230 Exam 3 Review
A woman usually eats an 1800-calorie diet. She is now in the second trimester of her pregnancy. Which of the following best describes the caloric nutritional needs for this woman during the second and third trimester? a. 1800 calories b. 2100 calories c. 2400 calories d. 2700 calories
B During pregnancy, a womans caloric needs increase by 300 calories. Someone who usually eats an 1800-calorie diet should increase her caloric intake to 2100 calories (1800 + 300 = 2100).
A nurse is caring for a woman who is in labor and the fetus descends to the lower birth canal. The woman is in which of the following stages of labor? a. First b. Second c. Third d. Fourth
B During the second stage of labor, the fetus descends through the lower birth canal toward the womans perineum.
A 9-month-old has mastered the pincer grasp. Which of the following tasks would the nurse anticipate that the infant can do by himself? a. Play with a rattle. b. Eat cheerios off a hard surface. c. Hold a spoon to feed himself. d. Drink from a cup.
B The pincer grasp is a fine motor skill that is necessary for picking items up off a surface. By this age, hand-mouth coordination has usually been met and therefore feeding the self with finger foods becomes possible.
A deviation of the line of vision from the midline resulting from extraocular muscle weakness or imbalance is known as: a. amblyopia b. farsightedness. c. nearsightedness. d. strabismus.
D A deviation of the line of vision from the midline resulting from extraocular muscle weakness or imbalance is known as strabismus.
Where do most accidents occur? a. In the home b. In the car c. At day care d. On the playground
A Accidents occur in many situations: in the home, outside, on the playground, and in automobiles. However, most accidents occur in the home.
Which of the following best describes an abnormality in structure or function that occurs during fetal development? a. Congenital defect b. Genetic defect c. Embryonic defect d. Chromosomal defect
A During fetal development, an abnormality in structure or function is known as a congenital defect.
A pregnant woman who is at the end of 20 weeks of gestation is at a prenatal visit. Which of the following changes in weight from pre-pregnancy would require the nurse to take additional action? a. 6 pound increase b. 11 pound increase c. 14 pound increase d. 20 pound increase
A If at the end of 20 weeks of gestation the woman has not gained at least 10 pounds, she risks delivering an ill infant suffering from intrauterine growth restriction.
A 2-month-old infant is in for a well-baby visit. Which of the following immunizations should the nurse administer to the infant? a. DTaP-1 b. MMR c. Varicella d. Influenza
A The Centers for Disease Control and Prevention (2007) recommends the following vaccines at 2 months of age: DTaP-1, Hib-1, PCV, Polio, RV.
The nurse performs a home visit for a new mother and infant. The nurse observes that the infant lacks a regular feeding schedule, has diapers that are not changed promptly, and cries for long periods of time before being consoled. Which of the following problems is the infant most at risk for encountering in the future? a. Developing enuresis as a toddler b. Having difficulty forming relationships c. Becoming a picky eater d. Taking longer to toilet train
B The infant may have difficulty forming relationships in the future because trust influences future relationships. By attending to the infants needs, parents are helping the infant develop trust in them. Not having his needs attended to hinders that developmental task.
During a home visit to the home of a 3-month-old infant, which environmental finding requires immediate anticipatory guidance? a. A pool in the backyard without a gate b. The lack of smoke detectors c. The lack of childproof latches on drawers and cupboards d. Two azalea plants in the living room
B The lack of a smoke detector places the infant at immediate risk if a fire were to occur. The majority of fire deaths occur in the home, and most people die from smoke inhalation, not burns. At 3 months of age, the infant is not yet able to crawl; thus, the other three findings, although risks, are not immediate.
Kohlbergs theory of moral development is based on: a. Eriksons theory of psychosocial development b. Piagets theory of cognitive development c. Vygotskys theory of cognitive development d. Gilligans theory of moral development
B Kohlbergs theory of moral development is based on Piagets theory of cognitive development.
Which of the following is the most common poison ingested by infants? a. Houseplants b. Lead c. Cleaning agents d. Aspirin
D The most common ingested poison is aspirin, followed by houseplants and cleaning agents.
Which of the following statements summarizes Vygotskys theory of development? a. All children develop cognitively at the same rate b. Social and cultural influences are not major factors in cognitive development. c. Learning is an individual activity. d. Experience creates learning.
D Vygotskys theory of development stresses that social and cultural influences can have a major impact on learning. He felt that cognitive development was dependent on exposure to many life experiences, was influenced by interaction with others, and did not proceed according to predetermined stages.
A mother asks a nurse what the best toy would be for her 2-month-old. Based on the growth and development of the infant, which of the following recommendations should be made by the nurse? a. Colorful mobile with music b. Rattle c. Stuffed teddy bear d. Play telephone
A The most appropriate toy based on the childs age and developmental level would be a colorful mobile with music. At this age, the infant can listen to sounds and follow objects. The mobile provides visual and auditory stimulation to continue to promote growth and development.
A child is focused on peer approval and avoidance of not fitting in. According to Kohlberg, this child is experiencing which of the following stages of moral development? a. Preconventional b. Conventional c. Postconventional d. Preoperational
B The goal of the conventional stage is gaining approval and avoiding disapproval. The goal of the preconventional stage is avoiding punishment and gaining reward, while the goal of the postconventional stage is agreeing upon rights, establishing personal moral standards, and achieving justice.
The inability of a toddler to put him- or herself in anothers shoes is known as: a. autonomy. b. egocentrism. c. self-perception. d. integrity.
B The inability of a toddler to put him- or herself in anothers shoes is known as egocentrism.
An infant is lying in a crib watching and listening to a colorful mobile. What is the purpose of having a mobile? a. Provides stimulation necessary for continued growth and development for the infant b. Provides too much stimulation for the infant, making it difficult for the infant to focus c. Serves as inadequate stimulation for the infant because it is an inanimate object d. Serves as a distractor for the infant, making it easier to fall asleep
A The mobile is providing the stimulation necessary for continued growth and development because both auditory and visual stimuli are necessary to promote growth and development. Additionally, soft sounds and voices are soothing to infants.
A client who is 36 weeks of gestation is at her prenatal visit. The nurse tells the client that she will be screened for group B Streptococcus during todays visit. Which of the following statements would be made by the nurse when providing client education about this screening test? a. Screening for group B Streptococcus is necessary as this infection can cause complications with pregnancy and to the unborn infant. b. This screening will help us to determine if your unborn infant will be susceptible to respiratory distress when he or she is born. c. Screening for group B Streptococcus will help us identify if you have been exposed to this or any other infections during your pregnancy. d. This screening is necessary to determine if there is any Rh blood group incompatibility between you and your unborn child.
A Screening at 36 to 37 weeks of pregnancy for group B Streptococcus infection has been recommended because this infection causes preterm rupture of the amniotic membranes, premature labor, fetal respiratory distress syndrome, fetal septicemia, and meningitis.
A nurse would like to be involved in promoting change in health care policies. Which of the following actions would be most appropriate for the nurse to accomplish this goal? a. Be an active member of a national nursing organization. b. Vote for political leaders in favor of health care reform. c. Enroll in a health policy class. d. Learn about community resources.
A The best way for a nurse to promote change in health care policies is to be an active member of a national nursing organization. As an active member, she can join other professionals in lobbying for change.
By what age is an infants retina fully developed? a. Birth b. 2 months c. 4 months d. 6 months
C Rod cells in the retina of the eyes, which are responsible for light perception, are functional at birth; however, the retina (the organ of visual perception) is not fully developed until approximately 4 months of age.
The mother of a 3-month-old is concerned because her infant usually falls asleep halfway through his bottle. Because of this, the mother is afraid he will not grow well and get sick. Which of the following would be the most therapeutic response by the nurse? a. Ask the mother about the infants feeding schedule. b. Assure the mother that he is growing fine. c. Tell the mother that half a bottle is probably enough for him. d. Tell the mother she should start to add solids to his diet.
A The most therapeutic response would be to ask the mother about the infants feeding schedule. The mothers concern needs to be explored further so that the nurse can understand if the child is receiving adequate nutrition. This response will open the lines of communication and allow the mother to discuss her fears as well as the feeding schedule. Parents look to nurses for anticipatory guidance. The nurse should listen before giving advice. Knowing the feeding schedule will help to determine the best intervention.
A delivery room nurse senses disappointment when a mother is told she just delivered a baby girl. Which of the following would be the most therapeutic response by the nurse? a. Yes, you just delivered a healthy, beautiful baby girl. b. This is your first baby. You can always try again for a boy. c. Dont worry, many parents often feel the same way you do. d. You are tired. I think you should get some rest.
A The nurse should respond by saying, Yes, you just delivered a healthy, beautiful baby girl. This response provides information that will help increase the mothers acceptance of having a girl rather than a boy. Acceptance and bonding are important in preventing child abuse. The fact that the mother appeared disappointed should be acknowledged with a positive comment.
A nurse is assessing a toddler during a well-child visit. Which of the following findings warrant further investigation? (select all that apply) a. Bare spots on the scalp, and broken hair b. Overly concerned parents c. Burns with sharply demarcated edges d. Bruises anywhere on the body
A,C Bare spots and broken hair as well as burns with sharply demarcated edges are warning signs of child abuse. Abusive parents often do not demonstrate any guilt and are hesitant to provide information. Typically, abusive parents have difficulty leaving a child and attempt to identify with their feelings. In addition, bruises caused by abuse are usually located on the back side of the body, from the neck to the knees.
A nurse is encouraging parents to immunize their infants. Which of the following strategies would be the best way for the nurse to facilitate this? a. Send a reminder for immunizations to the parents. b. Talk to the parents about immunizations during office visits. c. Track clients who have not been immunized. d. Memorize the CDC immunization schedule.
B The best way for a nurse to encourage immunization is to talk to parents about immunizations during office visits. Immunizations are important in the prevention of disease. Actively broadening ones knowledge base regarding immunizations and developing a close relationship with the parents that promotes open communication are important factors for motivating parents.
A nurse is attending a continuing education program about growth and development. Why is it necessary that nurses are well educated about this content? (select all that apply) a. Have a better understanding of genetics and genomics b. Can meet the requirements of Healthy People 2010 c. Can provide more effective health education d. Can deliver anticipatory guidance to families
A, C, D Genetics and genomics is an important part of our age of technology; understanding growth and development aids in the understanding of these topics as well. Health education is more effective when the nurse acknowledges and incorporates growth and developmental needs as well as the individuals prior understanding of beliefs about health and health-related concepts. Health promotion is an important part of Healthy People 2010, but there are no requirements within this document that nurses need to be educated about growth and development.
Which properties must the sperm possess for conception to occur? (select all that apply) a. High motility b. Uniform size c. Ability to secrete enzymes that dissolve the membrane surrounding the egg d. Life span of at least 3 hours
A,B,C The sperm must be of uniform size, be normally formed, possess high motility, and have an ability to secrete enzymes that dissolve the membrane surrounding the egg.
Which scenario places a toddler at risk for injury? (select all that apply) a. Toddler playing with his preschool siblings toy b. Mop and a bucket of clean water in the kitchen c. Cup of hot coffee on the kitchen counter d. Twenty-five pound toddler sitting in a forward-facing car seat in the back seat of a car
A,B,C Toys are a common source of injury, especially toys intended for older children. Hot water, boiling water, coffee, tea, and food are the most common sources of injury and should not be kept within reach of the child. Additionally, toddlers can drown in water just deep enough to cover their noses and mouths, and this includes pails of water. Once children reach 20 lb, they should be switched to a forward-facing child safety seat, and preferably be placed in the rear seat because of the risk of injury from air bags in the front seat.
A nurse is using the Denver Developmental Screening Test (DDST) II to assess a 10-month-old infant. Which of the following purposes does this screening serve? (select all that apply) a. Screens apparently healthy infants for developmental problems b. Allows the infants growth patterns to be compared with other infants c. Validates intuitive concerns about an infants development using an objective test d. Monitors high-risk children for developmental problems
A,C,D The Denver Developmental Screening Test (DDST) is one of several standardized tools that screens for developmental problems in children from birth to 6 years of age. The purposes identified for administering the Denver II: screening apparently healthy infants for developmental problems; validating intuitive concerns about an infants development with an objective test, and monitoring high-risk children for developmental problems.
Which of the following mothers would be most likely to bond appropriately with their infant? a. A mother who feels unloved will bond appropriately because now the baby will love her. b. A mother who feels great about herself will show love toward the infant and bond appropriately. c. A mother who feels empty by the birth of her child will bond appropriately once she holds the baby. d. A mother who feels ugly will bond appropriately with her child because her child will bring self-esteem.
B After birth, the woman gradually sees the infant more and more as a separate individual, dependent on her care. The mother starts to bond with her baby based on her self-perception. If she feels good about herself, she will show love toward the infant. When she feels ugly or unlovable, she may make uncomplimentary remarks about the infants appearance.
A mother comes to the pediatric clinic and says to the nurse, I am worried about my 11-month-old baby because he is not crawling yet and his brother crawled when he was 11 months old. Is something wrong? Which of the following statements should the nurse make? a. It is highly unusual for siblings not to reach developmental milestones at the same time. Ill ask the doctor to assess him. b. All babies reach developmental milestones at different rates. c. This may be something to worry about. Ill have the doctor examine him. d. Dont worry; hell crawl soon enough.
B Although developmental milestones follow a predictable pattern, each child develops at his or her own rate. Telling the mother not to worry is not answering her question.
The nurse is caring for a person who donated a kidney to a stranger in need. According to Gilligans stages of moral development, the person who donated the kidney is in which of the following stages? a. Preconventional b. Conventional c. Postconventional d. Midconventional
B Characteristics of the conventional stage of Gilligans stages of moral development include sacrifice to fulfill the needs of others.
According to Piagets theory of cognitive development, which of the following statements is correct? a. Cognitive function continues to become refined throughout life. b. A childs greatest task is to make sense of the world around him or her c. Culture plays a major role in cognitive development. d. Learning precedes development.
B Piaget theorized that cognitive development was complete by about age 15. He did not factor the effects of culture into his theory and felt that learning followed cognitive development.
An infant is going through the toys in his toy box. He looks at each one before dropping it to the floor and picking the next toy out of the box. Using a growth and development perspective, which of the following conclusions can the nurse draw by assessing this behavior? a. The infant is testing his limits. b. The infant is exploring his environment. c. The infant is expressing his emotions. d. The infant is developing fine motor skills.
B The infant is exploring his environment. By looking at each toy, he is developing the task of learning to understand and control his world through exploration.
During the first prenatal visit, the pregnant woman informs the nurse that she cannot wait to start wearing maternity clothes. This finding is based on an assessment of which functional health pattern? a. Cognitive-perceptual pattern b. Self-perceptionself-concept pattern c. Health-perceptionhealth-management pattern d. Values-beliefs pattern
B To develop a maternal identity, the woman must first accept the pregnant body image. The pregnant womans personality, maturity level, and psychological development influence her readiness to assume the role of mother. Being excited about wearing maternity clothes is an indication that she has accepted the pregnant body image. Such an assessment is a component of the self-perceptionself-concept pattern.
A nurse makes a home visit to monitor the blood pressure of a pregnant woman who is single. Which finding would be of most concern to the nurse? a. The bedroom is located on the second floor. b. She has a pet cat. c. There is an area rug in the living room. d. She has a 1-year-old child.
B Toxoplasmosis is caused by a protozoan that infects people through undercooked meat, handling of cat feces, and exposure to infected soil. Sixty percent of maternal infections acquired during the third trimester result in fetal infection, which can lead to rash, enlarged lymph nodes and liver, inflammation of the heart, pneumonia, jaundice, and severe central nervous system damage after birth or years later. Thus, pregnant women should avoid handling cats or cleaning cat litter boxes to avoid exposure to toxoplasmosis.
A nurse is completing an initial genetic counseling interview with a couple. Which of the following data would be collected during the interview? (select all that apply) a. Paternal age b. Maternal age c. Family history d. Religious affiliation
B,C An important aspect of genetic counseling is identifying families at increased risk and referring them as necessary. Aspects that would be reviewed in the initial interview include: maternal age, ethnic background, family history, reproductive history, and maternal disease.
The nurse at a well-baby clinic is assessing a 12-month-old child. At birth, the child weighed 7 lb. 3 oz. During this visit, the child weighs 21 lb. 10 oz. Which of the following conclusions would the nurse make about the childs weight? a. The infant is gaining weight faster than anticipated. b. The infant is malnourished. c. The infant is at the expected weight for his or her age. d. The infant is having a growth spurt.
C A 1-year-old infant is expected to have at least doubled his or her weight by 12 months of age.
A new mother has decided to breast-feed her infant after having bottle-fed her other two children. Which of the following information about having a breast-fed infant should the nurse discuss with the mother? a. Breast-fed infants have darker bowel movements than bottle-fed babies. b. Breast-fed infants have smellier bowel movements than bottle-fed babies. c. Breast-fed infants have more frequent bowel movements than bottle-fed babies. d. Breast-fed infants have harder bowel movements than bottle-fed babies.
C A breast-fed infants stools have an orange-yellow color and a soft, even consistency, with a slightly sour but clean smell, dissimilar to stools passed later in life. A bottle-fed infants stools are harder, smellier, and resemble those of an infant eating solid food. The breast-fed infant has many daily stools during the first and second months of life. The bottle-fed infant has two to four stools per day during the first month.
During the second prenatal visit, the pregnant woman informs the nurse that she has stopped smoking. This finding is based on an assessment of which functional health pattern? a. Cognitive-perceptual pattern b. Self-perceptionself-concept pattern c. Health-perceptionhealth-management pattern d. Values-beliefs pattern
C A womans acceptance of her pregnancy influences her health management practices. A woman who denies or has negative feelings about her pregnancy may fail to eat properly, get enough rest and exercise, and so on. A woman who has stopped smoking because she is pregnant indicates that she accepts her pregnancy and the health practices that must be instituted to promote a healthy pregnancy, delivery, and baby. Such an assessment is a part of the health perceptionhealth management pattern.
A nurse is caring for a woman who is in labor. The nurse anticipates that the labor will progress through which of the following sequences? a. Dilation stage, pressure stage, placental stage, recovery stage b. Dilation stage, pushing stage, pain stage, recovery stage c. Dilation stage, pushing stage, placental stage, recovery stage d. Dilation stage, pushing stage, placental stage, refractory stage
C The sequence for the four stages of labor is dilation stage, pushing stage, placental stage, and recovery stage.
At 1 minute of age, an infant has a heart rate of 95, a strong cry, some flexion of extremities, a cry reflex, and is completely pink. Which of the following is a correct assessment of the infants Apgar score? a. 4 b. 6 c. 8 d. 10
C There are five signs that are scored using the Apgar scoring system. A heart rate under 100 receives a score of 1, a strong cry receives a score of 2, some flexion of extremities receives a score of 1, a cry for the reflex irritability sign receives a score of 2, and an infant whose color is completely pink receives a score of 2: 1 + 2 + 1 + 2 + 2 = 8.
At a well-child visit, the parents of a toddler ask the nurse how they should teach their toddler the importance of dental hygiene. Which of the following actions should the nurse recommend to the parents? a. Remind the toddler to brush his teeth every day. b. Have the dentist tell the toddler about the importance of dental hygiene. c. Schedule a time to brush their own teeth with their toddler. d. Have the toddler watch an educational cartoon video on the teeth brushing.
C Toddlers identify with parents, caregivers, and other important role models, internalizing a wider range of lifestyle attributes. Parents and caregivers health perceptions and health behaviors should model the perceptions and behaviors desired for health promotion. Thus, scheduling a time to brush their teeth with their toddler is the best way for parents to teach their toddler the importance of dental hygiene.
Approximately how much sleep do toddlers require each day? a. 10 hours b. 11 hours c. 12 hours d. 13 hours
C Toddlers need for sleep decreases to 12 hours a day during this developmental period.
Which of the following statements describes Eriksons theory of development? a. A healthy personality is defined by the lack of pathology .b. Stages of development advance based on psychosocial factors. c. The main premise of the theory is that individuals are interdependent beings and rely on each other in order to develop successfully. d. An individual must successfully accomplish the developmental stage before proceeding to the next stage.
D Eriksons theory of development is based on the need of each person to develop a sense of trust in self and others and a sense of personal worth. Each stage depends on the preceding stage, which must be accomplished successfully for the person to proceed. Although the environment and others may influence development, it is primarily an individual task. A person may regress to an earlier stage during times of stress.
A nurse makes a home visit to a 15-month-old following a hospitalization for a fall. Which finding would be concerning to the nurse? a. Radiator heating system in the home b. The child drinking from a cup c. The child experiencing a temper tantrum d. A decorative bowl filled with colorful marbles on the coffee table
D A decorative bowl filled with colorful marbles on the coffee table is concerning because by 15 months of age the infant is mobile and can eat finger foods. By 7 months of age, the infant fixates on small objects; therefore a safe environment must be created for the infant. Small objects are the most common causes of foreign body aspiration. A bowl of colorful marbles poses a risk for foreign body obstruction.
A nurse is caring for a woman during the fourth stage of labor. Which of the following best describes an action the nurse would take during this stage? a. Providing constant reinforcement and education about the labor process and assisting the woman with pushing b. Explaining unusual interventions such as the use of a fetal heart monitor c. Assisting with labor discomfort by modeling breathing d. Teaching the new mother positioning of the infant to assist with breast-feeding
D Active nursing support during the third and fourth stages of labor includes observing for excessive vaginal bleeding after the placenta is expelled, assisting the woman with breast-feeding, monitoring vital signs, implementing uterine massage as indicated, and providing emotional support. Thus, the best response is the nurse teaching the new mother the football hold to assist with breast-feeding.
A nurse assesses that the task of development of affection for and from others has been met or is in the process of being met by an infant. Which of the following observations has the nurse made? a. The infant smiles at mirror images. b. The infant makes cooing noises. c. The infant begins to smile socially. d. The infant likes to be picked up.
D An infant who likes to be picked up is displaying affection for others. This task is usually accomplished by 6 months of age.
During a prenatal visit, pregnant parents ask the nurse what they can do to prepare their 4-year-old child for the birth of the new baby. Which of the following actions would be most appropriate for the nurse to suggest? a. Discourage any negative comments the child makes about the baby or the pregnancy. b. Do not make any plans regarding the baby in front of the 4-year-old child. c. Provide him with very detailed information about the pregnancy and the birth. d. Ask the 4-year-old boy to help decorate the new babys room.
D Children in the family also experience role changes during and after the pregnancy. Having a child participate in decisions about the baby helps to prepare the child for the arrival of the neonate. Helping the parents decorate the new babys room allows the child to participate in the arrival of the new baby.
During a prenatal visit, a pregnant woman informs the nurse that she and her husband have chosen godparents for the baby. This finding is based on an assessment of which functional health pattern? a. Cognitive-perceptual pattern b. Self-perceptionself-concept pattern c. Health-perceptionhealth-management pattern d. Values-beliefs pattern
D For women with strong spiritual needs related to their cultural backgrounds, spiritual interventions will help them integrate various dimensions of their lives, develop the ability to parent successfully, and find meaning in the changes and goals of pregnancy. Identifying godparents will help the woman find meaning in the changes and goals of pregnancy. Such religious beliefs assessments are components of the values-beliefs pattern.
Which of the following statements is correct related to the concept of growth a. Growth occurs mainly during early childhood. b. Older adults do not experience growth-related changes.. c. Growth refers only to the increase in the size of specific organs and systems. d. Growth occurs throughout the life cycle.
D People experience developmental transitions throughout life, not just during times of rapid physical growth. Growth changes that take place in young, middle-aged, and older adults should be noted. People who think of growth only as it applies to infants, children and adolescents are missing important changes from conception throughout adulthood.
During a prenatal visit, a nurse discovers that a Black woman has been occasionally craving and eating clay. Which of the following actions should be taken by the nurse? a. Tell the client that many pregnant women crave such nonfood substances, and it is not a problem. b. Ignore the comment because pica is acceptable in some rural Black cultures. c. Encourage the client to eat it with plenty of water because of the risk of constipation. d. Stress the importance of an appropriate diet and avoiding pica in a culturally sensitive way.
D Pica may negatively influence the quality of a womans nutrition during pregnancy. The practice of pica is acceptable in some rural Black cultures. However, it can lead to lead poisoning, fecal impaction, parasitic infections, prematurity, perinatal mortality, low birth weight infants, and anemia in infants. When the nurse identifies instances of pica, she should suggest a culturally sensitive diet that will better meet the needs of the woman and her fetus. The nurse must remain nonjudgmental but stress the importance of an appropriate diet and the dangers of pica.
At a well-child visit, a 2-year-old toddler measures 2 feet 8 inches tall. The nurse estimates the toddlers approximate final adult height to be: a. 4 feet 8 inches. b. 5 feet. c. 5 feet 2 inches. d. 5 feet 4 inches.
D The toddlers height at 2 years is approximately 50% of final adult height. Thus, at 2 feet 8 inches, the childs approximate final adult height would be 5 feet 4 inches tall (2 feet 8 inches 2).
A 15-month-old infant has been brought into the office by his Spanish-speaking mother for symptoms of an upper respiratory infection. Which of the following should be the initial action taken by the nurse? a. Ask the mother if she would like an interpreter b. Ask the mother what home remedies have been used. c. Ask the mother how long the child has had these symptoms. d. Ask the mother about any allergies the child may have.
A The nurse should start by asking the mother if she would like an interpreter. Once the need for an interpreter has been established, the nurse can continue with the other questions.
Which of the following changes is experienced by the urinary system during pregnancy? a. Increased urinary output secondary to total body water increase b. Decreased bladder capacity c. Decreased glomerular filtration rate (GFR) resulting from estrogen and progesterone surge d. Increased renal excretion of acidic drugs
A The urinary system undergoes dramatic changes during gestation. The changes include a 50% increase in GFR, an increase in the diameter of the ureters, and increase in urinary output related to total body water increase and an increase in bladder capacity.
A nurse is developing an educational program about SIDS for a new mothers support group in the community. Which of the following information would be included in this presentation? a. Parents are encouraged to place their infants in the supine sleeping position. b. SIDS is the leading cause of death among infants age 6 months to 1 year old. c. SIDS is associated with infants who have had difficulty sleeping at night. d. Parents are encouraged to limit the amount of tummy time of their infant.
A Through the Back to Sleep program developed by the AAP, there has been a lower number of infant deaths from SIDS. This has encouraged the supine sleeping position. One of the consequences of the supine sleeping position is plagiocephaly. The primary intervention to decrease the risk of plagiocephaly is tummy time. Parents should be instructed to allow supervised tummy time while the infant is awake and cautioned about the amount of time their infant spends in a car seat. SIDS is the leading cause of death among infants 28 to 365 days of age. By definition, the cause of SIDS is not known.
Which of the following toddlers would require further investigation from the nurse? a. Sitting quietly on a couch b. Experiencing a temper tantrum c. Playing with a toy next to another child also playing with a toy d. Exploring his environment and playing with new toys
A Toddlers are always busy. They spend most of their day playing and exploring their environment. Thus, a toddler sitting quietly is not an anticipated behavior and should be evaluated further.
A school nurse is obtaining the height and weight of a 9-year-old child. Which of the following is the best method to assess the childs growth? a. Use serial measurements over time. b. Use this measurement. c. Use this measurement and compare it with the childs peers. d. Use the WHO growth chart to assess this childs measurements.
A When assessing growth data for use in growth charts, it is important to remember that a single measurement taken at one point in time, although helpful in providing a baseline, does not allow for the best assessment of a childs growth. Serial measurements, plotted on a growth chart over time, best reflect a childs pattern of growth.
A nurse is completing a home visit of a new mother who is breast-feeding her infant. Which of the following instructions should the nurse provide during this visit? a. Consume 500 kcal/day above pre-pregnancy energy intake to avoid excessive weight loss. b. Drink 1 quart of fluids daily to produce sufficient quantity of breast milk. c. Use formula to provide the infant supplementation between feedings. d. Use a pacifier to help the infant to fall asleep so he does not fall asleep when breast-feeding.
B Community nurses who are caring for breast-feeding mothers should stress the following tips to increase the duration of this activity: drink 1 quart of fluids daily to produce sufficient quantity of breast milk; consume 300 to 400 kcal/day above pre-pregnancy energy intake to avoid excessive weight loss; learn the appropriate interventions for engorged breasts, sore nipples, plugged ducts, infection, and leaking; learn about the use of breast pumps and milk storage; join breast-feeding support groups for continued help within the community; learn about the effects of drugs, environmental pollutants, alcohol, and nicotine on breast milk. The use of formula and pacifiers should be discouraged with new infants who are breast-feeding.
A Mexican American woman comes to the office for a visit. She is found to be 30 weeks pregnant. Which of the following conclusions can the nurse draw from this finding? a. The woman does not value prenatal care. b. Client education may require a different approach because of dissimilar cultural beliefs. c. This culture does not believe in traditional medicine. d. Signs of pregnancy were not recognized by the woman.
B Cultural groups have unique ideas and beliefs related to pregnancy, childbirth, and childbearing that must be understood by the nurse to render individualized care to each pregnant woman. Mexican Americans may consider prenatal care not needed because pregnancy is a normal life event. In addition, education influences their prenatal care access. Therefore finding out that she is 30 weeks pregnant may be an indication that this woman may require a different approach to education because of dissimilar cultural beliefs.
Which of the following statements about race and culture in the United States is correct? a. The United States ranks 22nd in the world for infant mortality rate. b. Ethnic minority populations have higher rates of low-birth-weight infants. c. Black infants are more likely to have cleft palates than Native American infants. d. Whites have more fraternal twin pregnancies than non-Whites.
B Currently, the United States is 49th in the world ranking for infant mortality rate (IMR). This rate, which reflects the number of infants who die before the end of their first year of life is the leading indicator of a nations health, reflects the higher IMRs and low-birth-weight outcomes of Blacks, American Indians, and other ethnic minority populations in the United States. In the United States, non-Whites (mainly Blacks) have more fraternal twin pregnancies than Whites. More Native American, Latino, or Asian descent babies have cleft palates than do Black babies.
A nurse is caring for a client who is 30 weeks pregnant at a prenatal visit. Which of the following statements made by the client would be of concern to the nurse and warrant further explanation and close follow-up? a. I have been feeling more tired lately. b. My husband complains every time I ask him to do something for me. c. Sometimes, the smell of food makes me nauseous. d. I need to get up two times a night to go to the bathroom.
B Fatigue, nausea, and increased urinary frequency are all normal discomforts associated with pregnancy. These discomforts warrant anticipatory guidance from the nurse. A husband who resents the attention that his pregnant wife is receiving and the additional demands she may make on his time may lead him to abuse his wife. Therefore the nurse must obtain additional information and provide close follow-up when a woman states that her husband complains every time she asks him to do something because she may be at risk for abuse.
Which of the following statements about Gilligans theory of moral development is accurate? a. This theory is based on a sense of absolute right and wrong. b. This theory is gender specific. c. This theory is dependent on ones stage of cognitive development. d. This theory is based on the premise that women view situations in terms of rules.
B Gilligans theoretical work is based on womens moral development. Kohlberg postulated that men view situations in terms of justice and rules, and that moral development depends on cognitive development.
The nurse is explaining the concept of growth to a parent. Which of the following statements should be made by the nurse? a. Growth means adding height and weight to your body. b. We continue to grow in various ways throughout life. c. How much we grow is based on gender. d. Growth stops when we are young adults.
B Growth, in some form, continues throughout life, not just during puberty. Not all growth is based on gender. Growth indicates more than a change in height and weight.
A nurse is caring for a pregnant woman who has a pre-pregnancy body mass index (BMI) of 27. Which of the following instructions should the nurse provide the woman regarding weight gain during pregnancy? a. You should gain 11 to 20 pounds during your pregnancy. b. You should gain 15 to 25 pounds during your pregnancy. c. You should gain 25 to 35 pounds during your pregnancy. d. You should gain 28 to 40 pounds during your pregnancy.
B In 2009, the IOM released new weight gain guidelines that are based on revised BMI categories. Overweight women (BMI of 25 to 29.9) should gain 15 to 25 pounds. Healthy women at a normal weight for their height (BMI of 18.5 to 24.9) should gain 25 to 35 pounds. Underweight women (BMI less than 18.5) should gain 28 to 40 pounds. Obese women (BMI greater than 30) should limit their gain to 11 to 20 pounds.
A nurse is assessing a 4-month-old infant during a well-child visit. Which of the following findings will require the nurse to collect additional information? a. The infants shirt is wet from drooling. b. The infant has gained one pound since her 2-month well-child visit. c. The infant holds his or her head steady when in a sitting position. d. The infant grasps objects with two hands.
B One of the passive manifestations of abuse includes poor nutrition, failure to thrive, and severe malnutrition. Weight gain of 1 pound in 2 months indicates a problem with the infants growth and requires further data collection by the nurse. The other assessment findings are normal growth and development for a 4-month-old infant.
The client who is taking prescribed _____ would require preconception management to minimize the potential for drug-related birth defects a. antiemetics b. antiepileptics c. iron d. non-narcotic analgesics
B Oral antiepileptic medications require preconception management to minimize potential birth defects and minimize health problems.
A nurse who is conducting a parenting class is asked how to select a good day care center for an 18-month-old child. Which of the following responses should be made by the nurse? a. Day care centers that schedule age-appropriate educational videos increase verbal ability. b. Human interaction increases a toddlers verbal skills, so select a day care center that values adult-to-toddler interaction. c. Learning to understand the meaning of words is increased when toddlers are exposed to educational DVDs, so select a day care center that has an extensive library of age-appropriate, educational DVDs. d. There really is no difference in the quality of day care centers based on whether or not videos or DVDs are used for educational purposes.
B Research has demonstrated that toddlers who are exposed to videos and DVDs have a more limited vocabulary than toddlers who interact with caregivers.
A woman who just found out she is pregnant starts crying. She tells the nurse that over the last 3 days she was not feeling herself, so she took some Tylenol. She states if she knew she was pregnant, she never would have taken the medication. Which of the following actions should be taken by the nurse? a. Tell the client that there is a high probability that her baby will have a birth defect b. Tell the client not to worry because research indicates that in recommended doses Tylenol is safe. c. Tell the client not to worry because she did not know she was pregnant, but in the future, she should use herbal products instead of over-the-counter medication. d. Tell the client that there is a high probability of a stillbirth.
B Research on aspirin and Tylenol indicates that both medications are safe in recommended doses. Little is known about the effects of herbal products and their interaction with other medications. As a result, the nurse may need to encourage a client to reconsider the use of herbs when evidence exists that the herbs may harm the fetus or the mother. Providing the mother with appropriate information will help to decrease the mothers anxiety level.
A woman is Rh negative and the father of her baby is Rh negative. The woman states that her friend told her that she would need a shot to keep her baby alive. Which of the following statements would be the best response by the nurse? a. Yes, you will need an injection of RhoGAM at 28 weeks gestation and within 72 hours after birth. b. Because the father of the baby is also Rh negative, your baby will not inherit Rh positive blood cells and you will not need the injection. c. Yes, you will need the injection because this is your first pregnancy. You will not need it with subsequent pregnancies. d. No, you will not need the injection because you are White. Rh incompatibility affects only Black women.
B Rh incompatibility sometimes affects fetal development. The problem usually occurs when the mother has Rh-negative blood cells and the fetus has Rh-positive blood cells, inherited from the father who also has Rh-positive blood cells. All women should be assessed for blood type, Rh factor, and antibody development at their first prenatal visits and again at 24 to 28 weeks, unless the father is Rh-negative. Rh incompatibility may be prevented by administering RhoGAM at 28 weeks and within 72 hours after birth. In this case, because the father is Rh negative, RhoGAM is not necessary.
A woman who is 30 weeks pregnant tells the nurse that she and her husband are having sexual difficulties. Which of the following actions should the nurse take? a. Tell the woman she should not be sexually active at this point in her pregnancy because it may harm the fetus. b. Ask her to elaborate on the difficulties. c. Tell her that they should modify their positions during intercourse and that will take care of the problem. d. Tell her men like the way pregnant women look.
B Some women worry about intercourse during pregnancy, fearing that it will cause miscarriage, infection, early delivery, or harm to the baby. Sexual dissatisfaction of the couple may result from restrictions in sexual positions, pain on penetration, increased vaginal discharge, breast tenderness, or the other physical discomforts of pregnancy such as fatigue or heartburn. The couples feeling about the womans changing body may alter their sexual relationship. The nurses first step in primary prevention intervention is to support the couples needs and relate, in a sensitive fashion, accurate information that facilitates couples intimacy during pregnancy. Asking her to elaborate on the difficulties allows the nurse to understand the root of the problem and develop an appropriate intervention. It also opens the lines of communication, so the nurse can discuss common difficulties experienced by couples and help her and her husband adjust to the challenges and discomforts of pregnancy. Giving the woman advice on position changes or body image may not be effective if it is not the cause of the difficulties.
A mother asks the nurse when she should start feeding her infant solid foods. Which of the following is the most appropriate response by the nurse? a. It is recommended that solid foods are introduced no earlier than 3 months of age. b. It is recommended that solid foods are introduced no earlier than 6 months of age. c. You should wait until your child is 9 months old to start solid foods. d. You should wait until your child is 1 year old to start solid foods.
B The AAP (2011) recommends that waiting until the child is 6 months of age to introduce solid food decreases the tendency to develop food allergies and reduces the risk of childhood obesity.
A new father is installing a car seat for an infant in the car. Which of the following information should be given to the father by the nurse? a. The infant should be in a rear-facing car seat in the front seat. b. The infant should be in a rear-facing car seat in the back seat. c. The infant should be in a front-facing car seat in the front seat. d. The infant should be in a front-facing car seat in the back seat.
B The AAP recommends rear-facing car safety seats for most infants up to 2 years of age. The back seat is recommended because of the danger posed by air bags.
A pregnant woman is having a TORCH screening done at todays prenatal visit. She states she is anxious to get the results back because she recently had unprotected sex with someone she just met and is afraid she might have HIV. Which of the following statements would be the best response by the nurse? a. You will know your HIV status in about 1 week when the results come back. b. You will require additional testing for HIV as it is not tested for with the TORCH screen. c. You will need to be tested for HIV after you deliver because pregnancy can produce false HIV results. d. You need to be exposed for at least 6 months before being tested for HIV in order for the results to be accurate.
B The TORCH screening helps detect toxoplasmosis, hepatitis B, rubella, cytomegalovirus, and herpes simplex. HIV is not detected with the TORCH screen. Therefore she should tell the woman that she will require additional testing for HIV.
A nurse is educating new parents about normal growth and development for their child. Which of the following items would the nurse include in this discussion? (select all that apply) a. Trends in childhood obesity b. Availability of a well-balanced diet c. Exposure to lead-based pain d. Height/weight of relatives
B,C,D A well-balanced diet will help assure that the child reaches his or her growth potential. Lead poisoning, an environmental exposure, remains a significant threat to todays children. Genetic factors greatly influence growth and development.
A nurse is assessing a woman for positive signs of pregnancy. Which of the following assessment findings would the nurse discover? (select all that apply) a. Positive test for HCG in the maternal urine b. Detection of fetal heart tones c. Enlargement of the uterus d. Palpation of fetal body parts
B,D Positive signs of pregnancy include: detection of fetal heart tones by auscultation, ultrasonography, or a Doppler; palpation of fetal body parts using Leopold maneuvers; fetal movements visible and detected by examiner; and radiological or ultrasonographic demonstration of fetal parts. Enlargement of the uterus and positive test for HCG in the maternal urine are both probable signs of pregnancy.
A nurse is working with a family of an infant to improve their health-perception and health management pattern. Which of the following interventions would be most appropriate for the nurse to implement? a. Assess the home for safety hazards. b. Teach parents appropriate coping mechanisms. c. Demonstrate effective parenting skills. d. Encourage appropriate stimulation of the infant.
C Health is largely a subjective judgment. With this understanding, the nurse uses every opportunity to convey confidence in the parents health perception-health management pattern and their ability to act to enhance the infants health. When parents learn and adopt behaviors to improve their own health, they are more likely to ensure that the health needs of their infant are met. Parental modeling increases the changes that good health practices will be retained throughout the childs life.
A high school sophomore engages in risky behavior to fit in with his peers. According to Eriksons theory of human development, which of the following developmental conflicts is this student facing? a. Initiative versus guilt b. Industry versus inferiority c. Identity versus role confusion d. Intimacy versus isolation
C According to Erikson, a preschool child has a developmental conflict between initiative and guilt, a school-age child has a developmental conflict between industry and inferiority, and a young adult has a developmental conflict between intimacy and isolation. An adolescent has a developmental conflict between identity and role confusion.
A pregnant woman reports to the nurse that the first day of her last menstrual period was January 22. Using Ngeles rule, which of the following dates would be the most accurate estimated date of delivery? a. September 16 b. September 22 c. October 29 d. October 17
C An accurate estimated date of delivery is determined by using Ngeles rule. This is done by adding 7 days to the date of the first day of her last normal menstrual period and subtracting 3 months: 22 + 7 = 29. Subtracting 3 months from January is October. Thus, the estimated date would be October 29.
A nurse is assessing the nutritional-metabolic patterns of a pregnant woman. Which of the following findings would be of concern to the nurse? a. The woman drinks about 1 gallon of water a day. b. The woman works out at the gym daily c. The woman does not like vegetables. d. The woman usually eats three meals a day in addition to two snacks a day.
C Because of pressure from the enlarging uterus, slowed peristalsis, and supplemental iron and calcium intake, the woman is at risk for constipation that can then lead to hemorrhoids. Therefore, the woman should eat foods high in fiber, including vegetables and fruits. A woman who does not like or eat vegetables is at risk for constipation and hemorrhoids.
Which of the following infants is most at risk to experience child abuse? a. Father has experienced paternal engrossment b. Responds to parental touch c. Parents have low-self esteem d. Has been adopted
C Because the parents self-esteem is associated closely with their infants interactions and accomplishments, when parents self-esteem is low, disappointment, anger, and a disturbance in the relationship with their infant can occur. When a disturbed parent-infant relationship continues, the infant is at risk for abuse and behavior problems. The process of paternal engrossment has been used to describe the behavior patterns of fathers when they interact with their infants.
A -year-old toddler is in for an office visit. He was born at 6 pounds, 10 ounces. At todays visit, the nurse expects his weight to be: a. 13 pounds, 4 ounces. b. 19 pounds, 14 ounces. c. 26 pounds, 8 ounces. d. 33 pounds, 2 ounces.
C Birth weight usually quadruples by years of age: 6 pounds, 10 ounces 4 = 26 pounds 8 ounces.
A nurse is assessing the language development of a 6-month-old infant. Which of the following findings would the nurse anticipate? a. The infant forms two-syllable sounds. b. The infant coos and makes vowel sounds. c. The infant babbles. d. The infant says ma-ma and bye-bye.
C By 6 months, babbling sounds are heard, and by 9 to 10 months, the infant forms two-syllable sounds. By 12 months, words such as ma-ma and bye-bye are emerging. Cooing and vowel sounds are heard at approximately 2 to 3 months.
A woman who is 23 weeks pregnant is concerned because her baby is moving less than it was a few weeks ago. Which of the following statements would be the most appropriate response by the nurse? a. Your infant is in distress. We should call an ambulance. b. You need to be more active; take a dance class once a week. c. At this point in your pregnancy, the baby moves less frequently because of lack of space in the uterus. d. You probably counted incorrectly.
C Education and guidance are important nursing functions. It is true that by the end of the second trimester fetal movement occurs less frequently because of lack of space in the uterus. The nurse should provide the woman with this information, so she knows what to anticipate.
A nurse is caring for a person with the nursing diagnosis of chronic sorrow related to missed opportunities. Which of the following nursing interventions would be appropriate for this person? a. Sharing a personal story with the person to demonstrate empathy b. Assuring the person that he or she will be able to cope with the illness c. Encouraging the person to discuss his or her fears d. Contacting a support group representative for the person
C It is not appropriate to discuss personal issues with an individual. Assuring the individual what he or she will be able to cope with is not appropriate because it does not encourage the person to talk about his or her fears. It is not appropriate to contact a support group without the persons permission. The person may not be ready to discuss the issue with strangers. The correct response is part of grief work facilitation: helping another cope with painful feelings of actual or perceived responsibility.
A nurse is discussing the harmful effects that chemical agents can have on an unborn child with a woman who is pregnant. Which of the following statements made by the woman indicates a need for further teaching? a. It is safe to eat up to 12 ounces of cooked fish weekly. b. I should avoid using caffeine during pregnancy. c. Consumption of one drink per day will not cause any harm to my unborn baby. d. Use of nicotine during pregnancy may cause my child to be born prematurely.
C Numerous studies have shown that no safe level of alcohol use exists during pregnancy; therefore alcohol should be avoided during this time and when attempting conception.
A new young mother asks the nurse what she should do to play with her 3-month-old infant. Which of the following suggestions should the nurse provide? a. Take the infant for a walk outside. b. Place several toys around the infant when lying on the floor. c. Rock the infant in a rocking chair. d. Search the Internet for toys highly recommended for infants.
C Parental stimulation of the infant is an important developmental technique. The infant needs stimulation to learn about the world. This activity does not require expensive objects, but rather involves experiences in sight, sound, and touch that are free and can be provided by any parent. One example of a stimulating experience for infants is being rocked in a rocking chair. Infant who are 3 months old will hold toys, but not actively reach for them so surrounding the infant with toys would not be suggested.
A nurse is teaching parents of a toddler about nutrition. Which of the following statements should be made by the nurse? a. Raisins are a good finger food because they provide fiber b. Grapes are a good snack choice because they help toddlers meet their daily fruit requirements. c. Hot dogs are not a safe food choice because they may cause choking. d. A small piece of chewing gum will help strengthen jaw muscle; just be sure he or she does not swallow it.
C Raisins, grapes, and chewing gum all pose a choking hazard and should not be given to toddlers.
The mother of a 4-month-old infant is concerned about the possibility of SIDS because her neighbors daughter passed away last year as a result of SIDS. The mother reports she is so nervous that she has taken up smoking again. The mother informs you that the 4-month-old sleeps supine and takes a pacifier to help her fall asleep. Which of the following statements would be the best response from the nurse? a. You should place the infant in the bed with you until 6 months of age. b. You should never give the infant a pacifier while she is sleeping. c. You should try to stop smoking. d. You should place the infant on her stomach.
C The 2011 report from the American Academy of Pediatrics Task Force on SIDS recommended the following: healthy infants should be placed to sleep in the supine position; infants should be placed on a firm sleep surface keeping soft objects, loose bedding, or any objects that could increase the risk of entrapment, suffocation, or strangulation out of the crib; avoid the infant getting too hot by dressing him/her in too many clothes for the environment; keep the infant away from smokers and places where people smoke; sleep with the infant in the same room where you sleep, but not the same bed, for 6 months; and offer a pacifier at nap time and bedtime.
A nurse is completing a well-child assessment of a 6-month-old infant. Which of the following guidelines should be used when assessing the infants height and weight? a. CDC growth charts b. CDC body mass index (BMI) charts c. WHO growth standards d. Denver Developmental Screening height and weight standards
C The CDC recommends that health care providers use the WHO growth standards to monitor growth for infants and children ages 0 to 2 years of age in the United States and use the CDC growth charts for children age 2 years and older in the United States.
The school nurse has been asked to order growth charts. Which of the following growth charts should be selected to assessing children in first through fifth grades? a. Generic body mass index chart b. Height and weight chart c. Revised CDC growth chart d. WHO international growth chart
C The CDC recommends the revised 2000 CDC growth charts (including the BMI and the 3rd and 97th percentile) be used for children aged 2 to 20 years.
A 5-month-old boy was born at 6 pounds, 7 ounces. He is being seen in the office for a well-child visit. The nurse would expect him to weigh approximately: a. 10 pounds, 14 ounces b. 11 pounds, 7 ounces c. 12 pounds, 14 ounces d. 13 pounds, 7 ounces
C The child should weigh approximately 12 pounds, 14 ounces, because by 5 months of age, the child should weigh twice the birth weight.
During a routine clinic visit, a pregnant woman expresses concern about reflux she is experiencing. Which statement should be made by the nurse when addressing the womans concern? a. Frequent heartburn may be a sign of fetal distress and an ultrasound should be performed immediately. b. Frequent heartburn is caused by high levels of hormones during pregnancy. c. Frequent heartburn is a result of gastrointestinal system changes that occur during pregnancy. d. Frequent heartburn during pregnancy requires immediate consultation with a gastroenterologist.
C The gastrointestinal system undergoes dramatic changes during pregnancy, which include frequent heartburn secondary to upward displacement of the stomach and a relaxed gastroesophageal sphincter. Therefore the appropriate response for this woman would be to provide her with information regarding normal changes during pregnancy. In this case the frequent heartburn is a result of gastrointestinal system changes that occur during pregnancy.
The mother of an 8-month-old asks what the minimum recommended amount of fat intake is for her 10-kg infant. Which of the following would be the minimum recommended fat intake? a. 18 grams a day b. 28 grams a day c. 38 grams a day d. 48 grams a day
C The minimum recommended fat intake for this 8-month-old, 10-kg infant is 38 grams per day. The minimum recommended fat intake for an infant this age is 3.8 g/kcal. Thus, 3.8 10 = 38.
A nurse visits a 3-month-old infant of a single mother for a weight check. She finds two older children running around the home, the infant is crying, the mother yelling at the two children and a half-lit cigarette is in an ashtray. The mother tells the nurse the visit needs to be cut short today because she has to pick up her other children from the bus stop. Which of the following would be the most beneficial intervention this nurse can provide during this visit? a. Leave and tell the mother to call her to reschedule the appointment. b. Weigh the infant and contact the Department of Children and Families. c. Weigh the infant and offer community resources to the mother. d. Offer to go pick up the other children at the bus stop.
C The most beneficial intervention the nurse can provide is to keep the visit short, weigh the infant, and offer the mother the help of community services. Providing anticipatory guidance is important in maintaining health and preventing abuse. Abusing parents are often socially isolated and have few people to whom to turn. Women are more frequent abusers than men. Furthermore, economic conditions play a role in the care of children.
The mother of a 16-month-old infant asks a nurse her opinion about holiday decorating. Which of the following recommendations should the nurse provide to the mother? a. Avoid hanging a wreath with holly and berries on the front door. b. Avoid hanging decorative pictures of a bearded Santa Claus on the window. c. Avoid placing poinsettia plants around the home. d. Avoid hanging stockings on the fireplace mantle.
C The mother should avoid placing poinsettia plants around the home because, if swallowed, they could be fatal. By 16 months the infant can walk, and infants are more susceptible than adults to the effects of poisonous plants. Plants should be kept out of reach of infants. Berries on the wreath can also be fatal, but at 16 months, the child would not be able to reach the wreath.
During a home visit, the nurse finds a 9-month-old in a playpen with a couple of toys. Which of the following instructions would be most appropriate for the nurse to provide to the parent to encourage growth and development of the child? a. Encourage the addition of a few more toys to the playpen. b. Suggest keeping the infant in the playpen as much as possible to promote safe play. c. Encourage providing the infant with supervised time outside of the playpen. d. Suggest removing all toys from the playpen.
C The nurse should encourage the mother to provide the infant with sufficient supervised time outside of the playpen to allow the child to crawl and explore. These activities help promote growth and development. Additionally, by 9 months of age, most infants are crawling.
A mother is concerned because her 22-month-old has been skipping meals lately. Which of the following actions should the nurse recommend to the mother? a. Put the child in time out whenever he skips a meal. b. Offer him foods he likes such as cookies and chips. c. Limit the childs consumption of juices and cookies. d. Talk to the child about how important it is to eat three meals a day.
C Toddlers often use mealtime to assert their individuality. They sometimes do this by refusing to eat. Additionally they are often not hungry because they have been given empty calories by their parents, because the parents want to make sure the toddler eats something. However empty calories should be avoided. Parents should take control and offer the toddler healthy, age-appropriate foods. Punishment and focusing on food should be avoided.
The school nurse is conducting an in-service program for teachers that discusses the development of elementary school children. According to Piagets theory of cognitive development, which of the following information would the nurse include? (select all that apply) a. Use abstract thought to discuss a story. b. Make moral decisions concerning right and wrong actions. c. Listen to a peers point of view about a playground situation. d. Be influenced by his or her friends.
C,D Children age 7 to 11 are in the concrete operations stage of development according to Piaget. They are influenced by friends and can listen to and think about a peers point of view. Moral decision making and use of abstract thought occur during the formal operations stage of development, usually between the ages of 11 and 15 years.
A nurse is assessing the cognitive-perceptual pattern of a toddler. Which of the following findings would be cause for concern for the nurse? a. Uses the word blanky to mean both that he wants to go to bed and that he is cold b. Refuses to eat something he ate and enjoyed the day before c. Has visual acuity that is not 20/20 d. Has a history of recurrent ear infections
D Vision, hearing, speech, and taste/smell are all assessed as part of the cognitive-perceptual pattern. A toddler with recurrent ear infections is at risk for hearing loss, which can also lead to speech delay; thus this finding would be cause for concern. Visual acuity during the toddler years is approximately 20/40.
During which week would pregnancy begin to pose health concerns for the fetus? a. 36 weeks b. 38 weeks c. 40 weeks d. 42 weeks
D When pregnancy continues beyond 42 weeks, or 2 weeks beyond the calculated due date, placental function decreases even more, posing concerns about the well-being of the fetus.
