at spoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement at sight of food e. Manipulating finger foods ANS: A, E

The 7-month-old infant pulls the spoon toward his or her mouth and can manipulate finger foods. The 7-month-old infant does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food.

DIF: Cognitive Level: Comprehension TOP: Feeding Skills

REF: 367 OBJ: 14 KEY: Nursing Process Step: Data Collection

5. A nurse is educating parents of an 8-month-old infant who are concerned about the child’s sleep patterns. What information should the nurse include in the teaching? (Select all that apply.) a. Maintain a regular nap and bedtime schedule. b. Try different bedtime routines. c. Give the baby a bottle in the crib. d. Take the baby out of crib if he or she cries during the night and walk around to settle. e. Read a book prior to bedtime.

ANS: A, E Parents should try to maintain a regular nap and bedtime schedule and keep a consistent bedtime routine that may include reading a book. The infant should not have a bottle in the bed and if the infant wakens in the night, parents should go and ensure the child is all right but not take the child out of the crib.

DIF: Cognitive Level: Application REF: 362 OBJ: 6 TOP: Sleep KEY: Nursing Process Step: Implementation 6. What will a nurse take into coNnUsiRdS erI atN ioG nTwBh. enCeOdM ucating parents regarding infant nutrition?

(Select all that apply.) a. Cultural practices b. Sex of the infant c. Parental knowledge d. Infant’s developmental level e. Parent–child interaction ANS: A, C, D, E Parents have many concerns about feeding their infant during the first year of life. This is a period when readiness to receive nutrition education is usually high; therefore, the nurse looks for opportunities to provide accurate information. Assessment of parental knowledge; infant development, behaviour, and readiness; parent–child interaction; and cultural and ethnic practices is important. Sex of the infant does not enter into nutritional education.

DIF: Cognitive Level: Comprehension REF: 363 OBJ: 10 TOP: Nutrition KEY: Nursing Process Step: Implementation 7. Parents of an infant inform a nurse they are planning home preparation of solid foods. What directions should the nurse provide? (Select all that apply.) a. Boil foods in a large amount of water. b. Use honey as a sweetener. c. Add 1 teaspoon of salt per cup. d. Puree food in electric blender.

e. Add sugar sparingly.

ANS: D, E Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly and honey should not be given to children under 1 year of age. Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foods may be frozen in ice cube trays and defrosted for use.

DIF: Cognitive Level: Comprehension REF: 366 OBJ: 13 TOP: Nutrition KEY: Nursing Process Step: Implementation

NURSINGTB.COM

Chapter 15: The Toddler Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. Which behaviour reported by a parent of an 18-month-old toddler would a nurse suggest the child see the pediatric health care provider for? a. Has temper tantrums. b. Feeds self sloppily. c. Walks by holding onto furniture. d. Speaks in short sentences.

ANS: C By 18 months, a toddler should have been walking alone for several months. The toddler who walks holding onto furniture should be evaluated by a developmental specialist.

DIF: Cognitive Level: Analysis TOP: Developmental Delay

REF: 373 OBJ: 2 KEY: Nursing Process Step: Data Collection

2. What would a nurse assessing growth and development of a 2-year-old child expect to find? a. The child jumps with both feet. b. Twenty deciduous teeth have erupted. c. The child can hop on one foot. d. The child has a vocabulary of 900 words.

NURSINGTB.COM

ANS: A The 2-year-old child can jump with both feet. The remaining achievements occur after 2 years of age.

DIF: Cognitive Level: Knowledge TOP: Developmental Stages

REF: 373 OBJ: 2 KEY: Nursing Process Step: Data Collection

3. A parent remarks, “My 18-month-old daughter carries her blanket around everywhere. Is this normal?” What is the best explanation a nurse who has an understanding of toddler development might give? a. “She carries her blanket because she is ritualistic.” b. “Carrying her favourite blanket is self-consoling behaviour.” c. “This behaviour can be discouraged by offering new toys to the child.” d. “This could be indicative of emotional distress.”

ANS: B Favourite possessions and repetitive rituals are self-consoling behaviours for the toddler.

DIF: Cognitive Level: Application TOP: Self Consoling

REF: 376 OBJ: 2 KEY: Nursing Process Step: Implementation

4. A nurse observes three toddlers playing side by side with dolls. Closer observation revealed that the children were not interacting with one another. What type of play is this?

a. b. c. d.

Solitary Parallel Associative Cooperative

ANS: B Toddlers engage in parallel play. Children play next to, but not with, each other.

DIF: Cognitive Level: Comprehension REF: 384 OBJ: 11 TOP: Play KEY: Nursing Process Step: Data Collection 5. What instruction would a nurse include when planning anticipatory guidance for parents of a toddler? a. Adhere to a rigid schedule because the toddler is ritualistic. b. Limit setting should include praise. c. Shoes should fit snugly at the toe and arch. d. Dress the toddler in pants with a zipper so that he or she can learn to zip and unzip clothes.

ANS: B Limit setting should include praise, as well as disapproval for undesired behaviour.

DIF: Cognitive Level: Application TOP: Limit Setting

REF: 376 OBJ: 6 KEY: Nursing Process Step: Planning

6. What is the best advice a nurse can offer a parent concerned because her 2-year-old child is very active and does not eat m NuUcRh?SINGTB.COM a. Insist that the child eat one food on the plate. b. Encourage the child to take part in more physical activity to increase hunger. c. Maintain a routine around an eating schedule with the family. d. Serve the meal with a variety of interesting plates, cups, and utensils.

ANS: C Have routines around mealtimes and eat together as a family in order to model good eating behaviour.

DIF: Cognitive Level: Application REF: 376 OBJ: 9 TOP: Picky Eater KEY: Nursing Process Step: Implementation 7. How would a nurse advise a parent who states, “I never know how much food to feed my child”? a. Serving sizes should not exceed 1 teaspoon of each type of food. b. Food quantities must be carefully measured to avoid overfeeding. c. Let your child decide how much they want to eat. d. A toddler should eat three balanced meals. Snacks are not necessary.

ANS: C Children should be allowed to decide how much they want to eat. It is normal for them to eat more at some meals and less at other meals.

DIF:

Cognitive Level: Application

REF: 379

OBJ: 9

TOP: Food Portions

KEY: Nursing Process Step: Implementation

8. A nurse is discussing toilet independence with parents. What behaviour by the child would most identify toilet independence readiness? a. Willing to sit on the potty for 15 to 20 minutes b. Dry in the daytime for 4-hour periods c. Able to communicate that he or she is wet d. Curious about bathroom activities ANS: C Children are ready for toilet training when they can communicate in some fashion that they are wet or need to urinate or defecate.

DIF: Cognitive Level: Comprehension TOP: Toilet Independence

REF: 378 OBJ: 8 KEY: Nursing Process Step: Implementation

9. What is the most appropriate toy for a nurse to select for a 2-year-old child? a. Bicycle with training wheels b. Dump truck c. Wind-up toy d. Building block set ANS: B The 2-year-old child enjoys playing with objects that can be pushed or pulled.

DIF: Cognitive Level: Application REF: 383 OBJ: 11 TOP: Toys and Play EY NURSINGTBK .C O:M Nursing Process Step: Data Collection 10. What could a nurse recommend to a child’s mother to encourage her toddler son to practise independence? a. Offer a variety of items to choose from to stimulate his mind. b. Allow the child to determine his own daily routine. c. Offer him a choice between two items. d. Set the routine herself but discuss with her toddler how he or she would have done it differently.

ANS: C The toddler can be allowed to make choices as the situation warrants, but the number of choices should be limited because too many confuse the toddler.

DIF: Cognitive Level: Application TOP: Offering Choices

REF: 372 OBJ: 4 KEY: Nursing Process Step: Implementation

11. On a home visit, a nurse notes that parents of a 15-month old child require teaching regarding safety. What observation would lead the nurse to this conclusion? a. The fireplace has a screen. b. The dining room table has a tablecloth on it. c. There are paintings on the wall. d. The kitchen floor is clean but not shiny.

ANS: B

A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it. The toddler could be injured if items on the table are moved when the tablecloth is pulled.

DIF: Cognitive Level: Analysis TOP: Injury Prevention

REF: 381 OBJ: 10 KEY: Nursing Process Step: Data Collection

12. What does a nurse consider as an appropriate snack for a 2-year-old child? a. Hot dog sections b. Seedless grapes c. Popcorn d. Applesauce ANS: D Applesauce is a healthy and safe snack food for the toddler. The toddler is at risk for choking on foods such as whole grapes, hot dogs, and popcorn.

DIF: Cognitive Level: Analysis TOP: Injury Prevention

REF: 381 OBJ: 10 KEY: Nursing Process Step: Planning

13. Which finding would concern a nurse assessing vital signs on a 2-year-old child? a. Temperature of 37.1° C (98.8° F) b. Pulse at 100 beats/minute c. Respirations of 36 breaths/minute d. Blood pressure of 90/60 mm Hg ANS: C In the toddler period, the respNirU atRoS ryIrN atG eT isB2.

0C toO3M0 breaths/minute.

DIF: Cognitive Level: Analysis REF: 373 OBJ: 2 TOP: Vital Signs KEY: Nursing Process Step: Data Collection 14. What would be an expected finding when assessing language development in a 2-year-old child? a. A 900-word vocabulary b. Use of two-word sentences c. Use of pronouns and prepositions d. 100% of speech is understandable ANS: B The 2-year-old child should be using two-word sentences.

DIF: Cognitive Level: Analysis TOP: Speech Development

REF: 374 OBJ: 5 KEY: Nursing Process Step: Data Collection

15. A nurse is planning to explain the use of time-outs to the parent of a 3-year-old child. How many minutes will the nurse indicate is appropriate for a child of this age? a. 3 b. 6 c. 10 d. 15

ANS: A Timing for time-out is usually based on 1 minute per year of age.

DIF: Cognitive Level: Knowledge TOP: Guidance and Discipline

REF: 376 OBJ: 6 KEY: Nursing Process Step: Planning

16. The parent of a toddler tells a nurse, “My daughter’s appetite has decreased. Thank goodness she loves to drink milk.” What is the most appropriate response by the nurse? a. “Has your daughter been sick recently?” b. “How much milk does she drink in a day?” c. “Has she become a fussy eater, too?” d. “Have you tried offering her finger foods?”

ANS: B Milk intake of more than 750 mL per day can lead to decreased intake of solids which can lead to dietary deficiencies of iron.

DIF: Cognitive Level: Application TOP: Nutrition Counselling

REF: 379 OBJ: 9 KEY: Nursing Process Step: Data Collection

17. How many hours should toddlers be able to stay dry for the nurse to suggest they are ready to begin bladder training? a. 1 b. 2 c. 3 d. 4

NURSINGTB.COM

ANS: B If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective.

DIF: Cognitive Level: Comprehension TOP: Toilet Independence

REF: 378 OBJ: 8 KEY: Nursing Process Step: Implementation

18. Parents tell a nurse they are frustrated with their toddler’s recent behaviour and refusal to agree with anything they ask of them. What does the nurse explain as the term for when a toddler tests their own power? a. Negativism b. Dawdling c. Tantrums d. Food fads ANS: A By refusing to eat, dress, sleep, or anything else by saying “No,” toddlers test their own power to control. Because toddlers are also egocentric, they come to believe that their negativism is absolute. This is especially true if the adults give in to it.

DIF: Cognitive Level: Comprehension REF: 379 OBJ: 1 | 2 TOP: Negativism KEY: Nursing Process Step: Implementation

19. A nurse is assessing a 2 1/2-year-old toddler. What is the expected weight gain for this age child? a. Two times the birth weight b. Two and a half times the birth weight c. Three times the birth weight d. Four times the birth weight ANS: D The expected weight of a 2 1/2-year-old toddler is four times the birth weight.

DIF: Cognitive Level: Comprehension REF: 372 | 373 OBJ: 2 TOP: Weight Gain KEY: Nursing Process Step: Data Collection 20. What guideline should an adult follow when speaking to a toddler? a. Be at eye level with the child. b. Hold by the shoulders to keep the child’s attention c. Seat the child to focus on conversation. d. Speak in a firm strong voice.

ANS: A Being at eye level is helpful to hold the child’s attention and is especially important when the child is frightened.

DIF: Cognitive Level: Comprehension TOP: Conversing with Toddler

REF: 376 OBJ: 2 KEY: Nursing Process Step: Implementation

21. Why does day care for the toN ddUleRrSdI iffNerGfT roBm.tChO atMof the preschooler? a. Toddlers have a shorter attention span. b. Toddlers need more group play. c. Toddlers are less prone to environmental dangers. d. Toddlers require less outdoor space.

ANS: A Toddlers have a shorter attention span than preschoolers and are prone to investigate other opportunities in the environment that may put them in harm’s way. Toddlers are more interested in parallel play.

DIF: Cognitive Level: Comprehension REF: 379 TOP: Day Care KEY: Nursing Process Step: N/A

OBJ: 2

22. A 16-month-old child is attending a well-child visit at a pediatric clinic. Which assessment would indicate the biggest cause for concern? a. Does not walk independently b. Prefers finger feeding c. Limited to single words d. Is unable to climb steps ANS: A A child should be walking independently by 16 months. It is normal for a child this age to prefer finger feeding and to be limited to single words. Many children do not climb steps until 24 months of age.

DIF: Cognitive Level: Comprehension TOP: Development

REF: 373 OBJ: 2 KEY: Nursing Process Step: Data Collection

MULTIPLE RESPONSE 1. When selecting a potty chair, the parents are encouraged to select one that has which characteristic(s)? (Select all that apply.) a. Small enough for the child’s feet to touch floor b. Sturdy and stable c. Supportive of child’s back and arms d. Made of plastic or fibreglass e. Capable of being taken apart easily ANS: A, B, C Potty chairs should be small and sturdy and supportive of the child’s back and arms and if possible low enough that the child’s feet can touch the floor. The composition is not important as long as it is stable.

DIF: Cognitive Level: Comprehension REF: 378 OBJ: 8 TOP: Potty Chairs KEY: Nursing Process Step: Implementation 2. A nurse suggests offering which food(s) to support the toddler’s desire to self-feed? (Select all that apply.) a. Pureed foods b. Finger foods NURSINGTB.COM c. Foods served cold d. Foods in colourful dishes e. Foods that are varied and colourful ANS: B, D, E Finger foods that are varied and colourful and served in colourful dishes at a moderate temperature are all attractive. Foods can be chopped into small pieces but not pureed.

Children need food with different textures from a young age.

DIF: Cognitive Level: Comprehension TOP: Self-Feeding

REF: 379 OBJ: 9 KEY: Nursing Process Step: Implementation

3. A nurse points out which physiological change(s) in the toddler that serve(s) as protection against disease? (Select all that apply.) a. Toughening of the skin b. Increased capillary response for thermoregulation c. Stabilization of body temperature d. Elevation in white blood cell count e. Enlarged adenoids and tonsils ANS: A, B, C, E With the exception of an increased white blood cell (WBC) count, which is always pathological, the other options are all maturing changes that equip the toddler to better fight disease.

DIF: Cognitive Level: Comprehension TOP: Physiological Changes

REF: 373 OBJ: 2 KEY: Nursing Process Step: Implementation

4. Parents of a toddler are discussing the emotion of fear with a pediatric nurse. What information can the nurse offer regarding fear and the toddler? (Select all that apply.) a. Stress increases fear. b. Rituals help deal with fear. c. Teasing the child can decrease fear. d. Once fear is learned it is difficult to eliminate. e. Adults should openly share their fears.

ANS: A, B, D Once a fear has been learned, it is more difficult to eliminate. Clinging to favourite possessions and repetitive rituals are self-consoling behaviours for the toddler, particularly at bedtime and during separation from parents. Stress increases fear of separation. Adults should attempt to control their own fears in the presence of young children. Respect and understanding should always be accorded to children who are afraid. Making fun of the fear or shaming the child in front of others is detrimental to self-esteem.

DIF: Cognitive Level: Comprehension REF: 376 OBJ: 7 TOP: Fear KEY: Nursing Process Step: Implementation 5. A nurse is caring for a 2-year old child in the Emergency Department who has a fever and is irritable. The nurse knows that which of the following conditions are common in toddlers in could be the cause of the fever? (Select all that apply.) a. Otitis media NURSINGTB.COM b. Appendicitis c. Tonsillitis d. Upper respiratory tract infections e. Urinary tract infections ANS: A, C, D Appendicitis and urinary tract infections are not common illnesses in toddlers. The other conditions are more common.

DIF: Cognitive Level: Application TOP: Common Illnesses

REF: 373 OBJ: 2 KEY: Nursing Process Step: Data Collection

COMPLETION 1. A nurse assessing a 2 1/2-year-old is satisfied to see that the present weight of the child is times their birth weight.

ANS: 4 The birth weight has usually quadrupled by the time the child is 2 1/2 years of age.

DIF: Cognitive Level: Comprehension REF: 372 | 373 OBJ: 2 TOP: Weight KEY: Nursing Process Step: Data Collection

NURSINGTB.COM

Chapter 16: The Preschool Child Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. Which statement best describes the 3-year-old child? a. Boisterous, tattles on others b. Aggressive, shows off c. Helpful, wants to assist with chores d. Talkative, inquisitive about the environment ANS: C Three-year-old children are helpful and can assist in simple household chores.

DIF: Cognitive Level: Comprehension TOP: Development

REF: 392 OBJ: 3 KEY: Nursing Process Step: Data Collection

2. The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis. What knowledge would act as the basis for a nurse’s response? a. This behaviour indicates a normal curiosity about sexuality. b. Masturbation suggests the boy has an excessive fear of castration. c. It is usually a result of discomfort from a penile rash or irritation. d. The behaviour is abnormal and the child should be referred for counselling.

ANS: A NURSINGTB.COM Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality.

DIF: Cognitive Level: Comprehension TOP: Sexual Curiosity

REF: 391 OBJ: 10 KEY: Nursing Process Step: Implementation

3. A preschool child is asked, “Why do trees have leaves?” Which response would be an example of animism? a. “So I can have shade over my sandbox.” b. “Because God made them that way.” c. “To hide behind when they are scared.” d. “For the squirrels to play in.”

ANS: C Animism describes the tendency of preschool children to attribute human characteristics to nonhuman objects.

DIF: Cognitive Level: Application TOP: Cognitive Development

REF: 388 OBJ: 1 | 3 | 4 KEY: Nursing Process Step: Data Collection

4. A nurse would report the following vital sign to a primary health care provider? a. Heart rate 120 b. Respiratory rate 20

c. Blood pressure 100/66 d. Oxygen saturation 95% ANS: A The normal pulse for a preschooler is between 65 to 100 bpm. The other vital signs are normal.

DIF: Cognitive Level: Application REF: 387 TOP: Development—Safety KEY: Nursing Process Step: Data Collection

OBJ: 3

5. A 3-year-old child, while playing with a favourite toy in the playroom of the pediatric unit, is approached by another child who also wants to play with the same toy. What behaviour will a nurse anticipate from this child? a. Will play well with the other child b. Will give the toy up and then not play anymore c. Will become angry and a physical response might ensue d. Will ignore the toy and go on to something else ANS: C The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her possessions.

DIF: Cognitive Level: Application REF: 389 OBJ: 3 TOP: Egocentrism KEY: Nursing Process Step: Data Collection 6. A parent is concerned about hNeU rR chSilI drNeG n’T sB re. acCtiOoM n should their grandmother die. What understanding will guide a nurse’s response? a. Children are unlikely to notice their grandmother’s absence if no one reminds them. b. Young children often understand that other people die, but do not equate it with themselves. c. The children’s response will depend entirely on whether they have been acquainted with death before this. d. Children can understand the concept of a higher being much like adults can.

ANS: B Between 3 and 4 years of age, the children become curious about death and dying. They may realize that others die, but they do not relate death to themselves.

DIF: Cognitive Level: Comprehension TOP: Concept of Death

REF: 393 OBJ: 7 KEY: Nursing Process Step: Planning

7. What is the most appropriate intervention when dealing with occasional aggression in a 4-year-old child? a. Have the child take a time-out in the corner for 4 minutes. b. Spank the child at the time of the incident. c. Take away television privileges for the day. d. Send the child to their room for 30 minutes.

ANS: A

Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique.

DIF: Cognitive Level: Application TOP: Limit Setting

REF: 394 OBJ: 3 KEY: Nursing Process Step: Implementation

8. A father is concerned about how long his preschool-age child will continue sucking his thumb. What is the most helpful response from a nurse? a. “Most children will stop thumb sucking naturally by school age.” b. “Over-the-counter treatments that give a bad taste can be placed on the thumb to discourage the practice.” c. “Consistently touching the child’s fingers whenever he sucks his thumb is most effective.” d. “Thumb sucking is detrimental to the eruption of the child’s teeth and must be stopped as soon as possible.”

ANS: A Most children give up the habit of thumb sucking by the time they reach school. Finger or thumb sucking will not have a detrimental effect on the teeth as long as the habit is discontinued before 5 years of age.

DIF: Cognitive Level: Application TOP: Thumb Sucking

REF: 395 OBJ: 10 KEY: Nursing Process Step: Implementation

9. How does a nurse characterize the play of 5-year-old children? a. Enjoying rough and tumble play UeRsSINGTB.COM b. Playing well-organized gN am c. Following rules d. Preferring inside activities ANS: C The 5-year-old child wants to play by the rules but cannot accept losing. The rules may be very strict or change as the game progresses.

DIF: Cognitive Level: Comprehension REF: 389 OBJ: 13 TOP: Play KEY: Nursing Process Step: Data Collection 10. A nurse is discussing preschoolers’ sexual curiosity with the parent. What statement by the mother leads the nurse to determine that the mother understands the information? a. “Make up funny words for body parts.” b. “Distract the child with a toy if they ask about sex.” c. “Answer their questions when they ask.” d. “Tell them to ask you again when they are 6 years old.”

ANS: C Parents should provide sex education at the time the child asks about sex.

DIF: Cognitive Level: Analysis TOP: Sexual Curiosity

REF: 391 OBJ: 10 KEY: Nursing Process Step: Evaluation

11. What type of play is most appropriate when planning care for a child with moderate developmental delay? a. Exercise leg and arm muscles. b. Be educationally oriented to make up for lost time. c. Be adjusted to mental age rather than chronological age. d. Involve contact sports and aggressive physical activity with other children.

ANS: C The nurse must consider the child’s mental age rather than the chronological age when selecting toys for play.

DIF: Cognitive Level: Application REF: 399 TOP: Play KEY: Nursing Process Step: Planning

OBJ: 14

12. What is a nurse’s best advice to a parent about a preschooler’s “imaginary friend”? a. Having imaginary friends is a sign that the child has low self-esteem. b. It is common for preschoolers to have imaginary friends. c. Preschoolers invent an imaginary friend when they feel overwhelmed. d. The best approach to dealing with an imaginary friend is to ignore them.

ANS: B Imaginary friends are common and normal during the preschool period and serve many purposes, such as relief from loneliness, mastery of fears, and acting as a scapegoat.

DIF: Cognitive Level: Comprehension TOP: Imaginary Friend

REF: 398 OBJ: 3 | 13 KEY: Nursing Process Step: Implementation

NURSINGTB.COM

13. What intervention might a nurse suggest as helpful for the child with enuresis? a. Applying an electric pad that gently shocks the child b. Waking the child several times during the night to urinate c. Decreasing fluid intake after the evening meal d. Increasing dietary fibre intake ANS: C If a child is experiencing enuresis, liquids after dinner should be limited and the child should routinely void before going to bed.

DIF: Cognitive Level: Application REF: 396 OBJ: 10 TOP: Enuresis KEY: Nursing Process Step: Implementation 14. What should a nurse suggest as the most appropriate toy choice for a 3-year-old? a. A board game b. A small pet, such as a goldfish c. A large construction set d. Push-pull toys ANS: C Large construction sets are suitable toys for the preschool-age child.

DIF: Cognitive Level: Application REF: 398 OBJ: 13 TOP: Play KEY: Nursing Process Step: Implementation

15. Caregivers of a 3 1/2-year-old child tell a nurse, “My daughter points instead of speaking whenever she wants me to get something for her, but she understands me when I ask her to do something.” Based on the parent’s comment, what does the nurse suspect? a. Age-appropriate language development b. An expressive language delay c. A receptive language delay d. A potential hearing deficit ANS: B An expressive language delay is suspected when the child understands spoken language but is not talking.

DIF: Cognitive Level: Application TOP: Language Development

REF: 391 OBJ: 5 KEY: Nursing Process Step: Data Collection

16. Caregivers of a 4 1/2-year-old child tells a nurse, “Bedtime is difficult. We can’t get our son to go to bed at night.” The nurse and the parents discuss options. What intervention is the most appropriate choice? a. Allow the child to put himself to bed when tired. b. Let the child read in his room until he falls asleep. c. Establish a bedtime routine and use it consistently. d. Tire him out with physical activity before bedtime.

ANS: C Parents should engage the child in quiet activities before bedtime and establish a ritual that signals readiness for bedtimeN . URSINGTB.COM DIF: Cognitive Level: Application TOP: Bedtime Habits

REF: 391 OBJ: 6 KEY: Nursing Process Step: Implementation

17. What fear is unique to the preschool period? a. Water b. Animals c. Bodily harm d. Death ANS: C The fear of bodily harm, particularly the loss of body parts, is unique to this stage.

DIF: Cognitive Level: Knowledge REF: 392 TOP: Fear KEY: Nursing Process Step: N/A

OBJ: 3

18. A 4-year-old child tells a nurse she will not eat peas because they are green. This is an example of which of the following? a. Egocentrism b. Artificialism c. Animism d. Centring ANS: D

The tendency to concentrate on a single outstanding characteristic of an object while excluding other features is known as centring.

DIF: Cognitive Level: Application REF: 388 OBJ: 3 TOP: Centring KEY: Nursing Process Step: Data Collection 19. A 4-year-old child insists he has more money with a nickel than his father has with a dime.

What is this perception, as described in Piaget’s theory? a. Egocentrism b. Artificialism c. Animism d. Intuition ANS: D The intuitive stage, as described by Piaget, is prelogical thinking that is based on the outside appearance of objects. A nickel is larger than a dime and therefore more valuable.

DIF: Cognitive Level: Comprehension TOP: Cognitive Development

REF: 388 OBJ: 4 KEY: Nursing Process Step: Data Collection

20. Which of the following will a child who is unable to express themselves with words often do? a. Become reclusive and introspective b. Develop other methods of verbal communication c. Engage in more creative play d. Have tantrums and act out

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ANS: D Children with delayed communication skills will frequently have tantrums and act out when they are unable to make their needs known.

DIF: Cognitive Level: Comprehension REF: 388 OBJ: 5 TOP: Tantrums KEY: Nursing Process Step: Implementation 21. Which of the following is an example of associative play? a. Two children playing in house, one playing the role of the dad and the other playing the role of the mom b. Two children playing in a sand box, one building a wall and the other digging a hole c. Two children playing with sports-associated items, one with a football and the other with a bat d. Two children playing with a colouring book, one colouring pictures and the other looking at pictures ANS: A Associative play allows the preschoolers to use their enlarged vocabulary in play with other children to carry on conversations and describe scenarios for each to play.

DIF: Cognitive Level: Analysis TOP: Associative Play

REF: 392 OBJ: 13 KEY: Nursing Process Step: N/A

22. A nurse is educating a group of preschool parents about the importance of safety. Which statement by a parent indicates the need for further education? a. “I continue to provide a great deal of indirect supervision for my child.” b. “My stairway is always free of clutter.” c. “I only leave my child in the car for brief moments.” d. “Medications are kept in a locked cabinet.”

ANS: C Children must not play in or around the car or be left alone, even for a brief moment, in the car. Preschool children still require a good deal of indirect supervision to protect them from dangers that arise from their immature judgment or social environment. Stairways should be free of clutter and medications kept out of reach.

DIF: Cognitive Level: Comprehension REF: 397 OBJ: 12 TOP: Safety KEY: Nursing Process Step: Implementation 23. Parents of a 5-year-old child tell a nurse they are concerned about their child’s speech development by stating, “No one can understand him but us.” What clinical classification of speech disorder does the nurse suspect? a. Global language delay b. Expressive language delay c. Language loss d. Articulation disorder ANS: D When parents are the only peN opUlR eS toIuN ndGeT rsBta.nC dO thM eir preschool child, an articulation disorder is suspected.

DIF: Cognitive Level: Application TOP: Speech Development

REF: 391 OBJ: 5 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. A nurse includes play in the plan of care for a 5-year-old in order to do which of the following? (Select all that apply.) a. Exercise imagination b. Assume a role and act it out c. Offer an emotional outlet d. Avoid magical thinking e. Interact with other children ANS: A, B, C, E Benefits of play for the preschooler include exercising imagination, assuming a role and acting it out, offering an emotional outlet, and interacting with other children. Play employs the use of magical thinking.

DIF: Cognitive Level: Knowledge TOP: Purpose of Play

REF: 388 OBJ: 13 KEY: Nursing Process Step: Planning

2. What developmental milestone(s) assist a 5-year-old boy toward developing his sexual identity? (Select all that apply.) a. Begins to be less focused on his mother b. Ignores both parents totally c. Regresses to a more infantile level d. Forms a romantic attachment to the mother e. Identifies with the parent of the same sex ANS: A, D, E Children of this age become less focused on the mother as the central person and begin to identify with the parent of the same sex, forming a romantic attachment to the parent of the opposite sex. This little boy might say, “I’m going to marry my mother.” A little girl might say, “I’m going to marry my daddy.”

DIF: Cognitive Level: Application TOP: Development of Sexual Identity

REF: 392 OBJ: 2 KEY: Nursing Process Step: Implementation

3. Which bedtime preparation rituals are the most appropriate for a nurse to suggest to parents of a preschooler? (Select all that apply.) a. Telling a story b. Placing a favourite toy in bed c. Placing a glass of water at the bedside d. Letting the child watch TV just prior to bed e. Playing energetically ANS: A, B, C All options are soothing bedtN imUeRrS ituIaN lsGeT xcBe. ptCeO neMrgetic playing and watching TV prior to bed, which would be stimulating and counterproductive to sleep.

DIF: Cognitive Level: Comprehension TOP: Bedtime Habits

REF: 391 OBJ: 6 KEY: Nursing Process Step: Implementation

4. A nurse teaching parents, points out which of the following advantages of a nursery school experience? (Select all that apply.) a. Increasing self-confidence b. Fostering group cooperation c. Detecting adjustment problems d. Attainment of toilet training skills e. Playing experiences with other children ANS: A, B, C, E Nursery school increases self-confidence, group cooperation, social skills, and cooperative play. Objective observations by a nursery school instructor can detect early adjustment problems. The child is usually toilet trained prior to the start of nursery school.

DIF: Cognitive Level: Comprehension TOP: Advantages of Nursery School

REF: 396 OBJ: 12 KEY: Nursing Process Step: Implementation

5. Parents of a 5-year-old are concerned because their child regularly wets the bed at night.

What should a nurse teach the parents that would be beneficial for the child? (Select all that apply.) a. Have the child void prior to going to bed. b. Punish the child by making them change the bed in the morning on their own. c. Wake the child up frequently during the night to void. d. Avoid offering the child fluids prior to bedtime. e. Consider the use of a conditioning bed alarm.

ANS: A, D, E Limiting fluids and voiding prior to bed are useful. The Canadian Paediatric Society recommends the use of a conditioning bed alarm as the initial line of therapy. Management from parents should be non-punitive and it is not recommended to wake the child up frequently at night.

DIF: Cognitive Level: Application REF: 396 OBJ: 10 TOP: Enuresis KEY: Nursing Process Step: Implementation 6. Which major developmental tasks will a nurse expect a child to accomplish by the end of the preschool years? (Select all that apply.) a. Development of parallel play b. Acceptance of separation c. Increased communication skills d. Consistent appetite e. Control of bodily functions ANS: B, C, E NURSINGTB.COM The major tasks of the preschool child include preparation to enter school, development of a cooperative type of play, control of body functions, acceptance of separation, and increase in communication skills, memory, and attention span. Appetite remains inconsistent.

DIF: Cognitive Level: Comprehension TOP: Major Developmental Tasks

REF: 387 OBJ: 2 KEY: Nursing Process Step: Data Collection

COMPLETION 1. When planning an activity for a 3-year-old child, the nurse bases the plan on the average attention span of minutes.

ANS: 15 The average attention span of the preschooler is about 15 minutes.

DIF: Cognitive Level: Comprehension TOP: Attention Span of Preschooler

REF: 389 OBJ: 3 KEY: Nursing Process Step: Planning

Chapter 17: The School-Age Child Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse is assessing a school-age child. What will the nurse expect regarding physical development of the child? a. Growth of 7 to 10 cm per year b. Gain of 2.5 to 3.2 kg per year c. Increase of head circumference by 2.5 cm per year d. A visual acuity of 20/20 by 9 years of age ANS: B During the school-age period, the average weight gain per year is generally 2.5 to 3.2 kg.

DIF: Cognitive Level: Knowledge TOP: Physical Growth

REF: 403 OBJ: 3 KEY: Nursing Process Step: Data Collection

2. What should a nurse keep in mind when planning to teach a class on nutrition to fourth-grade students? a. School-age children can concentrate on only one aspect of a situation. b. School-age children can think abstractly. c. School-age children are egocentric in their thinking. d. School-age children think logically and concretely.

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ANS: D Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and an understanding of cause and effect.

DIF: Cognitive Level: Comprehension TOP: Cognitive Development

REF: 412 OBJ: 3 KEY: Nursing Process Step: Planning

3. What type of relationships are the preferred social interactions for a younger school-age child? a. Heterosexual interest groups b. Association with one “best friend” c. Rigidly organized groups with complex rules d. Same-sex peer groups ANS: D The preferred social interaction of the younger school-age child is in same-sex peer groups or cliques.

DIF: Cognitive Level: Analysis TOP: Social Development—Play

REF: 409 OBJ: 3 KEY: Nursing Process Step: Implementation

4. A nurse is advising parents of a 10-year-old boy about the most developmentally supportive experiences for their son. What is the best experience for this child according to Erikson’s theory? a. Constant variety of activities b. Successful performance in Little League c. Feeling healthy and strong d. Having a girlfriend ANS: B The child who is successful in activities will feel positively about himself or herself.

DIF: Cognitive Level: Analysis TOP: Psychosocial Development

REF: 403 OBJ: 3 KEY: Nursing Process Step: Implementation

5. The parents of an 8-year-old child tell a nurse the child wakes the household crying out during frequent nightmares. What is the nurse’s most helpful response to explain nightmares? a. They are a normal extension of the child’s fear of mutilation. b. They are an abnormal response to repressed feelings. c. They are a common result of latent sexuality. d. They are a side effect of overactivity and stimulation.

ANS: A The nightmares experienced by an 8-year-old child are an extension of their characteristic fear of mutilation.

DIF: Cognitive Level: ComNpUreRhS enIsN ioG n TBR OBJ: 3 .ECFO:M 412 TOP: Eight-Year-Old KEY: Nursing Process Step: Implementation 6. What is the best suggestion by a nurse for an appropriate toy for a hospitalized 6-year-old boy? a. Handheld video game b. MP3 player c. Adventure book d. Jigsaw puzzle ANS: A The 6-year-old child can perform numerous feats that require muscle coordination. At this age, the handheld video game will offer competition without overexertion.

DIF: Cognitive Level: Analysis TOP: Six-Year-Old

REF: 412 OBJ: 3 KEY: Nursing Process Step: N/A

7. A nurse discusses preparation for school with the parents of a 6-year-old girl who will soon be starting first grade. What statement by the girl’s father leads the nurse to determine that the parents understood the information? a. “We should put a stop to her thumb-sucking.” b. “We’ll tell her what school is like.” c. “We will let her walk to the bus stop by herself.” d. “We’ll have her meet some children who will be in her class.”

ANS: D To prepare a child for school, parents can arrange for the child to meet other children who will be entering school with her.

DIF: Cognitive Level: Application REF: 406 TOP: Parental Guidance for Starting School KEY: Nursing Process Step: Evaluation

OBJ: 4

8. A 9-year-old boy is often cranky and irritable, and his school performance has declined.

What of these factors in his life is the most likely causing this behaviour? a. He sleeps only 6 to 7 hours a night. b. He eats eggs every day. c. He has a new dog. d. He plays about 1 to 3 hours each evening.

ANS: A The 9-year-old child requires about 10 hours of sleep per night.

DIF: Cognitive Level: Application TOP: Nine-Year-Old

REF: 409 OBJ: 3 KEY: Nursing Process Step: Data Collection

9. A parent asks a nurse, “At what age are children capable of assuming more responsibility for personal belongings?” What is the nurse’s best response based on knowledge of growth and development? a. 6 years b. 7 years c. 9 years NURSINGTB.COM d. 12 years ANS: C The 9-year-old child is dependable and assumes more responsibility for personal belongings.

DIF: Cognitive Level: Comprehension TOP: Nine-Year-Old

REF: 409 OBJ: 3 KEY: Nursing Process Step: Implementation

10. A nurse is teaching parents of a 7-year-old child about normal cognitive development.

Which of the following topics would be included in the teaching? a. Is able to count by 5s b. Can name the months in order c. Can use fractions d. Has a vocabulary of 3000 words ANS: A Seven-year olds are able to count by 2s and 5s. The other options are appropriate for an 8-or 9-year-old.

DIF: Cognitive Level: Application TOP: Seven-year old

REF: 409 OBJ: 7 KEY: Nursing Process Step: Implementation

11. A parent states, “My 7-year-old really wants a dog. His 10-year-old brother has allergies to animal dander. I don’t know what to do.” What type of pet should the nurse suggest as the best choice? a. A small breed of dog because the large dogs produce more allergens. b. An older unneutered dog that produces fewer allergens than a younger one. c. A cat because it requires less care and is less allergenic. d. A poodle, which does not shed, making it a good choice for people with allergies ANS: D The poodle does not have a shed cycle and so it may be the least offensive pet for the allergic child.

DIF: Cognitive Level: Analysis TOP: Pet Ownership

REF: 414 | 415 OBJ: 8 KEY: Nursing Process Step: Implementation

12. When asked about her activities, a 10-year-old girl responded, “I like school. I play the flute in the school band, and I take tennis lessons.” What does a nurse know these activities will help this child develop? a. Initiative b. Industry c. Identity d. Intimacy ANS: B The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities facilitates the child’s sense of industry.

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DIF: Cognitive Level: Application TOP: Psychosocial Development

REF: 402 OBJ: 3 KEY: Nursing Process Step: Data Collection

13. A mother reports that she has a new job and her 11-year-old child is home alone for a time after school. Which statement made by the parent alerts a nurse to a potentially unsafe situation for this child? a. “I told him that he could invite a few friends after school.” b. “I put a list of emergency numbers next to the telephone.” c. “Last week we made a first aid kit together.” d. “There is a neighbour available in case of an emergency.”

ANS: A Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to be home alone in an unsupervised environment is an unsafe situation.

DIF: Cognitive Level: Application TOP: Latchkey Children

REF: 407 OBJ: 6 KEY: Nursing Process Step: Evaluation

14. A mother is concerned because her 9-year-old boy has developed the habit of twitching his eyes and flipping his hair while communicating with anyone. What is the best nursing response to this parent? a. “This may indicate that he needs eyeglasses.” b. “Children sometimes do these things for attention.”

c. “This behaviour suggests low self-esteem.” d. “Tics appear when a child is under stress.”

ANS: D The child cannot help such actions and should not be scolded for them because they are mainly a result of tension.

DIF: Cognitive Level: Application TOP: Nine-Year-Old

REF: 409 OBJ: 3 KEY: Nursing Process Step: Implementation

15. A seventh-grade girl tells a nurse that her art teacher, a woman, is her hero. What is the most appropriate interpretation of the girl’s comment? a. The student may be exploring her career options. b. The comment is cause for concern about sexual abuse. c. The child may have difficulty interacting with her peers. d. Hero worship is a normal phenomenon.

ANS: D School-age children tend to admire their teachers and adult companions. For the 11- to 12-year-old, hero worship is a normal phenomenon.

DIF: Cognitive Level: Comprehension TOP: Social Development

REF: 402 OBJ: 3 KEY: Nursing Process Step: Data Collection

16. Which stage of cognitive development is a 9-year-old child in according to Piaget? a. Formal operations b. Preoperational NURSINGTB.COM c. Concrete operations d. Sensorimotor ANS: C School-age children are in the concrete operations stage of cognitive development.

DIF: Cognitive Level: Knowledge TOP: Cognitive Development

REF: 402 OBJ: 3 KEY: Nursing Process Step: Data Collection

17. What statement by an 11-year-old child leads a nurse to determine the child has moved from the mind-set of egocentrism? a. “I am a member of the best Cub Scout group in the world.” b. “I must do my homework before I can play.” c. “My dad can do anything!” d. “I’m sorry. I bet that hurt your feelings.”

ANS: D The ability to see another’s point of view indicates moving away from egocentrism into a more altruistic mind-set.

DIF: Cognitive Level: Analysis TOP: Increasing Understanding

REF: 412 OBJ: 3 KEY: Nursing Process Step: Data Collection

18. A school-age child becomes frustrated with a school assignment and says, “I can’t do this!”

What is the most developmentally supportive response from a parent? a. Ask, “What is it that is so difficult?” b. Allow the child to quit the effort. c. Call in older siblings to help. d. Finish the project for them.

ANS: A Helping the child focus on the problem that is keeping him from mastery can limit frustration. Quitting or having someone else finish is detrimental to the development of industry.

DIF: Cognitive Level: Analysis REF: 405 TOP: Industry KEY: Nursing Process Step: N/A

OBJ: 3

19. What is best for a nurse to suggest to parents of an overweight 9-year-old child to help prevent obesity? a. Use whole milk as a between-meal snack because it is more filling than skim milk. b. Feed the child before family meal times to monitor intake more closely. c. Encourage the child to engage in physical activity for at least an hour a day. d. Remove all sweets and junk food from the house.

ANS: C Regular physical activity reduces weight.

DIF: Cognitive Level: Comprehension REF: 411 OBJ: 7 TOP: Prevention of ObesityNURSINGTBK EY .C O:M Nursing Process Step: Implementation 20. A parent confides in a nurse that her 8-year-old twins argue and bicker constantly. What is the best response by the nurse? a. Express alarm at the constant aggression. b. Voice concern and investigate referral for counselling. c. Inquire about what punitive action the parents have taken to stop it. d. Offer reassurance that such behaviour is normal for 8-year-olds.

ANS: D Argumentative and competitive behaviour is normal in 8-year-olds.

DIF: Cognitive Level: Application TOP: Argumentative Behaviour

REF: 412 OBJ: 3 KEY: Nursing Process Step: Implementation

21. A nurse is planning sex education classes for school-age children. What should the nurse be sure to do? a. Use simple terms. b. Avoid slang or “street” words and concepts. c. Keep topics on biological aspects of sexual development. d. Limit questions to keep content clear.

ANS: A Using simple terms is essential but slang and street terms need to be clarified. Apply age-specific information across broad aspects of biological, social, and current attitudes.

DIF: Cognitive Level: Application TOP: Sex Education

REF: 404 OBJ: 7 KEY: Nursing Process Step: Planning

22. Parents ask a pediatric nurse how school life might influence their growing child. What area of development will the nurse indicate that school affects the least? a. Moral development b. Social development c. Physical development d. Cognitive development ANS: C Physical development is the least affected by school life. Moral development occurs as they have experience with, and understand, rules and fairness in the school setting. Schools have a profound influence on the socialization of children, who bring to school what they have learned and experienced in the home. Success in school requires an integration of cognitive, receptive, and expressive (language) skills.

DIF: Cognitive Level: Application TOP: Impact of School Life

REF: 404 | 405 OBJ: 5 KEY: Nursing Process Step: Planning

MULTIPLE RESPONSE 1. What basic “feeling” words should a nurse use in attempting to help a 7-year-old girl express her feelings about being in a new school? (Select all that apply.) a. Mad NURSINGTB.COM b. Glad c. Sad d. Scared e. Jealous ANS: A, B, C, D The words “mad,” “glad,” “sad,” and “scared” are basic feeling words that can prompt a young child to better express his or her feelings.

DIF: Cognitive Level: Knowledge TOP: Expression of Feelings

REF: 411 OBJ: 3 KEY: Nursing Process Step: Implementation

2. A nurse is preparing an educational program for parents regarding school-age children.

What information is accurate for the nurse to include? (Select all that apply.) a. Participation in group activity increases. b. Egocentricity prevails. c. Thinking is logical. d. Preference is toward family interaction. e. Cause and effect is understood.

ANS: A, C, E

Piaget refers to the thought processes of the school-age period as concrete operations.

Concrete operations involve logical thinking and an understanding of cause and effect. The egocentric view of the preschool child is replaced by the ability to understand the point of view of another person. Between 5 and 12 years of age, children prefer friends of their own sex and usually prefer the company of their friends to that of their brothers and sisters.

DIF: Cognitive Level: Comprehension TOP: Personality Development

REF: 402 | 403 OBJ: 2 KEY: Nursing Process Step: Data Collection

3. A pediatric nurse is presenting school-age children with information on safety issues to follow when going home alone. What topics should be included in the class? (Select all that apply.) a. Ask for identification before letting someone in the house. b. Never accept rides with strangers. c. Keep doors locked. d. Do not enter house if door is ajar. e. Walk to and from school with friends.

ANS: B, C, D, E Strangers should never be allowed in the house. Children should be instructed never to accept rides with strangers, to keep doors locked, not to enter the house if the door is ajar, and to walk to and from school with friends.

DIF: Cognitive Level: Comprehension REF: 406 OBJ: 6 TOP: Safety KEY: Nursing Process Step: Implementation 4. A 10-year-old child with a phNyU siR caSl I diN saGbT iliBty.iC sO beMgging her parents for a dog. When at the pediatric clinic, the parents inquire about possible benefits pet ownership may provide to their child. What benefits of pet ownership should a nurse indicate? (Select all that apply.) a. Decrease the need for physical therapy b. Lower blood pressure c. Improve communication d. Foster trust e. Ease path to socialization ANS: B, C, D, E Studies have documented the positive influence of pet ownership on improving the medical and psychological outcome after illness or surgery. Disabled children especially benefit from interacting with pets. The interaction with animals can lower blood pressure and heart rate, reduce loneliness and feelings of isolation, improve communication, foster trust, and motivate participation in physical therapy. Pets allow the ill child who feels separated from other people to feel companionship and acceptance. Shy children often find pet ownership eases the path to socialization with others who initiate contact because of the pet.

DIF: Cognitive Level: Comprehension TOP: Pet Ownership COMPLETION

REF: 414 OBJ: 8 KEY: Nursing Process Step: Implementation

1. A nurse advises the parents of a 6-year-old child to try and ensure at least _ sleep daily for the child.

hours of

ANS: 11 The 6-year-old school-age child needs 11 to 13 hours of sleep.

DIF: Cognitive Level: Knowledge REF: 408 OBJ: 3 TOP: Sleep Needs KEY: Nursing Process Step: Implementation 2. The nurse is aware that by the age of

, the first permanent teeth erupt.

ANS: 6 At the age of 6, the first permanent teeth erupt: the 6-year molars.

DIF: Cognitive Level: Knowledge TOP: Eruption of Permanent Teeth

REF: 412 OBJ: 3 KEY: Nursing Process Step: Data Collection

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Chapter 18: The Adolescent Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse is assessing a 13-year-old boy. Which physical change indicates that male puberty has begun? a. Development of axillary and facial hair b. Enlargement of penis c. Enlargement of testicles d. Pigmentation of the scrotum ANS: C In boys, pubertal changes begin with enlargement of the testicles and internal structures.

DIF: Cognitive Level: Knowledge TOP: Physical Development

REF: 421 OBJ: 4 KEY: Nursing Process Step: Data Collection

2. A 13-year-old boy states, “The girls in my class tower over me.” What would be a nurse’s most informative response? a. “This is normal because girls have a growth spurt earlier than boys.” b. “Perhaps your parents are not exceptionally tall.” c. “Boys usually experience a growth spurt 1 year earlier than girls.” d. “You may feel short, but you are actually average height for your age.”

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ANS: A Although the age for growth spurts during puberty varies, growth spurts occur 6 months to 2 years earlier for girls than for boys.

DIF: Cognitive Level: Application TOP: Physical Development

REF: 419 OBJ: 4 KEY: Nursing Process Step: Implementation

3. A parent comments that her adolescent daughter seems to be daydreaming a lot. What does a nurse understand this behaviour to indicate regarding their daughter? a. She is bored. b. She is not getting enough rest. c. She is trying to block out stress and anxiety. d. She is mentally preparing for real situations.

ANS: D Daydreaming allows adolescents to act out in their imaginations what will be said or done in certain situations. This helps them to prepare for and cope with interactions with others.

DIF: Cognitive Level: Comprehension TOP: Development—Daydreams

REF: 427 OBJ: 5 KEY: Nursing Process Step: Data Collection

4. A nurse is planning a safety program for high school students. Which is the top cause of accidental deaths during adolescence?

a. b. c. d.

Firearms Automobiles Drowning Diving injuries

ANS: B The chief safety hazard for the adolescent is automobiles.

DIF: Cognitive Level: Knowledge REF: 432 TOP: Safety KEY: Nursing Process Step: Planning

OBJ: 14

5. A 16-year-old boy excitedly tells his parents that he was offered a part-time job. Which response represents an effective problem-solving approach for his parents? a. “Your studies are too important for you to have a part-time job.” b. “When we went to high school, academics were our priority.” c. “We want you to put your earnings in a savings account.” d. “How do you think you will manage your schoolwork and a job?”

ANS: D An effective approach to help adolescents learn to solve problems is for parents to guide them in exploring alternatives.

DIF: Cognitive Level: Application REF: 430 TOP: Parenting KEY: Nursing Process Step: Evaluation

OBJ: 5

6. A nurse is planning care of an adolescent. What psychosocial task does the nurse understand is important for the adolescenNt U toRdSeI veNloGpT ? B.COM a. A sense of initiative b. A sense of industry c. A sense of identity d. A sense of involvement ANS: C The key psychosocial task of adolescence is the development of identity.

DIF: Cognitive Level: Knowledge TOP: Psychosocial Development

REF: 423 OBJ: 5 KEY: Nursing Process Step: Planning

7. A 13-year-old girl tells a nurse that she is getting fat, especially in her hips and legs. What understanding by the nurse would best guide the response? a. Many adolescents are unaware of proper nutrition. b. Adolescents of this age become less active and should eat fewer calories. c. Puberty is often preceded by fat deposits in these areas. d. As soon as menarche occurs, she will lose this excess weight.

ANS: C Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips, thighs, and breasts, causing them to enlarge.

DIF: Cognitive Level: Application TOP: Physical Development

REF: 423 OBJ: 4 KEY: Nursing Process Step: Planning

8. A nurse is planning a program for girls about the physical changes of puberty. What is the target age the nurse should choose for this program? a. 10 years b. 12 years c. 14 years d. 16 years ANS: A Because puberty can occur in girls as early as age 10 years, instruction must be given by that age.

DIF: Cognitive Level: Comprehension TOP: Physical Development

REF: 423 OBJ: 4 KEY: Nursing Process Step: Planning

9. What statement made by a parent indicates an understanding about helping a 13-year-old adolescent manage his allowance? a. “I set amounts he can earn for particular chores.” b. “I give him a certain amount of money for each day.” c. “I put money into his bank account each month.” d. “I told him to ask me when he needs money.”

ANS: A If money is simply handed out as requested, it is difficult to develop responsibility for finances and money management. The older adolescent can get a job. The younger adolescent can earn money by doing particular chores.

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DIF: Cognitive Level: Comprehension TOP: Development—Responsibility

REF: 427 OBJ: 14 KEY: Nursing Process Step: Evaluation

10. What can a nurse suggest as a good dietary source of zinc for an adolescent who is a vegetarian? a. Green, leafy vegetables b. Citrus fruits c. Nuts d. Enriched breads ANS: C Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources include nuts, legumes, and wheat germ.

DIF: Cognitive Level: Comprehension REF: 431 OBJ: 12 TOP: Nutrition KEY: Nursing Process Step: Data Collection 11. An adolescent’s parent comments, “My son seems so preoccupied with his appearance these days. Is this normal?” What is a nurse’s best response? a. “It is his attempt to express his individualism.” b. “His preoccupation with his looks is quite normal.” c. “He is probably troubled with his physical changes.” d. “This shows that he has a positive self-image.”

ANS: B Preoccupation with self-image is normal and accounts for the constant primping of adolescents.

DIF: Cognitive Level: Application TOP: Development

REF: 421 OBJ: 4 KEY: Nursing Process Step: Planning

12. What foods would be a healthy choice for an adolescent who just finished playing in a strenuous sports game? a. A cheeseburger and soda b. A hot fudge sundae c. Two sausage and egg breakfast sandwiches and orange juice d. A bagel with peanut butter and skim milk ANS: D A bagel with peanut butter and milk provides a rapid supply of carbohydrates and protein to the muscles. To hasten muscle energy recovery, the young athlete should consume protein and carbohydrates within 30 minutes of exercise, and again within 1 to 2 hours of exercise, to help reload muscles with glycogen and allow for proper recovery.

DIF: Cognitive Level: Analysis REF: 431 OBJ: 14 TOP: Nutrition KEY: Nursing Process Step: Data Collection 13. When planning to answer a 16-year-old girl’s questions about menstruation, a nurse must consider cognitive development. What is developed during adolescence according to Piaget? a. The ability to view a situation from multiple perspectives b. The ability to focus moreNoU nR thSeIpN asG tT thB an.pCrO esM ent situations c. The ability to exercise concrete reasoning d. The ability to consider hypothetical situations ANS: D According to Piaget, in the formal operations stage adolescents have the ability to think abstractly.

DIF: Cognitive Level: Comprehension TOP: Cognitive Development

REF: 427 OBJ: 2 KEY: Nursing Process Step: Planning

14. A girl tells a nurse that she and her best friend belong to the popular clique. She states, “I love Lady Gaga, and I want to be a singer.” The nurse recognizes the girl’s statement as characteristic of what time period? a. Early adolescence b. Middle adolescence c. Late adolescence d. The entire adolescent period ANS: A Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent.

DIF:

Cognitive Level: Comprehension

REF: 421

OBJ: 9

TOP: Social Development

KEY: Nursing Process Step: Data Collection

15. A nurse is leading a discussion group with parents of adolescents. One parent comments, “My son can’t do anything without checking with his friends first. My opinion doesn’t count anymore.” What knowledge regarding this behaviour would the nurse formulate as a response? a. It is unusual for adolescent boys. b. It is often more apparent in boys than girls. c. It is a normal phenomenon during adolescence. d. It is suggestive of feelings of low self-worth.

ANS: C Parents may need help understanding that the adolescent’s exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family.

DIF: Cognitive Level: Comprehension TOP: Peer Relationships

REF: 426 OBJ: 9 KEY: Nursing Process Step: Planning

16. What does an adolescent’s peer group serve as related to development? a. Social outlet b. Association to blur personal identity c. Platform for “group think” d. Initial separation from family ANS: D Being a member of a peer groNuU pRanSdIcNoG mT mBu. niC caOtiM ng with and seeking approval from this group are hallmarks of the first separation from the family.

DIF: Cognitive Level: Comprehension REF: 425 | 426 TOP: Peer Groups KEY: Nursing Process Step: N/A

OBJ: 9

17. According to Freud’s theory, what stage is the adolescent considered to be in? a. Conceptual b. Genital c. Glandular d. Pubertal ANS: B Freud describes the adolescent period as genital.

DIF: Cognitive Level: Knowledge REF: 419 OBJ: 2 TOP: Freud KEY: Nursing Process Step: Data Collection 18. A nurse using the CRAFFT screening tool for persons at risk for substance use arrives at a score of 2 for an adolescent patient. How would the nurse interpret this score? a. Nonindicative of potential substance misuse b. Normal experimentation of the adolescent c. Need to schedule another CRAFFT interview in 3 months d. Indication for referral for counselling

ANS: D If two or more of the CRAFFT letters are problem areas, the adolescent may be at high risk for substance misuse and requires a professional referral.

DIF: Cognitive Level: Analysis TOP: Substance Misuse

REF: 434 OBJ: 14 KEY: Nursing Process Step: Data Collection

19. What does adolescent acne result from? a. Ineffective sweat glands b. Oily skin c. Inadequate hygiene d. A poor diet ANS: B Adolescent acne is the result of overactive sweat glands and oily skin.

DIF: Cognitive Level: Comprehension REF: 419 OBJ: 14 TOP: Acne KEY: Nursing Process Step: Implementation 20. A nurse suggests the use of “I” messages to communicate a parent’s feeling to an adolescent. What is the most appropriate example of an “I” message? a. “I feel frightened when you stay out past your curfew.” b. “I am your mother, and I insist that you observe your curfew.” c. “I am sick and tired of your staying out late.” d. “I expect you to show me proper respect.”

ANS: A NURSINGTB.COM This is the only statement that associates the parent’s feelings about the adolescent behaviour that is not aggressive or accusatory.

DIF: Cognitive Level: Analysis TOP: “I” Statements

REF: 430 OBJ: 14 KEY: Nursing Process Step: Implementation

21. A 13-year-old girl tells a nurse she is concerned because she has not had her first menstrual period. What is the best initial response from the nurse? a. “Your hormone levels may be irregular.” b. “Could you be pregnant?” c. “Age of first menstrual cycle varies.” d. “Do not worry about it.”

ANS: C Puberty is easily recognized in girls by the onset of menstruation. The first menstrual period is called the menarche. It commonly occurs about age 12 or 13 years, but this varies. It may occur as early as age 10 years or as late as age 15 years.

DIF: Cognitive Level: Application TOP: Menstrual Cycle

REF: 423 OBJ: 10 KEY: Nursing Process Step: Implementation

22. A nurse is documenting the assessment of a female patient. When assessing Tanner’s stages of breast development there is elevation of papilla only. What stage of development will the nurse document? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: A According to Tanner’s Stages of Sexual Maturity, Stage 1 (preadolescent) is elevation of papilla only.

DIF: Cognitive Level: Application TOP: Breast Development

REF: 422 OBJ: 6 KEY: Nursing Process Step: Data Collection

23. A nurse is educating high school students about guidelines to be followed when participating in sports. Which statement by a student alerts the nurse of the need for further information? a. “I will eat carbohydrates and protein after practice.” b. “I drink sports drinks when I play a long soccer game.” c. “I wear protective gear every time I play sports.” d. “I will drink caffeine when participating in sports.”

ANS: D Caffeine and alcohol deplete body water and are to be avoided. Fluids lost by sweat should be replaced by drinking sports drinks when the workout is long. Carbohydrates and protein that provide both energy and N oth erSnI utri s a.rC eO beMst for athletes. Protective gear should be UR NGenTtB worn by all team players in any contact sport.

DIF: Cognitive Level: Application TOP: Nutrition During Sports

REF: 432 OBJ: 13 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. Restlessness in adolescence is most likely attributed to which changes? (Select all that apply.) a. Drive to be accepted by society as an individual b. Urge for independence c. Establishment of a personal identity d. Intense libido e. Slowing of body changes ANS: A, B, C, D All the options listed are sources of stress to the adolescent and are stimulants to restlessness except option E; body changes are rapid.

DIF: Cognitive Level: Comprehension REF: 418 TOP: Sources of Stress for the Adolescent KEY: Nursing Process Step: Implementation

OBJ: 7

2. What are the best breakfast choices for a nurse to point out prior to a big exam, to provide high levels of alertness and increased memory? (Select all that apply.) a. Pancakes and syrup b. Coffee and chocolate-covered donuts c. Bacon and fried eggs d. Whole grain cereal and yogurt e. Oatmeal and sliced apples ANS: D, E Meals high in protein will break down into norepinephrine and increase alertness. Meals with a high sugar content result in a soothing sleepy response. Meals high in fats digest slowly and draw blood from the brain during the lengthy digestive process.

DIF: Cognitive Level: Application REF: 432 OBJ: 12 TOP: Nutrition KEY: Nursing Process Step: Implementation 3. A nurse considers what “rites of passage” as valued by the adolescent in Canadian society?

(Select all that apply.) a. Attaining legal drinking age b. Selection of a career c. Religious affiliation d. Obtaining a driver’s licence e. High school graduation ANS: A, D, E Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, driver’s licence, and gradu tinSgIhNigGhTsB ch.oC olOaM re such signals. Religious affiliation and NUaR selection of a career path do not necessarily signal adulthood.

DIF: Cognitive Level: Knowledge TOP: Rites of Passage

REF: 433 OBJ: 9 KEY: Nursing Process Step: Data Collection

4. A mother confides in a nurse that she witnessed her son kissing another boy. Which concepts should guide the nurse to base a reply? (Select all that apply.) a. Homosexual behaviour in adolescents is not uncommon. b. Homosexuality is a mental disorder. c. Adolescents often desire to explore alternative lifestyles. d. Homosexual tendencies should be addressed with counselling. e. Parents should immediately seek a support group for parents of gays.

ANS: A, C Adolescents may experiment with an alternate sexual expression as part of their self-discovery. Homosexual activities are not uncommon in adolescence.

DIF: Cognitive Level: Comprehension TOP: Homosexuality

REF: 429 OBJ: 11 KEY: Nursing Process Step: Implementation

5. A nurse is discussing challenges of the adolescent years with a group of high school students in health class. What challenges toward adolescent development will the nurse include? (Select all that apply.)

a. b. c. d. e.

Developing intimacy Maintaining dependence on parents Searching for identity Adjusting to body changes Establishing future goals

ANS: A, C, D, E Adolescents face the challenges of developing intimacy, searching for identity, adjusting to body changes, and establishing goals for the future. Adolescents are striving for independence from parents.

DIF: Cognitive Level: Comprehension REF: 418 OBJ: 3 TOP: Challenges KEY: Nursing Process Step: Implementation 6. Which of the following symptoms would a nurse assess in a female athlete related to female athlete triad? (Select all that apply) a. Eating disorder b. Menstrual irregularities c. Low BMI d. Osteoporosis e. Repetitive stress injury ANS: A, B, D Assessment of the female athlete in training should include identification of the “female athlete triad,” which includes an eating disorder, amenorrhea, and osteoporosis. Low BMI and repetitive stress injury are not related to female athlete triad.

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DIF: Cognitive Level: Application TOP: Female athlete triad

REF: 433 OBJ: 14 KEY: Nursing Process Step: Data Collection

COMPLETION 1. A nurse stresses the need for using a sunscreen with a sun protection factor (SPF) of at least .

ANS: 30 A sunscreen with an SPF of at least 30 is recommended to block sun rays that cause cancer.

DIF: Cognitive Level: Knowledge TOP: Sun Protection

REF: 432 OBJ: 14 KEY: Nursing Process Step: Implementation

Chapter 19: The Child’s Experience of Hospitalization Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. Which child would have the most difficulty in coping with separation from caregivers because of hospitalization? a. 3-month-old child b. 16-month-old child c. 4-year-old child d. 7-year-old child ANS: B Separation anxiety occurs after age 6 months and is most pronounced in the toddler.

DIF: Cognitive Level: Comprehension TOP: Separation Anxiety

REF: 441 OBJ: 3 KEY: Nursing Process Step: Data Collection

2. A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago. What does this behaviour suggest? a. The toddler feels abandoned by his mother. b. The child still has not adjusted to his hospitalization. c. The child is not separated from his mother often. d. There is a poor mother–child bond.

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ANS: A Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization are obvious.

DIF: Cognitive Level: Analysis TOP: Separation Anxiety

REF: 441 OBJ: 3 KEY: Nursing Process Step: Data Collection

3. Which statement best corresponds to a preschooler’s understanding of hospitalization? a. “A germ made me get sick.” b. “I got sick because I was mad at my brother.” c. “My tonsils are sick and they have to come out.” d. “I have a cast because I broke my leg.”

ANS: B The preschooler may feel guilty, particularly if an accident happens as a result of mischief on his or her part.

DIF: Cognitive Level: Application TOP: The Hospitalized Preschooler

REF: 452 OBJ: 5 | 10 KEY: Nursing Process Step: Data Collection

4. The caregivers of a hospitalized toddler are upset because she seems more interested in her toys when they come to visit her. In which stage of separation anxiety is the toddler? a. Protest

b. Despair c. Denial d. Attachment ANS: C In the stage of denial or detachment, the child appears to deny the need for the caregivers and becomes uninterested in their visits. On the surface, it appears the child has adjusted to the separation. However, it is important for the nurse to understand that the child is using a coping mechanism to detach and reduce the emotional pain.

DIF: Cognitive Level: Comprehension TOP: Separation Anxiety

REF: 441 OBJ: 3 KEY: Nursing Process Step: Data Collection

5. A nurse must make a room assignment for a 16-year-old adolescent with cystic fibrosis.

Which roommate would be the most appropriate for this patient? a. A 4-year-old child who had an appendectomy b. A 10-year-old child with sickle cell disease in vaso-occlusive crisis c. A 15-year-old adolescent with type 1 diabetes mellitus d. No roommate ANS: C Adolescents usually do better in rooms with one or more roommates than in single rooms.

The adolescent would do best with a roommate who is closest to his or her age and also lives with a chronic illness.

DIF: Cognitive Level: Application REF: 453 OBJ: 9 | 11 TOP: The Hospitalized AdoNleUsR ceS ntINGTBK EY .C O:M Nursing Process Step: Planning 6. The caregivers of a hospitalized 9-month-old infant ask if their preschool son may visit his younger sister. What understanding would assist a nurse most in formulating a response? a. Preschool children can be disruptive in the hospital environment. b. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided. c. The sibling could view the infant from the doorway but not enter the room to prevent the spread of microorganisms. d. The preschooler needs to visit his sister to reassure himself that she is all right.

ANS: D Siblings are affected by a child’s hospitalization. Their ability to cope is influenced by their age, experience, and intactness of the family.

DIF: Cognitive Level: Application REF: 448 TOP: Siblings Reaction to Hospitalization KEY: Nursing Process Step: Implementation

OBJ: 8

7. A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except a favourite bottle. What is the most likely reason for this behaviour in the child? a. Is dealing with the anxiety of hospitalization by regressing b. Is demonstrating attention-seeking behaviours because of an overabundance of

attention in the hospital c. Is attempting to refocus the attention of the adults around him to avoid further painful procedures d. Is exhibiting normal behaviour for this age, as children often stop new behaviours after they believe they have mastered them ANS: A Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital.

DIF: Cognitive Level: Comprehension REF: 449 OBJ: 1 | 10 TOP: Regression KEY: Nursing Process Step: Data Collection 8. A nurse encourages a school-age child to draw a picture after a painful procedure. What is the best rationale for this nursing intervention? a. Attempting to re-establish rapport b. Providing a way for the child to express his feelings c. Encouraging quiet play d. Distracting the child from thinking about the pain ANS: B After treatments, the nurse should encourage children to draw and talk about their drawings or to act out their feelings through puppet play.

DIF: Cognitive Level: Comprehension REF: 453 TOP: The Hospitalized SchN ooUl-RASgI eN CG hiT ldB.COM KEY: Nursing Process Step: Implementation

OBJ: 9 | 10

9. What is the best suggestion by a nurse when caregivers ask, “When is the best time to begin to prepare a 5-year-old child for surgery and hospitalization?” a. “As soon as the surgery is scheduled.” b. “About 2 weeks before surgery.” c. “About 4 days before surgery.” d. “On the night before admission to the hospital.”

ANS: C Caregivers should prepare children for procedures and hospitalization a few days in advance.

DIF: Cognitive Level: Application REF: 440 OBJ: 10 TOP: The Nurse’s Role in Hospital Admission—Preparing the Child KEY: Nursing Process Step: Implementation 10. The mother of a 3-year-old child tells a nurse that she will be in to visit tomorrow around 12:00 PM. The next morning, the child asks the nurse, “When is my mommy coming?”

What is the nurse’s best response? a. “Your mommy will be here around noon.” b. “Your mommy will be here when you have lunch.” c. “Mommy will be here very soon.”

d. “Your mommy is coming in 4 hours.”

ANS: B The toddler and preschooler do not understand time yet. They understand time relationships through activities in their experience, such as naptime and mealtimes.

DIF: Cognitive Level: Application TOP: The Hospitalized Preschooler

REF: 450 OBJ: 10 KEY: Nursing Process Step: Implementation

11. A 13-year-old girl has been hospitalized for the past week. When discussing the girl’s feelings about her illness, what would the nurse expect the girl to express as her biggest concern? a. Invasive procedures b. Loss of control c. Appearance d. Separation from her boyfriend ANS: C Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image.

DIF: Cognitive Level: Comprehension TOP: The Hospitalized Adolescent

REF: 453 OBJ: 11 KEY: Nursing Process Step: Implementation

12. A nurse notices that the mother of a child with cerebral palsy corrects and redoes many of the things a nurse does for her child. What is the nurse’s most appropriate response to this mother? a. “Would you like to do allNoU fR yoSuI rN chGilT d’Bs.caCrO e?M” b. “I’m doing the very best job that I can with your child.” c. “Why don’t you go have a cup of coffee? You are going to be exhausted if you don’t take a break.” d. “I’d love for you to share with me some of the special things you do for your child.”

ANS: D The person who cares daily for the child with a chronic illness can provide information that will best guarantee continuity of care between the home and the hospital.

DIF: Cognitive Level: Application TOP: Caregivers’ Reaction

REF: 440 OBJ: 4 KEY: Nursing Process Step: Implementation

13. The mother of a hospitalized toddler states, “He cries when I visit. Maybe I should just stay away.” What is a nurse’s best response? a. “Perhaps you are right. He only gets upset when you have to leave.” b. “It is important that you are here. This is a common reaction in children when they are separated from their caregivers.” c. “It might be easier for your child if you would stay with him, but this decision is up to you.” d. “We take good care of him and he seems fine when you are not here.”

ANS: B

During the second stage of separation anxiety (despair), the child is quiet, is not crying, and is sad and depressed. The child will revert to protest when the caregiver arrives for a visit.

DIF: Cognitive Level: Application TOP: Separation Anxiety

REF: 441 OBJ: 3 KEY: Nursing Process Step: Implementation

14. What should a nurse preparing to collect an admission history from caregivers who have recently emigrated from Russia, keep in mind? a. Eye-to-eye contact is considered disrespectful. b. Touching the child’s head means the nurse is superior. c. Smiling is inappropriate in a serious situation. d. Staring is a sign of the nurse’s rudeness.

ANS: C In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.

DIF: Cognitive Level: Comprehension REF: 446 TOP: Fostering Intercultural Communication KEY: Nursing Process Step: Planning

OBJ: 7

15. Which nursing action would facilitate rapport with a child and the child’s caregivers during the admission process? a. Direct the caregivers to undress the child. b. Answer questions in a calm and matter-of-fact way. c. Perform assessments and ask questions as quickly as possible. d. Express concern about the seriousness of the child’s condition.

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ANS: B The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless of the child’s condition.

DIF: Cognitive Level: Application REF: 448 TOP: Nurse’s Role in Hospital Admission KEY: Nursing Process Step: Implementation

OBJ: 4

16. When a 2-year-old child returns to the hospital room following a diagnostic procedure the caregivers are not available, and the child is crying loudly. Which technique is most appropriate for a nurse to use to alleviate the child’s distress? a. Rock the child gently to sleep. b. Play with the child using pop-up toys. c. Role-play with the child to act out any feelings. d. Ask the child to draw a picture about any feelings.

ANS: B Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help reduce anxiety and pain.

DIF: Cognitive Level: Application TOP: The Hospitalized Toddler

REF: 451 OBJ: 10 KEY: Nursing Process Step: Implementation

17. A 4-year-old child begins to cry when his mother tells him it is time for his operation. A nurse understands this is an expected reaction. On which particular fear of the preschooler does the nurse base this understanding? a. Loss of control b. Restricted mobility c. Unfamiliar routines d. Invasive procedures ANS: D The preschool child is afraid of bodily harm, particularly invasive procedures.

DIF: Cognitive Level: Comprehension TOP: The Hospitalized Preschooler

REF: 452 OBJ: 5 KEY: Nursing Process Step: Data Collection

18. What statement by a caregiver of a hospitalized toddler leads a nurse to determine the caregiver understands the needs of a hospitalized toddler? a. “This stuffed animal makes him feel secure.” b. “He insisted on bringing this dirty old blanket with him.” c. “I’m going to buy him a big stuffed animal from the gift shop.” d. “I’d like to get him some toys from the playroom.”

ANS: A The use of a transitional object, such as a blanket or a favourite toy, promotes security for the hospitalized child.

DIF: Cognitive Level: Application REF: 450 OBJ: 5 TOP: The Hospitalized TodN dlUeR r SINGTBK EY .C O:M Nursing Process Step: Evaluation 19. An 8-year-old child with a fractured femur will be hospitalized for several weeks in skeletal traction. What does a nurse realize immobilization in this age group can generate feelings of in planning care of this child? a. Loss of control b. Altered body image c. Shame and guilt d. Fear of bodily harm ANS: A Forced dependency in the hospital, such as immobilization, can result in a feeling of loss of control and loss of security.

DIF: Cognitive Level: Application REF: 452 TOP: The Hospitalized School-Age Child KEY: Nursing Process Step: Planning

OBJ: 10

20. A nurse explains to the caregivers of a hospitalized child that their child will receive fentanyl for an upcoming procedure. What advantage of fentanyl will the nurse include in the teaching? a. It is specifically designed for children. b. It has a rapid onset. c. It is nonaddictive.

d. It has a long duration.

ANS: B Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.

DIF: Cognitive Level: Knowledge REF: 444 OBJ: 6 TOP: Fentanyl KEY: Nursing Process Step: Implementation 21. A nurse shares the information and timelines recorded on the interdisciplinary outline of care for a child. What is this document called? a. Clinical pathway b. Comprehensive nursing care plan c. Holistic care approach d. Incorporated cost analysis ANS: A This document is the clinical pathway, which is a broad outline of the interdisciplinary plan of care with specific timelines.

DIF: Cognitive Level: Comprehension TOP: Clinical Pathway

REF: 449 OBJ: 9 KEY: Nursing Process Step: Implementation

22. An anxious caregiver asks if there is a danger of her 2-year-old child becoming addicted to the opioid pain reliever. What is a nurse’s most helpful response? a. “Although this drug is addictive, the health care provider monitors the dose very carefully.” b. “Don’t worry. Addicted cNhU ildRrS enIaNreGvTeB ry.eCasOyMto wean off the medication.” c. “Addiction is rare in children when opiates are given for pain.” d. “Addictive behaviours are easy to assess. The medication will be stopped if that happens.”

ANS: C Addiction is rare in children.

DIF: Cognitive Level: Comprehension REF: 444 TOP: Pain Relief KEY: Nursing Process Step: Intervention

OBJ: 6

23. A nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention is appropriate for the nurse to implement? a. Involve the caregivers. b. Provide a simple explanation to the child. c. Let the child examine the equipment. d. Suggest coping techniques.

ANS: A It is appropriate to involve the caregivers when performing a procedure on an infant.

Providing a simple explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate interventions for an infant.

DIF: Cognitive Level: Application TOP: Age-Appropriate Interventions

REF: 440 OBJ: 4 KEY: Nursing Process Step: Implementation

24. A pediatric nurse is caring for a child who weighs 15 kg and calls the pediatric health care provider for an order for acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates ordering? a. 100 mg b. 150 mg c. 225 mg d. 250 mg ANS: C Acetaminophen is commonly used for the relief of mild to moderate pain in infants and children. The maximum dose is 15 mg/kg/dose for infants and children, with a maximum of 5 doses in 24 hours.

DIF: Cognitive Level: Analysis TOP: Age-Appropriate Interventions

REF: 444 OBJ: 6 KEY: Nursing Process Step: Planning

25. A child who was not immunized is admitted to the pediatric unit due to complications from measles. What is the best approach a nurse can take with the parents? a. Ask the parents why they did not get the child immunized. b. Report the parents to the local health unit. c. Encourage the parents to verbalize any concerns. d. Provide care for the child and ignore the parents.

ANS: C Parents of hospitalized children may have feelings of guild, helplessness and anxiety. Even though the hospitalization is N duUeRtoSaIpNaG reTnB ta. l dCeO ciM sion, nothing is gained by blaming the parents.

DIF: Cognitive Level: Application REF: 447 TOP: Parental Response to Hospitalization KEY: Nursing Process Step: Implementation

OBJ: 4

26. A 15-year old girl asks a nurse about obtaining a prescription for birth control as she is in a sexual relationship with her boyfriend. The nurse explains which of the following to the teenager? a. I will first need to contact your parents to ask permission b. You are too young to receive a prescription c. You should use abstinences as a method of birth control d. I will refer you to someone who can write you a prescription ANS: D There is no age of consent if the child is able to understand and make decisions regarding their own health and treatment. Two general requirements and conditions for obtaining consent to medical treatment are that the patient must have capacity for the treatment decision and that the consent must be informed.

DIF: Cognitive Level: Application TOP: Age of Consent

REF: 454 OBJ: 11 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. What will a nurse include when documenting the discharge of a pediatric patient? (Select all that apply.) a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation e. Instructions that were given by the pediatric health care provider ANS: A, B, C, D Information that should be included in the discharge note include time of discharge, adults accompanying the child and relationship to the child, condition of the child, and method of transportation. It should also be documented that instructions were given to caregivers.

DIF: Cognitive Level: Application TOP: Discharge Documentation

REF: 454 OBJ: 12 KEY: Nursing Process Step: Implementation

2. A nurse teaches caregivers that their child’s surgery will be in the outpatient surgical centre.

What advantage(s) does this type of facility have to offer? (Select all that apply.) a. Lower health care costs b. Less incidence of health care–associated infections c. Reduction of parent–child separation d. Ample time for recuperation at the facility e. Decreased emotional impact of illness ANS: A, B, C, E NURSINGTB.COM All options listed are advantages of outpatient services with the exception of recuperating at the facility.

DIF: Cognitive Level: Knowledge TOP: Outpatient Facilities

REF: 439 OBJ: 2 KEY: Nursing Process Step: Implementation

3. What are the basic fears of a young child being hospitalized? (Select all that apply.) a. Separation b. Permanent scarring c. Pain d. Death e. Body intrusion ANS: A, C, E Small children all share the same basic fears relative to hospitalization, which are separation from family, pain, and body intrusion or mutilation.

DIF: Cognitive Level: Comprehension REF: 441 OBJ: 5 TOP: Basic Fear KEY: Nursing Process Step: Data Collection 4. What information will a nurse include when taking a developmental history? (Select all that apply.) a. Previous experience with hospitalization

b. c. d. e.

Cultural needs History of illness Allergies Child’s nickname

ANS: A, B, E The developmental history has information about the child and the child’s developmental and cultural needs and personal preferences. The information relative to history of illness or allergies would be covered in the medical history.

DIF: Cognitive Level: Application TOP: Developmental History

REF: 448 OBJ: N/A KEY: Nursing Process Step: Data Collection

5. A nurse is preparing to obtain a throat culture on a toddler. What interventions are appropriate for the nurse to implement? (Select all that apply.) a. Model desired behaviour. b. Instruct patient not to yell. c. Use distractions. d. Explain the procedure in detail. e. Encourage the child to ask questions.

ANS: A, C Whenever possible the caregiver should be involved in the preparation for and initiation of a treatment or procedure, and the child should be prepared according to his or her developmental level. For a toddler, model the behaviour desired (i.e., opening the mouth), tell the child it is okay to yell if the treatment or procedure is uncomfortable, and use distractions. Explaining the pN roUcR edSuI reNinGT deBta.ilCaO ndMencouraging questions are appropriate interventions for an older child.

DIF: Cognitive Level: Application TOP: Promoting a Positive Experience

REF: 440 OBJ: N/A KEY: Nursing Process Step: Intervention

6. Parents are preparing their child for admission to the pediatric unit for minor surgery. What should they expect to see when visiting the pediatric unit? (Select all that apply.) a. Nurses wearing all white b. Formal atmosphere c. Availability of a playroom d. Dim lighting e. Coloured bedding ANS: C, E The children’s hospital unit differs in many respects from adult divisions. The pediatric unit or hospital is designed to meet the needs of children and their caregivers. A cheerful, casual atmosphere helps to bridge the gap between home and hospital and is in keeping with the child’s emotional, developmental, and physical needs. Nurses wear colourful uniforms, and coloured bedspreads and wagons or strollers for transportation provide a more homelike atmosphere. The physical structure of the unit includes furniture of the proper height for the child, soundproof ceilings, and colour schemes with eye appeal. Most pediatric departments include a playroom.

DIF: Cognitive Level: Knowledge REF: 440 TOP: Health Care Delivery Settings/Pediatric Unit KEY: Nursing Process Step: Planning

OBJ: 2

7. A nurse is providing home care to a child with a chronic illness who has a tracheostomy.

What interventions are important for the nurse to include in the care of this child? (Select all that apply.) a. Organize appropriate equipment for the child. b. Provide community resources and support for the family. c. Teach the caregivers about respite care options. d. Perform all the care for the child.

ANS: A, B, C Nurses often spearhead multidisciplinary teams when caring for children in the community.

It is important to provide care to the entire family, which includes providing resources and support as well as teaching to families about the importance of respite care. The nurse would not perform all the care but rather facilitate the family to be able to provide the care.

DIF: Cognitive Level: Application TOP: Nursing Care in the Community

REF: 440 OBJ: 2 KEY: Nursing Process Step: Implementation

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Chapter 20: Health Care Adaptations for the Child and Family Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What is the best pulse location for a nurse to use when assessing the pulse rate on a 12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral ANS: B Apical pulses are advised for children under age 5 years.

DIF: Cognitive Level: Knowledge TOP: Physical Assessment

REF: 462 OBJ: 10 KEY: Nursing Process Step: Data Collection

2. A nurse is preparing to administer medication to a 2-month-old infant and discovers there is no ID bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the child’s name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine.

NiGssTioBn. d. Delay the medication untN il U thReSadIm sC ofO fiM ce can supply a new ID bracelet.

ANS: C After confirmation of the child’s identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

DIF: Cognitive Level: Application REF: 458 OBJ: 2 TOP: ID Bracelets KEY: Nursing Process Step: Implementation 3. A nurse has taught an adolescent female about collecting a clean-catch urine specimen.

What statement made by the adolescent leads the nurse to determine she understood the instructions? a. “I should wash my perineum with soap and water, then begin to urinate.” b. “I clean the perineum from front to back with an antiseptic wipe before I urinate.” c. “I’ll collect the first stream of urine in a sterile container.” d. “I will discard the first void and collect a freshly voided specimen 30 minutes later.”

ANS: B To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

DIF: Cognitive Level: Analysis TOP: Collecting Specimens

REF: 468 OBJ: 7 KEY: Nursing Process Step: Evaluation

4. Which strategy might a nurse use when administering oral medications to a young child who is reluctant? a. Mix the medication with chocolate milk. b. Tell the child that the medication is candy. c. Give the medication quickly if the child is crying. d. Offer the child fruit juice after the medication is swallowed.

ANS: D The nurse can offer a chaser of water or fruit juice after the medication has been swallowed.

Medications should not be mixed with food or drinks with important nutrients, such as milk, because the child may develop distaste for it.

DIF: Cognitive Level: Application REF: 475 OBJ: 9 TOP: Administering Oral Medications KEY: Nursing Process Step: Implementation 5. A parent tells a nurse, “I’m not sure how to give this medicine to my infant.” How would the nurse teach the parent to best administer an oral suspension? a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and place the medication in the side of the infant’s mouth. d. Administer the medication with a dropper onto the back of the infant’s tongue.

ANS: C An oral syringe is a useful device for measuring small quantities of medications for infants.

The syringe is placed midway back, at the side of the mouth.

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DIF: Cognitive Level: Application TOP: Administering Oral Medications

REF: 474 | 475 OBJ: 9 KEY: Nursing Process Step: Implementation

6. Gentamicin ear drops are prescribed for a 4-year-old child. How would a nurse position the auricle when administering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out ANS: A For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

DIF: Cognitive Level: Application TOP: Administering Ear Drops

REF: 476 OBJ: 9 KEY: Nursing Process Step: Implementation

7. A nurse is assessing blood pressure using the popliteal artery in a 5-year-old. What does the nurse know about the resulting blood pressure compared with a radial artery BP? a. The BP will be the same b. The BP will be slightly lower c. The BP will be higher by 10 to 20% d. The systolic BP will be higher, but the diastolic will be the same.

ANS: C Pressure readings in the lower extremities is normally 10 to 20% higher than the brachial artery pressure.

DIF: Cognitive Level: Comprehension TOP: Blood Pressure Assessment

REF: 463 OBJ: 10 KEY: Nursing Process Step: Data Collection

8. Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? a. Discard the residual and increase the volume of feeding by the amount of residual. b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding. c. Refill the syringe with formula after it has completely emptied. d. Position the child on the right side or in Fowler’s position after a feeding.

ANS: D To prevent regurgitation and aspiration, the child is placed in the Fowler’s position or on the right side to promote gastric emptying after a gastrostomy tube feeding.

DIF: Cognitive Level: Application TOP: Enteral Feedings

REF: 488 OBJ: 14 KEY: Nursing Process Step: Implementation

9. If a restraint is required, which would be most appropriate for the insertion of an intravenous line in a scalp vein of an infant? a. Mummy b. Clove hitch c. Jacket d. Elbow NURSINGTB.COM ANS: A If a restraint is necessary, a mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein. The use of restraint should be avoided if possible.

DIF: Cognitive Level: Comprehension TOP: Restraining the Infant

REF: 459 OBJ: 12 KEY: Nursing Process Step: Implementation

10. How often should a child who has a continuous intravenous infusion be assessed? a. Hourly b. Every 2 hours c. Every 3 hours d. Every 4 hours ANS: A The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

DIF: Cognitive Level: Knowledge REF: 478 TOP: Administering Parenteral Medications KEY: Nursing Process Step: Data Collection

OBJ: 12

11. The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The medication is supplied as a unit dose of 600,000 units in a 5-mL vial. How many millilitres (mL) should a nurse provide? a. 1.25 b. 1.4 c. 1.6 d. 1.8 ANS: B

This dose would have to be given in divided doses as only 1 mL should be injected in one site on an infant.

DIF: Cognitive Level: Analysis TOP: Administering Injections

REF: 477 OBJ: 11 KEY: Nursing Process Step: Planning

12. Which intervention will a nurse implement when suctioning a tracheostomy? a. Suction for two to three breaths. b. Clear the catheter with water after suctioning for reuse. c. Apply suction for no more than 5 seconds. d. Establish a regular schedule for suctioning.

ANS: C Suctioning should be limited to no more than 5 seconds for pediatric patients.

.ECFO:M 489 DIF: Cognitive Level: AppN liU caRtiS onINGTBR OBJ: 16 TOP: Tracheostomy Care KEY: Nursing Process Step: Implementation 13. What emergency action should be implemented for airway obstruction in the infant? a. Six to 10 midsternal thrusts b. Five back blows followed by five chest thrusts c. Five chest thrusts followed by five back blows d. Abdominal thrusts until the object is expelled ANS: B Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the infant.

DIF: Cognitive Level: Knowledge REF: 491 TOP: Management of Airway Obstruction KEY: Nursing Process Step: Implementation

OBJ: 2

14. A 4-year-old child asks tearfully if the IM injection will hurt. What is a nurse’s most effective response? a. “No. It is over before you know it.” b. “Yes. It will sting a little.” c. “No. Would you like to see the syringe?” d. “Yes. Your mom and I are going to hold you to help you be still.”

ANS: B Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

DIF: Cognitive Level: Application TOP: Preparation for an IM Injection

REF: 477 OBJ: 11 KEY: Nursing Process Step: Implementation

15. Where is the best site for giving an IM injection to a 15-month-old child? a. Ventrogluteal muscle b. Dorsogluteal muscle c. Deltoid muscle d. Vastus lateralis muscle ANS: D The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

DIF: Cognitive Level: Application TOP: Administering Injections

REF: 477 OBJ: 11 KEY: Nursing Process Step: Planning

16. What factor does a nurse explain affects the infant’s physiological response to medications? a. Faster metabolism in the liver b. Slower intestinal transit c. Immature kidney function d. Increased secretion of hydrochloric acid ANS: C Immature kidney function preNvUenRtS s eIfN feG ctT ivBe.exCcOreMtion of drugs from the body in infants less than 1 year of age.

DIF: Cognitive Level: Comprehension REF: 474 TOP: Physiological Responses to Medication KEY: Nursing Process Step: Implementation

OBJ: N/A

17. What intervention should a nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant? a. Diaper the infant snugly with a disposable diaper. b. Cover the area with a transparent dressing. c. Apply a cloth diaper. d. Place the infant on a plastic pad, undiapered.

ANS: C Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left undiapered on a cloth pad.

DIF: Cognitive Level: Application TOP: Rapid Absorption of Drug

REF: 477 OBJ: 2 KEY: Nursing Process Step: Implementation

18. A nurse enters the hospital room and decides parents of a 1-year-old infant could benefit from safety education to prevent unintentional injury based on which of the following observations?

a. b. c. d.

The blanket is not tucked into the mattress.

Diapers and wipes are stacked at the foot of the crib.

The crib side is locked in the up position.

Pillows are stacked on the bedside table.

ANS: B Disposable diapers and supplies must be kept out of the infant’s reach to prevent accidental suffocation.

DIF: Cognitive Level: Analysis TOP: Essential Safety Measures

REF: 458 OBJ: 2 KEY: Nursing Process Step: Evaluation

19. A 9-year-old child is being prepared for a lumbar puncture. What position will a nurse explain to the child they will assume for the procedure? a. On your stomach with your head turned to the side b. On your side, keeping the legs bent and the head arched back c. On your back with your legs extended straight out d. On your side with the knees bent and the head close to the knees ANS: D The child is positioned on his or her side with the knees flexed, and the head is brought down close to the flexed knees.

DIF: Cognitive Level: Application REF: 472 TOP: Collecting Specimens—Lumbar Puncture KEY: Nursing Process Step: Implementation

OBJ: 8

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20. A nurse is caring for a 4-year-old child. What will the nurse expect the child’s daily urinary output to be? a. 400 to 500 mL b. 500 to 600 mL c. 600 to 700 mL d. 700 to 1000 mL ANS: C The average daily excretion of urine for a 4-year-old child is 600 to 700 mL. DIF: Cognitive Level: Knowledge REF: 471 TOP: Collecting Specimens—Urine Output KEY: Nursing Process Step: Data Collection

OBJ: 7

21. An infant’s dry diaper weighs 25.5 g. The wet diaper weighs 67 g. How would the nurse record the infant’s urine output? a. 47 mL b. 41.5 mL c. 43.5 mL d. 40.5 mL ANS: B

Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one millilitre of output. 67 – 25.5 = 41.5 g = 41.5 mL of urine.

DIF: Cognitive Level: Analysis REF: 471 TOP: Collecting Specimens—Urine Output KEY: Nursing Process Step: Data Collection

OBJ: 7

22. A nurse instructs a mother of a 2-year-old child who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse? a. Red meat b. Green, leafy vegetables c. Acidic fruit juices d. Egg yolks ANS: D Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement.

DIF: Cognitive Level: Application TOP: Food/Drug Interactions

REF: 487 OBJ: 2 KEY: Nursing Process Step: Implementation

23. A pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention? a. Toddler with an axillary temperature of 37.2 C b. School-age child with widNeUnR inS gI puNlG seTpBre.ssCuO reM c. Infant pulse rate of 100 beats/minute d. Adolescent with a respiratory rate of 20 breaths/minute ANS: B A widening pulse pressure can indicate increased intracranial pressure (ICP); therefore, it is the priority. An axillary temperature of 37.2 C, infant pulse of 100 bpm, and adolescent respiratory rate of 20 are expected assessments.

DIF: Cognitive Level: Analysis REF: 461 OBJ: 5 TOP: Vital Signs KEY: Nursing Process Step: Data Collection 24. A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will a nurse maintain for this patient? a. Left side-lying b. Supine c. Prone d. Semi-Fowler’s ANS: B The adolescent may avoid post–lumbar puncture headache by lying flat for some time.

DIF: Cognitive Level: Application TOP: Lumbar Puncture

REF: 472 OBJ: 8 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. Informed consent for a surgical procedure for a minor guarantees that the child, parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be brought for damages d. That the document must be signed and witnessed e. That information was given ANS: A, B, D, E The informed consent establishes that the child, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed for a surgical procedure.

DIF: Cognitive Level: Comprehension TOP: Informed Consent

REF: 457 OBJ: 2 KEY: Nursing Process Step: N/A

2. Which specific medication(s) should be checked with a second nurse prior to administration? (Select all that apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts NURSINGTB.COM e. Anticoagulants ANS: A, B, D, E Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a second nurse prior to administration.

DIF: Cognitive Level: Comprehension TOP: Medication Administration

REF: 480 OBJ: 2 KEY: Nursing Process Step: Implementation

3. A 3-year-old patient is admitted to the pediatric unit with a fever of 39.4 C. Which actions will a nurse implement? (Select all that apply.) a. Assess rectal temperature every 4 hours. b. Administer acetaminophen as ordered. c. Assess skin turgor. d. Restrict fluids. e. Assess level of consciousness.

ANS: B, C, E

When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill.

Because dehydration is a common problem in infants and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.

DIF: Cognitive Level: Application REF: 465 | 466 OBJ: 6 TOP: Fever KEY: Nursing Process Step: Implementation 4. What should a nurse assess to determine the method of transportation for a pediatric patient?

(Select all that apply.) a. Age b. Race c. Vital signs d. Distance to travel e. Level of consciousness ANS: A, D, E The means by which the child is transported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel.

DIF: Cognitive Level: Comprehension TOP: Modes of Transportation TRUE/FALSE

REF: 459 OBJ: 3 KEY: Nursing Process Step: Data Collection

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1. A nurse is aware that hyperthermia is treated with antipyretics.

ANS: F Treatment of hyperthermia involves vigorous cooling measures such as cold blankets and intravenous (IV) fluids.

DIF: Cognitive Level: Comprehension TOP: Hyperthermia

REF: 465 OBJ: 5 KEY: Nursing Process Step: Planning

2. During an annual physical assessment, a 2-year-old child would have the blood pressure assessed.

ANS: F Routine blood pressure screening is not recommended for children less than 3 years of age, but all other children should have their blood pressure checked annually.

DIF: Cognitive Level: Comprehension TOP: Blood Pressure Assessment COMPLETION

REF: 463 OBJ: 5 KEY: Nursing Process Step: Data Collection

1. An order reads, “Give ampicillin oral suspension 400 mg PO every day.” The vial reads, “Ampicillin 125 mg/5 mL.” A nurse will give a dose of mL. ANS: 16

DIF: Cognitive Level: Analysis TOP: Pediatric Dose Calculation

REF: 474 OBJ: 13 KEY: Nursing Process Step: Implementation

2. After instilling nose drops, a nurse will keep the infant in the head do5wn position for at least seconds.

ANS: 30 The child should be kept in the head down position for 30 seconds to 1 minute to allow the nose drops to enter deeply into the nostril.

DIF: Cognitive Level: Comprehension REF: 476 OBJ: 9 TOP: Nose Drops KEY: Nursing Process Step: Implementation

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Chapter 21: Complementary and Alternative Health Modalities in Pediatric Nursing Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A child receiving chemotherapy gets relief from nausea after having a therapy that involves pressure and massage on meridian sites. What type of therapy does this describe? a. Acupuncture b. Acupressure c. Aromatherapy d. Ayurveda ANS: B Acupressure uses finger pressure and massage on the meridian sites. It can be used to control nausea, backache, and pain.

DIF: Cognitive Level: Knowledge REF: 501 OBJ: 4 TOP: Acupressure KEY: Nursing Process Step: Data Collection 2. A nurse is aware that which child should not receive massage therapy? a. 15-year-old with a fractured femur b. 12-year-old with diabetes mellitus c. 8-year-old with Down syndrome d. 17-year-old with an eating disorder

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ANS: C Children with Down syndrome are prone particularly to cervical spine anomalies and may be injured by massage therapy.

DIF: Cognitive Level: Knowledge REF: 500 OBJ: 4 TOP: Massage KEY: Nursing Process Step: Implementation 3. A 12-year-old with rheumatoid arthritis finds aromatherapy helpful for relieving her joint discomfort. Which essential oil is useful for children with chronic pain? a. Lavender b. Ephedra c. Ginseng d. Kava-kava ANS: A Lavender, chamomile, and sandalwood essential oils are useful in aromatherapy for children with chronic pain.

DIF: Cognitive Level: Knowledge REF: 501 TOP: Alternative Health Practices—Aromatherapy KEY: Nursing Process Step: Implementation

OBJ: 4

4. A nurse points out that light therapy is used in the treatment of patients with which of the following disorders? a. Digestive disorders b. Seasonal affective disorder c. Inflammatory diseases d. Stress disorders ANS: B Light therapy has proven effective in the treatment of persons with seasonal affective disorders.

DIF: Cognitive Level: Comprehension TOP: Light Therapy

REF: 501 OBJ: 9 KEY: Nursing Process Step: Implementation

5. A parent asks the nurse, “What is guided imagery?” Which statement is the most accurate response? a. “It is a technique where the patient focuses on an image to relieve stress.” b. “It involves using water to promote relaxation.” c. “The patient enters a hypnotic state of sleep to promote relaxation.” d. “It helps the patient recognize tension in the muscles with responses on an electronic machine.”

ANS: A In guided imagery, by focusing on a specific image, stress reduction and improved performance can result.

DIF: Cognitive Level: KnoNwUleRdS geINGTBR OBJ: 9 .ECFO:M 502 TOP: Guided Imagery KEY: Nursing Process Step: Implementation 6. A teenager takes St. John’s wort and ginseng daily and is scheduled to have orthopedic surgery in 3 weeks. What instruction should a nurse provide? a. The herbs are not likely to cause any problems during the surgery. b. The St. John’s wort must be stopped prior to surgery, but teen can continue the ginseng. c. The ginseng should be stopped 1 week before surgery. d. The teen should discontinue taking both herbs 2 weeks before surgery.

ANS: D Both St. John’s wort and ginseng can cause problems during surgery, and their use should be discontinued 2 weeks before surgery.

DIF: Cognitive Level: Application TOP: Herbal Remedies

REF: 498 OBJ: 6 KEY: Nursing Process Step: Implementation

7. Which herb can a nurse may be used for treatment of infant colic? a. Evening primrose oil b. Chamomile c. Milk thistle d. Blue-green algae ANS: B

Chamomile may be used to treat infant colic.

DIF: Cognitive Level: Knowledge TOP: Herbal Remedies

REF: 503 OBJ: 10 KEY: Nursing Process Step: Implementation

8. A young mother asks, “Is there an alternative medicine for children with asthma?” Which form of alternative medicine would be the most helpful for a nurse to suggest? a. Reflexology b. Rolfing c. Guided imagery d. Acupressure ANS: C The use of guided imagery has helped relieve some of the symptoms of asthma.

DIF: Cognitive Level: Comprehension TOP: Guided Imagery

REF: 502 OBJ: 4 | 9 KEY: Nursing Process Step: Implementation

9. What is the difference between complementary therapy and alternative therapy? a. Complementary therapy must be administered by a medical doctor. b. Complementary therapy is administered with conventional therapy. c. Complementary therapy replaces conventional therapy. d. Complementary therapy is administered to a group of patients at the same time.

ANS: B Complementary therapy is administered with conventional therapy, such as massage with muscle relaxants for low backNU paRinS. INGTB.COM DIF: Cognitive Level: Comprehension REF: 497 OBJ: 2 TOP: CAHM KEY: Nursing Process Step: Implementation 10. A nurse uses a diagram to show the location of meridians. How will the nurse explain the definition of meridians? a. They are lymph nodes. b. They are invisible pathways for energy. c. They are lines that divide the body into 10 zones. d. They are areas of skin that are specifically innervated.

ANS: B Meridians are invisible pathways through which energy travels to effect acupuncture treatment.

DIF: Cognitive Level: Knowledge TOP: Acupuncture: CAHM

REF: 502 OBJ: 8 KEY: Nursing Process Step: Implementation

11. Which herbal remedy used by a patient taking anticoagulant should a nurse report to a primary health care provider? a. Garlic b. Chamomile c. Ginseng

d. Kava-kava ANS: A Garlic increases bleeding time and caution should be used when the patient is taking an anticoagulant.

DIF: Cognitive Level: Application TOP: Herbal Remedies

REF: 498 OBJ: 4 KEY: Nursing Process Step: Data Collection

12. What should a nurse remind a parent who is considering homeopathic remedies for treatment of her child’s asthma? a. Should be drunk with large amounts of fluid b. Can be taken with traditional Western medications c. Can be enhanced by drinking hot tea d. May contain mercury, alcohol, or arsenic ANS: D Homeopathic remedies often contain mercury, alcohol, or arsenic and are taken sublingually. All Western medications should be stopped when the homeopathic therapy is begun. Caffeine drinks are to be avoided during homeopathic treatment.

DIF: Cognitive Level: Application TOP: Homeopathic Remedies

REF: 503 OBJ: 9 KEY: Nursing Process Step: Implementation

13. The focus of acupressure is to restore the balance of what? a. Chi b. Shiatsu NURSINGTB.COM c. Yin and yang d. Ayurveda ANS: A Acupressure is focused on the return of the balance of Chi to control disease processes.

DIF: Cognitive Level: Comprehension REF: 501 OBJ: 9 TOP: Acupressure KEY: Nursing Process Step: Implementation 14. Which of the following CAHM could be provided to patients by a nurse with basic nursing education? a. Chiropractic care b. Acupuncture c. Therapeutic touch d. Massage ANS: D Massage can be provided by nurses without extra education. The other CAHM modalities require registration (i.e. acupuncture and chiropractic) or additional education (i.e. therapeutic touch).

DIF: Cognitive Level: Comprehension TOP: Nursing Role in CAHM

REF: 500 OBJ: 3 KEY: Nursing Process Step: Implementation

15. A pregnant patient with a stasis ulcer asks if she might be a candidate for hyperbaric oxygen therapy (HBOT). What is a nurse’s best response? a. “Yes. HBOT should have no harmful effect on your baby.” b. “No. High amounts of oxygen in your system will cause changes in your baby’s heart.” c. “Yes. HBOT is a much better option than using antibiotics.” d. “No. HBOT may cause the placenta to separate from the uterine wall.”

ANS: B High concentrations of oxygen in the mother’s blood can cause closure of the ductus arteriosus and cause fetal death.

DIF: Cognitive Level: Application REF: 505 OBJ: 11 TOP: HBOT KEY: Nursing Process Step: Implementation 16. A teenager is providing history information to an admitting nurse about treatment used for chronic pain. The teen reports she participates in a type of relaxation therapy that enables her to recognize tension in the muscles via responses on an electronic machine and visual electromyography responses. What type of therapy does the nurse record on admission record? a. Guided imagery b. Biofeedback c. Hypnotherapy d. Chiropractic care ANS: B Biofeedback is a type of relaxNaU tiR onStI heNrG apTyBth.aC t eOnMables the patient to recognize tension in the muscles via responses on an electronic machine and visual electromyography responses.

The process is also used by traditional health care providers for drug addiction and chronic pain control.

DIF: Cognitive Level: Comprehension REF: 502 OBJ: 9 TOP: CAHM KEY: Nursing Process Step: Data Collection 17. Which of the following pediatric patients would most benefit from massage therapy? a. Child with cardiac disorder b. Child with liver cancer c. Preterm infant d. Child with cellulitis in leg ANS: C Gentle touch massage therapy has had positive effects on premature infants, who gain weight more quickly. Massage and manipulative therapy may be contraindicated in patients with cancer, osteoporosis, localized infection, and cardiac and circulatory disorders because of the increase it causes in blood flow to affected areas.

DIF: Cognitive Level: Analysis TOP: Massage Therapy MULTIPLE RESPONSE

REF: 500 OBJ: 4 | 9 KEY: Nursing Process Step: Implementation

1. What conditions would a nurse expect to see treated with hyperbaric oxygen therapy (HBOT)? (Select all that apply.) a. Wounds b. Carbon monoxide poisoning c. Hyperemesis gravidarum d. Decompression illness e. Pneumonia ANS: A, B, D HBOT uses an airtight enclosure to provide compressed air or oxygen under increased pressure. HBOT is used to revive children with carbon monoxide poisoning, to aid wound healing, and to treat the diving syndrome known as decompression illness. HBOT is contraindicated during pregnancy, because the increased oxygen saturation can cause the ductus arteriosus to close, resulting in fetal death.

DIF: Cognitive Level: Knowledge REF: 505 OBJ: 11 TOP: HBOT KEY: Nursing Process Step: Implementation 2. The mother of a pediatric patient asks a nurse about safety concerns with using herbal supplements with children. Which herbal products would the nurse educate this mother are safe to use in most of the pediatric population? (Select all that apply.) a. Ephedra b. Ginger c. Fish oil d. Chamomile e. Aloe vera NURSINGTB.COM ANS: B, C, D, E Ginger, fish oil, chamomile, and aloe vera are safe herbal products for children. However, some herbs, such as ephedra, can be fatal to children.

DIF: Cognitive Level: Knowledge TOP: Herbal Therapies

REF: 503 OBJ: 10 KEY: Nursing Process Step: Implementation

3. Which of the following medicines are important for Indigenous healing? (Select all that apply.) a. Sage b. Cedar c. Garlic d. Tobacco e. Sweetgrass ANS: A, B, D, E The four medicines used in Indigenous healing are tobacco, sweetgrass, cedar, and sage.

These medicines are used in a variety of ways.

DIF: Cognitive Level: Knowledge TOP: Indigenous Ways of Healing

REF: 500 OBJ: 5 KEY: Nursing Process Step: Planning

4. What advantage(s) of alternative health care should a nurse outline when providing information to patients? (Select all that apply.) a. Offers more patient control of health care b. Offers a variety of health care advisors c. Keeps patients from having to make decisions d. Uses natural products rather than chemical ones e. Incorporates cultural beliefs and practices ANS: A, B, D, E Alternative health care actually promotes the patient’s decision making in care.

DIF: Cognitive Level: Comprehension REF: 499 OBJ: 4 TOP: CAHM KEY: Nursing Process Step: Implementation 5. Which approaches to care are combined with osteopathy? (Select all that apply.) a. Manipulation therapy b. Aromatherapy c. Herbal application d. Pressure point therapy e. Traditional medicine ANS: A, D, E Osteopaths combine manipulative therapy including pressure point therapy with traditional (allopathic) medicine.

DIF: Cognitive Level: Knowledge REF: 500 OBJ: 9 TOP: Osteopathy KEY: NNUuRrsSinIgNPGroTcB es.s C SO teM p: Implementation 6. Which of the following concerns would a nurse teach a parent in relation to the use of cannabis in teenagers? (Select all that apply.) a. Will not increase the use of tobacco smoking b. There is not impact on driving when under the influence of cannabis c. Is linked to other substance use disorders d. There is an increased risk of mental illness e. May cause a decrease in school performance ANS: C, D, E Cannabis has been shown to be linked to other substance use disorders, a decrease in school performance, an increased risk of mental health concerns, and increase in the initiation of tobacco smoking, and an increase risk of motor vehicle accidents when driving under the influence of cannabis.

DIF: Cognitive Level: Application REF: 505 OBJ: 3 TOP: Cannabis KEY: Nursing Process Step: Implementation

Chapter 22: Chronic Conditions and Palliative Care: Caring for the Child and Family Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy? a. Athetoid b. Ataxic c. Spastic d. Mixed ANS: C Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

DIF: Cognitive Level: Comprehension TOP: Cerebral Palsy

REF: 514 OBJ: 9 KEY: Nursing Process Step: Data Collection

2. Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which statement by the parents alerts the nurse they need further instruction? a. “We dress our son every morning for school.” b. “Our son participates in tN heUSRpS ecIiaNl G OTlyBm.pC icO sM 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 child with an intellectual disability needs to develop a sense of accomplishment.

Caregivers should not “take over” projects because of their own need to assist or speed up the process.

DIF: Cognitive Level: Application TOP: Cognitive Impairment

REF: 517 OBJ: 6 KEY: Nursing Process Step: Implementation

3. What important focus of nursing care for the dying child and the family should a 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 the child’s care.

ANS: C Hearing is intact even when there is a loss of consciousness.

DIF:

Cognitive Level: Analysis

REF: 523

OBJ: 9

TOP: Dying Child KEY: Nursing Process Step: Planning 4. A 6-year-old child with leukemia asks, “Who will take care of me in heaven?” What is the best response by a nurse? a. “Who do you think will take care of you?” b. “Your grandparents and God will take care of you.” c. “Your mom will know more about that than I do.” d. “Why are you asking me that?”

ANS: A This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed responses shut off communication. The asking of a “why” question is not therapeutic as it calls for justification.

DIF: Cognitive Level: Application REF: 509 OBJ: 9 TOP: Dying KEY: Nursing Process Step: Implementation 5. A nurse is caring for a preschool child with a life-threatening illness. What should the nurse remember the child’s 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.

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DIF: Cognitive Level: Comprehension TOP: Nursing Care of the Dying Child

REF: 520 OBJ: 9 KEY: Nursing Process Step: Data Collection

6. Which of the following statements made by a family with a child with a chronic illness, would indicate they may require more support? a. “Our family is going on vacation next month.” b. “We have a plan for respite care once a month.” c. “Our other children are not able to take part in sports.” d. “We have taught our other children how to give injections.”

ANS: C The importance of coping with chronic illness is maintaining normalcy and routine into family life and to recognize when the family requires a break. If other children are penalized because of a family member with a chronic illness the family may require more support and education.

DIF: Cognitive Level: Analysis TOP: Family Coping

REF: 512 OBJ: 5 | 6 KEY: Nursing Process Step: Data Collection

7. A child with a chronic illness develops a sense of guilt at his inability to master tasks. A nurse is aware that this child is most likely in which stage of development? a. Toddler b. Preschooler

c. School-age d. Adolescent ANS: B The preschooler is developing a sense of initiative and the inability to master tasks can delay this.

DIF: Cognitive Level: Analysis REF: 511 TOP: Developmental Impact of Chronic Illness KEY: Nursing Process Step: Data Collection

OBJ: 4

8. It is most important that a nurse provide praise and encouragement to which child with a chronic illness in order to improve their sense of ability? a. 2-year-old b. 4-year-old c. 6-year-old d. 13-year-old ANS: C When school-age children are praised and encouraged, their self-confidence and feelings of competence build. Those children who receive little or no praise and reinforcement will doubt their ability to succeed. For school-age children with chronic conditions, their opportunities to achieve this sense of industry might be limited by their inability to participate in certain activities or events due to their condition.

DIF: Cognitive Level: Application REF: 511 TOP: Developmental ImpacNt U ofRC ShIroNnGicTIBllne .CssOM KEY: Nursing Process Step: Planning

OBJ: 4

9. A nurse is caring for a 3-year-old child who has just been diagnosed with diabetes. The mother states she feels guilty as she knows she is the reason the child developed the disease.

What is the best action of the nurse at this point? a. Explain to the mother the disease is caused by heredity so it could be her fault b. Explain to the mother that the disease is usually caused by the father c. Tell the mother it is okay to feel guilty about this d. Teach the mother about diabetes ANS: D It is normal to feel guilt regarding a diagnosis of a chronic illness in a child. The nurse should teach the family about the disease and encourage the family to verbalize their feelings.

DIF: Cognitive Level: Comprehension TOP: Guilt in Parents

REF: 512 OBJ: 6 KEY: Nursing Process Step: Implementation

10. A nurse caring for a child with cerebral palsy (CP) administers the medication baclofen in order to decrease which of the following symptoms? a. Pain b. Seizures c. Drooling

d. Spasticity ANS: D Baclofen reduces spasticity. When given via an implanted pump it is more effective then when given orally.

DIF: Cognitive Level: Comprehension TOP: Cerebral Palsy

REF: 514 OBJ: 9 KEY: Nursing Process Step: Implementation

11. A nurse providing care to a child with an intellectual disability should make which of the following interventions the priority? a. Teach the parents to provide all care. b. Normalize the opportunities for the child as much as possible. c. Provide resources for specialized schools for intellectually impaired children. d. Perform an intelligence test.

ANS: B The goal of care is to normalize the opportunities for the child and family as much as possible. Parents do not need to provide all care as the child should be encouraged to perform as much as possible. Children should also be integrated into regular classrooms as much as possible.

DIF: Cognitive Level: Application TOP: Intellectual Disability

REF: 517 OBJ: N/A KEY: Nursing Process Step: Implementation

12. A young child on the pediatric unit cannot express himself well and has been diagnosed with an intellectual disabilityN .W raT peBu. tiC cO inM tervention might a nurse implement that URhaStIthNeG allows children enhance their development? a. Play therapy b. Art therapy c. Music therapy d. Cognitive behavioural therapy ANS: A Play therapy should be prescribed to nurture growth and development, which is a priority for children with an intellectual disability.

DIF: Cognitive Level: Comprehension REF: 518 TOP: Goals of Care for Children with Intellectual Disability KEY: Nursing Process Step: Implementation

OBJ: N/A

13. A nurse is admitting a child with an intellectual disability to the pediatric unit. When assessing the child’s diet, the best question the nurse could ask would be which of the following? a. “What food does your child eat?” b. “Does your child feed herself?” c. “Tell me about your child’s eating habits” d. “How does your child get fluids?”

ANS: C

Open-ended questions that have a positive approach will help develop a good relationship between the parents and nurse as well as provide more information.

DIF: Cognitive Level: Application TOP: Intellectual Disability

REF: 517 OBJ: N/A KEY: Nursing Process Step: Data Collection

14. The most important goal of a nurse who provides palliative care to a child would be which of the following? a. Assessment and management of pain b. Ensuring parents can get a break c. Ensuring siblings talk about their feelings d. Ensuring a peaceful death occurs at home ANS: A The goal of palliative care is to prevent and relieve suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial or spiritual.

DIF: Cognitive Level: Analysis TOP: Palliative Care

REF: 518 OBJ: 15 KEY: Nursing Process Step: Implementation

15. A nurse who works in palliative care should first do which of the following? a. Encourage the patient to verbalize feelings b. Reflect on own feelings about death and dying c. Develop a close relationship with the patient d. Go to church to discuss concerns with minister

NURSINGTB.COM

ANS: B One of the most important tasks to prepare for in working with the dying patient is self-exploration. One’s attitudes about life and death affect our nursing practice. Emotions buried deep within can form barriers to effective communication unless they are recognized and released.

DIF: Cognitive Level: Comprehension TOP: Palliative Care

REF: 519 OBJ: 10 | 11 KEY: Nursing Process Step: N/A

16. A nurse is providing care for a family whose child has just died. The family is worried about their 4 year old’s response to the death of the sibling. A nurse would know the teaching has been appropriate when the family says they may expect the 4-year-old to do which of the following? a. Tries to take care of the parents b. Does not understand what happened c. May express anger at the death of the sibling d. May think their sibling will be coming back ANS: C Preschoolers may think death is temporary and they may blame self for sibling’s death DIF: Cognitive Level: Analysis TOP: Sibling of Dying Child

REF: 520 OBJ: 12 KEY: Nursing Process Step: Implementation

17. What would be important to teach a family about pain management who have a child who is dying of cancer? a. Opioids would not be an option for a child for pain. b. It is best to wait until the child states they have pain before giving them medication. c. Pain medication should be administered around the clock. d. Care related to medication dosage is important, so the child does not become addicted.

ANS: C Pain medication should be offered around the clock to manage the pain. Opioids would be offered to a child when needed and addiction is not a concern at this point.

DIF: Cognitive Level: Application TOP: Palliative Care Pain Management

REF: 522 OBJ: 14 KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in his 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 beingNsU upRpS orItiN veGoTfBh. erCpOaM rents 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: 512 OBJ: 14 TOP: Siblings KEY: Nursing Process Step: Implementation 2. A school-age child is living with a chronic disease process. How would the nurse anticipate chronic illness will affect 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 result in the loss of a grade level in school because of illness, and inability to participate or compete can lead to sense of inferiority. A sense of independence and accomplishment can be lost. Being different from peers may impede child’s sense of belonging.

DIF: Cognitive Level: Comprehension REF: 511 TOP: Chronic Illness/Growth and Development

OBJ: 14

KEY: Nursing Process Step: Data Collection 3. A nurse is providing care for an adolescent with cystic fibrosis in the community. What teaching to the parents would be important to incorporate into the care? (Select all that apply.) a. Give the child the option of not attending school. b. Teach the parents about allowing the child to make their own choices about care. c. Ensure the parents have final say in all health care decisions. d. Teach the child about the treatment options. e. Encourage the parents to allow the child to have sleep overs with friends.

ANS: B, D, E For an adolescent to develop a sense of identity they need to be encouraged to participate in their own health care decisions and should be encouraged to be assertive when discussing and participating in this decision-making. Families also need to be supported to learn to balance the need for parental guidance and the adolescents need for more control DIF: Cognitive Level: Application REF: 511 | 512 TOP: Adolescent Development with Chronic Illness KEY: Nursing Process Step: Implementation

OBJ: 7

4. What are the priorities for nursing care when providing care to a hospitalized child who has cerebral palsy (CP)? (Select all that apply.) a. Prevent contractures b. Prevent skin breakdown c. Encourage child to do as much of care as possible d. Tell parents to take a breaNkURSINGTB.COM e. Schedule naps or breaks ANS: A, B, C, E All of these are important aspects of providing care for a child with CP except for telling parents to take a break. The nurse needs to work collaboratively with the family and determine goals together.

DIF: Cognitive Level: Knowledge REF: 514 | 515 | 516 OBJ: 9 TOP: Cerebral Palsy KEY: Nursing Process Step: Implementation 5. The definition of an intellectual disability can include which of the following? (Select all that apply.) a. Difficulty with self-care b. IQ of less than 85 c. Limitations in social skills d. Difficulty with communication e. Limitations in academics ANS: A, C, D, E Limitations in all of the above, except for IQ, are related to children with intellectual disability. IQ of less than 75 is part of the definition of intellectual disability.

DIF: Cognitive Level: Comprehension TOP: Intellectual Disability

REF: 517 OBJ: N/A KEY: Nursing Process Step: Data Collection

6. A nurse teaches a family that the following may be manifestations of grief? (Select all that apply.) a. Anger b. Shortness of breath c. Restlessness d. Physical pain e. Acceptance ANS: A, B, C, D All of these are signs of grief except for acceptance. This may come much later in the process.

DIF: Cognitive Level: Comprehension REF: 519 OBJ: 11 TOP: Grieving KEY: Nursing Process Step: Data Collection

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Chapter 23: The Child with an Eye, Ear, or Neurological Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A parent comments that her infant has had several ear infections in the past few months.

Why are infants more susceptible to otitis media? a. Infants are in a supine or prone position most of the time. b. Sucking on a nipple creates middle ear pressure. c. They have increased susceptibility to upper respiratory tract infections. d. The Eustachian tube is short, straight, and wide.

ANS: D An infant’s Eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.

DIF: Cognitive Level: Knowledge REF: 532 OBJ: 5 TOP: Otitis Media KEY: Nursing Process Step: Data Collection 2. What statement by a patient’s mother leads a 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 prescribNeUdRdS osIeN s uGnTtiB l a.llCtO heMmedication 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: 533 TOP: Otitis Media KEY: Nursing Process Step: Evaluation

OBJ: 5

3. What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid? a. Meningitis b. Meningocele c. Spina bifida occulta d. Hydrocephalus ANS: D Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.

DIF: Cognitive Level: Knowledge TOP: Hydrocephalus

REF: 546 OBJ: 13 KEY: Nursing Process Step: Data Collection

4. What is the best way for a nurse to communicate with a 10-year-old child who has a hearing impairment? a. Use gestures and signs as much as possible. b. Let the child’s parents communicate for the child. c. Face the child and speak clearly in short sentences. d. Recognize that the child’s ability to communicate will be on a 6-year-old child’s level.

ANS: C The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.

DIF: Cognitive Level: Application TOP: Hearing Impairment

REF: 534 OBJ: 6 KEY: Nursing Process Step: Implementation

5. What would a 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. Teaching about follow-up hearing testing ANS: D After a tympanostomy, children should have their hearing tested to ensure no long-term hearing loss. They do not need to avoid water sports or getting water in the ears.

DIF: Cognitive Level: ComNpUreRhS enIsN ioG n TBR .ECFO:M 533 TOP: Postoperative Care of Tympanostomy KEY: Nursing Process Step: Planning

OBJ:

5

6. What assessment made by a 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 has symptoms 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: 530 OBJ: 3 TOP: Strabismus KEY: Nursing Process Step: Data Collection 7. What might a 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: 530 OBJ: 3 TOP: Amblyopia KEY: Nursing Process Step: Implementation 8. What assessment does a nurse recognize as the cardinal sign of a hyphema? a. Opacity of the lens b. A yellow-white reflex on the pupil c. A dark red spot in front of the iris d. Inflamed mucous membranes of the eyelids ANS: C A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.

DIF: Cognitive Level: Knowledge REF: 528 | 529 OBJ: 4 TOP: Hyphema KEY: Nursing Process Step: Data Collection 9. The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement? a. Align the limbs. b. Support the head. c. Keep the head lower than the hip. d. Check intake and output.

ANS: B NURSINGTB.COM The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the child to prevent injury to the neck.

DIF: Cognitive Level: Application TOP: Hydrocephalus

REF: 547 OBJ: 13 KEY: Nursing Process Step: Planning

10. A nurse observes that an infant’s anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant? a. Prone, with the head of the bed elevated b. Supine, with the head flat c. Side-lying on the operative side d. In a semi-Fowler’s position ANS: D If the fontanelles are bulging, the child will be positioned in a semi-Fowler’s position to promote drainage from the ventricles through the shunt.

DIF: Cognitive Level: Application TOP: Hydrocephalus

REF: 549 OBJ: 13 KEY: Nursing Process Step: Implementation

11. What does a nurse explain to parents of a child with febrile seizures? a. They occur when the body temperature exceeds 38.3° C (101° F). b. They can be prevented by anticonvulsant medication.

c. They usually lead to the development of epilepsy. d. They occur when the temperature rises quickly.

ANS: D Febrile seizures occur in response to a rapid rise in temperature, often above 38.8° C (102° F).

DIF: Cognitive Level: Comprehension TOP: Febrile Seizures

REF: 550 OBJ: 14 KEY: Nursing Process Step: N/A

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 behaviour 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: 552 OBJ: 14 TOP: Seizures KEY: Nursing Process Step: Data Collection 13. An adolescent has just had a generalized seizure and collapsed at school. When should a nurse should call 911?

NURSINGTB.COM a. The seizure lasts more than 5 minutes. b. The child is sleepy and lethargic after the seizure. c. The child vomited at the onset of the seizure. d. The child is confused and has slurred speech after the seizure.

ANS: A If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.

DIF: Cognitive Level: Application REF: 555 OBJ: 15 TOP: Epilepsy KEY: Nursing Process Step: Implementation 14. What is an appropriate nursing action when a child is experiencing a generalized tonic–clonic seizure? a. Assist the child to bed and then go for help. b. Move objects out of the child’s immediate area. c. Stick a padded tongue blade between the child’s teeth. d. Manually restrain the child.

ANS: B During a generalized tonic–clonic seizure, the immediate area is cleared to protect the child from injury.

DIF:

Cognitive Level: Application

REF: 552

OBJ: 15

TOP: Epilepsy

KEY: Nursing Process Step: Implementation

15. A child diagnosed with epilepsy had a generalized tonic–clonic seizure that lasted 90 seconds. What would a 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: 552 OBJ: 15 TOP: Epilepsy KEY: Nursing Process Step: Data Collection 16. What would a nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)? a. The medication should be given on an empty stomach. b. Insomnia can be a significant side effect. c. Gums should be massaged regularly to prevent hyperplasia. d. Blood pressure should be closely monitored.

ANS: C Phenytoin can cause gum overgrowth, which can be minimized by regular massaging.

Phenytoin frequently causes drowsiness and should be given with meals at the same time each day.

NURSINGTB.COM DIF: Cognitive Level: Comprehension REF: 554 OBJ: 15 TOP: Epilepsy KEY: Nursing Process Step: Implementation 17. What nursing action will the nurse implement after feeding an infant with hydrocephalus? a. Position the infant sitting upright in an infant seat. b. Place the infant over the shoulder to burp. c. Leave the infant in a side-lying position. d. Stimulate the infant by rubbing its feet.

ANS: C Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-lying position in a quiet atmosphere to reduce the incidence of vomiting.

DIF: Cognitive Level: Application REF: 548 TOP: Feeding a Child with Hydrocephalus KEY: Nursing Process Step: Implementation

OBJ: 13

18. Which assessment finding in a child with meningitis should a nurse report 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: 545 OBJ: 11 TOP: Meningitis KEY: Nursing Process Step: Data Collection 19. A nurse observes a child’s position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture? a. Correct anatomical position b. Decorticate c. Decerebrate d. Opisthotonos ANS: C In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.

DIF: Cognitive Level: Application REF: 557 OBJ: 17 TOP: Posturing KEY: Nursing Process Step: Data Collection 20. 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. States symptoms of a stifN f nUeR ckSINGTB.COM c. Cannot remember what happened d. Pupils react sluggishly to light ANS: C A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

DIF: Cognitive Level: Analysis REF: 555 OBJ: 17 TOP: Head Injury KEY: Nursing Process Step: Data Collection 21. A child is admitted to the hospital after having had a seizure. The parents report that for the past few weeks the child has had headaches, with vomiting, that are worse in the morning.

What does a nurse suspect? a. Meningitis b. Reye’s syndrome c. Brain tumour d. Encephalitis ANS: C The signs and symptoms of a brain tumour are related to its size and location. Most tumours create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

DIF: Cognitive Level: Analysis TOP: Brain Tumour

REF: 546 OBJ: N/A KEY: Nursing Process Step: Data Collection

22. A nurse teaches a mother of a 6-month-old child about the importance of getting 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 TOP: Prevention of Meningitis

REF: 544 OBJ: 12 KEY: Nursing Process Step: Implementation

23. A nurse is caring for a 3-year-old child with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)? a. Temperature increase from 37.2° C (99° F) to 37.7° C (100° F) b. Increase in blood pressure with an attendant decrease in pulse c. Increase in respirations d. Equilateral pupils ANS: B Increasing blood pressure, acN coUmRpSanIiN edGbTyBd. ecCrO eaM sing pulse, and accompanied by unequal pupils are indicators of ICP. DIF: Cognitive Level: Comprehension REF: 549 OBJ: 8 TOP: ICP KEY: Nursing Process Step: Data Collection 24. 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: 530 TOP: Strabismus KEY: Nursing Process Step: Planning

OBJ: 3

25. A newborn was just admitted to the NICU with a meningomyelocele. What is the priority preoperative nursing care of this newborn? a. Keep the sac dry. b. Diaper snugly. c. Position prone in an isolette.

d. Move from side to side every hour.

ANS: C The infant is placed prone in a humidified isolette, and the sac is covered with dressings of sterile saline. The infant’s hips are kept lower than the lesion, and the infant is usually not in diapers.

DIF: Cognitive Level: Analysis TOP: Myelodysplasia and Spina Bifida

REF: 543 OBJ: 11 KEY: Nursing Process Step: Planning

26. A nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response? a. Elevate the child’s head. b. Check bowel sounds. c. Record retention of feeding. d. Notify the charge nurse of possible malabsorption.

ANS: D An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum.

DIF: Cognitive Level: Application REF: 548 OBJ: 13 TOP: VP Shunt KEY: Nursing Process Step: Implementation MULTIPLE RESPONSE

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1. Which assessments would cause a pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.) a. Hypersensitivity to noise b. Irritability c. Ecchymotic ear canal d. Rolls head from side to side e. Temperature of 39.4° C (103° F) ANS: B, D, E Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.

DIF: Cognitive Level: Comprehension TOP: Indications of Ear Infection

REF: 533 OBJ: 5 KEY: Nursing Process Step: Data Collection

2. Which aspect(s) of a child’s development does a nurse caution parents that hearing impairment can affect? (Select all that apply.) a. Speech clarity b. Language development c. Immunity to disease d. Personality development e. Academic achievement

ANS: A, B, D, E All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.

DIF: Cognitive Level: Comprehension TOP: Hearing Impairment

REF: 534 OBJ: 6 KEY: Nursing Process Step: Implementation

3. What intervention(s) would a 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: 545 TOP: Nursing Care of Child with Meningitis KEY: Nursing Process Step: Implementation

OBJ: 12

4. What will a nurse include when documenting a generalized tonic–clonic seizure? (Select all that apply.) a. Presence of incontinence b. Current dose of antispasmNoUdR icSmIeN diG caTtiBo. n COM c. Activity level prior to and following seizure d. Level of consciousness (LOC) following seizure e. Length of seizure ANS: A, C, D, E Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in colour, respiration, muscle tone, and length of seizure.

Reporting of medication regimen is not necessary.

DIF: Cognitive Level: Application TOP: Documentation of Seizure

REF: 551 OBJ: 15 KEY: Nursing Process Step: Data Collection

5. An 8-year-old submersion injury victim is rushed into the emergency department. 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 TOP: Submersion Injury

REF: 558 OBJ: 17 KEY: Nursing Process Step: Implementation

6. What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often to maintain level of consciousness. d. Hold and cuddle frequently to stimulate. e. Observe for increased intracranial pressure.

ANS: A, B, E These children should be kept positioned with the head elevated, fed slowly, and monitored for increased intracranial pressure. Children with intracranial hemorrhages are not stimulated and are kept in a quiet environment.

DIF: Cognitive Level: Comprehension TOP: Topic: Intracranial Hemorrhage

REF: 557 OBJ: 13 KEY: Nursing Process Step: Planning

7. What manifestations of increasing intracranial pressure (ICP) in the hydrocephalic child should the nurse be aware of? (Select all that apply.) a. High-pitched cry NURSINGTB.COM b. Unequal pupils c. Bulging fontanelles d. Diarrhea e. Hiccups ANS: A, B, C Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles.

DIF: Cognitive Level: Knowledge REF: 549 OBJ: 13 TOP: Signs of ICP KEY: Nursing Process Step: Data Collection

Chapter 24: The Child with a Musculoskeletal Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What would a nurse include in planning teaching to parents of a child with Legg-Calvé-Perthes disease about the long-term effects of this disease? a. There are no long-term effects. b. The disease is self-limited and requires no long-term treatment. c. Degenerative arthritis may develop later in life. d. There is risk of osteogenic sarcoma in adulthood.

ANS: C Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life.

DIF: Cognitive Level: Comprehension TOP: Legg-Calvé-Perthes Disease

REF: 579 OBJ: N/A KEY: Nursing Process Step: Planning

2. What intervention will a nurse caring for a child in Buck skin traction implement? a. Position in high Fowler’s position. b. Assist the child to be pulled up in bed. c. Keep child’s heel on the bed surface. d. Maintain child’s feet against the foot of the bed.

NURSINGTB.COM

ANS: B Buck traction is a type of skin traction that relies on the child’s weight as counterbalance.

The child must be kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.

DIF: Cognitive Level: Application TOP: Buck’s Traction

REF: 569 OBJ: 8 KEY: Nursing Process Step: Implementation

3. What will a nurse include when caring for a child in Buck’s extension? a. Positioning the child with the hips flexed 90 degrees at all times b. Keeping the weights in contact with the floor c. Checking for skin irritation from traction equipment d. Releasing the weights on a schedule ANS: C The skin exposed to frequent friction may break down.

DIF: Cognitive Level: Application REF: 573 OBJ: 8 TOP: Traction KEY: Nursing Process Step: Implementation 4. A nurse is reviewing the characteristics of Ewing sarcoma. Which statement if made by the nurse indicates correct understanding of this disease? a. “Amputation is the accepted treatment.”

b. “The disease is sensitive to radiation and chemotherapy.” c. “Metastasis is rare.” d. “The disease is more prevalent among toddlers and preschoolers.”

ANS: B Ewing sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize.

DIF: Cognitive Level: Comprehension TOP: Ewing Sarcoma

REF: 580 OBJ: 12 KEY: Nursing Process Step: Implementation

5. What characteristic manifestation does a nurse caring for a child with Duchenne muscular dystrophy document? a. Ambulates by holding onto furniture b. Exhibits atrophy of the calf muscles c. Falls frequently and is clumsy d. Has delayed fine-motor development ANS: C Frequent falling and clumsiness are clinical manifestations of Duchenne muscular dystrophy.

DIF: Cognitive Level: Knowledge TOP: Duchenne Muscular Dystrophy

REF: 578 OBJ: 11 KEY: Nursing Process Step: Data Collection

6. A nurse is assessing a child wNitUhRjuSvI enNile atM oid arthritis notes the child’s right knee GTrhBe.um CO and ankle are swollen, warm, and tender. The child has a temperature of 38.8° C (102° F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest? a. Psoriatic b. Enthesitis c. Systemic d. Acute febrile ANS: C The systemic form of juvenile rheumatoid arthritis is associated with an elevated temperature, erythrocyte sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash.

DIF: Cognitive Level: Application TOP: Juvenile Rheumatoid Arthritis

REF: 580 OBJ: 13 KEY: Nursing Process Step: Data Collection

7. A nurse is providing instructions about how to treat a sprained ankle. What statement by a caregiver does the nurse recognize as indicative of a need for additional teaching? a. “Apply warm compresses to the ankle for the first 24 hours.” b. “Put an ice pack on the ankle for 15-minute intervals up to three times per day.” c. “Have them walk immediately to maintain mobility.” d. “Keep the leg elevated to hip level when sitting.”

ANS: B

Heat is not a treatment for soft tissue injuries. A cold pack and elastic wrap will reduce edema and bleeding and relieve pain and should be applied at 15-minute intervals one to three times a day, in the first 36 hours after injury. The principles of managing soft tissue injuries are protection, relative rest, ice, compression, and elevation (above the level of the heart).

DIF: Cognitive Level: Application TOP: Soft Tissue Injury

REF: 565 OBJ: 4 KEY: Nursing Process Step: Evaluation

8. How does Russell traction provide adequate skin traction? a. Subluxates the tibia b. Does not interfere with range of motion (ROM) c. Prevents the knee from flexing d. Supplies continuous pull in two directions ANS: D Russell traction is skin traction, similar to Buck, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions.

DIF: Cognitive Level: Comprehension TOP: Russell Traction

REF: 569 OBJ: 8 KEY: Nursing Process Step: Implementation

9. A nurse is checking for capillary refill on a child in Bryant traction. How long does it take for the toe to regain colour if adequate perfusion is assessed? a. 3 seconds b. 4 seconds NURSINGTB.COM c. 5 seconds d. 6 seconds ANS: A Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.

DIF: Cognitive Level: Comprehension REF: 567 OBJ: 8 TOP: Fracture KEY: Nursing Process Step: Data Collection 10. A parent of a child with osteomyelitis asks why the child is in so much pain. What will a nurse respond causes the pain experienced with osteomyelitis? a. “Pressure of inelastic bone” b. “Purulent drainage in the bone marrow” c. “The cast applied on the extremity” d. “Circulatory congestion of the skin” ANS: B Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.

DIF: Cognitive Level: Analysis TOP: Osteomyelitis

REF: 577 OBJ: N/A KEY: Nursing Process Step: Implementation

11. A child hospitalized for treatment of osteomyelitis states that he is tired of being sick and wants to know when the antibiotic protocol will end. How long will a nurse indicate that antibiotic therapy will probably last? a. 2 weeks b. 6 weeks c. 2 months d. 3 months ANS: B Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.

DIF: Cognitive Level: Application TOP: Osteomyelitis

REF: 578 OBJ: 1 KEY: Nursing Process Step: Implementation

12. What finding would a nurse assessing the neurovascular status of a child in Russell traction report immediately? a. Skin that is warm to the touch b. Capillary refill less than 3 seconds c. Ability to wiggle toes d. Bluish colouration of skin ANS: D Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.

DIF: Cognitive Level: AppN liU caRtiS onINGTBR OBJ: 7 | 8 .ECFO:M 568 TOP: Neurovascular Assessment KEY: Nursing Process Step: Data Collection 13. A 13-year-old girl is diagnosed with functional scoliosis. What does a nurse explain as the cause of this spinal curvature defect? a. Juvenile rheumatoid arthritis b. Poor posture c. Heredity d. Myelomeningocele ANS: B Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.

DIF: Cognitive Level: Knowledge REF: 581 OBJ: N/A TOP: Scoliosis KEY: Nursing Process Step: Implementation 14. When bathing an infant, what sign does the nurse recognize as a sign of developmental dysplasia of the hip? a. Hypotonicity of the leg muscles b. One leg is shorter than the other c. Broadening and flattening of the buttocks d. Two skinfolds on the back of each thigh ANS: B

When developmental dysplasia of the hip is present, the leg on the affected side will appear shorter than the leg on the unaffected side.

DIF: Cognitive Level: Comprehension REF: 574 TOP: Developmental Dysplasia of the Hip KEY: Nursing Process Step: Data Collection

OBJ: 10

15. What nursing action will significantly decrease the risk of serious complications for a child in Bryant traction? a. Neurovascular checks are done frequently. b. Bandages are wrapped tightly. c. The child is restrained from rolling over. d. The child’s buttocks are resting on the bed.

ANS: A The nurse caring for a child in traction must be alert for Volkmann’s ischemia, which occurs when circulation is obstructed.

DIF: Cognitive Level: Application TOP: Traction: Volkmann’s Ischemia

REF: 571 OBJ: 7 | 8 KEY: Nursing Process Step: Data Collection

16. Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis? a. Wearing splints at night to prevent extension contractures b. Applying moist heat packs upon awakening c. Taking a warm tub bath the evening before d. Sleeping with two pillowN s uUnRdS erIthNeGhTeB ad.COM ANS: B Application of moist heat, with a compress or having a tub bath upon awakening in the morning, will help to lessen stiffness.

DIF: Cognitive Level: Application TOP: Juvenile Rheumatoid Arthritis

REF: 580 OBJ: 13 KEY: Nursing Process Step: Implementation

17. What instruction would a nurse provide to an adolescent who has been fitted with a Milwaukee brace? a. Wear the brace directly against the skin. b. Wear the brace over regular clothing. c. Wear the brace over a T-shirt for a minimum of 16 hours a day. d. Remove the brace before sleeping.

ANS: C A Milwaukee brace is worn approximately 16 to 23 hours a day over a T-shirt, which protects the skin.

DIF: Cognitive Level: Application REF: 581 | 582 OBJ: 14 TOP: Scoliosis KEY: Nursing Process Step: Implementation

18. Which observation is most likely to cause a nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs? a. Red, green, and yellow bruises on his body. b. Bruises are dispersed on his head, arms, and legs. c. A broken arm last year, and the child being described as accident-prone. d. The mother is very anxious for her son to get medical attention.

ANS: A As bruises heal, they change colour in stages. Different colours of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretaker’s explanation of what happened.

DIF: Cognitive Level: Analysis REF: 586 OBJ: 16 TOP: Child Abuse KEY: Nursing Process Step: Data Collection 19. A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child? a. Pain resulting from tissue trauma b. High risk for impaired skin integrity resulting from immobility c. Altered growth and development related to separation from family d. Altered urinary elimination related to immobility and traction ANS: A Although all these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.

NURSINGTB.COM

DIF: Cognitive Level: Analysis REF: 572 | 573 TOP: The Child with a Fracture in Traction KEY: Nursing Process Step: Nursing Diagnosis

OBJ: 7 | 8

20. What would a nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child? a. Has inward-turned knees while standing b. Walks on the toes c. Appears to have flat feet d. Swings his arms when walking ANS: B Toe walking after 3 years of age may indicate a muscle problem.

DIF: Cognitive Level: Analysis REF: 563 TOP: Assessment of the Musculoskeletal System KEY: Nursing Process Step: Data Collection 21. Why does a child’s fracture heal more rapidly than the adult’s? a. A child’s bones are less porous than adult bone. b. A child’s bones are covered by a thicker periosteum. c. A child’s bones are not affected by bone overgrowth. d. A child’s bones have faster callus formation.

OBJ: 3

ANS: D Callus forms more rapidly in the child than the adult.

DIF: Cognitive Level: Knowledge REF: 562 | 563 TOP: Differences Between the Child and Adult KEY: Nursing Process Step: N/A

OBJ: 2

22. On entering the room of a child in Buck traction, a nurse makes all of the following observations. Which observation requires a nursing intervention? a. Child’s heels are placed firmly against the foot of the bed b. Head of bed is elevated 20 degrees c. Weights are hanging freely d. Ropes are on pulleys ANS: A Buck traction is dependent on the child as a counterweight. The heels should be elevated above the level of the foot of the bed.

DIF: Cognitive Level: Application TOP: Buck’s Traction

REF: 569 OBJ: 7 | 8 KEY: Nursing Process Step: Implementation

23. Approximately how old does a nurse assess a large green bruise on the thigh of a 4-year-old to be? a. 2 days b. 4 days c. 6 days d. 8 days NURSINGTB.COM ANS: C Bruises heal in various stages that are indicated according to colour; after 5 to 7 days bruise are green.

DIF: Cognitive Level: Comprehension REF: 586 OBJ: 16 TOP: Child Abuse KEY: Nursing Process Step: Data Collection 24. A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur.

What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse? a. Stress fracture b. Compound fracture c. Spiral fracture d. Greenstick fracture ANS: C A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not correlate with X-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity.

DIF: Cognitive Level: Comprehension TOP: Fractures/Child Abuse

REF: 565 OBJ: 5 | 16 KEY: Nursing Process Step: Data Collection

25. A child is sent for an assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body.

What do these finding indicate? a. Sexual abuse b. Physical abuse c. Neglect d. Emotional abuse ANS: C Neglect is the failure to provide for the basic physical needs of the child, including food, clothing, shelter, and basic cleanliness.

DIF: Cognitive Level: Comprehension TOP: Child Abuse Triggers

REF: 585 OBJ: 15 KEY: Nursing Process Step: Data Collection

26. Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary? a. Pulses b. Capillary refill c. Movement d. Pupils ANS: D Neurovascular checks include assessment of capillary refill and signs of poor circulation, pallor, cyanosis, swelling, coldness, numbness, pain, or burning. Pupils are assessed with a neurological check.

NURSINGTB.COM DIF: Cognitive Level: Comprehension TOP: Neurovascular Assessment

REF: 567 | 568 OBJ: 7 KEY: Nursing Process Step: Data Collection

27. A 3-month-old infant is diagnosed with developmental dysplasia of the hip. A nurse knows that what is the usual treatment for an infant with this diagnosis? a. A Pavlik harness b. A body spica cast c. Traction d. Triple-diapering ANS: A In infants who are more than 2 months of age, longer-term immobilization with a Pavlik harness is required.

DIF: Cognitive Level: Comprehension REF: 575 TOP: Developmental Dysplasia of the Hip KEY: Nursing Process Step: Implementation

OBJ: 10

28. What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied? a. Prop the child upright with pillows for meals. b. Use the bar between the legs to turn the child.

c. Put the child on the abdomen to sleep. d. Change the child’s position frequently.

ANS: D The child’s position must be changed frequently to relieve pressure and promote circulation.

DIF: Cognitive Level: Application REF: 575 TOP: Developmental Dysplasia of the Hip KEY: Nursing Process Step: Implementation

OBJ: 10

29. What assessment made by the nurse would lead the nurse to suspect hip dysplasia? a. Asymmetrical gluteal folds b. Limited adduction of the affected side c. Foot turned inward d. Deep inguinal creases ANS: A The gluteal folds are asymmetrical because the head of the femur has slipped out of the acetabulum. There is also limited abduction of the affected side, and when the legs are flexed the affected leg seems to be shorter.

DIF: Cognitive Level: Comprehension REF: 574 TOP: Developmental Dysplasia of the Hip KEY: Nursing Process Step: Data Collection MULTIPLE RESPONSE

OBJ: 10

NURSINGTB.COM

1. What factor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to childcare ANS: A, C, D, E All options except high self-esteem are possible triggers for a parent to become abusive.

DIF: Cognitive Level: Comprehension TOP: Child Abuse Triggers

REF: 584 OBJ: 15 KEY: Nursing Process Step: Data Collection

2. The nurse demonstrates which similarities among all traction devices? (Select all that apply.) a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb ANS: A, B, D, E

Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some traction devices may relieve pain, many may actually cause pain.

DIF: Cognitive Level: Comprehension REF: 569 OBJ: 8 | 9 TOP: Traction KEY: Nursing Process Step: Implementation 3. A nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equal to uncasted limb b. Patient is aware of touch and warm and cold application c. Limb is cool to the touch d. Capillary refill is 5 seconds e. Distal limb can flex and extend ANS: C, D The limb should be warm, and capillary refill should be less than 3 seconds.

DIF: Cognitive Level: Comprehension TOP: Neurovascular Assessment

REF: 572 | 573 OBJ: 7 KEY: Nursing Process Step: Implementation

4. How does the pediatric skeletal system differ from that of the adult? (Select all that apply.) a. Lower mineral content b. More ossification c. Open epiphyses d. Less porosity e. Greater strength NURSINGTB.COM ANS: A, C, E The child’s skeletal system has lower mineral content, greater porosity, open epiphyses, greater bone strength, and a thicker periosteum.

DIF: Cognitive Level: Comprehension TOP: Skeletal Differences

REF: 562 | 563 OBJ: 2 KEY: Nursing Process Step: N/A

5. What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying b. Check toes for capillary refill c. Circle with a pen any area of bleeding on the cast d. Keep casted leg lowered e. Observe for skin irritation ANS: A, B, C, E The casted leg should be kept elevated. All the other options are necessary nursing interventions for a child who is freshly casted.

DIF: Cognitive Level: Comprehension TOP: Repair of Clubfoot

REF: 572 | 573 OBJ: 6 KEY: Nursing Process Step: Implementation

Chapter 25: The Child with a Respiratory Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What will a nurse tell parents of a child with a positive throat culture for group A beta-hemolytic streptococcus that the treatment is most likely to be? a. Acetaminophen and plenty of fluids b. Oral penicillin for 10 days c. Penicillin until his sore throat is gone d. Streptococcus immunization ANS: B When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.

DIF: Cognitive Level: Comprehension TOP: Acute Pharyngitis

REF: 594 OBJ: N/A KEY: Nursing Process Step: Implementation

2. Which initial intervention will a nurse suggest to the parents of a child experiencing laryngeal spasm? a. Take the child outside in the cool air. b. Bring the child directly to the emergency department. c. Take the child to the bathroom and turn on a hot shower. d. Have the child drink plenN tyUoRf S flI uiN dsG. TB.COM ANS: C The child experiencing laryngeal spasm should be placed in a high-humidity environment, such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.

DIF: Cognitive Level: Application TOP: Croup Syndromes

REF: 595 OBJ: 5 KEY: Nursing Process Step: Implementation

3. A nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate? a. Bleeding from the surgical site b. Pain at the incision area c. Sore throat from postnasal drip d. Potential vomiting ANS: A Hemorrhage is the most common postoperative complication. Blood trickling down the back of the child’s throat could cause frequent swallowing.

DIF: Cognitive Level: Comprehension TOP: Post-operative Tonsillectomy

REF: 601 OBJ: 9 KEY: Nursing Process Step: Data Collection

4. What is the best choice for fluid replacement that a nurse can offer a child who has just had a tonsillectomy? a. A popsicle b. Chocolate milk c. Orange juice d. Cola drink ANS: A Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated.

DIF: Cognitive Level: Application TOP: Tonsillectomy Care

REF: 601 OBJ: 9 KEY: Nursing Process Step: Implementation

5. When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would a nurse report immediately? a. Respiration rate decreases from 40 to 32 breaths/minute b. Heart rate decreases from 110 to 100 beats/minute c. “Quiet chest” from previous assessment of wheezing d. Oxygen saturation of 90% ANS: C A “quiet chest” after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.

DIF: Cognitive Level: AnaN lyUsiR s SINGTBR OBJ: 3 | 5 .ECFO:M 598 TOP: Respiratory Syncytial Virus (RSV) KEY: Nursing Process Step: Data Collection 6. What classic sign would a nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, expect to find? a. Fine crackles b. Coarse rhonchi c. Expiratory wheezing d. Decreased breath sounds at lung bases ANS: C The child experiencing an acute asthma attack wheezes as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced.

DIF: Cognitive Level: Knowledge REF: 603 OBJ: 3 TOP: Asthma KEY: Nursing Process Step: Data Collection 7. What is the best intervention for a nurse caring for a child experiencing an acute asthma attack? a. Offer plenty of fluids, particularly carbonated beverages. b. Place the child in a humidified cool mist tent with oxygen. c. Administer sedatives as ordered to decrease anxiety. d. Position the child with arms resting on the overbed table.

ANS: D

This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea.

DIF: Cognitive Level: Comprehension REF: 607 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Implementation 8. What should a nurse explain to the parent of a child with exercise-induced asthma about when to use a cromolyn inhaler? a. Before exercise to prevent attacks b. At the initial onset of the attack c. During the attack to relieve symptoms d. As often as four times a day ANS: A Anti-inflammatory inhalants are taken before exercise to prevent attacks. These medications can do nothing for the attack in progress. They are meant to be used as prophylactic therapies.

DIF: Cognitive Level: Application REF: 605 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Implementation 9. The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is a nurse’s best response based on the understanding of CF? a. Only one parent carries the CF gene. b. Both parents are carriers N ofUthReSCIFNgGeT neB. .COM c. The inheritance pattern is multifactorial. d. The result is probably a genetic mutation.

ANS: B Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease.

DIF: Cognitive Level: Comprehension TOP: Cystic Fibrosis

REF: 609 OBJ: N/A KEY: Nursing Process Step: Implementation

10. Which statement indicates that the child’s parents understand how to perform respiratory therapy for a child with cystic fibrosis? a. “We do her postural drainage before the aerosol therapy.” b. “We give her respiratory treatments when she is coughing a lot.” c. “We give the aerosol followed by postural drainage before meals.” d. “She needs respiratory therapy every day when she has an infection.”

ANS: C Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting.

DIF: Cognitive Level: Analysis TOP: Cystic Fibrosis

REF: 613 OBJ: 14 KEY: Nursing Process Step: Evaluation

11. What will a nurse teach the child with cystic fibrosis to take in order to facilitate digestion and absorption of nutrients? a. Pancreatic enzymes b. Water-soluble minerals c. Fat-soluble vitamins d. Salt supplements ANS: A An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the child’s body cannot produce.

DIF: Cognitive Level: Knowledge TOP: Cystic Fibrosis

REF: 613 OBJ: 14 KEY: Nursing Process Step: Implementation

12. How would a nurse advise a caregiver to clear the nostrils when an infant has a cold? a. Clear the nasal passages after the infant has a feeding. b. Use over-the-counter nose drops to clear passages. c. Remove nasal secretions with a bulb syringe. d. Instill saline nose drops after clearing away secretions.

ANS: C The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe.

DIF: Cognitive Level: Application REF: 593 OBJ: 5 TOP: Nasopharyngitis EY NURSINGTBK .C O:M Nursing Process Step: Implementation 13. A nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through dyspnea. Which fluids are most appropriate? a. Room temperature water b. Carbonated beverages c. Iced fruit juice d. Cold milk ANS: A Room temperature fluids are the best. Carbonated and iced beverages increase spasm. Milk stimulates mucus production.

DIF: Cognitive Level: Comprehension REF: 607 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Implementation 14. An asthmatic child who has been taking theophylline is tachycardic and shaking. What does a nurse recognize as the cause of these symptoms? a. Severe asthma attack b. Allergic response to theophylline c. Onset of bronchitis d. Medication toxicity ANS: D The symptoms described are the signs of theophylline toxicity.

DIF: Cognitive Level: Analysis REF: 606 OBJ: 13 TOP: Asthma KEY: Nursing Process Step: Data Collection 15. A nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS).

What significant information would the nurse include? a. Wrapping the infant snugly for rest periods b. Positioning the infant prone for sleep c. Sitting the infant up in an infant seat d. Placing infants on their backs for sleep ANS: D Health Canada recommends that all healthy infants be placed in the supine position on a firm mattress to prevent SIDS. DIF: Cognitive Level: Knowledge TOP: Sudden Infant Death Syndrome

REF: 617 OBJ: 16 KEY: Nursing Process Step: Planning

16. A nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction? a. Restlessness b. Tachycardia c. Brassy cough d. Expiratory wheezing ANS: A Restlessness is a primary signNoUfRinScI reNasGeT dB re.spCirOaM tory obstruction.

DIF: Cognitive Level: Analysis REF: 595 OBJ: 5 TOP: Acute Croup KEY: Nursing Process Step: Data Collection 17. The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder in order to prevent which of the following? a. Discolouration of tooth enamel b. Halitosis c. Irritation of oral membranes d. Candidiasis ANS: D Inhalant powders can cause candidiasis (yeast) infection of the mouth.

DIF: Cognitive Level: Comprehension REF: 608 TOP: Candidiasis KEY: Nursing Process Step: Planning

OBJ: 13

18. A nurse is caring for a 3-year-old child who suffered a smoke inhalation injury. How long is this patient at the highest risk for pulmonary edema after exposure? a. 2 hours b. 4 hours c. 18 hours

d. 72 hours ANS: D Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after exposure.

DIF: Cognitive Level: Comprehension TOP: Smoke Inhalation

REF: 600 OBJ: 8 KEY: Nursing Process Step: Data Collection

19. Which is the most appropriate nursing action when planning care for a child hospitalized with cystic fibrosis? a. Provide chest physiotherapy before meals every day b. Assess weight monthly c. Administer pancreatic enzyme with protein food at mealtime d. Ensure high-protein, high-calorie diet ANS: D The maintenance of adequate nutrition is essential. The diet is high in protein and calories.

Chest physiotherapy should be done between meals. Pancreatic enzyme powder should be given with applesauce or other nonstarch, nonfat, nonprotein food. Children with cystic fibrosis should be weighed more frequently than monthly.

DIF: Cognitive Level: Application TOP: Cystic Fibrosis

REF: 613 OBJ: 14 KEY: Nursing Process Step: Implementation

20. The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to prevent this from hapN peUnR inS gIwNitG hT thBe .chCiO ldMthey are currently expecting. What will the nurse explain as the best way to prevent BPD? a. Maternal intake of folic acid b. Exercise c. Prevention of preterm birth d. Provision of oxygen therapy to the newborn ANS: C Bronchopulmonary dysplasia (BPD) is a fibrosis, or thickening, of the alveolar walls and the bronchiolar epithelium. It occurs in premature infants (less than 32 weeks) who have abnormal or arrested lung development and receive ventilation and oxygen for more than 28 days to survive. Respiratory distress in the newborn is the major reason why oxygen and ventilators are used for prolonged periods. The main cause of respiratory distress in the newborn is prematurity. Therefore, the prevention of preterm birth is the best way to prevent BPD. DIF: Cognitive Level: Knowledge TOP: Bronchopulmonary Dysplasia

REF: 616 OBJ: 15 KEY: Nursing Process Step: Planning

21. The parents of a child diagnosed with cystic fibrosis ask a nurse what caused this disorder.

What is the most appropriate response? a. “Cystic fibrosis is a chromosomal defect.” b. “Cystic fibrosis is a metabolic defect.” c. “Cystic fibrosis is a malformation present at birth.”

d. “Cystic fibrosis is a blood disorder.”

ANS: B Inborn errors of metabolism include a number of inherited diseases that affect body chemistry. There may be an absence or a deficiency of a substance necessary for cell metabolism. The deficient substance is usually an enzyme. Almost any organ of the body may be damaged. Examples of inborn errors of metabolism include cystic fibrosis and phenylketonuria (PKU).

DIF: Cognitive Level: Knowledge TOP: Cause of Cystic Fibrosis

REF: 609 OBJ: N/A KEY: Nursing Process Step: Implementation

MULTIPLE RESPONSE 1. A nurse describes the “allergic salute” as a cluster of what signs related to chronic allergy?

(Select all that apply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva ANS: B, C, E The allergic salute does not include a productive cough or cause mouth breathing.

DIF: Cognitive Level: Comprehension REF: 601 OBJ: 10 NURSINGTB .

C O M TOP: Allergic Salute KEY: Nursing Process Step: Data Collection 2. A nurse would suggest to parents of an asthmatic child the encouragement of participation in which sport(s)? (Select all that apply.) a. Swimming b. Gymnastics c. Baseball d. Cross-country skiing e. Distance running ANS: A, B, C Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion.

DIF: Cognitive Level: Comprehension REF: 606 TOP: Sports Activities Suitable for Asthmatics KEY: Nursing Process Step: Implementation

OBJ: 12

3. A nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all that apply.) a. Abdominal distention b. Vomiting c. Hiccoughing d. Jaundice

e. Absence of stool ANS: A, B, E Distended abdomen, vomiting, and absence of stool are the signs indicating meconium ileus in the newborn.

DIF: Cognitive Level: Comprehension TOP: Meconium Ileus

REF: 610 OBJ: 1 KEY: Nursing Process Step: Data Collection

4. What would a nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select all that apply.) a. Inhale deeply through nose with mouth closed b. Make exhalation twice as long as inhalation c. Use medicated inhaler prior to perform breathing exercise d. Exhale through mouth as if whistling e. Exhale forcefully ANS: A, B, D The technique requires that breath be inhaled through the nose and exhaled through pursed lips in a nonforceful manner. The exhalation should be twice as long as the inhalation.

DIF: Cognitive Level: Comprehension TOP: Pursed-Lip Breathing

REF: 613 OBJ: 13 KEY: Nursing Process Step: Implementation

5. A toddler with the diagnosis of pneumonia should maintain bed rest. What actions will the nurse implement? (Select all that apply.) a. Maintain strict bed rest NURSINGTB.COM b. Consider age c. Assess developmental level d. Implement light play activities e. Provide hypnotic medication as ordered ANS: B, C, D Confinement to bed for a child does not always result in physical rest. In pediatrics, “bed rest” means providing play therapy that promotes minimal activity. The nurse should consider the age and developmental level of the child and the activity level involved in the play when designing appropriate activities and guiding parents in the home care of their child.

DIF: Cognitive Level: Application REF: 593 OBJ: 5 TOP: Bed Rest KEY: Nursing Process Step: Implementation 6. A nurse suspects a 6-year old has sinusitis. Which symptoms might lead the nurse to this suspicion? (Select all that apply.) a. Child reports tooth pain b. Severe wheezing is auscultated on inspiration c. Child reports, “I have had a cold for 2 weeks.” d. Nurse observes periorbital swelling e. Halitosis is present ANS: A, C, D, E

The proximity of the sinus to the tooth roots often results in tooth pain when the sinus is infected. The maxillary and ethmoid sinuses are most often involved in childhood sinusitis.

Therefore, the signs and symptoms of sinusitis in children are different from those in adults, depending on the age of the child and which sinus is fully developed. An acute sinusitis is suspected when an upper respiratory infection lasts longer than 10 days, with a daytime cough. Halitosis is often present. Untreated sinusitis can lead to periorbital cellulitis. Severe wheezing is not indicative of sinusitis.

DIF: Cognitive Level: Comprehension REF: 594 OBJ: 5 TOP: Sinusitis KEY: Nursing Process Step: Data Collection 7. A nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.) a. Harsh cough b. Restlessness c. Edematous epiglottis d. Child insists on lying down e. Drooling ANS: B, C, E H. influenzae type B most often occurs in children 3 to 6 years of age. It can occur in any season. The course is rapid and progressive. The onset of epiglottitis is abrupt, and the child presents with classic symptoms. The child insists on sitting up, leans forward with the mouth open, and drools saliva because of the difficulty in swallowing. The child appears wide-eyed, anxious, and restless, and he or she may emit a froglike croaking sound on inspiration. Cough is absent. N InUspReS ctI ioNnGoT fB th. eC thO roMat shows an enlarged, reddened edematous epiglottis much like a “beefy-red thumb.” However, the examining tongue blade may trigger a laryngospasm and result in sudden respiratory arrest.

DIF: Cognitive Level: Comprehension REF: 595 OBJ: 6 TOP: Epiglottitis KEY: Nursing Process Step: Data Collection 8. What will a nurse discourage when providing education to parents of a child with asthma?

(Select all that apply.) a. Stuffed toys b. Pet ownership c. Gymnastics d. Basketball e. Cotton blankets ANS: A, D Use of stuffed toys is discouraged due to potential allergens. Basketball might not be well tolerated because of the constant physical exertion. Certain pets are encouraged, gymnastics is usually well tolerated, and cotton blankets are recommended for children with asthma.

DIF: Cognitive Level: Comprehension REF: 604 TOP: Asthma KEY: Nursing Process Step: Planning

OBJ: 11

9. A nurse who is assessing a 7-year old child with a pneumothorax would expect to see which of the following symptoms? (Select all that apply.) a. Chest pain b. Respiratory rate of fifteen breaths per minute c. Asymmetrical chest wall movement d. Decreased breath sounds e. Temperature of 38.0 °C ANS: A, C, D Chest pain may be present as well as signs of respiratory distress such as paleness or cyanosis, tachypnea, nasal flaring, indrawing, and grunting. There may be asymmetrical chest wall movements with decreased or absent sounds or hyperresonance on the affected side as well as tachycardia. Temperature would not be increased.

DIF: Cognitive Level: Comprehension TOP: Pneumothorax

REF: 599 OBJ: 7 KEY: Nursing Process Step: Data Collection

NURSINGTB.COM

Chapter 26: The Child with a Cardiovascular Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. What does a nurse explain occurs when a ventricular septal defect is present? a. Blood shunts left to right, causing increased pulmonary flow and no cyanosis b. Blood shunts right to left, causing decreased pulmonary flow and cyanosis c. No shunting because of high pressure in the left ventricle d. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume ANS: A Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.

DIF: Cognitive Level: Comprehension TOP: Congenital Heart Disease

REF: 624 OBJ: 3 | 5 KEY: Nursing Process Step: Implementation

2. Which assessment would lead a nurse to suspect that a newborn infant has a ventricular septal defect? a. A loud, harsh murmur with a systolic thrill b. Cyanosis when crying c. Blood pressure higher in N thU eR arSmIsNthGaT nB in.tC heOlM egs d. A machinery-like murmur ANS: A A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.

DIF: Cognitive Level: Comprehension TOP: Congenital Heart Disease

REF: 625 OBJ: 5 KEY: Nursing Process Step: Data Collection

3. What finding would a nurse expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta? a. Blood pressure higher on the right side b. Blood pressure higher on the left side c. Blood pressure lower in the arms than in the legs d. Blood pressure lower in the legs than in the arms ANS: D The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.

DIF: Cognitive Level: Comprehension TOP: Congenital Heart Disease

REF: 625 OBJ: 4 KEY: Nursing Process Step: Data Collection

4. A father asks why his child with tetralogy of Fallot seems to favour a squatting position.

What is a nurse’s best response? a. Squatting increases the return of venous blood back to the heart. b. Squatting decreases arterial blood flow away from the heart. c. Squatting is a common resting position when a child is tachycardic. d. Squatting increases the workload of the heart.

ANS: A The squatting position allows the child to breathe more easily because systemic venous return is increased.

DIF: Cognitive Level: Comprehension TOP: Tetralogy of Fallot

REF: 626 OBJ: 4 KEY: Nursing Process Step: Implementation

5. An infant is experiencing dyspnea related to a patent ductus arteriosus (PDA). What does a nurse understand regarding why dyspnea occurs? a. Blood is circulated through the lungs again, causing pulmonary circulatory congestion. b. Blood is shunted past the pulmonary circulation, causing pulmonary hypoxia. c. Blood is shunted past cardiac arteries, causing myocardial hypoxia. d. Blood is circulated through the ductus from the pulmonary artery to the aorta, bypassing the left side of the heart.

ANS: A When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.

NURSINGTB.COM DIF: Cognitive Level: Comprehension TOP: Patent Ductus Arteriosus

REF: 625 OBJ: 3 KEY: Nursing Process Step: Planning

6. Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant? a. Counting the apical rate for 30 seconds before administering the medication b. Withholding a dose if the apical heart rate is less than 100 beats/minute c. Repeating a dose if the child vomits within 30 minutes of the previous dose d. Checking respiratory rate and blood pressure before each dose ANS: B As a rule, if the pulse rate of an infant is less than 100 beats/minute, the medication is withheld and the health care provider is notified. The pulse should be assessed for 60 seconds prior to administering the medication.

DIF: Cognitive Level: Application TOP: Heart Failure

REF: 629 OBJ: 3 KEY: Nursing Process Step: Implementation

7. A child develops carditis from rheumatic fever. Which areas of the heart are affected by carditis? a. Coronary arteries b. Heart muscle and the mitral valve

c. Aortic and pulmonic valves d. Contractility of the ventricles ANS: B The tissues that cover the heart and heart valves are affected. The heart muscle may be involved, and the mitral valve is frequently involved.

DIF: Cognitive Level: Knowledge TOP: Rheumatic Fever

REF: 632 OBJ: 7 KEY: Nursing Process Step: Data Collection

8. Which comment made by a parent of a 1-month-old infant would alert a nurse about the presence of a congenital heart defect? a. “He is always hungry.” b. “He tires out during feedings.” c. “He is fussy for several hours every day.” d. “He sleeps all the time.”

ANS: B Fatigue during feeding or activity is common to most infants with congenital cardiac problems.

DIF: Cognitive Level: Application TOP: Congenital Heart Disease

REF: 620 | 621 OBJ: 3 KEY: Nursing Process Step: Data Collection

9. A nurse is caring for a child with a diagnosis of Kawasaki disease. The child’s parent asks the nurse, “How does Kawasaki disease affect my child’s heart and blood vessels?” On what understanding is the nurse’s rNesUpR onSsI eN baGsT edB?.COM a. Inflammation weakens blood vessels, leading to aneurysm. b. Increased lipid levels lead to the development of atherosclerosis. c. Untreated disease causes mitral valve stenosis. d. Altered blood flow increases cardiac workload with resulting heart failure.

ANS: A Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.

DIF: Cognitive Level: Comprehension TOP: Kawasaki Disease

REF: 637 OBJ: 12 KEY: Nursing Process Step: Implementation

10. A nurse explains how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the caregiver leads the nurse to determine the parent understood the instructions? a. “If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest.” b. “If the baby turns blue, I will lay him down on a firm surface with his head lower than the rest of his body.” c. “If the baby turns blue, I will immediately put the baby upright in an infant seat.” d. “If the baby turns blue, I will put the baby in supine position with his head elevated.”

ANS: A

In the event of a paroxysmal hypercyanotic or “tet” spell, the infant should be placed in a knee-chest position.

DIF: Cognitive Level: Application TOP: Tetralogy of Fallot

REF: 626 OBJ: 6 KEY: Nursing Process Step: Evaluation

11. The parent of a 1-year-old child with tetralogy of Fallot asks a nurse, “Why do my child’s fingertips look like that?” On what understanding does the nurse base a response? a. Clubbing occurs as a result of untreated congestive heart failure. b. Clubbing occurs as a result of a left-to-right shunting of blood. c. Clubbing occurs as a result of decreased cardiac output. d. Clubbing occurs as a result of chronic hypoxia.

ANS: D Clubbing of the fingers develops in response to chronic hypoxia.

DIF: Cognitive Level: Comprehension TOP: Tetralogy of Fallot

REF: 626 OBJ: 3 KEY: Nursing Process Step: Implementation

12. A child has an elevated antistreptolysin O (ASO) titre. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever? a. Subcutaneous nodules and fever b. Painful, tender joints, and carditis c. Erythema marginatum and arthralgia d. Chorea and elevated sedimentation rate ANS: B NURSINGTB.COM The presence of two major Jones criteria would indicate a high probability of rheumatic fever.

DIF: Cognitive Level: Application TOP: Rheumatic Fever

REF: 633 OBJ: 7 KEY: Nursing Process Step: Data Collection

13. An infant with heart failure is receiving digoxin (Lanoxin). What does a nurse recognize as a sign of digoxin toxicity? a. Restlessness b. Decreased respiratory rate c. Increased urinary output d. Vomiting ANS: D Symptoms of digoxin toxicity include nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

DIF: Cognitive Level: Comprehension TOP: Heart Failure

REF: 629 OBJ: 6 KEY: Nursing Process Step: Data Collection

14. Through what does an infant born with hypoplastic left heart syndrome acquire oxygenated blood? a. The patent ductus arteriosus

b. A ventricular septal defect c. The closure of the foramen ovale d. An atrial septal defect ANS: A Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the foramen ovale and the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.

DIF: Cognitive Level: Knowledge TOP: Hypoplastic Left Heart Syndrome

REF: 626 OBJ: 3 KEY: Nursing Process Step: Planning

15. A child with rheumatic fever begins involuntary, purposeless movements of the limbs. What does a nurse recognize that this indicates? a. Seizure activity b. Hypoxia c. Sydenham’s chorea d. Decreasing level of consciousness ANS: C As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenham’s chorea, manifested by involuntary, purposeless movements of the limbs.

DIF: Cognitive Level: Knowledge TOP: Sydenham’s Chorea

REF: 632 OBJ: 7 KEY: Nursing Process Step: Data Collection

16. What is accurate about the chNarUaR ctS erI isN ticGsToB f. hiC ghO-M density lipoproteins (HDLs)? a. They have high amounts of triglycerides. b. They have only small amounts of protein. c. They have little cholesterol. d. They aid in steroid production.

ANS: C HDLs have low amounts of triglycerides, large amounts of proteins, and low amount of cholesterol, and are excreted via the liver. They have no role in the production of steroids.

DIF: Cognitive Level: Knowledge TOP: High-Density Lipoproteins

REF: 636 OBJ: 11 KEY: Nursing Process Step: Planning

17. A nurse is planning a hypertension-prevention program. What should be the main focus of the nurse when presenting information? a. Pharmacological treatment b. Surgical interventions available c. Patient education d. Reduction of aerobic exercise ANS: C The main focus of a hypertension-prevention program is patient education.

DIF: Cognitive Level: Knowledge TOP: Hypertension Prevention

REF: 635 OBJ: 11 KEY: Nursing Process Step: Implementation

18. A pediatric patient is scheduled for a noninvasive procedure to determine if his heart is structurally normal and to localize a murmur. What diagnostic test does a nurse anticipate? a. Barium swallow b. Chest X-ray c. Electrocardiogram d. Echocardiogram ANS: D Echocardiography is a noninvasive procedure that localizes murmurs and determines if the heart is structurally normal.

DIF: Cognitive Level: Knowledge TOP: Diagnostic Tests

REF: 622 OBJ: N/A KEY: Nursing Process Step: Planning

MULTIPLE RESPONSE 1. How would a nurse caring for an infant with heart failure (HF) modify feeding techniques to adapt for the child’s weakness and fatigue? (Select all that apply.) a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula ANS: A, B, C, E Infants with HF fatigue easilyN. U FR eeSdI inN gG caTnBb. eC giOvM en more frequently in smaller amounts through a soft, large-holed nipple. Formulas with a denser caloric content can be offered.

The child may be encouraged to nurse if he or she is held.

DIF: Cognitive Level: Application TOP: Feeding Infant with HF

REF: 628 OBJ: 6 KEY: Nursing Process Step: Implementation

2. What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select all that apply.) a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventral septal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta ANS: A, B, D, E The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus, stenosis of pulmonary artery, and dextroposition of the aorta.

DIF: Cognitive Level: Knowledge TOP: Tetralogy of Fallot

REF: 626 OBJ: 5 KEY: Nursing Process Step: Implementation

3. What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.)

a. b. c. d. e.

Spontaneous cyanosis Dyspnea Weakness Dry cough Syncope

ANS: A, B, C, E Indicators of a paroxysmal hypercyanotic episode or a “tet” episode are spontaneous cyanosis, dyspnea, weakness, and syncope.

DIF: Cognitive Level: Comprehension REF: 626 OBJ: 3 TOP: “Tet” Spells KEY: Nursing Process Step: Data Collection 4. Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that apply.) a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Dextroposition of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs) ANS: A, D, E The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus.

DIF: Cognitive Level: Comprehension REF: 624 OBJ: 5 TOP: Congenital Heart DefN ecUtsRSINGTBK EY .C O:M Nursing Process Step: Implementation 5. A 16-year-old patient is diagnosed with primary hypertension. What risk factors does a nurse teach when providing education on this diagnosis to the patient and his family? (Select all that apply.) a. Heredity b. Stress c. Congenital defect d. Obesity e. Poor diet ANS: A, B, D, E Primary, or essential, hypertension implies that no known underlying disease is present.

Nevertheless, heredity, obesity, stress, and a poor diet and exercise pattern can contribute to any type of hypertension.

DIF: Cognitive Level: Comprehension TOP: Primary Hypertension

REF: 635 OBJ: 9 | 10 KEY: Nursing Process Step: Planning

6. A nurse is aware that the following would be included in the care of a child with acute rheumatic fever? (Select all that apply.) a. Bedrest b. Administration of antibiotic treatment for 10 days c. Administration of medication for fever and pain

d. Brushing teeth once per day e. Use of a bed cradle ANS: A, B, C, E Care for the child with acute rheumatic fever includes antibacterial therapy, physical and mental rest, relief of pain and fever, and management of cardiac failure should it occur. Bed rest during the initial attack is recommended until the ESR returns to normal levels. A bed cradle can be used to prevent pressure on painful extremities. Care includes special attention to the skin, especially over bony prominences; back care; good oral hygiene; and small, frequent feedings of nourishing foods. Maintaining healthy teeth and preventing cavities is of special importance.

DIF: Cognitive Level: Application TOP: Rheumatic Fever

REF: 633 OBJ: 7 | 8 KEY: Nursing Process Step: Implementation

7. A nurse assessing a newborn with pulse oximetry screening is aware that which of the following conditions can be detected with this test? (Select all that apply.) a. Ventricular septal defect b. Atrial septal defect c. Tetralogy of Fallot d. Hypoplastic left heart syndrome e. Transposition of the great ANS: C, D, E Pulse oximetry screening is used to detect critical congenital heart disease that have a hypoxemia component. Ventricular septal defects and atrial septal defects are not detected with pulse oximetry screeninN g.URSINGTB.COM DIF: Cognitive Level: Comprehension REF: 621 | 622 TOP: Screening for Critical Congenital Heart Disease KEY: Nursing Process Step: Data Collection

OBJ: 4

8. A nurse would include the following in teaching a family how to manage hypertension in their 10-year-old child. (Select all that apply.) a. Limit salty food. b. Ensure moderate exercise for 30 minutes per day. c. Limit screen time per day. d. Increase intake of fruit, vegetables and whole grains. e. Put on a strict weight loss diet.

ANS: A, C, D Children with hypertension should limit intake of salty food, have screen time limited, get 60 minutes of aerobic exercise three to five times per week and follow the DASH diet.

Weight may need to be reduced but a strict weight loss diet would not be appropriate.

DIF: Cognitive Level: Comprehension TOP: Hypertension Guidelines COMPLETION

REF: 636 OBJ: 11 | 12 KEY: Nursing Process Step: Implementation

1. Children over the age of

should have blood pressure assessed at every examination.

ANS: 3 The assessment of blood pressure levels should be part of every physical examination during childhood for children over 3 years of age.

DIF: Cognitive Level: Knowledge TOP: Blood Pressure Screening

REF: 635 OBJ: 9 KEY: Nursing Process Step: Data Collection

NURSINGTB.COM

Chapter 27: The Child with a Condition of the Blood, Blood-Forming Organs, or Lymphatic System Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A 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. Dried fruit c. A banana d. A carrot ANS: B Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, iron-fortified cereal, dried fruits, beans, nuts, and wholegrain breads.

DIF: Cognitive Level: Comprehension TOP: Iron Deficiency Anemia

REF: 643 OBJ: 6 KEY: Nursing Process Step: Implementation

2. Which statement by a caregiver may indicate a cause for a 9-month-old’s iron deficiency anemia? a. “Formula is so expensive. We switched to regular milk right away.” b. “She almost never drinks water.” c. “She doesn’t really like pN eaUcR heSsIoN r pGeT arBs,.sC oO wM e stick to bananas for fruit.” d. “I give her a piece of bread now and then. She likes to chew on it.”

ANS: A Because cow’s milk contains very little iron, infants should drink iron-fortified formula for the first year of life.

DIF: Cognitive Level: Application TOP: Iron Deficiency Anemia

REF: 643 OBJ: 4 KEY: Nursing Process Step: Evaluation

3. What is important for a nurse to consider when administering elemental iron drops to a child on the pediatric unit? a. Administer with milk b. Administer with orange juice c. Administer with water d. Administer on a full stomach ANS: B Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.

DIF: Cognitive Level: Application TOP: Iron Deficiency Anemia

REF: 643 OBJ: 4 KEY: Nursing Process Step: Implementation

4. What is the result of a deficiency of factor IX? a. Thalassemia b. Idiopathic thrombocytopenic purpura c. Hemophilia A d. Christmas disease ANS: D Christmas disease, or hemophilia B, is caused by the deficiency of factor IX. DIF: Cognitive Level: Knowledge TOP: Christmas Disease

REF: 648 OBJ: 11 KEY: Nursing Process Step: N/A

5. A 2-year-old child has been diagnosed with hemophilia A. What information should a nurse include in a teaching plan about home care? a. If bleeding occurs, apply pressure, ice, elevate, and rest the extremity. b. Children’s aspirin in lowered doses may be given for joint discomfort. c. A firm, dry toothbrush should be used to clean teeth at least twice a day. d. Do not permit interactive play with other children.

ANS: A When bleeding occurs, the traditional approach is to follow PRICE—protection, relative rest, ice, compression, and elevation.

DIF: Cognitive Level: Application REF: 649 TOP: Hemophilia KEY: Nursing Process Step: Planning

OBJ: 12

6. What will a nurse teach the pN arU enRtsSoIfNaGcT hiB ld.w thMa low platelet count to avoid?

CiO a. Benadryl b. Aspirin c. Caffeine d. Prednisone ANS: B Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding.

DIF: Cognitive Level: Application TOP: Low Platelets

REF: 649 OBJ: 12 KEY: Nursing Process Step: Implementation

7. What should a nurse closely assess for in a child receiving a transfusion? a. Fever b. Lethargy c. Jaundice d. Bradycardia ANS: A The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain.

DIF: Cognitive Level: Comprehension TOP: Blood Transfusion

REF: 654 OBJ: 16 KEY: Nursing Process Step: Data Collection

8. On admission, a child with leukemia has widespread purpura and a platelet count of 19  109/L. 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: 650 TOP: Leukemia KEY: Nursing Process Step: Planning

OBJ: 15

9. An adolescent is diagnosed with Hodgkin disease. Lymph nodes on both sides of the diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this? a. I b. II c. III d. IV ANS: C Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage-III Hodgkin disease.

NURSINGTB.COM

DIF: Cognitive Level: Application TOP: Hodgkin Disease

REF: 654 OBJ: N/A KEY: Nursing Process Step: Data Collection

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 TOP: Sickle Cell Disease

REF: 645 OBJ: 8 KEY: Nursing Process Step: Data Collection

11. Which statement made by a parent is the best indication of 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. “My child should wear protective equipment when playing contact sports.” d. “My child shouldn’t receive any immunizations until 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 TOP: Sickle Cell Disease

REF: 646 OBJ: 9 KEY: Nursing Process Step: Evaluation

12. A couple who are considering pregnancy are seeking genetic counselling because they are both carriers of the sickle cell trait. How can a nurse best explain the children’s risk of inheriting this disease? a. Every fourth child will have the disease; two others will be carriers. b. All of their children will be carriers, just as they are. c. Each child has a one in four chance of having the disease and a two in four chance of being a carrier. d. The risk levels of their children cannot be determined by this information.

ANS: C The sickle cell gene is inherited from both parents; therefore, each offspring has a one in four chance of inheriting the disease.

DIF: Cognitive Level: Analysis TOP: Sickle Cell Disease

REF: 645 OBJ: 7 KEY: Nursing Process Step: Implementation

13. A child with thalassemia major receives blood transfusions frequently. A nurse is aware that which of the following is a complication of repeated blood transfusions? a. Hemarthrosis b. Hematuria NURSINGTB.COM 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: 647 OBJ: 16 TOP: Thalassemia KEY: Nursing Process Step: Data Collection 14. A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction of immature white blood cells in the bone marrow? a. Decreased T-cell production b. Decreased hemoglobin c. Increased blood clotting d. Increased susceptibility to infection ANS: D An overproduction of immature white blood cells increases the child’s susceptibility to infection.

DIF: Cognitive Level: Comprehension REF: 650 OBJ: 14 | 15 TOP: Leukemia KEY: Nursing Process Step: Data Collection

15. A child receiving a transfusion states symptoms of back pain and itching. What is the best initial action by a nurse? a. Notify the charge nurse. b. Disconnect intravenous lines immediately. c. Give diphenhydramine (Benadryl). d. Clamp off blood and keep line open with normal saline.

ANS: D If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse.

DIF: Cognitive Level: Application TOP: Blood Transfusion

REF: 654 OBJ: 16 KEY: Nursing Process Step: Implementation

16. What would a nurse include in a teaching plan about mouth care of a child receiving chemotherapy? a. Use a 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.

NURSINGTB.COM

DIF: Cognitive Level: Application TOP: Leukemia Care

REF: 650 OBJ: 15 KEY: Nursing Process Step: Planning

17. A nurse notes that a 4-year-old child’s gums bleed easily and there is bruising and petechiae on the extremities. Which lab value is consistent with these symptoms? a. Platelet count of 25  109/L b. Hemoglobin level of 80 g/L c. Hematocrit level of 0.3 d. Leukocyte count of 14  109/L ANS: A The normal platelet count is 150 to 400  109/L. This finding is very low, indicating an increased bleeding potential.

DIF: Cognitive Level: Analysis REF: 649 TOP: Idiopathic Thrombocytopenic Purpura KEY: Nursing Process Step: Data Collection

OBJ: 14

18. A nurse is caring for a child receiving chemotherapy, and notes that the child’s abdomen is firm and slightly distended. There is no record of a bowel movement for the last 2 days.

What do these assessment findings suggest? a. Peripheral neuropathy b. Stomatitis

c. Myelosuppression d. Hemorrhage ANS: A Peripheral neuropathy may be signalled by severe constipation resulting from decreased nerve sensations in the bowel.

DIF: Cognitive Level: Analysis REF: 652 OBJ: 14 | 15 TOP: Leukemia KEY: Nursing Process Step: Data Collection 19. A nurse finds an adolescent with Hodgkin disease crying. The adolescent says, “I am so scared.” What is the most appropriate nursing response to this comment? a. “I understand how you must feel.” b. “You shouldn’t feel that way.” c. “Is this the strongest feeling you’ve had today?” d. “Tell me what’s got you scared.”

ANS: D The nurse should encourage the adolescent to express her feelings and concerns.

DIF: Cognitive Level: Application REF: 653 TOP: Adolescent with Cancer—Fear of Death KEY: Nursing Process Step: Implementation

OBJ: N/A

20. 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 NURSINGTB.COM 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: 646 TOP: Chemotherapy: Neutropenia KEY: Nursing Process Step: Nursing Diagnosis

OBJ: 15

21. A nurse is presenting information on the congenital disorder of hemophilia A. What fact will the nurse include? a. It is seen in males and females equally. b. It is transmitted by symptom-free females. c. It is a sex-linked dominant trait. d. It is a defective gene located on the Y chromosome.

ANS: B Hemophilia A affects mostly males who received the sex-linked recessive trait from a symptom-free female. The defective gene is on the X chromosome.

DIF: Cognitive Level: Comprehension REF: 648 TOP: Hemophilia KEY: Nursing Process Step: Planning

OBJ: 11

22. A child is diagnosed with iron deficiency anemia. What will a nurse explain can occur if this disorder goes untreated? a. Hemorrhage b. Heart failure c. Infection d. Pulmonary embolism ANS: B Untreated iron deficiency anemias progress slowly, and in severe cases the heart muscle becomes too weak to function. If this happens, heart failure follows.

DIF: Cognitive Level: Comprehension TOP: Iron Deficiency Anemia

REF: 643 OBJ: 5 KEY: Nursing Process Step: Data Collection

MULTIPLE RESPONSE 1. A nurse is caring for a child with a low platelet count. What skin assessments would alert the nurse to bleeding? (Select all that apply.) a. Petechiae b. Purpura c. Ecchymosis d. Hematoma e. Lymphadenopathy ANS: A, B, C, D The reduction or destruction N ofUpRlaSteIleNtsGiT nB th.eCbO odMy interferes with the clotting mechanism.

Skin lesions that are common to these disorders include petechiae, a bluish, nonblanching, pinpoint-sized lesion; purpura, groups of adjoining petechiae; ecchymosis, an isolated bluish lesion larger than a petechia; and hematoma, a raised ecchymosis. Lymphadenopathy is an enlargement of lymph nodes that is indicative of infection or disease.

DIF: Cognitive Level: Comprehension TOP: Manifestations of Bleeding

REF: 649 OBJ: 13 KEY: Nursing Process Step: Data Collection

2. What should be included in the nursing care of a 12-year-old child receiving radiation therapy for Hodgkin 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 TOP: Effects of Radiation

REF: 654 OBJ: N/A KEY: Nursing Process Step: Planning

3. What are the classic symptoms of thalassemia major (Cooley’s anemia)? (Select all that apply.) a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Renal failure ANS: A, B, C, D All of the options are classic signs of thalassemia major except renal failure.

DIF: Cognitive Level: Comprehension REF: 647 OBJ: 10 TOP: Thalassemia KEY: Nursing Process Step: Data Collection 4. The family of a child receiving chemotherapy for leukemia should be taught to focus on which aspect(s) of the child’s care? (Select all that apply.) a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration d. Continuing with scheduled immunizations e. Reporting exposure to infectious diseases ANS: A, B, C, E Support groups are helpful for emotional support and realistic tips on care. The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect ofNtU heRm edNicGatio cause the medications suppress the bone SI TBn.s.CBOeM marrow, children are at risk for infection, and the suppression will not allow the antibody response needed for immunization.

DIF: Cognitive Level: Analysis TOP: Chemotherapy

REF: 652 | 653 OBJ: 15 KEY: Nursing Process Step: Implementation

5. A newborn’s blood results would demonstrate which of the following? (Select all that apply) a. Increased hemoglobin b. Increased red blood cells c. Increased white blood cells d. Increased Vitamin K e. Low iron ANS: A, B, C The newborn has a high hemoglobin and red blood cell count at birth. A high white blood cell level is also evident at birth but decreases by 1 week to a stable level. The vitamin K level is low in the newborn and is required for the development of several blood clotting factors. Iron levels are normal at birth but decrease after 6 months of age.

DIF: Cognitive Level: Analysis TOP: Normal Blood Values

REF: 641 OBJ: 3 KEY: Nursing Process Step: Data Collection

Chapter 28: The Child with a Gastrointestinal Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. Which finding in a newborn is suggestive of tracheoesophageal fistula? a. Failure to pass meconium in 24 hours b. Choking on the first feeding c. Palpable mass in the sternal area d. Visible peristalsis across abdomen ANS: B After birth, a newborn with tracheoesophageal fistula will vomit and choke when the first feeding is introduced.

DIF: Cognitive Level: Comprehension TOP: Esophageal Atresia

REF: 663 OBJ: 8 KEY: Nursing Process Step: Data Collection

2. A child is brought to the pediatric clinic due to vomiting for the past 2 days. What acid-base imbalance would a nurse expect to occur from this persistent vomiting? a. Hyperkalemia b. Hypernatremia c. Acidosis d. Alkalosis

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ANS: D Hydrochloric acid and sodium chloride from the stomach are lost from persistent vomiting.

This results in alkalosis.

DIF: Cognitive Level: Comprehension TOP: Acid-Base Balance

REF: 668 OBJ: 11 KEY: Nursing Process Step: Data Collection

3. On the second day of hospitalization for a 3-month-old admitted for treatment for gastroenteritis, a nurse makes all of the assessments listed below. Which assessment finding best indicates ineffectiveness of treatment? a. Weight loss of 120 g b. Dry mucous membranes c. Decreased skin turgor d. Depressed fontanelle ANS: A Weight loss is the most significant indicator of dehydration because an infant’s weight comprises 77% water.

DIF: Cognitive Level: Application REF: 673 OBJ: 11 TOP: Dehydration KEY: Nursing Process Step: Data Collection 4. Why are rapid respirations a possible cause of dehydration in a child?

a. b. c. d.

They prevent the child from drinking.

They increase circulation, thus increasing urine production.

They cause evaporation of fluid of the mucous membranes.

They often lead to vomiting.

ANS: C Rapid respirations cause increased insensible fluid loss.

DIF: Cognitive Level: Comprehension REF: 674 OBJ: 10 TOP: Dehydration KEY: Nursing Process Step: Data Collection 5. Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux? a. Position the infant a Fowler’s sling. b. Administer medication as ordered to stimulate the pyloric sphincter. c. Give thin rice cereal with formula before feeding solid foods. d. Place the infant in an infant seat after feedings.

ANS: A After being fed, the infant should be placed in an upright position or propped on the left side. The body is inclined about 30 degrees, and the infant may be held in place by a Fowler’s sling DIF: Cognitive Level: Application TOP: Gastroesophageal Reflux

REF: 671 OBJ: 7 KEY: Nursing Process Step: Implementation

6. A nurse is interviewing parenNtsUoRf S anIiNnG faT ntBw.iC thOhM ypertrophic pyloric stenosis. What would the nurse expect the parents to report? a. Diarrhea b. Projectile vomiting c. Poor appetite d. Constipation ANS: B Vomiting is the outstanding symptom of hypertrophic pyloric stenosis. Food is ejected with considerable force, which is described as projectile vomiting.

DIF: Cognitive Level: Comprehension TOP: Pyloric Stenosis

REF: 659 OBJ: 3 KEY: Nursing Process Step: Data Collection

7. A mother reports that her child has been scratching the anal area and has symptoms of itching. What does a nurse suspect, based on this information? a. Pinworms b. Giardiasis c. Ringworm d. Roundworm ANS: A With pinworms, the nurse or parent may notice that the child scratches the anal area and has itching. The other choices do not cause this reaction.

DIF: Cognitive Level: Comprehension REF: 679 OBJ: 14 TOP: Worms KEY: Nursing Process Step: Data Collection 8. A nurse is teaching a parent about pyrvinium. What would be included regarding potential side effects? a. Diarrhea b. Skin rash c. Red stool d. Metallic taste ANS: C The nurse should advise parents that pyrvinium stains clothing and turns stools red.

DIF: Cognitive Level: Knowledge REF: 679 OBJ: 14 TOP: Worms KEY: Nursing Process Step: Implementation 9. What instruction will a nurse give to parents about preventing the spread and reinfection of pinworms? a. Keep children’s nails short. b. Dress child in loose-fitting underwear. c. Clean the bathroom with bleach solution. d. Wash bed linens in cold water.

ANS: A One intervention to prevent the further spread of pinworms is to keep the child’s fingernails short. Pinworms are not spread from person to person.

NURSINGTB.COM

DIF: Cognitive Level: Comprehension REF: 679 OBJ: 14 TOP: Worms KEY: Nursing Process Step: Implementation 10. A mother reports that her 2-year-old child experiences constipation frequently. Which food would a nurse recommend including in the child’s diet? a. Cooked vegetables b. Pretzels c. Wholegrain cereal d. Yogurt ANS: C Dietary modifications for constipation include eating more high-roughage foods such as wholegrain breads and cereals.

DIF: Cognitive Level: Comprehension REF: 672 OBJ: N/A TOP: Constipation KEY: Nursing Process Step: Implementation 11. What description of a child’s stool characteristic leads a nurse to suspect intussusception? a. Currant jelly b. Black and tarry c. Green liquid d. Greasy and foul-smelling ANS: A

Bowel movements of blood and mucus that contain no feces (“currant jelly” stools) are common about 12 hours after the onset of the obstruction.

DIF: Cognitive Level: Comprehension TOP: Intussusception

REF: 662 OBJ: 6 KEY: Nursing Process Step: Data Collection

12. What is the treatment of choice for a child with intussusception? a. An air enema b. Immediate surgery c. IV fluids until the spasms subside d. Gastric lavage ANS: A A pneumoenema (air enema) with or without water-soluble contrast or ultrasound-guided hydrostatic (saline) enema is used to reduce the defect. Surgery is scheduled only if reduction is not achieved.

DIF: Cognitive Level: Knowledge TOP: Intussusception

REF: 662 OBJ: 6 KEY: Nursing Process Step: Implementation

13. Parents ask a nurse how their infant developed a Meckel’s diverticulum. What condition, will the nurse explain, is present causing this diagnosis? a. The yolk sac remains connected to the intestine. b. There is inflammation of the ileocecal valve. c. A pouch forms when the vitelline duct fails to disappear. d. There is a weakness in the abdominal wall.

NURSINGTB.COM

ANS: C If the vitelline duct fails to disappear completely after birth, a blind pouch may form.

DIF: Cognitive Level: Knowledge TOP: Meckel’s Diverticulum

REF: 662 OBJ: 2 KEY: Nursing Process Step: Data Collection

14. An infant is admitted to the hospital with severe isotonic dehydration. What is this child at the highest risk for? a. Metabolic alkalosis b. Hypocalcemia c. Sepsis d. Shock ANS: D Shock is the greatest threat to life in isotonic dehydration.

DIF: Cognitive Level: Comprehension REF: 675 TOP: Dehydration KEY: Nursing Process Step: Planning

OBJ: 11

15. A child is brought to the emergency department because of ingesting an unknown quantity of acetaminophen (Tylenol). What does a nurse expect this child to most likely receive following gastric lavage? a. Activated charcoal

b. N-acetylcysteine c. Vitamin K d. Syrup of ipecac ANS: B Gastric lavage is followed by N-acetylcysteine (Mucomyst), the antidote for acetaminophen.

DIF: Cognitive Level: Comprehension TOP: Acetaminophen Poisoning

REF: 681 OBJ: 16 KEY: Nursing Process Step: Implementation

16. A nurse is planning a parent education program about lead poisoning prevention. What will be included regarding primary sources of lead in the community? a. Increased lead content of air b. Use of aluminum cookware c. Food and drinking water d. Inhaling smog ANS: C Lead-based paint may still be present in older homes. For infants and children, ingestion of non-food items containing lead (such as dust, lead-based paint, soil and products), along with food and drinking water, are the greatest sources of exposure to lead in the environment.

DIF: Cognitive Level: Knowledge TOP: Lead Poisoning

REF: 683 OBJ: 17 KEY: Nursing Process Step: Planning

17. An 18-month-old child had aNsur aiB r. ofCaOcM left palate and is now allowed to eat a URgiScaIlNreGpT regular diet. What nursing action is the most appropriate? a. Feed solid foods with the spoon at the side of the mouth. b. Puree foods and offer them through a straw. c. Place small bites of food in the mouth with a tongue blade. d. Offer small, frequent meals of finger foods.

ANS: A The primary concern with feeding is to protect the operative site. The child can be fed with a spoon, but only the side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of the mouth.

DIF: Cognitive Level: Application TOP: Cleft Lip and Palate

REF: 665 OBJ: 9 KEY: Nursing Process Step: Implementation

18. A nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately? a. Facial paralysis b. Ear infections c. Increased intracranial pressure d. Drooling ANS: B Children with cleft palate are at risk of ear infections and dental disorders. Parents should be instructed to take the child to the health care provider at the first sign of earache.

DIF: Cognitive Level: Application TOP: Complication of Cleft Palate

REF: 666 OBJ: 9 KEY: Nursing Process Step: Implementation

19. What does a nurse expect the appearance of the stools of a child with celiac disease to be? a. Ribbon like b. Hard, constipated c. Bulky, frothy d. Loose, foul-smelling ANS: C Celiac disease causes malabsorption. Stools that are large, bulky, and frothy may indicate malabsorption.

DIF: Cognitive Level: Comprehension TOP: Celiac Disease

REF: 666 OBJ: 4 KEY: Nursing Process Step: Data Collection

20. A nurse has reviewed dietary restrictions for celiac disease with concerned parents. Which grain will the nurse explain can be eaten with celiac disease? a. Wheat b. Oats c. Barley d. Rice ANS: D Rice is a gluten-free grain that can be eaten by children afflicted with celiac disease. These children will have a lifelong rNeU stR ricStiIoN nG ofTwBh.eC atO , oMats, barley, and rye.

DIF: Cognitive Level: Knowledge TOP: Celiac Disease

REF: 666 OBJ: 4 KEY: Nursing Process Step: Evaluation

21. A 7-month-old infant is admitted to the hospital with a diagnosis of acute gastroenteritis.

What will be a nurse’s priority goal of the infant’s care? a. Prevent fluid and electrolyte imbalance. b. Prevent nutritional deficiency. c. Prevent skin breakdown. d. Prevent malabsorption.

ANS: A The priority goal of care in gastroenteritis is preventing fluid and electrolyte imbalance.

DIF: Cognitive Level: Analysis TOP: Gastroenteritis

REF: 668 OBJ: N/A KEY: Nursing Process Step: Planning

22. A nurse is speaking to the parent of a 3-year-old child who has mild diarrhea. What dietary modification would the nurse advise? a. Soft foods with rice, bananas, toast, and applesauce b. Small amounts of clear fluids such as gelatin c. An oral rehydrating solution, such as Pedialyte d. Chicken soup because it is high in sodium

ANS: C An oral rehydrating solution is recommended to replace fluids and electrolytes lost from frequent bowel movements.

DIF: Cognitive Level: Application REF: 668 OBJ: 11 TOP: Diarrhea KEY: Nursing Process Step: Implementation 23. What would a nurse expect to find in a child admitted to the hospital for failure to thrive? a. Cries to be picked up b. Has vomiting or diarrhea c. Responsive to cuddling d. Weight in the 10th percentile for age ANS: B Infants who fail to thrive are often admitted to the hospital for evaluation with presenting symptoms of weight loss or failure to gain, irritability, and disturbances of food intake such as anorexia or pica (abnormal consumption of nonfood materials). Vomiting, diarrhea, and general neuromuscular spasticity sometimes accompany the condition. These children fall below the 5th percentile in weight and height on standard growth charts.

DIF: Cognitive Level: Comprehension TOP: Failure to Thrive

REF: 677 OBJ: 12 KEY: Nursing Process Step: Data Collection

24. Which nursing interventions will be implemented for the mother of a 10-month-old infant with failure to thrive? a. Pointing out errors that the nurse observes when the mother is caring for the infant b. Discussing negative charaNcU teR riS stI icN sG ofTthBe.iC nfO anMt with the mother c. Having the nurse provide as much of the infant’s care as possible d. Teaching the mother about the developmental milestones to expect in the next few months ANS: D The nurse can increase parent’s knowledge of growth and development by providing anticipatory guidance about normal developmental milestones.

DIF: Cognitive Level: Application TOP: Failure to Thrive

REF: 677 OBJ: 12 KEY: Nursing Process Step: Implementation

25. Which statement by a mother may indicate a cause of her child’s vitamin C deficiency? a. “We get our fruits from homemade preserves.” b. “We use milk from our own goats.” c. “We grow all our own vegetables.” d. “We’re not big meat eaters.”

ANS: A Vitamin C is destroyed by heat.

DIF: Cognitive Level: Comprehension REF: 678 OBJ: 10 TOP: Scurvy KEY: Nursing Process Step: Data Collection

26. A nurse is instructing a mother how to administer oral nystatin suspension prescribed to treat thrush. What will the nurse include? a. Pour the prescribed amount into a nipple and have the infant suck the medication. b. Squirt the prescribed dose into the back of the mouth and have the infant swallow. c. Give the medication mixed with a small amount of juice in a bottle. d. Use a sterile applicator to swab the medication on the oral mucosa.

ANS: D An appropriate way to administer nystatin is to moisten a sterile applicator with the medication and then swab it on the inside of the mouth.

DIF: Cognitive Level: Application REF: 679 OBJ: 13 TOP: Thrush KEY: Nursing Process Step: Implementation 27. Why are infants more vulnerable to fluid and electrolyte imbalances than adults? a. They have a smaller surface area than adults in proportion to body weight. b. Water needs and losses per kilogram are lower than those for adults. c. A greater percentage of body water in infants is extracellular. d. Infants have a lower metabolic turnover of water.

ANS: C A greater percentage of body water is contained in the extracellular compartment of children under 2 years of age.

DIF: Cognitive Level: Knowledge REF: 672 OBJ: 10 TOP: Dehydration KEY: Nursing Process Step: Data Collection

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28. Postoperative nursing care of the infant following surgical repair of a cleft lip would include which of the following? a. Feeding the infant with a spoon to avoid sucking. b. Positioning the infant on the abdomen to facilitate drainage. c. Resuming breastfeeding within the first day after surgery. d. Providing minimal stimulation to prevent injury to the incision.

ANS: C Breastfeeding can resume within the first day without any complications to the surgical site.

DIF: Cognitive Level: Application TOP: Cleft Lip and Palate

REF: 664 OBJ: 9 KEY: Nursing Process Step: Implementation

29. Following surgery for pyloric stenosis, an infant awoke from anesthesia hungry and crying.

What is the most appropriate nursing action? a. Delay feeding the child for 6 hours. b. Offer regular formula thinned with water. c. Give small amounts of regular formula thickened with cereal. d. Allow 30 mL of glucose water at frequent intervals.

ANS: D Small oral feedings of glucose water are given after recovery from anesthesia. Feedings are gradually increased to larger amounts of breastmilk or formula.

DIF: Cognitive Level: Application TOP: Postoperative Pyloric Stenosis

REF: 660 OBJ: 3 KEY: Nursing Process Step: Implementation

30. The nurse is caring for an 8.2-kg child who has had one stool of diarrhea. The nurse knows that the child needs to consume how many millilitres of oral fluid to make up for the fluid loss? a. 18 b. 42 c. 64 d. 82 ANS: D The formula for oral fluid replacement is 10 mL/kg. 8.2 kg  10 = 82 mL. DIF: Cognitive Level: Analysis TOP: Oral Fluid Replacement

REF: 675 OBJ: 11 KEY: Nursing Process Step: Implementation

31. Which statement made by a parent alerts a nurse to the need for additional education about poison prevention? a. “I keep the poison control centre phone number easily accessible.” b. “All medication is kept out of reach in a locked cabinet.” c. “I keep a bottle of syrup of ipecac handy.” d. “Our garden is free from marigolds.”

ANS: C In the past, syrup of ipecac was the treatment of choice to remove some types of poisons from a child’s system and parNeU ntR sS wI erN eG adTvBis. edCtOoMkeep a supply on hand in the home.

However, parents are now advised to call the poison control centre to determine the treatment necessary and if admission is necessary to bring the container of the substance ingested to the hospital emergency department as quickly as possible because stomach lavage is rarely effective 1 hour or more after ingestion. Ipecac syrup should not be kept in the home. Uncontrolled vomiting can cause serious complications.

DIF: Cognitive Level: Comprehension TOP: Poison Control

REF: 680 OBJ: 15 KEY: Nursing Process Step: Implementation

32. Which assessment would the nurse report to the pediatric health care provider immediately? a. 2-month-old with a urine output of 150 mL in 24 hours b. 3-year-old with a urine output of 650 mL in 24 hours c. 8-year-old with a urine output of over 1000 mL in 24 hours d. 14-year-old with a urine output of 800 mL in 24 hours ANS: A The urine output of a 2-month-old infant should be between 400 and 500 mL/24 hours.

DIF: Cognitive Level: Application REF: 675 OBJ: 11 TOP: Dehydration KEY: Nursing Process Step: Data Collection MULTIPLE RESPONSE

1. What assessment(s) would lead a nurse to suspect Hirschsprung disease in a 1-month-old infant? (Select all that apply.) a. Ribbon-like stools b. Fever c. Failure to thrive d. Vomiting e. Diminished peristalsis ANS: A, C, D, E All options are significant indicators of Hirschsprung disease except for fever.

DIF: Cognitive Level: Comprehension TOP: Hirschsprung Disease

REF: 667 OBJ: 5 KEY: Nursing Process Step: Data Collection

2. What sign(s) indicate(s) moderate dehydration? (Select all that apply.) a. 10% weight loss b. Dry mucous membranes c. Normal anterior fontanel d. Increased urinary output e. Lethargy ANS: A, B, C The child that is moderately dehydrated will have lost 10% of his body weight, will have dry mucous membranes, normal (nonsunken) anterior fontanelle, decreased urine output, and will be irritable.

DIF: Cognitive Level: ComNpUreRhS enIsN ioG n TBR OBJ: 11 .ECFO:M 675 TOP: Moderate Dehydration KEY: Nursing Process Step: Planning 3. A child is brought into the emergency department with suspected appendicitis. What signs and symptoms does a nurse expect to assess? (Select all that apply.) a. Left lower quadrant pain b. Guarding c. Rebound tenderness d. Decreased C-reactive protein e. Pain on lifting thigh when supine ANS: B, C, E With appendicitis, on examination, characteristic tenderness in the right lower quadrant (RLQ) known as McBurney point will occur. Other diagnostic signs include guarding (tightening of the abdominal muscles or rigidity of the abdomen on palpation); rebound tenderness (pressing the RLQ with rapid release of pressure causes severe pain); and pain on lifting the thigh while in the supine position (caused by muscle irritation.) C-reactive protein levels will be increased after 12 hours if any infection is present.

DIF: Cognitive Level: Comprehension REF: 678 OBJ: N/A TOP: Appendicitis KEY: Nursing Process Step: Data Collection 4. Parents have adopted a child with the diagnosis of kwashiorkor. What is most likely to be observed when assessing this child? (Select all that apply.)

a. b. c. d. e.

Hyperactivity White streak in hair Edematous abdomen Slowed growth Thick, oily hair

ANS: B, C, D In kwashiorkor, which is rare in Canada, there is a severe deficiency of protein in the diet even though the number of calories consumed may be nearly adequate. The child fails to grow normally. The muscles become weak and wasted. There is edema of the abdomen that may become generalized. Diarrhea, skin infections, irritability, anorexia, and vomiting may be present. The hair becomes thin and dry. Because protein is the basis of melanin, which is a substance that provides colour to hair, melanin becomes deficient. This is the reason that the earliest sign of this protein malnutrition is a white streak in the hair of the child (depigmentation). The child looks apathetic and weak with a protuberant abdomen and a reddish-brown scaling of the skin.

DIF: Cognitive Level: Comprehension TOP: Nutritional Deficiencies

REF: 677 OBJ: 12 KEY: Nursing Process Step: Data Collection

COMPLETION 1. The nurse explains the medically accepted definition of constipation in children under 4-years of age is fewer than bowel movements in a 1-week period. (Input your answer in words.)

NURSINGTB.COM

ANS: Two Functional constipation is diagnosed according to the ROME IV criteria, and for children under 4 years of age this includes fewer than two defecations per week, a history of hard bowel movements, large diameter stools, and one episode per week of incontinence (after being toilet trained).

DIF: Cognitive Level: Knowledge REF: 671 | 672 OBJ: N/A TOP: Constipation KEY: Nursing Process Step: Implementation

Chapter 29: The Child with a Genitourinary Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse discusses strategies with a parent to prevent a recurrence of urinary tract infection in the child. Which statement made by the parent indicates a need for further teaching? a. “My daughter should wash and wipe the perineal area from front to back.” b. “I am only going to have my daughter wear cotton underwear.” c. “It is acceptable to take frequent bubble baths.” d. “She needs to drink lots of fluids and void frequently.”

ANS: C Oils in bubble bath and similar products are known to irritate the urethra.

DIF: Cognitive Level: Comprehension TOP: Acute Urinary Tract Infection

REF: 695 OBJ: 6 KEY: Nursing Process Step: Evaluation

2. When asked about correcting the hypospadias of a newborn, what does a nurse explain about this condition? a. No intervention is necessary as the defect will correct itself over time. b. Surgical repair of the hypospadias is done before 18 months of age. c. Corrective surgery is usually delayed until the preschool age. d. Repairing the defect will increase the risk of testicular cancer.

NURSINGTB.COM

ANS: B Treatment of hypospadias consists of surgical repair and is usually performed between 6 and 18 months of age.

DIF: Cognitive Level: Comprehension REF: 691 OBJ: 5 TOP: Hypospadias KEY: Nursing Process Step: Implementation 3. What is an initial sign of acute glomerulonephritis that a nurse might note in a child? a. Raspberry-like rash b. Periorbital edema c. Temperature elevation d. Abdominal pain ANS: B From 1 to 3 weeks after a streptococcal infection has occurred, the parent may notice that the child has periorbital edema when awakening in the morning and that the child’s urine is smoky brown or bloody.

DIF: Cognitive Level: Knowledge TOP: Glomerulonephritis

REF: 697 OBJ: 9 KEY: Nursing Process Step: Data Collection

4. What is it important to assess in a child receiving prednisone to treat nephrotic syndrome? a. Infection

b. Urinary retention c. Easy bruising d. Hypoglycemia ANS: A Prednisone depresses the immune response and increases susceptibility to infection.

Because steroids mask signs of infection, the child must be assessed for more subtle symptoms of illness.

DIF: Cognitive Level: Comprehension TOP: Nephrotic Syndrome

REF: 696 OBJ: 9 KEY: Nursing Process Step: Data Collection

5. During a physical assessment of a hospitalized 5-year-old child, a nurse notes that the foreskin has been retracted and is very tight on the shaft of the penis; the nurse is unable to return it over the head of the penis. What action should the nurse implement? a. Forcibly push the foreskin down over the head of the penis. b. Place a warm compress on the penis. c. Notify the charge nurse. d. Wait a few hours and try again.

ANS: C Notify the charge nurse of this occurrence of paraphimosis. The tight foreskin can impede blood flow to the penis; this should be remedied immediately.

DIF: Cognitive Level: Application TOP: Paraphimosis

REF: 690 OBJ: N/A KEY: Nursing Process Step: Implementation

NURSINGTB.COM

6. A 7-year-old child with acute glomerulonephritis ha s gross hematuria and has been confined to bed. What is the most important nursing intervention for this child? a. Providing activities for the child on restricted activity b. Feeding the child a protein-restricted diet c. Carefully handling edematous extremities d. Observing the child for evidence of hypotension ANS: A Although children may feel well, activity is limited until hematuria resolves.

DIF: Cognitive Level: Application TOP: Acute Glomerulonephritis

REF: 697 OBJ: 9 KEY: Nursing Process Step: Planning

7. Which urinary diversion procedure is the least damaging to the body image of the adolescent? a. Urostomy b. Ileal conduit c. Nephrostomy d. Suprapubic placement ANS: B The ileal conduit diverts urine to the colon, and the urine is excreted with the feces. There is no external appliance, as is needed with the other diversion methods.

DIF: Cognitive Level: Comprehension REF: 692 TOP: Obstructive Uropathy—Urinary Diversions KEY: Nursing Process Step: Implementation

OBJ: 12

8. A mother of a 5-year-old child taking prednisone for nephrotic syndrome tells a nurse the child requires immunizations prior to entering kindergarten. What does the nurse clarify about receiving immunizations while on prednisone? a. Can interfere with the treatment for nephrosis b. Require that the child have antibiotic coverage c. Can be given in smaller, divided doses d. Should be delayed ANS: D No vaccinations or immunizations should be administered while the disease is active and during immunosuppressive therapy.

DIF: Cognitive Level: Comprehension TOP: Nephrotic Syndrome

REF: 696 OBJ: N/A KEY: Nursing Process Step: Data Collection

9. Diuresis has not occurred on a child with nephrotic syndrome after a month on corticosteroids. What protocol can the nurse encourage to bring about diuresis? a. Ibuprofen, an anti-inflammatory agent b. Furosemide (Lasix), a diuretic c. Ciprofloxacin (Cipro), an antibiotic d. Cyclophosphamide, an immunosuppressant ANS: D NURSINGTB.COM A potent antisuppressant such as cyclophosphamide can bring about diuresis when corticosteroids have proven ineffective.

DIF: Cognitive Level: Application TOP: Nephrotic Syndrome

REF: 696 OBJ: 9 KEY: Nursing Process Step: Implementation

10. What foods does a nurse recommend the child with acute glomerulonephritis avoid, to prevent hyperkalemia? a. Dairy products b. Wholegrain cereals c. Organ meats d. Bananas ANS: D Bananas are very high in potassium and should be avoided.

DIF: Cognitive Level: Comprehension REF: 697 OBJ: 9 TOP: AGN KEY: Nursing Process Step: Implementation 11. Which physical assessment technique will a nurse omit when caring for a 2-year-old child diagnosed with Wilms tumour? a. Performing range-of-motion exercises on lower extremities b. Palpating the abdomen

c. Assessing for bowel sounds d. Percussing ankle and knee reflexes ANS: B Palpation of the abdomen could disturb the tumour and cause the malignancy to spread.

DIF: Cognitive Level: Application TOP: Wilms Tumour

REF: 698 OBJ: 10 KEY: Nursing Process Step: Planning

12. Parents are speaking with the urologist about their son’s undescended testicle. Which statement by the child’s father causes a nurse to determine he understands the information presented? a. “An undescended testicle can reduce fertility.” b. “The testicle usually descends spontaneously during the first month of life.” c. “Surgical correction reduces the risk for testicular tumours.” d. “The optimal time to surgically correct the condition is at diagnosis.”

ANS: A Although orchiopexy improves the condition, the fertility rate among patients may be reduced even when only one testis is undescended.

DIF: Cognitive Level: Application TOP: Cryptorchidism

REF: 699 OBJ: 11 KEY: Nursing Process Step: Evaluation

13. A parent tells a nurse that her child is scheduled for an X-ray of the bladder and urethra that is done while the child is urinating. What is this test known as? a. Cystometrogram NURSINGTB.COM b. Cystoscopy c. Voiding cystourethrogram d. Intravenous pyelogram ANS: C An x-ray examination of the bladder and urethra before and during micturition is called a voiding cystourethrogram.

DIF: Cognitive Level: Comprehension TOP: Diagnostic Procedures

REF: 693 OBJ: 4 KEY: Nursing Process Step: Data Collection

14. A 6-year-old child with daytime enuresis has symptoms of dysuria and urgency. What does a nurse recognize these signs and symptoms indicate? a. Urinary tract infection b. Nephrotic syndrome c. Acute glomerulonephritis d. Vesicoureteral reflux ANS: A Urinary frequency and pain during micturition are symptoms of acute urinary tract infection.

DIF: Cognitive Level: Comprehension TOP: Acute Urinary Tract Infection

REF: 694 OBJ: 6 KEY: Nursing Process Step: Data Collection

15. What is the most important intervention for the edematous child with reduced mobility related to nephrotic syndrome? a. Put things close to the child to minimize body movements. b. Change the child’s position frequently. c. Keep the head of the child’s bed flat. d. Keep edematous areas moist and covered.

ANS: B The child should be turned frequently to prevent respiratory tract infection and to prevent pressure on delicate skin.

DIF: Cognitive Level: Application TOP: Nephrotic Syndrome

REF: 696 OBJ: 9 KEY: Nursing Process Step: Implementation

16. Which statement made by a parent of a child with nephrotic syndrome indicates an understanding of discharge teaching? a. “I will make sure he gets his measles vaccine as soon as he gets home.” b. “He can stop taking his medication next week.” c. “I should check his urine for protein when he goes to the bathroom.” d. “He should eat a low-protein diet for the next few weeks.”

ANS: C The parents should be instructed to keep a daily record of the child’s urinary proteins.

DIF: Cognitive Level: Application TOP: Nephrotic Syndrome

REF: 696 OBJ: 9 KEY: Nursing Process Step: Evaluation

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17. A 5-year-old boy is admitted to the hospital with acute glomerulonephritis. In taking the child’s history, what does a nurse recognize as the probable cause? a. Recovery from German measles 2 months ago b. Dysuria since the previous night c. A history of allergy d. A sore throat 2 weeks ago ANS: D Acute glomerulonephritis develops from 1 to 3 weeks after a streptococcal infection, which causes an allergic-type response that alters the effectiveness of the glomeruli.

DIF: Cognitive Level: Comprehension TOP: Acute Glomerulonephritis

REF: 697 OBJ: 9 KEY: Nursing Process Step: Data Collection

18. A nurse is explaining to a 17-year-old female the actions to prevent urinary tract infection.

Which is the best beverage for the nurse to recommend to keep urine acidic? a. Milk b. Grape juice c. Apple juice d. Orange juice ANS: C Juices such as apple or cranberry help maintain acidity of urine.

DIF: Cognitive Level: Comprehension TOP: Acute Urinary Tract Infection

REF: 694 OBJ: 6 KEY: Nursing Process Step: Evaluation

19. A 6-year-old child scheduled for an orchiopexy shyly asks a nurse, “What are they going to do to me ‘down there’?” What is the nurse’s best response? a. “They are going to fix you up ‘down there’.” b. “They will move your testicle from your abdomen to your scrotum.” c. “What do you think your doctor is going to do?” d. “You shouldn’t worry. Your doctor knows exactly what to do.”

ANS: C Encourage the patient to talk about what he knows and what feelings he has about the surgery. School-age children have a fear of bodily harm.

DIF: Cognitive Level: Application REF: 699 OBJ: 11 | 12 TOP: Orchiopexy KEY: Nursing Process Step: Implementation 20. What will a nurse caution the parents of a child who has had a nephrectomy for Wilms tumour that he will have to avoid? a. Contact sports b. Horseback riding c. Alcohol d. Diuretic medications ANS: A Children who have only one kidney should avoid contact sports to prevent injury to that remaining organ.

NURSINGTB.COM DIF: Cognitive Level: Comprehension TOP: Postnephrectomy Instruction

REF: 698 OBJ: 10 | 12 KEY: Nursing Process Step: Implementation

21. Parents of a newborn are concerned that their son’s scrotum is enlarged and swollen on one side. What is a nurse’s best response? a. “It is very common in the newborn that one gonad is larger than the other.” b. “Birth trauma caused bruising to the scrotum. It will reduce in size in a few days.” c. “It is a collection of fluid that will most likely correct itself in a year.” d. “The health care provider will drain this collection of blood before your baby is discharged.”

ANS: C These signs are indicative of a hydrocele, a collection of fluid in the scrotum that usually corrects itself in a year.

DIF: Cognitive Level: Comprehension REF: 698 OBJ: 5 TOP: Hydrocele KEY: Nursing Process Step: Implementation 22. A nurse is providing information to parents of a child born with bilateral cryptorchidism.

What information is accurate to include? a. This is the most common form. b. Fertility will be unaffected.

c. Surgical intervention is not recommended. d. An inguinal hernia may be present.

ANS: D When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism. The unilateral form is more common. Because the testes are warmer in the abdomen than in the scrotum, the sperm cells begin to deteriorate. If both testes are affected, sterility results. Inguinal hernia often accompanies this condition. Occasionally, a testis or the testes spontaneously descend during the first year of life. An operation called an orchiopexy may be performed.

DIF: Cognitive Level: Comprehension TOP: Cryptorchidism

REF: 698 OBJ: 5 | 11 KEY: Nursing Process Step: Planning

23. An adolescent male is admitted to the emergency department with severe acute scrotal pain.

When documenting the medical history, a nurse notes cryptorchidism at birth. What diagnosis does the nurse expect? a. Urinary tract infection b. Nephrosis c. Torsion d. Phimosis ANS: C When one or both testes fail to lower into the scrotum, the condition is termed cryptorchidism. Acute scrotal pain may indicate a testicular torsion (twisting), which necessitates immediate surgery to preserve testicular function.

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DIF: Cognitive Level: Comprehension REF: 698 OBJ: 1 | 5 TOP: Torsion KEY: Nursing Process Step: Data Collection MULTIPLE RESPONSE 1. A 7-year-old child has a BUN of 25 mmol/L. What is a nurse aware this lab value might indicate? (Select all that apply.) a. Dehydration b. Renal disease c. Need for steroid therapy d. Diabetes e. Pituitary malfunction ANS: A, B, C Increased BUN can indicate dehydration, renal disease, and/or need for steroid therapy.

Normal BUN is 2.9–7.1 mmol/L for a child over 2 years of age.

DIF: Cognitive Level: Analysis TOP: Diagnostic Tests

REF: 690 OBJ: 5 KEY: Nursing Process Step: Data Collection

2. What will a nurse caring for a newborn with exstrophy of the bladder include in the care?

(Select all that apply.) a. Diaper infant tightly

b. c. d. e.

Protect skin around bladder Position infant on back Prepare for surgical closure Cover exposed bladder with shield

ANS: B, C, D, E The infant is kept on his back with special attention to the skin around the exposed bladder, which is constantly bathed with urine. These infants are diapered loosely, if at all. The bladder is covered with a plastic shield or appropriate dressing to protect its mucosa but still to allow for urinary drainage. Surgical closure is done as quickly as possible.

DIF: Cognitive Level: Application TOP: Exstrophy of the Bladder

REF: 691 OBJ: 5 KEY: Nursing Process Step: Implementation

3. A nurse caring for a child with nephrotic syndrome is alert to which classic symptoms of this disorder. (Select all that apply.) a. Proteinuria b. Grossly bloody urine c. Hyperalbuminemia d. Fatigue e. Generalized edema ANS: A, B, D, E All options listed are those of nephrotic syndrome, with the exception of hyperalbuminemia.

The nephrotic child has hypoalbuminemia, as most of the protein has been spilled in the urine.

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DIF: Cognitive Level: Knowledge TOP: Nephrotic Syndrome

REF: 695 OBJ: 9 KEY: Nursing Process Step: Data Collection

4. A nurse is aware that genitourinary surgery is especially stressful for preschool children.

What factors lend to this stress? (Select all that apply.) a. They may perceive the treatment as punishment. b. They are especially prone to separation anxiety. c. They are sexually curious and developmentally fixated on their genitals. d. They have a fear of castration. e. They fear death.

ANS: A, B, C, D All options, except fear of death, are especially stressful for preschool children undergoing genitourinary surgery. Children in this age group do not have an understanding of the concept of death.

DIF: Cognitive Level: Comprehension REF: 699 TOP: Topic: Impact of Surgery on Preschoolers KEY: Nursing Process Step: Planning

OBJ: 12

5. What special considerations are related to long-term prednisone therapy in preschoolers?

(Select all that apply.) a. Delayed immunization

b. c. d. e.

Hypertension Enlargement of the sex organs Alteration in nutrition Increased risk for infection

ANS: A, E Delayed immunization and greater risk for infection are concerns relative to long-term prednisone therapy.

DIF: Cognitive Level: Comprehension TOP: Long-Term Prednisone Therapy

REF: 696 OBJ: 9 KEY: Nursing Process Step: Planning

COMPLETION 1. A nurse is measuring output on an infant on the pediatric unit. When weighing the diaper and subtracting the weight of the dry diaper, the nurse records 30 g and documents this as mL. ANS: 30 Diapers may be weighed on a gram scale before application and after removal (1 g = 1 mL).

DIF: Cognitive Level: Analysis TOP: Urinary Output

REF: 696 OBJ: 3 KEY: Nursing Process Step: Data Collection

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Chapter 30: The Child with a Skin Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse is careful to apply only the prescribed amount of ointment to the skin of a 2-month-old infant. How is infant skin different from adult skin? a. Less perfusion b. Greater moisture c. More perspiration d. Greater absorption ANS: D The child’s skin has a dramatically greater ability to absorb than does that of the adult.

DIF: Cognitive Level: Application TOP: Skin Comparison

REF: 702 OBJ: 2 KEY: Nursing Process Step: Implementation

2. What risk is increased with children who have been diagnosed with infantile eczema? a. Pneumonia b. Acne c. Sun sensitivity d. Asthma ANS: D NURSINGTB.COM Some children with eczema also develop asthma and hay fever–type allergies.

DIF: Cognitive Level: Knowledge TOP: Infantile Eczema

REF: 707 OBJ: 6 KEY: Nursing Process Step: Planning

3. What is the appropriate technique for the application of a topical treatment for a child with eczema? a. Apply skin lotions in a circular motion. b. Apply prescribed ointments with a gloved hand. c. Apply as much and as frequently as relieves the symptoms. d. Choose lanolin-based ointments.

ANS: B The prescribed amount of ointment is usually applied to the skin by a gloved hand in long, smooth strokes in order to minimize contact with the skin. Lanolin-based preparations should be avoided because of a possible allergy to wool.

DIF: Cognitive Level: Knowledge TOP: Infantile Eczema

REF: 708 OBJ: 7 | 8 KEY: Nursing Process Step: Implementation

4. A 2-day-old infant is noted to have small pustules on her skin. What is the best nursing action? a. Report it immediately because it may be a staphylococcus infection.

b. Keep the affected area dry and clean. c. Teach the parents how to care for seborrheic dermatitis. d. Chart the finding because it may be the beginning of a strawberry nevus.

ANS: A A staphylococcal infection can spread readily from one infant to another. Small pustules on the newborn must be reported immediately.

DIF: Cognitive Level: Application TOP: Staphylococcal Infection

REF: 709 OBJ: 3 KEY: Nursing Process Step: Implementation

5. The home health nurse discovers a family infected with pediculosis. What information can the nurse provide to the mother to start eradication of the lice? a. Cover the hair with petroleum jelly. b. Apply a soda–vinegar solution to the hair. c. Comb through the hair with a vinegar–water solution. d. Shampoo the hair with dish detergent.

ANS: C Combing a vinegar–water solution through the hair with a fine-tooth comb and then shampooing is an initial step toward eradication.

DIF: Cognitive Level: Application TOP: Tinea Capitis

REF: 712 OBJ: 9 KEY: Nursing Process Step: Implementation

6. A group of football players is taking oral griseofulvin for tinea pedis. What should a nurse caution them to avoid?

NURSINGTB.COM a. Citrus fruit and juice b. Eating shellfish c. Alcohol consumption d. Taking corticosteroids ANS: C Consumption of alcohol while taking griseofulvin will cause severe tachycardia.

DIF: Cognitive Level: Comprehension REF: 710 OBJ: 9 TOP: Tinea Pedis KEY: Nursing Process Step: Implementation 7. What should a nurse suggest before a 17-year-old girl starts a protocol of isotretinoin (Accutane) for her acne? a. Get a prescription for oral contraceptives. b. Increase the dose of the present medication. c. Limit intake of chocolate, cola, and peanuts. d. Increase exposure to sunlight.

ANS: A Oral contraceptives are often prescribed for adolescents with acne. Accutane can cause birth defects, so pregnancy should be prevented.

DIF: Cognitive Level: Application TOP: Acne Vulgaris

REF: 706 OBJ: 5 KEY: Nursing Process Step: Implementation

8. A child had a burn, evidenced by pink skin and blistering. The child states feelings of pain and is crying. How does a nurse classify this burn when documenting? a. First-degree b. Second-degree superficial c. Second-degree deep dermal d. Third-degree ANS: B A second-degree superficial burn appears blistered, moist, and pink or red. The pain associated with this burn indicates tissue viability.

DIF: Cognitive Level: Analysis REF: 714 OBJ: 10 TOP: Burns KEY: Nursing Process Step: Data Collection 9. A child has sustained a second-degree deep thermal burn to the hand. What is the priority nursing action? a. Immerse the burned area in cool water. b. Apply ice to the burned area. c. Break any blisters that are present. d. Apply petroleum jelly to the burned skin.

ANS: A First aid treatment of a second-degree deep thermal burn is immersion of the burned area in cool water or normal saline to halt the burning process.

DIF: Cognitive Level: AppN liU caRtiS onINGTBR OBJ: .ECFO:M 714 TOP: Burns KEY: Nursing Process Step: Implementation

10 | 12

10. Which allergy would contraindicate the use of silver sulfadiazine (Silvadene) as a topical agent for burns? a. Penicillin b. Iodine c. Tetanus immunizations d. Sulpha ANS: D The use of Silvadene cream on burns is contraindicated if the patient has a sulpha allergy.

DIF: Cognitive Level: Knowledge REF: 716 OBJ: 10 TOP: Burns KEY: Nursing Process Step: Data Collection 11. What would help the child with a serious burn meet nutritional needs during the subacute phase of recovery? a. Decrease calories because when on bed rest will not need as many b. Increase calories and protein to compensate for the healing process c. Increase fat to replace the layer of fat next to the burned skin d. Decrease carbohydrates and starches during the healing process ANS: B

Frequent meals and snacks high in calories, protein, and iron are needed to meet the increased metabolic needs of the child with burns.

DIF: Cognitive Level: Comprehension REF: 718 OBJ: 13 TOP: Burns KEY: Nursing Process Step: Implementation 12. Which statement made by a parent indicates an understanding of the topical application of medications for a skin condition? a. “I apply the medication after I give my child a bath.” b. “I rub the ointment in a circular motion over the rash.” c. “I increased the amount of cream because the rash was not improving.” d. “I use powder and cornstarch to keep the skin dry.”

ANS: A Absorption of topical medications is best when preparations are applied after a warm bath.

DIF: Cognitive Level: Comprehension TOP: Topical Medications

REF: 709 OBJ: 7 KEY: Nursing Process Step: Evaluation

13. On the first day following a severe burn, a body’s fluid reserves leave the circulating volume and enter the interstitial space, causing massive edema. What should a nurse monitor for very closely in the burn victim? a. Increasing intracranial pressure b. Reduced urine output c. Eschar formation d. Fluid overload

NURSINGTB.COM

ANS: B With the fluid shift associated with severe burns, the nurse must be observant for the reduction of urine, an indication of altered renal function.

DIF: Cognitive Level: Analysis REF: 716 OBJ: 11 TOP: Burns KEY: Nursing Process Step: Data Collection 14. At a 2-month well-child visit, parents ask a nurse about the red area on the infant’s neck.

They tell the nurse that the mark appeared a few weeks after birth. What does the nurse recognize this skin lesion as? a. A port wine nevus b. A strawberry nevus c. Exanthem d. Intertrigo ANS: B The strawberry nevus is a common hemangioma consisting of dilated capillaries in the dermal space, which may not become apparent for a few weeks after birth.

DIF: Cognitive Level: Comprehension TOP: Congenital Lesions

REF: 702 OBJ: 3 KEY: Nursing Process Step: Data Collection

15. A mother is concerned about what might have caused a heat rash on her infant. A nurse observes tiny pinhead-sized reddened papules on the infant’s neck and axilla. What does the nurse explain as the most likely cause of this rash? a. Sun exposure b. Allergic reaction c. Infection d. Heat and moisture ANS: D Miliaria, or prickly heat rash, is caused by excess body heat and moisture.

DIF: Cognitive Level: Comprehension TOP: Skin Infections

REF: 704 OBJ: 3 KEY: Nursing Process Step: Implementation

16. What is the correct nursing response to a mother who asks, “How can I get rid of the baby’s cradle cap?” a. “Rub baby oil on the infant’s head at night and shampoo the hair the next morning.” b. “Use a brush with firm bristles to loosen the scales on the baby’s head several times a day.” c. “Wash the baby’s head every night with a dandruff-control shampoo.” d. “Lubricate the baby’s head every morning with a small amount of olive oil.”

ANS: A Scales may be softened by applying baby oil to the head the evening before and the hair should be shampooed in the morning.

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DIF: Cognitive Level: Application TOP: Seborrheic Dermatitis

REF: 705 OBJ: 7 KEY: Nursing Process Step: Implementation

17. Which statement made by a parent indicates the need for further teaching about strategies to control itching for the infant with eczema? a. “Wool is the best fabric for the infant’s clothing.” b. “I should avoid laundry detergents with fragrances.” c. “I put cotton gloves on the infant’s hands.” d. “The infant’s fingernails are kept short.”

ANS: A Clothing should be made of cotton. Wool is avoided because of its allergy potential.

DIF: Cognitive Level: Comprehension TOP: Infantile Eczema

REF: 708 OBJ: 2 KEY: Nursing Process Step: Evaluation

18. What will a nurse include when teaching about general skin care measures that could help prevent acne? a. Eliminating chocolate, peanuts, and cola from the diet b. Washing the face with a cleansing product frequently c. Planning indoor activities to avoid sun exposure d. Eating a balanced diet and getting sufficient rest ANS: D

General hygienic measures of cleanliness, rest, and avoidance of emotional stress may help prevent exacerbations.

DIF: Cognitive Level: Comprehension TOP: Acne Vulgaris

REF: 706 OBJ: 4 | 5 KEY: Nursing Process Step: Implementation

19. A nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet. What is the most appropriate nursing action? a. Report this sign immediately. b. Place a warm towel over the extremities. c. Gently sponge with cool water. d. Medicate for pain.

ANS: D A purple flush indicates the return of sensation and causes extreme pain.

DIF: Cognitive Level: Application REF: 721 OBJ: 14 TOP: Frostbite KEY: Nursing Process Step: Implementation 20. A child is brought to the emergency department with burns on the face and chest. What is the nurse’s first priority? a. Assess respiratory status. b. Administer pain medication. c. Remove clothing. d. Insert a Foley catheter.

ANS: A NURSINGTB.COM Airway assessment and establishing an airway are the initial priorities.

DIF: Cognitive Level: Application REF: 713 OBJ: 10 | 12 TOP: Burns KEY: Nursing Process Step: Implementation 21. An adolescent girl with acne is being treated with an antibiotic, in addition to topical applications. What side effect does a nurse caution the girl to expect? a. Lessened effectiveness of oral contraceptives b. Urinary burning and frequency c. Breast engorgement d. Vaginitis ANS: D Antibiotic therapy can cause a monilial vaginitis.

DIF: Cognitive Level: Application REF: 706 OBJ: 5 | 7 TOP: Acne KEY: Nursing Process Step: Implementation 22. A nurse observes a tarry stool from a 16-year-old burn victim who has been in the ICU for 2 weeks. Which complication does the nurse anticipate? a. Diverticulitis b. Stress diarrhea c. Curling ulcer

d. Perforated bowel ANS: C Curling ulcer is a complication of burn victims resulting from the stress of their trauma.

DIF: Cognitive Level: Application REF: 716 OBJ: 13 TOP: Burns KEY: Nursing Process Step: Data Collection 23. A child is brought to the emergency department with severe frostbite. Which body parts should be warmed first? a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso ANS: D In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the extremities.

DIF: Cognitive Level: Application REF: 720 OBJ: 14 TOP: Frostbite KEY: Nursing Process Step: Implementation 24. An adolescent is at the pediatric health care provider’s office because he has been experiencing intense itching, particularly in the axilla and between the fingers. The itching is worse during the night and he has not been sleeping well. With what is this symptom associated? a. Scabies NURSINGTB.COM b. Pediculosis capitis c. Tinea corporis d. Eczema ANS: A Intense itching, especially at night, is characteristic of scabies.

DIF: Cognitive Level: Comprehension REF: 712 OBJ: 9 TOP: Scabies KEY: Nursing Process Step: Data Collection 25. What should a nurse stress to the mother of a child with impetigo? a. The condition is caused by the herpes simplex virus type I. b. The crusts on the lesions should be left in place. c. The lesions may spread, but the disease is not contagious. d. Small cuts and bites should be treated promptly.

ANS: D Small cuts and bites should be treated promptly to prevent the invasions of the bacteria that cause impetigo. The crusts from the lesions should be gently removed. The disease is contagious.

DIF: Cognitive Level: Comprehension REF: 710 OBJ: 3 | 4 TOP: Impetigo KEY: Nursing Process Step: Implementation

26. A nurse is caring for a 3-year-old child with severe burns. What is the nurse aware is the minimum adequate hourly urine output? a. 5 mL/hr b. 10 mL/hr c. 15 mL/hr d. 20 mL/hr ANS: D The minimum acceptable hourly urine output for children over the age of 2 years is 20 to 30 mL/hr.

DIF: Cognitive Level: Comprehension TOP: Urine Output after Burn

REF: 716 OBJ: 13 KEY: Nursing Process Step: Planning

27. An adolescent patient at a pediatric clinic presents with a butterfly rash. What diagnosis does a nurse suspect? a. Tuberous sclerosis b. Eczema c. Psoriasis d. Systemic lupus erythematosus (SLE) ANS: D Butterfly rash over the nose and cheeks can be associated with photosensitivity and may be associated with SLE. DIF: Cognitive Level: Comprehension REF: 704 OBJ: N/A TOP: Skin Manifestations oNf U IlR lnS esIs NGTBK EY .C O:M Nursing Process Step: Data Collection 28. A nurse is documenting a description of a skin assessment. What term can be used for an elevated, fluid-filled blister? a. Pustule b. Papule c. Wheal d. Vesicle ANS: D A vesicle is an elevated, fluid-filled blister (cold sore, chicken pox).

DIF: Cognitive Level: Comprehension TOP: Skin Conditions

REF: 703 OBJ: 1 KEY: Nursing Process Step: Data Collection

29. How would a nurse document a rash that has erythematous, circular raised lesions? a. Macular b. Papular c. Vesicular d. Pustular ANS: B A papule is a circular, reddened elevated area on the skin.

DIF:

Cognitive Level: Knowledge

REF: 703

OBJ: N/A

TOP: Rashes

KEY: Nursing Process Step: Data Collection

30. What should a nurse consider when providing care to a school-age child hospitalized with a burn injury? a. Hospitalization will be brief. b. Analgesics should be given immediately after dressing changes. c. Contact with peers should be maintained. d. Parents usually handle injury worse than the child.

ANS: C A burn injury is taxing to the child and parents. It requires long periods of hospitalization and frequent readmissions. The accident itself is terrifying for the child but is made even worse if caused by disobedience. Nurses encourage children to express their feelings.

Analgesics are administered before painful procedures. The long-term patient requires diversions of various types. School tutors are requested, and contact is maintained with peers through cards or e-mail.

DIF: Cognitive Level: Comprehension REF: 719 OBJ: 11 | 13 TOP: Burns KEY: Nursing Process Step: Implementation MULTIPLE RESPONSE 1. Parents of a child show a nurse that their child has a flat strawberry nevus. What information can the nurse provide in educating the parents regarding strawberry nevus?

(Select all that apply.) a. It is a rare skin variation.

NURSINGTB.COM b. It is harmless. c. It gradually becomes raised. d. Laser treatment is available. e. Sometimes it can disappear spontaneously.

ANS: B, C, D, E The strawberry nevus is a common hemangioma (consists of dilated capillaries in the dermal space) that may not become apparent for a few weeks after birth. Although it is harmless and usually disappears without treatment, it is disturbing to parents, especially when it appears on the head or face. At first it is flat, but it gradually becomes raised. The lesions gradually blanch, with 60% disappearing spontaneously by 5 years of age and 90% disappearing by 9 years of age. Laser treatment or excision may be considered if the area becomes ulcerated.

DIF: Cognitive Level: Knowledge TOP: Strawberry Nevus

REF: 702 | 703 OBJ: 3 KEY: Nursing Process Step: Data Collection

2. What would a nurse teach parents to do in order to avoid diaper rash? (Select all that apply.) a. Use ointments b. Keep perineum covered at all times c. Use disposable diapers d. Scrub area vigorously e. Change diaper frequently

ANS: A, C, E Keeping the skin dry and protected with some ointments, leaving the area exposed to light and air periodically, changing the diaper frequently.

DIF: Cognitive Level: Comprehension TOP: Avoiding Diaper Rash

REF: 705 | 706 OBJ: N/A KEY: Nursing Process Step: Implementation

3. A nurse speaking to a group of junior high school students informs them that acne can be exacerbated by which medications? (Select all that apply.) a. Steroids b. Phenytoin c. Phenobarbital d. Aspirin e. Oral contraceptives ANS: A, B, C Long-term use of steroids, phenytoin, phenobarbital, lithium, and vitamin B12 can cause acne. Oral contraceptives are used to treat acne.

DIF: Cognitive Level: Knowledge REF: 706 OBJ: 5 TOP: Acne KEY: Nursing Process Step: Implementation 4. What interventions should a nurse include when preparing a teaching plan for the care of a child with infantile eczema? (Select all that apply.) a. Bathe the child using products with a light fragrance. b. Use oatmeal and baking soda as bath additives. c. Add bath oil to bath wateN r aUfR teS r tIhN eG chTilB d. haCsOsM oaked. d. Apply lanolin-based lotions after the bath. e. Avoid allergenic foods until child is older.

ANS: B, C Use of oatmeal, baking soda, and baking powder is soothing. Adding oil to the bath water after the child has soaked for a while makes the oil application more effective. Items with any fragrance should be avoided as well as lanolin-based products. It is not recommended to omit allergy causing foods until the child is older. They should be introduced at 6 months of age.

DIF: Cognitive Level: Comprehension TOP: Infantile Eczema

REF: 708 OBJ: 6 KEY: Nursing Process Step: Planning

5. Which factors activate the herpes simplex virus type I? (Select all that apply.) a. Stress b. Sun c. Menses d. Fever e. Food allergies ANS: A, B, C, D The herpes simplex virus type I can be activated to cause a cold sore by exposure to stress, sun, initiation of menses, and fever. Food allergies do not activate the virus, as a rule.

DIF: Cognitive Level: Comprehension TOP: Herpes Simplex Type I

REF: 707 OBJ: 4 KEY: Nursing Process Step: Planning

NURSINGTB.COM

Chapter 31: The Child with a Metabolic Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A nurse is planning to teach a family about Tay-Sachs disease. What will the nurse relay about the pattern of inheritance for inborn errors of metabolism? a. They are usually autosomal recessive. b. They are usually autosomal dominant. c. They are usually X-linked recessive. d. They are usually multifactorial.

ANS: A The pattern of inheritance is generally autosomal recessive.

DIF: Cognitive Level: Knowledge TOP: Tay-Sachs Disease

REF: 724 OBJ: 2 KEY: Nursing Process Step: Planning

2. What occurs as a result of an inadequate secretion of insulin? a. Protein synthesis is increased. b. Increased fat breakdown leads to ketonemia. c. Serum glucose levels are markedly decreased. d. More rapid conversion and storage of carbohydrates to glucose occurs.

ANS: B NURSINGTB.COM When insulin is deficient, the body cannot metabolize carbohydrates for energy. The body is also unable to store and use fat properly. Incomplete fat metabolism produces ketone bodies that accumulate in the blood.

DIF: Cognitive Level: Comprehension TOP: Diabetes Mellitus

REF: 727 OBJ: 7 KEY: Nursing Process Step: Implementation

3. On what understanding does a nurse plan the care of a child with a new diagnosis of type 1 diabetes mellitus? a. There is an absolute deficiency of insulin. b. Oral hypoglycemic agents can control it. c. Insufficient quantities of insulin are produced by the pancreas. d. Insulin deficiency is caused by another disease affecting the pancreas.

ANS: A Type 1 insulin-dependent diabetes mellitus is characterized by an absolute or complete deficiency of insulin.

DIF: Cognitive Level: Comprehension TOP: Diabetes Mellitus

REF: 727 OBJ: 5 KEY: Nursing Process Step: Planning

4. A child receives a combination of regular and NPH insulin at 0800. At 0845 the breakfast trays have not yet arrived from the kitchen. What is the best action by a nurse?

a. b. c. d.

Notify the health care provider.

Ambulate the patient in the hall for a short time.

Give the patient a snack of graham crackers and milk.

Give the patient more insulin according to the sliding scale.

ANS: B A child who receives regular insulin before meals may have an insulin reaction if food is not eaten within 20 minutes. A snack of graham crackers and milk will prevent an episode of hypoglycemia.

DIF: Cognitive Level: Application TOP: Prevention of Hypoglycemia

REF: 738 | 739 OBJ: 8 | 9 KEY: Nursing Process Step: Implementation

5. Although the child with type 1 diabetes had her prescribed insulin at 0730, the child says she is hungry and thirsty and is feeling drowsy at 1030. What should a nurse do first? a. Walk the patient in the hall for 10 minutes. b. Allow the patient a short nap. c. Give the patient a cup of orange juice. d. Test the patient’s blood with a glucometer and give insulin according to the sliding scale.

ANS: C The immediate remedy is to give orange juice to raise the blood glucose. Giving more sugar will increase the blood glucose in a hyperglycemic child. Walking exercise will use up even more glucose. The treatment for hyperglycemia is to give the patient more insulin.

DIF: Cognitive Level: AppN liU caRtiS onINGTBR OBJ: 7 | 8 .ECFO:M 738 | 739 TOP: Hypoglycemia KEY: Nursing Process Step: Implementation 6. Which comment made by a school-age child indicates that he needs more teaching about diabetes mellitus and exercise? a. “I carry a piece of hard candy with me in case I start to feel shaky.” b. “I make sure I have emergency money when I have soccer practice or a game.” c. “Sometimes I skip my breakfast when I have a game in the morning.” d. “I play in soccer games that are scheduled after dinner.”

ANS: C Blood glucose is high after meals. The child with type 1 diabetes mellitus who skips a meal before exercise is at risk for hypoglycemia.

DIF: Cognitive Level: Comprehension TOP: Diabetes Mellitus

REF: 731 OBJ: 8 KEY: Nursing Process Step: Implementation

7. Which statement made by a 7-year-old child with type 1 diabetes mellitus indicates a need for more teaching? a. “My pancreas is sick and needs insulin until it is well.” b. “I will need to take my insulin every day.” c. “I need to keep a piece of candy in my pocket in case I start to feel shaky.” d. “I give myself insulin shots twice a day.”

ANS: A

The child with type 1 diabetes mellitus has an insulin deficiency and will require lifelong management of this disease. Insulin does not cure the pancreas.

DIF: Cognitive Level: Comprehension TOP: Diabetes Mellitus

REF: 728 OBJ: 5 | 8 KEY: Nursing Process Step: Evaluation

8. Which general dietary measure should a nurse include in a teaching plan for the child with type 1 diabetes mellitus? a. Control intake of carbohydrates and consume fewer calories. b. Focus on complex carbohydrates and eat foods high in fibre. c. Obtain most calories from proteins and fats. d. Eat a diet low in fat and low in complex carbohydrates.

ANS: B The nutritional needs of a child with diabetes mellitus are essentially the same as those of the nondiabetic child, except for the elimination of concentrated carbohydrates such as sugar. Fibre has been shown to reduce blood glucose levels.

DIF: Cognitive Level: Comprehension REF: 736 TOP: Diet KEY: Nursing Process Step: Planning

OBJ: 8

9. A child with diabetes is brought to the emergency department. The child is flushed and drowsy, and the skin is dry. The child’s caregiver states that the child has been feeling progressively worse since the morning. What is this child most likely experiencing? a. Somogyi phenomenon b. Dawn syndrome c. Ketoacidosis NURSINGTB.COM d. Water intoxication ANS: C In ketoacidosis, the child’s skin is dry, and the face is flushed. Patients appear dehydrated.

They may perspire and be restless. The breath has a fruity odour, and there is no rest period between inspiration and expiration.

DIF: Cognitive Level: Analysis TOP: Ketoacidosis

REF: 730 OBJ: 6 KEY: Nursing Process Step: Data Collection

10. A mother reports that her 6-month-old infant is lethargic, sleeps 18 hours a day, and snores.

The nurse recognizes these signs are characteristic of which condition? a. Hypothyroidism b. Hyperthyroidism c. Type 1 diabetes mellitus d. Tay-Sachs disease ANS: A The infant with hypothyroidism will appear sluggish, and the tongue will be enlarged, causing noisy respiration.

DIF: Cognitive Level: Analysis TOP: Hypothyroidism

REF: 725 OBJ: 3 KEY: Nursing Process Step: Data Collection

11. What is an important consideration for a school-age child taking DDAVP for diabetes insipidus? a. Observe for signs of water deprivation. b. Restrict the child’s physical education program. c. Arrange for the child to use the bathroom when needed. d. Limit fluid intake other than during the lunch period.

ANS: C The child with diabetes insipidus needs liberal access to bathrooms and water fountains.

Arrangements may have to be made with the school to allow access.

DIF: Cognitive Level: Application TOP: Diabetes Insipidus

REF: 727 OBJ: 4 KEY: Nursing Process Step: Implementation

12. What condition does a nurse suspect when a child with type 1 diabetes mellitus has hyperglycemia, diaphoresis, and headaches in the morning? a. Dawn phenomenon b. Somogyi phenomenon c. Honeymoon effect d. Ketoacidosis ANS: B The Somogyi phenomenon (rebound hyperglycemia) occurs when the blood glucose level is lowered to the point at which the body’s counter-regulatory hormones are released, producing the symptoms described.

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DIF: Cognitive Level: Analysis TOP: Somogyi Phenomenon

REF: 735 OBJ: 11 KEY: Nursing Process Step: Data Collection

13. What would be the most appropriate nursing response to a woman who says, “My sister had a child with Tay-Sachs disease, and I want to know if I could have a child with this condition”? a. “The disease is rare. It is unlikely that you would have a child with Tay-Sachs disease.” b. “A screening test can be done to determine if you are a carrier of the gene.” c. “The gene for Tay-Sachs disease is transmitted by the father.” d. “The cause of Tay-Sachs disease is thought to be an autoimmune response to a virus.”

ANS: B Carriers can be identified by screening tests. Tay-Sachs disease has an autosomal recessive pattern of transmission.

DIF: Cognitive Level: Comprehension TOP: Tay-Sachs Disease

REF: 724 OBJ: 2 KEY: Nursing Process Step: Implementation

14. A nurse is preparing to administer a long-acting insulin. Which insulin is considered long acting? a. Lispro

b. Aspart c. Glargine d. Regular ANS: C Insulin glargine is a long-acting insulin. Regular is short acting. Lispro and Aspart are rapid acting.

DIF: Cognitive Level: Knowledge REF: 733 OBJ: 9 TOP: Insulin KEY: Nursing Process Step: Implementation 15. After a closed head injury, an unconscious 10-year-old child begins to excrete copious amounts of pale urine along with a drop in blood pressure (BP). Based on these symptoms, what does a nurse suspect has developed? a. Diabetes insipidus b. Diabetes mellitus c. Hypothyroidism d. Hyperthyroidism ANS: A Diabetes insipidus can be acquired as the result of a head injury or tumour, and suppression of the posterior pituitary causes copious urine output along with a drop in BP. The child can become dehydrated very quickly if some remedy is not applied.

DIF: Cognitive Level: Analysis TOP: Diabetes Insipidus

REF: 726 OBJ: 4 KEY: Nursing Process Step: Data Collection

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16. A nurse is teaching the parents of a child with diabetes insipidus about water intoxication.

The nurse would teach the parents to be alert for what symptom? a. Polyuria b. Cough c. Weight loss d. Lethargy ANS: D Signs of water intoxication include edema, lethargy, nausea, and central nervous system signs.

DIF: Cognitive Level: Comprehension TOP: Diabetes Insipidus

REF: 727 OBJ: 4 KEY: Nursing Process Step: Implementation

17. What does a nurse instruct a 12-year-old to do when teaching how to administer insulin? a. Make sure injection sites are 10 cm apart. b. Select an injection site that was recently exercised. c. Inject the needle at a 90-degree angle. d. Give the injection deep into the muscle.

ANS: C Children often find it easier to learn to inject the needle at a 90-degree angle.

DIF:

Cognitive Level: Application

REF: 732

OBJ: 9

TOP: Diabetes Mellitus

KEY: Nursing Process Step: Implementation

18. A nurse discusses treatment of hypoglycemia with an adolescent. Which statement by the adolescent leads the nurse to determine the patient understood the instructions? a. “When my blood glucose is low or if I begin to feel hungry and weak, I will eat six LifeSavers.” b. “When my blood glucose is low or if I begin to feel hungry and weak, I will give myself Lispro insulin.” c. “When my blood glucose is low or if I begin to feel hungry and weak, I will have a slice of cheese.” d. “When my blood glucose is low or if I begin to feel hungry and weak, I will drink a diet soda.”

ANS: A The immediate treatment of hypoglycemia consists of administering sugar in some form such as orange juice, hard candy, or a commercial product. Cheese will eventually raise the blood glucose, but not as quickly as candy.

DIF: Cognitive Level: Application TOP: Diabetes Mellitus

REF: 735 OBJ: 7 KEY: Nursing Process Step: Evaluation

19. Why does a nurse instruct an 11-year-old diabetic child to use the side of the finger for blood testing? a. It has fewer capillaries. b. It is easier to puncture. c. It is less likely to become infected. d. It has fewer nerve endingN s.URSINGTB.COM ANS: D The sides of the finger have fewer nerve endings and more capillaries but are not easier to puncture than the fingertip. The risk for infection is remote for either site.

DIF: Cognitive Level: Comprehension TOP: Blood Glucose Testing

REF: 732 OBJ: 8 KEY: Nursing Process Step: Implementation

20. What is the function of an insulin pump? a. Releases insulin as blood glucose rises b. Provides continuous infusion of insulin c. Decreases need for painful glucose monitoring d. Delivers a prescribed amount of insulin twice a day ANS: B The insulin pump that is attached to a subcutaneous tube releases a continuous infusion of insulin.

DIF: Cognitive Level: Knowledge TOP: Insulin Pump MULTIPLE RESPONSE

REF: 734 OBJ: 8 KEY: Nursing Process Step: Implementation

1. When discussing possible causes of diabetes in children, a nurse mentions chromosomal defects. Which chromosomes are associated with diabetes? (Select all that apply.) a. 6 b. 7 c. 11 d. 20 e. 21 ANS: A, C Defects in chromosomes 6, 11, and other genetic disorders are associated with diabetes mellitus syndrome.

DIF: Cognitive Level: Knowledge TOP: Diabetes Mellitus

REF: 728 OBJ: 5 KEY: Nursing Process Step: Planning

2. A nurse teaches a patient that which of the following food sources are high in soluble fibre?

(Select all that apply.) a. Raw fruits b. Cooked vegetables c. Beans d. Lean meat e. Bran cereal ANS: A, C, E Foods high in soluble fibre include raw fruits, beans, and bran cereal.

DIF: Cognitive Level: ComNpUreRhS enIsN ioG n TBR OBJ: 8 .ECFO:M 736 TOP: Dietary Fibre Sources KEY: Nursing Process Step: Implementation 3. What does a nurse teach an adolescent with diabetes that soluble fibre in the diet can reduce? (Select all that apply.) a. Blood glucose b. Serum cholesterol c. Incidence of infections d. Absorption of sugar e. Insulin requirements ANS: A, B, D, E Soluble fiber can reduce blood glucose, serum cholesterol, absorption of sugar, and insulin requirements. It has no effect on infections.

DIF: Cognitive Level: Comprehension REF: 736 OBJ: 8 TOP: Fibre in Diet KEY: Nursing Process Step: Implementation 4. Which processes does a nurse explain the endocrine system is primarily responsible for controlling? (Select all that apply.) a. Maturation b. Reproduction c. Stress response d. Sexual identity

e. Growth ANS: A, B, C, E The endocrine system governs maturation, reproduction, stress response, and sexual maturity. Sexual identity is a psychosocial response.

DIF: Cognitive Level: Comprehension TOP: Endocrine System

REF: 723 OBJ: 3 KEY: Nursing Process Step: Implementation

5. A nurse is monitoring an 8-month-old child with hypothyroidism taking levothyroxine (Synthroid). Which symptoms does the nurse recognize as signs of overdose? (Select all that apply.) a. Tachycardia b. Irritability c. Vomiting d. Weight gain e. Diaphoresis ANS: A, B, E All the options except for weight gain and vomiting are indications of overdose of Synthroid. Weight loss is a symptom of overdose, however.

DIF: Cognitive Level: Comprehension REF: 726 TOP: Levothyroxine (Synthroid) Overdose KEY: Nursing Process Step: Data Collection

OBJ: 3

6. What factors make it more diN ffU icR ulSt I foN rG anTaBd. olC esOcM ent to cope with type 1 diabetes? (Select all that apply.) a. Hormonal changes b. Developmental conflicts c. Preference for fast food d. Growth spurts e. Knowledge of disease ANS: A, B, C, D The adolescent who is in a growth spurt and may have significant hormone fluctuations.

They may resent or deny the need to be dependent on a medication. Medication schedules and diet restrictions do not correlate well with the adolescent’s lifestyle of eating fast foods.

“Bouncing” blood glucose levels may make adolescent feel out of control and there is anger and resentment as they may have to deal with a deviation in what they consider an “ideal body.” They have more difficulty in resolving their conflict between dependence and independence. This may lead to rebellion against parents and treatment regimens.

DIF: Cognitive Level: Comprehension TOP: Adolescent with Diabetes

REF: 739 OBJ: 8 KEY: Nursing Process Step: Implementation

7. A child with diabetes mellitus is observed to have cold symptoms. What signs and symptoms will alert parents of the possibility of ketoacidosis? (Select all that apply.) a. Chest congestion b. Ear pain

c. Fruity smelling breath d. Hyperactivity e. Nausea ANS: C, E Symptoms of ketoacidosis are compared with those of hypoglycemia. Signs and symptoms include a fruity odour to the breath, nausea, decreased level of consciousness and dehydration. Lab values include ketonuria, decreased serum bicarbonate concentration (decreased CO2 levels) and low pH, and hypertonic dehydration.

DIF: Cognitive Level: Comprehension TOP: Ketoacidosis

REF: 730 OBJ: 6 KEY: Nursing Process Step: Data Collection

8. A nurse is discussing insulin shock with parents of a child recently diagnosed with diabetes mellitus. What will the nurse respond when the parents ask why children are more prone to insulin reactions? (Select all that apply.) a. “The condition is more unstable in children.” b. “Parents are often noncompliant.” c. “The activities are irregular.” d. “They are still growing.” e. “Sleep patterns are not established.”

ANS: A, C, D Children are more prone to insulin reactions than adults because of the following: the condition itself is more unstable in young people; they are growing; their activities are more irregular.

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DIF: Cognitive Level: Comprehension TOP: Insulin Shock

REF: 735 OBJ: 10 KEY: Nursing Process Step: Planning

TRUE/FALSE 1. Parents of a child newly diagnosed with diabetes mellitus tell a nurse, “Our son’s body is resistant to insulin.” A nurse recognizes that this description is consistent with type 1 diabetes mellitus.

ANS: F Type 2 diabetes mellitus is caused by insulin resistance or failure of the body to use the insulin.

DIF: Cognitive Level: Comprehension TOP: Insulin Resistance

REF: 728 OBJ: 5 KEY: Nursing Process Step: Data Collection

COMPLETION 1. A nurse explains that the diagnosis of diabetes is made when the fasting blood glucose level is greater than mmol/L on two separate occasions, and the history is positive for indication of the disease. (Input the answer nearest to one decimal place.)

ANS: 7.0 An elevated blood glucose level of 7.0 mmol/L on two separate occasions is grounds for the diagnosis of diabetes mellitus when the history is positive for the disease.

DIF: Cognitive Level: Comprehension TOP: Diagnosis of DM

REF: 728 OBJ: 8 KEY: Nursing Process Step: Implementation

2. The nurse assessing a glycosylated hemoglobin (HbA1c) test is aware that this test can evaluate average glucose levels over a period of 3 to months.

ANS: 4 Glucose attaches to the red cells over the life span of the cell and can be read as percentages.

An HbA1c reading of 7% to 7.5% is the goal for a diabetic child, depending on their age.

DIF: Cognitive Level: Knowledge TOP: Glycosylated Hemoglobin

REF: 729 OBJ: 8 KEY: Nursing Process Step: Data Collection

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Chapter 32: Childhood Communicable Diseases Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. Which classification of medication would make a child most susceptible to an opportunistic infection? a. Anticonvulsant b. Beta-adrenergic agent c. Antibiotic d. Corticosteroid ANS: D Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic infections.

DIF: Cognitive Level: Knowledge TOP: Effect of Steroids

REF: 742 OBJ: 3 KEY: Nursing Process Step: Data Collection

2. An 8-year-old child asks a nurse how she got the antibodies that kept her from getting whooping cough. What is the nurse’s best explanation? a. “You received borrowed antibodies from another person who had whooping cough.” b. “You were given a tiny case of whooping cough and then you made your own NURSINGTB.COM antibodies.” c. “An immunization strengthened the 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: 752 OBJ: 7 TOP: Vaccines KEY: Nursing Process Step: Implementation 3. A pandemic is referred to which of the following? a. Worldwide high incidence of a communicable disease b. A sudden increase of a communicable disease in a specific area c. The continuous incidence of a communicable disease expected in a localized area d. Lower rates of a communicable disease worldwide ANS: A A pandemic is a worldwide high incidence of a communicable disease. A sudden increase is an epidemic. Endemic refers to the continuous incidence of a communicable disease in a specific geographical area.

DIF: Cognitive Level: Knowledge REF: 742 TOP: Pandemic KEY: Nursing Process Step: N/A

OBJ: 1 | 6

4. Which finding would lead a nurse to delay the administration of DTaP for an infant? a. Diarrhea b. Temperature of 40.5° C after the previous inoculation c. Teething d. Travelling 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 TOP: Immunizations

REF: 754 OBJ: 7 KEY: Nursing Process Step: Implementation

5. What type of precautions are necessary when caring for a toddler with varicella? a. Contact b. Protective c. Airborne d. Droplet ANS: C Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubella. Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room.

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DIF: Cognitive Level: Application TOP: Isolation Precautions

REF: 749 OBJ: 4 KEY: Nursing Process Step: Implementation

6. Which statement assures a nurse that parents understand how long a child who has varicella is contagious? a. “My child should stay home from school for a few 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 a fever is present.”

ANS: A The child with varicella is contagious for a few days after the appearance of the rash.

DIF: Cognitive Level: Comprehension REF: 743 TOP: Varicella KEY: Nursing Process Step: Evaluation

OBJ: 2

7. Which statement made by a sexually active adolescent girl indicates an understanding of the prevention of sexually transmitted infections (STIs)? a. “I always douche after intercourse.” b. “I think you can get a vaccination for STIs 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 STIs is not considered 100% effective but is recommended for sexual intercourse.

DIF: Cognitive Level: Comprehension TOP: Sexually Transmitted Infections

REF: 756 OBJ: 8 KEY: Nursing Process Step: Evaluation

8. What is the priority nursing diagnosis for a hospitalized infant who is HIV positive? a. Risk for injury b. Altered nutrition c. Impaired skin integrity d. Risk for infection ANS: D The infant who is HIV positive has impaired immunological functioning and is at high risk for infection.

DIF: Cognitive Level: Application REF: 757 TOP: Human Immunodeficiency Virus KEY: Nursing Process Step: Nursing Diagnosis

OBJ: 9

9. How would the nurse document a rash that has erythematous, circular raised lesions? a. Macular b. Papular c. Vesicular d. Pustular ANS: B NURSINGTB.COM A papule is a circular, reddened elevated area on the skin.

DIF: Cognitive Level: Knowledge REF: 751 OBJ: 2 TOP: Rashes KEY: Nursing Process Step: Data Collection 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: 745 OBJ: 3 TOP: Hepatitis A KEY: Nursing Process Step: Implementation 11. An infant is hospitalized for respiratory syncytial virus (RSV) bronchiolitis. Which type of precautions would a nurse use when caring for the infant? a. Large-droplet infection precautions b. Airborne-infection precautions c. Droplet-contact precautions

d. Protective precautions ANS: C Droplet and contact precautions are used for RSV, which can be spread when an infected person coughs or sneezes and through direct contact.

DIF: Cognitive Level: Application REF: 751 TOP: Routine and Additional Precautions KEY: Nursing Process Step: Implementation

OBJ: 4

12. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response for a nurse to make when the child asks, “Why do you have to wear a gown and mask when you are in my room?” a. “Because you have a condition that could be spread to others.” b. “To protect you because you could get an infection very easily.” c. “I’m wearing this because there are a lot of bacteria in the hospital.” d. “You won’t need this after you have had medication for 24 hours.”

ANS: B Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly susceptible to infection.

DIF: Cognitive Level: Application TOP: Protective Isolation

REF: 751 OBJ: 4 KEY: Nursing Process Step: Implementation

13. A nurse is preparing to administer immunizations at a well-child clinic. Which method of administration will the nurse N im UpRleSmIeNntG?TB.COM 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. DTaP is given intramuscularly and varicella is given subcutaneously.

DIF: Cognitive Level: Knowledge REF: 754 TOP: Hib Vaccine KEY: Nursing Process Step: Evaluation

OBJ: 5 | 7

14. A child was sent to the clinic because of a rash. A nurse notes the rash is present on the trunk, extremities, and face and the child’s cheeks are bright red. What condition is this rash consistent with? 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 TOP: Fifth Disease

REF: 744 OBJ: 2 KEY: Nursing Process Step: Data Collection

15. What statement leads a nurse to determine that a child’s caregiver understands information related to tick bites? a. “I’ll have my son wear dark clothing on his hike.” b. “We should all get the Lyme disease vaccine before our trip.” c. “I’ll get a prescription for amoxicillin to take with us.” d. “We will wear long pants and long-sleeved shirts in the woods.”

ANS: D People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites.

DIF: Cognitive Level: Application TOP: Prevention of Tick Bites

REF: 746 OBJ: 3 KEY: Nursing Process Step: Evaluation

16. An adolescent is taking tetracycline for a sexually transmitted infection. What would a 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 reNsiUstR anStItoNtG etT raBc. ycCliO neMs. DIF: Cognitive Level: Comprehension TOP: Sexually Transmitted Infections

REF: 756 OBJ: 9 KEY: Nursing Process Step: Implementation

17. A nurse explains to caregivers that their child is in the prodromal stage of varicella. What does this mean? a. The child is now immune to varicella. b. The child has varicella but has not yet broken out. c. The child is infected with varicella but is not contagious. d. The child does not have varicella but has been exposed to it.

ANS: B The prodromal stage is the initial stage of the communicable disease in which the child is infected and contagious but does not yet have outward signs of the disease.

DIF: Cognitive Level: Comprehension TOP: Prodromal Period

REF: 742 OBJ: 1 | 2 KEY: Nursing Process Step: Implementation

18. 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 a nurse identify this laceration? a. Reservoir b. Portal of entry

c. Portal of exit d. Vector ANS: B The chain of infection refers to the way in which organisms spread and infect the individual. A portal of entry is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit is the route by which the organisms exit the body (e.g., feces or urine). A reservoir for infection is a place that supports the growth of organisms (e.g., standing, stagnant water). A vector is an insect or animal that carries and spreads a disease.

DIF: Cognitive Level: Comprehension TOP: Chain of Infection

REF: 742 OBJ: 1 KEY: Nursing Process Step: Data Collection

19. Place the following steps of the chain of infection into the CORRECT order.

1. Reservoir 2. Portal of exit 3. Susceptible host 4. Portal of entry 5. Mode of transmission a. 1, 2, 5, 4, 3 b. 2, 5, 1, 4, 3 c. 4, 2, 1, 3, 5 d. 1, 2, 4, 3, 5 ANS: A The chain of infection refers to the way in which organisms spread and infect the individual (Fig. 32.4).

NURSINGTB.COM DIF: Cognitive Level: Knowledge TOP: Chain of Infection

REF: 757 OBJ: 3 KEY: Nursing Process Step: Planning

MULTIPLE RESPONSE 1. Which of the following factors may influence why an adolescent with an STI resists reporting the condition? (Select all that apply.) a. Reluctant to name contacts b. Is embarrassed c. Worries about confidentiality d. Doesn’t want to take the medication e. Is anxious about a pelvic examination ANS: A, B, C, E Adolescents may be uncomfortable about the pelvic examination and require a lot of support. Adolescents worry about the confidentiality of the agency and are reluctant to name contacts.

DIF: Cognitive Level: Comprehension TOP: Reporting STIs

REF: 742 OBJ: 8 KEY: Nursing Process Step: Planning

2. What sources are examples of acquired immunity? (Select all that apply.)

a. b. c. d. e.

Gamma globulin The disease Maternal antibodies The vaccine 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 TOP: Acquired Immunity

REF: 755 OBJ: 1 KEY: Nursing Process Step: N/A

3. A nurse is preparing to give which immunizations to a healthy 2-month-old infant? (Select all that apply.) a. DTaP b. Hib c. IPV d. MMR e. PCV ANS: A, B, C, E All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps, measles, and rubella are not expected until the child is 1-year old.

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DIF: Cognitive Level: Knowledge TOP: Inoculations for a 2-Month-Old

REF: 743 OBJ: 5 KEY: Nursing Process Step: Planning

4. A child has symptoms of vomiting and diarrhea. Which of the following conditions does a nurse assess the child for? (Select all that apply) a. Rotavirus b. Chicken pox c. Measles d. Mumps e. Norwalk virus ANS: A, E Rotavirus and Norwalk virus have symptoms of vomiting and diarrhea. The other conditions do not have these symptoms.

DIF: Cognitive Level: Knowledge TOP: Symptoms of Infectious Disease

REF: 742 OBJ: 2 KEY: Nursing Process Step: Data Collection

5. Which of the following factors would increase a child’s resistance to disease? (Select all that apply) a. Enhanced nutritional intake b. Intact mucous membranes c. Vaccinations

d. Administration of steroids e. Increased white blood cells ANS: A, B, C, E All of these factors will increase resistance to disease except for the administration of steroids which can decrease the resistance.

DIF: Cognitive Level: Application TOP: Resistance to Disease

REF: 747 OBJ: 3 KEY: Nursing Process Step: Planning

6. A nurse is assisting with an admission assessment of a child with scarlet fever. Which actions will the nurse expect to implement? (Select all that apply.) a. Obtain a throat culture b. Encourage ambulation c. Assess for desquamation d. Initiate droplet precautions e. Administer isoniazid ANS: A, C A diagnosis of scarlet fever would indicate throat culture and assessment for desquamation.

Bed rest with quiet activity is indicated. Droplet precautions would not be implemented for scarlet fever. Isoniazid is administered for tuberculosis.

DIF: Cognitive Level: Application TOP: Scarlet Fever TRUE/FALSE

REF: 748 | 749 OBJ: 2 KEY: Nursing Process Step: Implementation

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1. A nurse is caring for a child who has no known infectious diseases. When taking the child’s blood pressure (BP) the nurse will wear gloves.

ANS: F Routine precautions require a nurse to wear gloves when there is risk of exposure to blood or body fluids. This is not a risk when taking a BP in a non-infectious patient.

DIF: Cognitive Level: Comprehension TOP: Routine Precautions

REF: 748 OBJ: 4 KEY: Nursing Process Step: Implementation

COMPLETION 1. A parent is concerned because her son was exposed to varicella at preschool. The nurse would tell this parent that the incubation period for varicella is 10 to days.

ANS: 21 The incubation period for varicella is 10 to 21 days.

DIF: Cognitive Level: Knowledge REF: 743 OBJ: 2 TOP: Varicella KEY: Nursing Process Step: Implementation

2. The nurse demonstrates proper hand hygiene pointing out that the process should take a minimum of seconds.

ANS: 15 Hand hygiene should take a minimum of 15 seconds to complete.

DIF: Cognitive Level: Knowledge TOP: Hand Hygiene

REF: 751 OBJ: 4 KEY: Nursing Process Step: Implementation

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Chapter 33: The Child with an Emotional or Behavioural Condition Keenan-Lindsay: Leifer’s Introduction to Maternity and Pediatric Nursing in Canada, 1st Edition MULTIPLE CHOICE 1. A child with anxiety is being treated using supportive and interpersonal therapy. A nurse teaches the family that this treatment involves which of the following? a. Using communication strategies to help the child adjust how they see their world b. Targeting thoughts, physical symptoms and behaviours that characterizes anxiety c. Using mindfulness strategies to help the child live in the moment d. Using talk and play therapy ANS: A Supportive and interpersonal therapy utilizes attachment and communication strategies to help individuals adjust how they see their world. This type of therapy starts with identifying the underlying reasons why the person is having interpersonal difficulties and gauges the amount and depth of the available social support. Interpersonal therapy is most effective in making relationships, transitions, and their sense of social isolation more understandable.

DIF: Cognitive Level: Comprehension TOP: Treatment for Anxiety

REF: 768 OBJ: 7 KEY: Nursing Process Step: Implementation

2. What would be the appropriate nursing response to an adolescent who states, “This has been the worst day of my life?”

NiUndRS a. “You should focus your m onIpNoG siT tivBe.tC hoOuM ghts.” b. “Everybody has a bad day now and then.” c. “You’re young. What could be so terrible?” d. “Tell me about the worst day of your life.”

ANS: D The nurse establishes a rapport with the adolescent by acknowledging his or her feelings and giving the adolescent full attention.

DIF: Cognitive Level: Application REF: 766 OBJ: 3 | 7 TOP: Suicide KEY: Nursing Process Step: Implementation 3. A nurse asks, “Do your parents drink every day?” The adolescent suddenly shouts, “I’m not going to talk about that! It’s none of your business, anyway! Leave me alone!” How does the nurse interpret the adolescent’s behaviour? a. The adolescent is acting out and needs to be brought under control so the conference can continue. b. The adolescent is trying to shift the focus of the conference away from himself, and the nurse needs to refocus. c. The adolescent is demonstrating that this problem requires the assistance of a psychiatrist. d. The adolescent is responding to the discrediting of his parents, which causes anxiety.

ANS: D Discrediting parents threatens the child’s security and creates anxiety.

DIF: Cognitive Level: Analysis TOP: Care of Adolescent

REF: 762 OBJ: 7 KEY: Nursing Process Step: Data Collection

4. A nurse is answering phone calls at a local suicide prevention hotline. Which statement would be recognized as the greatest risk of suicide? a. “I just needed to talk to someone to keep myself from thinking silly thoughts about killing myself.” b. “My parents aren’t home and won’t be back for 4 hours. That should be enough time for the pills to work. I’ve got a hundred of them.” c. “My dad will be home first, so he’ll find me. So I think I’ll use his gun. I hope he didn’t lock the cabinet.” d. “My girlfriend is here with me. She told me to call because I was talking crazy about killing myself.”

ANS: B The risk of death increases when there is a definite plan of action, the means are readily available, and the person has few resources for help and support.

DIF: Cognitive Level: Analysis REF: 764 OBJ: 6 | 7 TOP: Suicide KEY: Nursing Process Step: Data Collection 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 sN peUnR dS tiI mN eG wT ithB. hiC sO giM rlfriend. b. He spends all of his time at the library studying to qualify for the honour 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 behavioural change from baseline that interferes with school, family life, and age-specific activities, frequently signalled by giving prized possessions away.

DIF: Cognitive Level: Analysis REF: 763 OBJ: 5 | 6 TOP: Depression KEY: Nursing Process Step: Data Collection 6. A mother is concerned because her adolescent son is always in trouble for fighting at school and always seems to be angry and unable to control his behaviour. What does a nurse know is the most likely diagnosis? a. Major depression. b. Persistent depressive disorder. c. Bipolar disorder. d. Disruptive mood dysregulation disorder.

ANS: D Disruptive mood dysregulation disorder is a persistent irritability and extreme inability to control behaviour exhibited in children under the age of 18.

DIF: Cognitive Level: Comprehension REF: 763 TOP: Disruptive Mood dysregulation Disorder KEY: Nursing Process Step: Data Collection

OBJ: 5

7. What is the most appropriate classroom intervention for a child with attention-deficit/hyperactivity disorder (ADHD) for a 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: 769 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Implementation

OBJ: 7

8. A 14-year-old girl with obsessive-compulsive disorder (OCD) tells a 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. Anxiety c. ADHD d. A learning disability

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ANS: B OCD is related to anxiety and other psychiatric disorders.

DIF: Cognitive Level: Comprehension TOP: Obsessive-Compulsive Disorder

REF: 766 OBJ: 5 KEY: Nursing Process Step: Data Collection

9. A 16-year old teenager attends the clinic stating feelings of decreased interest in previous activities, social isolation, and decreased performance in school. What is the first action a nurse should perform? a. Refer to a psychiatrist b. Screen using the Patient Health Questionnaire c. Initiate cognitive behaviour therapy d. Encourage the teen to get a prescription for an antidepressant ANS: B The first action of the nurse is to screen the child to determine if there is a depressive disorder. If depression is diagnosed further treatment will be required.

DIF: Cognitive Level: Application TOP: Diagnosis of Depression

REF: 763 OBJ: 8 KEY: Nursing Process Step: Implementation

10. What is an appropriate nursing intervention for a hospitalized child who has autism spectrum disorder?

a. Place the child in a location where she can watch all of the activity on the unit. b. Use the child’s chronological age as a guide for communication. c. Keep the child’s room free of toys or objects that she might want to take home with her. d. Approach the child with a slow pace and few distractions.

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: 771 OBJ: 7 TOP: Autism KEY: Nursing Process Step: Implementation 11. A nurse is planning to speak with a parent support group about childhood autism. What will the nurse include in the class? a. Significant signs of the disorder manifest by 2 years 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 babble or point by 12 months and no two-word spontaneous phrases by 24 months are signs to seek early interventions. In Canada it is recommended that all children are screened for ASD between 18 and 24 months if any of the following are present: failed items on the social, emotional, or communication skills inquiry; a sibling with autism; or developmental concern expressed by the parent, caregiver, or health care provider.

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DIF: Cognitive Level: Comprehension REF: 770 TOP: Autism KEY: Nursing Process Step: Planning

OBJ: 5

12. An adolescent is brought to the emergency department after an automobile accident. When a nurse approaches the adolescent, he is relaxed and denies feeling any pain. The nurse notes he has an increased pulse, and dilated pupils. What does the nurse suspect the adolescent has used? a. Alcohol b. Cocaine c. Amphetamines d. Cannabis ANS: D Cannabis can produce relaxation and euphoria and can alter the perception of pain. It also changes perception, distorts time, and decreases attention span and can result in deficits in memory, body tremors, and impaired motor functioning. Other physical effects of recent cannabis use include increased heart rate and appetite, increased blood pressure, dilated pupils, red eyes, dry mouth and throat, and bronchodilation.

DIF: Cognitive Level: Analysis TOP: Cannabis Use

REF: 775 OBJ: 8 KEY: Nursing Process Step: Data Collection

13. A child is being treated with cognitive behaviour therapy (CBT) to treat depression. What does a nurse teach the parents and child about the goal of CBT? a. Focuses on problem solving b. Focuses on strengthening parent-child relationships c. Uses talk therapy to discuss feelings d. Uses play to work through feelings ANS: A Cognitive behavioural therapy focuses on problem solving and emotional management skills.

DIF: Cognitive Level: Comprehension TOP: Cognitive Behavioural Therapy

REF: 765 OBJ: 7 KEY: Nursing Process Step: N/A

14. Psychological dependence related to substance use involves which of the following characteristics? a. Need to increase the amount of the substance used to get the same effect b. Need the substance to avoid the feeling of withdrawal c. An emotional need to use a substance d. The central nervous system becomes habituated to the substance ANS: C Psychological dependence includes a mild wish to a craving for or a compulsive emotional need to use a substance. Physical dependence is when physiological cellular adaptation occurs and the central nervous system and peripheral nervous system become habituated to the substance such that the person physically needs the drug to function or to avoid the physical pain of withdrawal. N ToUlR erS anIcN eG deTvB el. opCsOwMhen a user’s body becomes accustomed to certain drugs. The person must then increase the dose each time to maintain its effect.

DIF: Cognitive Level: Application TOP: Substance Use Disorder

REF: 772 OBJ: 9 KEY: Nursing Process Step: N/A

15. Which of the following is a characteristic of persistent depressive disorder? a. A period of decreased interest in activities for 2 weeks b. A depressed and irritable mood for at least 1 year c. Alternating periods of mania with periods of flat emotions d. A period of extreme inability to control behaviour ANS: C A persistent depressive disorder (dysthymia) is a chronic, low-grade, depressed or irritable mood for at least 1 year.

DIF: Cognitive Level: Comprehension TOP: Persistent Depression

REF: 763 OBJ: 5 KEY: Nursing Process Step: Data Collection

16. An adolescent states that life is not worth living and that he has a stock of pills that he is going to take that evening. What is the most important intervention a nurse can do? a. Tell him that life is not that bad b. Tell him that you will keep this information confidential c. Encourage him to talk about his feelings

d. Call his parents and tell them to get rid of the pills ANS: C It is important that a teenager does not have his feelings contradicted but rather he is encouraged to express feelings. When someone tells you they plan on committing suicide, it is important that this is not kept confidential.

DIF: Cognitive Level: Application REF: 766 OBJ: 6 TOP: Suicide KEY: Nursing Process Step: Implementation 17. A child presents with symptoms of constantly worrying about their performance in school and being a perfectionist. Based on these symptoms what does a nurse suspect the child has? a. Separation anxiety b. Performance anxiety c. Generalized anxiety disorder (GAD) d. Social anxiety disorder ANS: C Children with GAD worry more often and more intensely than other children. They tend to be very hard on themselves and strive for perfection. They may worry excessively about their grades, family issues, relationships with peers, performance in sports, about personal safety and the safety of family members, or about natural disasters and future events.

DIF: Cognitive Level: Application TOP: Generalized Anxiety Disorder MULTIPLE RESPONSE

REF: 767 OBJ: 5 KEY: Nursing Process Step: Data Collection

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1. A nurse who practices using a harm reduction approach uses the following intervention?

(Select all that apply) a. Providing safe injection sites b. Focusing on the determinants of health that are impacting the person c. Using a non-judgemental approach to the use of substances d. Insisting on the reduction of substance use ANS: A, B, C Harm reduction is a therapeutic approach that attempts to reduce the negative consequences associated with substance use. Those who practice from a harm reduction perspective incorporate a number of practical strategies aimed at “meeting people where they are at,” facilitating safer use, managed use, abstinence, and addressing other concerns related to a variety of determinants of health.

DIF: Cognitive Level: Application TOP: Harm Reduction

REF: 776 OBJ: 9 KEY: Nursing Process Step: Implementation

2. A child who has a parent with depression has increased risk for which of the following conditions? (Select all that apply). a. Anxiety disorder b. Mood disorder c. Substance-use disorder

d. Attention deficit hyperactivity disorder e. Conduct disorder ANS: A, B, D, E A child with a parent with depression is at risk for developing an anxiety disorder, mood disorder, conduct disorder, or substance-use disorder. The parent’s inability to model effective coping strategies can lead to learned helplessness, the creation of anxiety or apathy, and an inability to master the environment.

DIF: Cognitive Level: Knowledge TOP: Parental Mental Illness

REF: 761 OBJ: 2 KEY: Nursing Process Step: Data Collection

3. What is the first step in the continuum of care when considering mental health treatment?

(Select all that apply) a. health promotion b. prevention c. harm reduction d. psychological counselling e. addiction services ANS: A, B, C The continuum of services begins with health promotion, prevention, and harm reduction.

This is the first step in reducing the effect of emotional and behavioural symptoms in child and adolescent population. Childhood and adolescence is the optimal time to target prevention and intervention strategies as 80% of adults with mental illness experienced their first symptoms in childhood.

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DIF: Cognitive Level: Comprehension TOP: Continuum of Care

REF: 762 OBJ: 4 KEY: Nursing Process Step: Planning

4. What should a nurse teach a teenager who is taking antidepressants? (Select all that apply) a. Report any suicidal thoughts b. Psychological counselling will complement the medication c. Discontinue taking St John’s wort d. It is okay to continue to drink alcohol e. The use of cannabis will enhance the effect of the medication ANS: A, B, C Adverse effects of the medication also require astute monitoring. At highest risk for developing serious adverse effects from medications are adolescents who use alcohol, diet pills, over-the-counter medications, or recreational drugs. Selective serotonin reuptake inhibitor (SSRI) medications are generally well tolerated by adolescents; however, there is the potential for those who take the medication to develop agitation and suicidal thoughts.

Medication to help treat a depression should never be used without offering complementary psychosocial interventions.

DIF: Cognitive Level: Comprehension TOP: Antidepressant Treatment

REF: 765 OBJ: 7 KEY: Nursing Process Step: Implementation

5. A parent of a 15-year old is worried that the child may have started using drugs. What signs would a nurse teach the parent to be aware of that may indicate substance use in a teen?

(Select all that apply) a. Declining grades at school b. An increase in borrowing money c. New use of mouthwash d. Interest in getting a job e. Use of incense in bedroom ANS: A, B, C, E All of these are signs of possible substance use in a teen except for the interest in getting a job.

DIF: Cognitive Level: Knowledge TOP: Substance Misuse

REF: 776 OBJ: 9 KEY: Nursing Process Step: Implementation

6. A child is diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which characteristics would the nurse assess in this child? (Select all that apply.) a. Social anxiety b. Impulsivity c. Hyperactivity d. Distractibility e. Inattention ANS: B, C, D, E ADHD is characterized by inattention, hyperactivity, impulsivity, and distractibility.

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DIF: Cognitive Level: Knowledge REF: 768 TOP: Attention Deficit Hyperactivity Disorder KEY: Nursing Process Step: Data Collection

OBJ: 6 | 7

7. Which of the following are features of anxiety disorders? (Select all that apply.) a. Interferes with ability to complete activities of daily living b. The reasons for the anxiety are not obvious c. Attempts to decrease anxiety through logic do not work d. It can be treated effectively e. It always results in depression ANS: A, B, C, D All anxiety disorders share four common features. The anxiety or preoccupation interferes with the child or adolescent’s ability to enjoy life or to complete activities of daily living.

The reasons that the feelings of anxiety or worries originated are often unclear. Attempts to use logical explanations to reduce the experience of anxiety do not decrease the worries. The last feature is that problems with symptoms of anxiety can be helped with effective treatment strategies. While anxiety and depression can be related, it is not always the case.

DIF: Cognitive Level: Comprehension REF: 766 | 767 TOP: Anxiety KEY: Nursing Process Step: N/A

OBJ: 3 | 5

8. What are some of the factors related to a greater risk for death by suicide in Indigenous youth? (Select all that apply.) a. Lack of access to social activities b. Stressful life events c. Colonization d. Culturally acceptable e. Residential schools ANS: A, B, C, E Some of the factors that increase risk for suicide among Indigenous teenagers include high prevalence of mental health disorders, increased substance and alcohol use and increased social deprivation and stressful life events. Some of this is due to the historical undermining and dismantling of cultural processes and structures, due to forced colonial practices, such as relocations and residential schools, which has impacted family functioning (McLoughlin et al., 2015). It is not a culturally acceptable practice.

DIF: Cognitive Level: Comprehension TOP: Indigenous Health

REF: 766 OBJ: 2 KEY: Nursing Process Step: N/A

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