Test 5 - CH 51, 18, 19, 26, 55, 49, 52

5. A new mother is concerned that the baby is not going to receive enough calories from breast milk to grow. What should the nurse instruct the mother as the daily caloric requirements per pound of weight for a newborn? A) 50 to 55 B) 100 to 120 C) 150 to 170 D) 200 to 225

Ans: A Feedback: An infant up to 2 months of age requires 110 to 120 calories per kilogram of body weight or 50 to 55 kcal/lb every 24 hours to provide an adequate amount for maintenance and growth. The other choices are incorrect information.

9. The nurse is caring for a school-age child newly diagnosed with juvenile arthritis. Which diagnosis would be a priority for this patient? A) Knowledge deficit related to care needs B) Risk for inefficient peripheral tissue perfusion C) Ineffective coping related to physical limitations D) Imbalanced nutrition: less than body requirements

Ans: A Feedback: With newly diagnosed juvenile arthritis, the child and family will need to learn how to manage the symptoms by planning exercise and medication programs around school or other activities. Juvenile arthritis does not affect peripheral tissue perfusion. Because the child is newly diagnosed, it is premature to use the diagnosis of ineffective coping. There is no evidence that the child has imbalanced nutrition.

1. A toddler is diagnosed with osteomyelitis. What should the nurse anticipate as a priority intervention when planning this child's care? A) Assisting the child with crutch walking B) Maintaining intravenous antibiotic therapy C) Keeping the child quiet while in skeletal traction D) Restricting fluid to encourage red cell production

Ans: B Feedback: For osteomyelitis, medical therapy includes administration of intravenous antibiotics, which is usually initiated in the hospital and then continued at home for as long as 2 weeks; an intermittent infusion device or peripherally inserted central catheter may be used. After this, the child will be prescribed an oral antibiotic for 3 to 4 more weeks. There is no enough information to determine the location of the infection so crutch walking may not be applicable. Skeletal traction is not needed to treat osteomyelitis. Fluid restriction does not encourage red blood cell production and may be harmful to the care of this child.

5. The nurse is visiting the home of a family with a previous history of physical neglect. Which observation indicates that interventions have not been successful? A) The mother feeds the children a total vegetarian diet. B) The father encourages male children to play high school football. C) The mother worries that immunizations will be painful for the children. D) The father allows the children to stay home from school whenever they desire.

Ans: D Feedback: Not requiring a child to attend school may be interpreted as neglect. Following a vegetarian diet, encouraging participating in sports, and concern about immunization discomfort do not indicate that interventions to address physical neglect have not been successful.

6. The nurse is teaching a pregnant patient about the nutritional value of breast milk. What information should the nurse include about the number of calories in a fluid ounce? A) 12 B) 20 C) 24 D) 30

Ans: B Feedback: Breast milk contains 20 calories per fluid ounce, which is the same number of calories in commercially prepared infant formula. Breast milk does not contain 12, 24, or 30 calories per fluid ounce.

12. The nurse receives report from the admission department that a child with a slipped femoral epiphysis is en route to the care area. For which type of child should the nurse begin to plan care? A) Tall, thin female B) Preadolescent female C) Active school-age male D) Obese preadolescent male

Ans: D Feedback: A slipped femoral epiphysis is a slipping of the femur head in relation to the neck of the femur at the epiphyseal line. This disorder occurs most frequently in preadolescence and its highest incidence is in obese children. It is twice as frequent in boys as girls.

4. The nurse is evaluating a school-age child's ability to crutch walk so that no weight is placed on an injured leg. Which walking technique indicates that teaching has been effective A) Walking gait B) Two-point gait C) Single-crutch support gait D) Three-point swing-through gait

Ans: D Feedback: A three-point swing-through gait is used when no weight bearing is allowed on one foot. A two-point gait is used when a child needs support for weakened muscles or balance but may bear weight on both lower extremities. Walking gait and single-crutch support gait are not identified crutch walking approaches.

13. When assessing a newborn's 5-minute Apgar score, how will the nurse determine reflex irritability? A) Dorsiflexing a foot against pressure resistance B) Raising the infant's head and letting it fall back C) Tightly flexing the infant's trunk and then releasing it D) Slapping the soles of the feet and observing the response

Ans: D Feedback: One of two possible cues is used to evaluate reflex irritability: response to a suction catheter in the nostrils or response to having the soles of the feet slapped. Reflex irritability is not assessed by dorsiflexing the foot, permitting the head to fall, or flexing the infant's trunk and releasing it.

15. The nurse is preparing to administer surfactant (Survanta) 4 mg/kg every 12 hours for 2 days. The newborn weighs 2,300 g. How many milligram of the medication will the newborn receive for all of the doses? (Numeric value only. Round to the nearest tenth decimal point.)

Ans: 36.8 mg Feedback: The nurse needs to first convert the baby's weight of 2,300 g to kilogram by dividing by 1,000 or 2,300 / 1,000 = 2.3 kg. Then the nurse is to multiply the prescribed dose of 4 mg × 2.3 kg = 9.2 mg. This is the amount of medication the baby is to receive for each dose. Since the baby is to receive one dose every 12 hours for 2 days or a total of four doses, the nurse would then multiply the single dose amount of 9.2 mg × 4 = 36.8 mg. The baby will receive 36.8 mg of the medication for the total four doses.

5. The nurse is caring for a newborn that weighed 7 lb 3 oz at birth. What action should the nurse take first based on this weight? A) Plot the weight on a gestational age graph. B) Ask for a physician to examine the newborn. C) Draw additional blood work for cholesterol level. D) Turn off the radiant heat warmer for physical assessment.

Ans: A Feedback: A newborn's weight is important because it helps to determine maturity as well as establish a baseline against which all other weights can be compared. The birth weight of newborns varies depending on the racial, nutritional, intrauterine, and genetic factors that were present during conception and pregnancy. The weight in relation to the gestational age should be plotted on a standard neonatal graph. The nurse does not need to ask a physician to examine the newborn. There is no evidence to suggest that the infant needs a cholesterol level drawn. The weight does not influence if the newborn needs to be placed in a radiant heat warmer.

3. During a home visit, a new mother is concerned that, after three meconium stools, her newborn has had a bright green stool. What should the nurse explain to the mother? A) This is a normal finding. B) This is most likely a symptom of diarrhea. C) The baby may be developing an allergy to breast milk. D) The child will need to be isolated until the stool can be cultured.

Ans: A Feedback: After meconium stools, the newborn's stool changes in color and consistency. This is a transitional stool and is green. It might look like diarrhea. This does not indicate that the baby is developing an allergy to breast milk or that the child needs to be isolated until the stool can be cultured.

11. The nurse gives a preschool-age child two anatomically correct dolls to play with in efforts to determine if the child has been sexually abused. Which observation indicates to the nurse that this is a possibility? A) Child inserts the male doll's penis into the female doll's mouth. B) Child holds both dolls together to make them walk together holding hands. C) Child takes off the dolls' clothing, laughs, and then puts the clothes back on. D) Child holds dolls facing each other and moves the arms so that the dolls hug.

Ans: A Feedback: Allowing young children to play with anatomically correct dolls is a common method for determining whether sexual maltreatment is occurring. The child who is involved in an incestuous relationship may make the dolls perform a sexual act, such as placing the male doll's penis into the female doll's mouth. The average reaction of a preschool-age child who has not been maltreated is to undress the dolls, giggle for a moment or two about how they look, and then redress or put them aside. Playing with the dolls so that they hold hands and hug does not indicate that the child has been sexually abused.

15. A new mother asks the nurse what medications she can and cannot take into her body because it might affect breast milk. What should the nurse respond to this mother's request? A) Almost all drugs are excreted to some extent in breast milk. B) A mother should halt breastfeeding for 1 week after taking any drug. C) A mother can plan on taking common over-the-counter drugs without difficulty. D) A mother has to limit her exposure to narcotics and sedatives while breastfeeding.

Ans: A Feedback: Almost any drug may cross into the acinar cells and be secreted in breast milk. As a general rule, the mother should take no drug unless prescribed or approved by her primary care provider while breastfeeding. Halting breastfeeding could impact the mother's ability to continue at a later time.

1. A pregnant patient in labor asks the nurse how soon the baby can be breastfed after delivery. What should the nurse respond to the patient? A) Immediately after birth B) After the infant is allowed to rest C) In 24 hours after her infant is given water D) Once the infant has a first feeding of formula

Ans: A Feedback: Breastfeeding should begin as soon after birth as possible, ideally while the woman is still in the birthing room and while the infant is in the first reactivity period. Breastfeeding should not wait until the baby rests. Twenty-four hours is too long to wait to begin breastfeeding. Mixing breastfeeding and formula feeding is not recommended.

6. The nurse is concerned that a preschool-age child is demonstrating signs of Duchenne muscular dystrophy. What did the nurse assess in this child? A) Gower sign B) Facial weakness C) Inability to whistle D) Inadequate use of respiratory muscles

Ans: A Feedback: Children with Duchenne muscular dystrophy usually have a history of meeting motor milestones, but by about 3 years of age, symptoms are more acute and obvious. Rising from the floor is done by rolling onto the stomach and then pushing up to the knees. To stand, the hands are pressed against the ankles, knees, and thighs. This is Gower sign. Facial weakness and inability to whistle are manifestations of facioscapulohumeral muscular dystrophy. Inadequate use of respiratory muscles is a manifestation of congenital myotonic dystrophy.

14. The community nurse is visiting a victim of rape at home. Which observation indicates that crisis intervention goals have not been met? A) Husband hopes to meet the rapist in a back alley 1 day. B) Victim and husband sit with the nurse at the kitchen table and discuss feelings. C) Victim states that intimate relationship with the husband has resumed without incident. D) Husband holds the victim's hand and expresses endearing terms while the victim smiles.

Ans: A Feedback: Goals of crisis intervention for families of rape victims include helping the family be supportive of the victim, discussing the sexual relationship between partners, and the partner expressing feelings have not changed. A goal is also to discourage violent retribution toward the rapist. The husband desiring to meet the rapist in a back alley indicates that crisis intervention goals have not been met.

9. The mother of a terminally ill child stays with the child day and night. Which statement indicates that the mother is in the chronic sorrow of depression stage? A) "I will never accept that my child is dying." B) "I know that there is nothing that can be done for my child." C) "There must be another doctor somewhere than can help my child." D) "I will go to church every week if this will keep my child from dying."

Ans: A Feedback: In the stage of depression, parents begin to face what is happening. They feel sad and unprotected. Some parents never reach the stage of acceptance and will always remain in the chronic sorrow of the depression stage. Saying that the child's dying will never be accepted indicates the chronic sorrow of depression stage. Knowing that nothing can be done for the child is acceptance. Looking for another doctor to help the child is the stage of anger. Going to church every week to prevent the child from dying is bargaining.

7. The nurse is caring for a large-for-gestational-age infant born to a patient with diabetes mellitus. Why should the nurse schedule routine blood glucose measurements for the infant? A) To detect rebound hypoglycemia B) To determine insulin dosage to administer C) To explain the effects of maternal hyperglycemia on the baby D) To estimate the amount of calories to provide the infant through formula

Ans: A Feedback: Large-for-gestational age infants need to be carefully assessed for hypoglycemia in the early hours of life because large infants require large amounts of nutritional stores to sustain their weight. If the mother had diabetes that was poorly controlled, the infant would have had an increased blood glucose level in utero to match the mother's glucose level; this caused the infant to produce elevated levels of insulin. After birth, these increased insulin levels will continue for up to 24 hours of life, possibly causing rebound hypoglycemia. Frequent blood glucose monitoring in large-for-gestational-age infants is not done to determine insulin dosage, to explain the effects of maternal hyperglycemia on the baby, or to estimate the amount of calories to provide the infant through formula.

10. A school-age child is scheduled for a muscle biopsy. What should the nurse teach the patient about the procedure? A) Medication will be given so pain is minimized. B) The amount of muscle tissue taken is about 2 in. C) Bed rest for several days will need to be done afterward. D) Long-term pain medication will be needed after the procedure.

Ans: A Feedback: Muscle biopsies are usually done using conscious sedation and a local anesthetic. The amount of tissue taken is about the size of the lead in a pencil. There is no need for bed rest for several days after the procedure. This procedure does not cause long-term pain.

4. When beginning care for a victim of rape, the nurse asks the patient to "talk about what happened" to her. For which nursing diagnosis is the nurse using this approach? A) Anxiety related to recent rape B) Fear related to repeated episodes of maltreatment C) Disabling family coping related to recent rape of family member D) Risk for other-directed violence related to admitted poor self-control

Ans: A Feedback: One need of any victim after a violent act is to talk about what happened because a person who can describe an incident can also begin to "put a fence around" or bring the event down from "something terrible has happened," a situation which leaves the person with a continuing high anxiety level, to "this specific thing has happened," a situation that allows the traumatic event to be examined and managed. Asking the victim to describe the incident to with an introduction such as "Most people find it helps to talk about what happened to them" helps the victim begin to put a fence around the incident. The nurse is not asking the patient to "talk about what happened" because of fear of maltreatment, disabling family coping related to the rape, or risk for violence related to poor self-control.

3. Immediately after birth, a preterm infant is placed in a radiant heat warmer. For which nursing diagnosis is this intervention addressing? A) Ineffective thermoregulation related to immaturity B) Risk for imbalanced nutrition, less than body requirements C) Risk for deficient fluid volume related to insensible water loss D) Impaired gas exchange related to immature pulmonary functioning

Ans: A Feedback: Placing the preterm infant in a radiant heat warmer is addressing the diagnosis of ineffective thermoregulation related to immaturity. Interventions regarding intake would be appropriate for the diagnosis of risk for imbalanced nutrition. Interventions related to intravenous fluids would be appropriate for the diagnosis of risk for deficient fluid volume. Interventions related to oxygenation would be appropriate for the diagnosis of impaired gas exchange.

9. The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective? A) Newborn is placed on the back to sleep. B) Mother removes a pacifier from the baby's mouth. C) The baby is on an every-2-hour formula-feeding schedule. D) Parents signed a waiver refusing routine immunizations after birth.

Ans: A Feedback: Putting newborns to sleep on the back has decreased the incidence of SIDS by 50% to 60%. Other recommendations to decrease SIDS include using a pacifier, breastfeeding, and having routine immunizations. Removing the pacifier, bottle feeding, and refusing routine immunizations after birth all increase the infant's risk for experiencing SIDS.

2. The results of an amniocentesis conducted just prior to birth showed a fetus's lecithin/sphingomyelin ratio as being 1:1. From this information, for which respiratory problem should the nurse anticipate providing care once the baby is delivered? A) Alveolar collapse on expiration B) Bronchial constriction from room air C) Wheezing from excess fluid accumulation D) Inspiratory constriction from air contaminants

Ans: A Feedback: Respiratory distress syndrome (RDS) of the newborn most often occurs in preterm infants. Pulmonary surfactant is not present in preterm infant. Surfactant is needed to prevent alveolar collapse upon expiration. RDS rarely occurs in mature infants. Dating a pregnancy by sonogram and by documenting the level of lecithin in surfactant obtained from amniotic fluid exceeds that of sphingomyelin by a 2:1 ratio are both important ways to be certain that an infant is mature enough that RDS is not likely to occur. RDS does not present as bronchial constriction from room air, wheezing from excess fluid accumulation, or inspiratory constriction from air contaminants.

3. The nurse is preparing an educational session for community members that focuses on the 2020 National Health Goals. Which information should the nurse include to ensure a healthy musculoskeletal system? A) Importance of daily exercise B) Early diagnosis of painful joints C) Need for at least 8 hours of sleep D) Ensure an adequate intake of calcium

Ans: A Feedback: The 2020 National Health Goals focus on proper exercise to maintain a healthy musculoskeletal system. The nurse can help the nation achieve these goals by educating community members on the importance of physical activity. Diagnosis of painful joints, hours of sleep, and dietary intake are not identified as actions to ensure a healthy musculoskeletal system.

3. At the completion of a health interview, the nurse is concerned that a newborn is at risk for maltreatment. Which observation caused the nurse to come to this conclusion? A) Mother does not look at the baby. B) Mother helps the nurse loosen the baby's clothing for a physical examination. C) Mother explains that the husband helps with feeding the baby during the night. D) Mother quickly changes a dirty diaper and uses personal supplies to cleanse the child.

Ans: A Feedback: The mother's inability to establish eye contact, or maintain a direct en face position with the baby, can indicate the potential for child maltreatment. Helping the nurse loosen clothing for an examination, identifying someone to help with child care, and prompt attention to the baby's needs when changing a soiled diaper indicate the mother is bonding with the child, and the child is not at risk for maltreatment.

17. The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lb. How much formula should the nurse teach the parents to provide each day? A) 20 to 24 oz B) 30 to 36 oz C) 42 to 54 oz D) 60 to 72 oz

Ans: A Feedback: The total fluid ingested for 24 hours must be sufficient to meet the infant's fluid needs and is calculated by determining 75 to 90 ml or 2.5 to 3.0 oz of fluid per pound of body weight per day. Because the infant weighs 8 lb, the amount of formula would be between 8.0 × 2.5 or 20 oz and 8.0 × 3.0 or 24 oz. The other choices are inaccurate calculations for the amount of formula to provide to an infant weighing 8 lb.

14. What instructions should the nurse include when teaching a mother to care for her newborn's umbilical cord? A) Keep it dry. B) Cover it with dry gauze. C) Wash it with soap and water. D) Apply petroleum jelly to it daily.

Ans: A Feedback: Until the cord falls off, fold diapers below the level of the umbilical cord, so that when the diaper becomes wet, the cord does not become wet also. Remind the mother to continue to keep the cord dry until it falls off. The nurse should not teach the mother cover the umbilical cord with dry gauze, wash it with soap and water, or apply petroleum jelly to the site.

12. The nurse in the emergency department is documenting the appearance and care provided to a victim of rape. Which statement should the nurse include when documenting this care? A) Victim has blood stains on both inner thighs. B) Victim claims to be raped but does not appear fearful or traumatized. C) Victim handling the incident well by talking with the male police officers. D) Victim wearing provocative low-cut lace blouse and bra and short skirt with high heels.

Ans: A Feedback: When documenting the care and condition of a victim of rape, the nurse needs to be certain that statements are accurate and unbiased. The nurse should describe the victim's appearance in unbiased detail, including the presence and location of injuries. Making a statement such as "victim claims to be raped but does not appear fearful or traumatized" is a biased statement. The statement that the victim is handling the incident well by talking with male police officers and using the word "provocative" when describing the victim's clothing are biased statements and should not be a part of the medical record.

10. The nurse is planning care to help young parents adjust to their newborn's long-term illness. Which assessment findings about the parents will help the nurse plan for their care? (Select all that apply.) A) Parents belong to a local church. B) Parents have strong ties with their parents and siblings. C) Parents are strong in their marriage and frequently hold hands. D) Parents state issues with having to spend time at the hospital instead of working. E) Parents are overheard discussing the cost of the medical care and if insurance will cover it.

Ans: A, B, C Feedback: Factors that ease parental adjustment to a child's long-term illness include having a strong religious faith, having a good relationship with their parents, having support people available such as siblings, and having a good marital bond. Having concerns about missing work and having enough money for medical care are not findings that will help the parents adjust to their newborn's long-term illness.

2. The hospice nurse is planning a community program that emphasizes the 2020 National Health Goals to reduce long-term illness and early death in children. Which information should the nurse include in this program? (Select all that apply.) A) Strategies to prevent unintentional injury B) Seeking early prenatal care when pregnant C) Following recommended immunization schedules D) Supporting childhood physical activity expectations E) Following recommended dietary intake requirements

Ans: A, B, C Feedback: Nurses can help the nation achieve the 2020 National Health Goals to reduce long-term illness and early death in children by educating women to seek care during pregnancy so that congenital anomalies are less frequent and to teach unintentional injury prevention and the importance of immunizations so unintentional injuries and infectious diseases that can lead to long-term illness can be reduced. Physical activity expectations and dietary intake requirements are not strategies to achieve the 2020 National Health Goals to reduce long-term illness and early death in children.

12. The nurse is caring for a small-for-gestational-age infant born to a drug-dependent patient. For which manifestations should the nurse assess as evidence of withdrawal symptoms in the newborn? (Select all that apply.) A) Tremors B) Convulsions C) High-pitched cry D) Constant movement E) Sluggish respiratory rate

Ans: A, B, C, D Feedback: Infants of drug-dependent women tend to be small for gestational age. If the patient took a drug close to birth, the infant may show withdrawal symptoms shortly after birth that include tremors, convulsions, high-pitched cry, and constant movement. Respiratory rate would be rapid and not sluggish.

13. The nurse is instructing the parents of a preterm infant about the care the infant will receive within the neonatal intensive care unit. What should the nurse include when teaching the parents at this time? (Select all that apply.) A) Bring in a small toy to be placed in the baby's bassinette. B) Coordinate the times to visit the baby with the primary nurse. C) Ask the nurse to explain equipment and the purpose for their use. D) Write down the name of the baby's primary nurse and primary care provider. E) Limit telephone calls to the care area since the nurses will not be able to respond.

Ans: A, B, C, D Feedback: When teaching parents of a newborn in the intensive care unit, the nurse should encourage the parents to bring in a small toy to be placed in the baby's bassinette. The parents should also coordinate the times to visit the baby with the primary nurse so that quality time will be available. The parents should be reminded to ask questions about equipment being used for the baby's care. The name of the primary nurse and primary care provider should be recorded in case the parents have any questions. Telephone calls are encouraged and should not be limited. The parents play an active part in the care of the baby.

6. While providing care, the nurse suspects that a preterm infant is developing respiratory distress. What did the nurse most likely assess in this patient? (Select all that apply.) A) Grunting B) Nasal flaring C) Intercostal retractions D) Oxygen saturation 96% E) Increasing respiratory rate

Ans: A, B, C, E Feedback: A steadily increasing respiratory rate, grunting, and nasal flaring are often the first signs of obstruction or respiratory compromise in newborns. If these are present, undress the baby's chest and look for intercostal retractions, which reflect the degree of difficulty the newborn is having in drawing in air. Oxygen saturation of 96% is within normal limits and does not indicate respiratory distress.

5. The nurse is planning developmental care for a preterm infant in the neonatal intensive care unit. Which interventions should the nurse include in this patient's plan of care? (Select all that apply.) A) Provide audio stimulation with the use of music. B) Stop procedures if the infant shows signs of distress. C) Provide a nest with blankets to provide a sense of security. D) Provide tactile stimulation by tickling the bottom of the feet. E) Provide care consistently so the infant develops sleep/wake cycles.

Ans: A, B, C, E Feedback: Developmental care for a preterm infant in the neonatal intensive care unit should include audio stimulation, stop procedures at signs of distress, provide a nest of blankets for security, and provide consistent care so sleep/wake cycles develop. Tactile stimulation should be provided by gentle back rubbing or massage. Tickling the feet would be too harsh for this young patient.

4. The nurse manager of a labor and delivery unit is reviewing the skill set needed for the nursing staff to meet the 2020 National Health Goals regarding preterm births. Which skills should the manager validate that the nursing staff has to meet these goals? (Select all that apply.) A) Resuscitation at birth B) Actions to prevent apnea C) Identify characteristics of preterm labor D) Actions to prevent maternal hypotension E) Interventions to prevent intraventricular hemorrhage

Ans: A, B, C, E Feedback: Nurses can help the nation achieve the 2020 National Health Goals for preterm births by teaching women the symptoms of preterm labor so that birth can be delayed until infants reach term. Nurses also need to be prepared for resuscitation at birth of high-risk infants and to plan developmental care that can help prevent conditions such as apnea and intraventricular hemorrhage. Actions to prevent maternal hypotension would not help achieve the 2020 National Health Goals for preterm labor.

7. The nurse is instructing the mother of a school-age child with a leg cast about cast care at home. What should the nurse include in this teaching? (Select all that apply.) A) Cover the cast with a plastic bag to bathe. B) Remind that nothing is to be put down the cast. C) Recommend using magic markers for autographs. D) Use the cool setting on a hair dryer to ease itchy skin. E) Encourage usual activities but restrict strenuous actions.

Ans: A, B, D, E Feedback: When teaching the mother about cast care at home, the nurse should include covering the cast with a plastic bag while bathing so the cast does not get wet, not placing anything down the cast, using the cool setting on a hair dryer to ease itching, and encourage usual activities but reducing strenuous activities while the cast is in place. Magic markers should not be used for autographs because the ink can seep into the cast material.

14. The nurse is caring for a school-age child recovering from an open reduction for a fractured femur. Which assessment findings indicate that the child is developing an infection? (Select all that apply.) A) Lethargy B) Increased pulse rate C) Reduced pulse in the ankle D) Cyanosis of the casted foot E) Increased body temperature

Ans: A, B, E Feedback: Children with an open reduction are prone to infection. The nurse should suspect an infection if the systemic symptoms of increased pulse, increased temperature, and lethargy are present. Reduced pulse in the ankle and cyanosis of the casted foot are manifestations of compartment syndrome.

10. A preterm infant in the neonatal intensive care unit is receiving care for inadequate fluid balance. What did the nurse assess that supports this nursing diagnosis? (Select all that apply.) A) Specific gravity of 1.022 B) Respiratory rate of 40 breaths/min C) Urine output less than 2 ml/kg/hr D) Heart rate of 135 beats/min E) Abdominal skin temperature of 96.9°F

Ans: A, C Feedback: An output less than 2 ml/kg/hr or a specific gravity greater than 1.015 to 1.020 suggests inadequate fluid intake. Respiratory rate of 40 breaths/min, heart rate of 135 beats/min, and abdominal skin temperature of 96.9°F are all within normal limits and do not suggest inadequate fluid balance.

4. The nurse is planning to instruct a new mother on care of the newborn. Which instructions support the 2020 National Health Goals for the newborn? (Select all that apply.) A) Place the infant on the back to sleep. B) Wash the baby's hair at least once a week. C) Continue to breastfeed the baby until age 6 months. D) Bath the baby from the most soiled to the cleanest areas. E) Do not provide the baby with a bottle while falling asleep.

Ans: A, C, E Feedback: Nurses can help achieve 2020 National Health Goals by encouraging mothers to continue breastfeeding through the first 6 months of life. The mother should be instructed to place the infants on the back to sleep and the danger of tooth decay from allowing a baby to drink from a bottle of milk or juice while falling asleep. Bathing should be from the most clean to the most soiled and hair should be washed daily. Bathing and hair washing do not impact achievement of the 2020 National Health Goals.

4. The parents of a school-age child are informed that their child has muscular dystrophy and will be wheelchair bound going forward. Which nursing diagnosis should the nurse identify as appropriate for the parents at this time? A) Hopelessness related to steady progression of child's disease B) Interrupted family processes related to recent diagnosis of chronic illness in a child C) Decisional conflict related to treatment options and choice of setting for child's final care D) Risk for delayed growth and development related to lack of age-appropriate stimulation because of disability

Ans: B Feedback: Because the parents are just learning of the diagnosis of muscular dystrophy, this news will interrupt family processes. There is no enough information to determine if the parents are hopeless. The child is not diagnosed with a terminal illness. There is no enough information to determine if the child is at risk for delayed growth and development.

11. A new mother is concerned that she will not have enough breast milk because of small breasts. What should the nurse respond to the mother? A) "Have you discussed this concern with your physician?" B) "The size of breasts does not impact the amount of breast milk that is made." C) "The baby's diet can be supplemented with formula beginning on the second day." D) "No woman has to worry about milk production as long as she feeds the baby frequently."

Ans: B Feedback: Breast milk is formed in the acinar cells of the mammary glands and begins production after the delivery of the placenta. When the progesterone level falls, the production of prolactin is stimulated, which cause breast milk to be made. The nurse can discuss the patient's concern; it does not need to be discussed with the physician. Supplementing a breastfeeding baby with formula is not recommended. The nurse's comment about milk production and the frequency of feeding does not address the mother's concern.

9. The nurse is preparing a seminar on breastfeeding for a group of pregnant patients. Which information should the nurse include during this seminar? A) Uterine involution is slowed by breastfeeding. B) Breastfeeding enhances bonding with the infant. C) Breastfeeding might increase the risk of breast cancer. D) Breastfeeding mothers have a decreased risk of developing thrombophlebitis.

Ans: B Feedback: Breastfeeding provides an excellent opportunity to enhance a true symbiotic bond between mother and child. Breastfeeding enhances uterine involution and reduces the risk of breast cancer. There is no information to support the impact of breastfeeding on thrombophlebitis.

1. The nurse is planning care for a preschool-age child with spastic cerebral palsy. Which nursing diagnosis should the nurse identify to guide care for this patient's musculoskeletal status? A) Risk for self-care deficit related to impaired mobility B) Risk for disuse syndrome related to spasticity of muscle groups C) Impaired verbal communication related to neurologic impairment D) Risk for delayed growth and development related to activity restriction

Ans: B Feedback: Children with cerebral palsy need promotion of any function that is not already impaired to prevent further loss of function and allow them to master the highest level of self-care. Learning to be ambulatory is an important part of self-care because it pays a large role in determining how independent the child can become. Walking can be difficult for the child to master because of lack of muscle coordination. Preventing contractures is also important to maintain motor function. Risk for self-care deficit focuses on self-care measures such as dressing, toothbrushing, bathing, and toileting, so the child can not only gain self-esteem by accomplishing these tasks but also achieve optimal independence. Impaired verbal communication addresses focuses on speech and not necessary the entire musculoskeletal status. The risk for delayed growth and development focuses on the child's potential inability to pursue stimulating activities and surroundings because of not being fully mobile.

13. The nurse is planning teaching for the parents of a child with Legg-Calvé-Perthes disease. On what should the nurse emphasize when conducting this teaching? A) Surgery is needed with supporting rods. B) The child will have a non-weight-bearing period. C) The child will need passive range-of-motion exercises three times a day. D) The child will need to exercise to increase muscle strength of the knee joint.

Ans: B Feedback: For Legg-Calvé-Perthes disease, both parents and the child need thorough education about treatment and care because it can be difficult for young children to accept the extended treatment period involved with this disorder. There are long-term consequences if rest is not followed conscientiously. Parents may need assistance with devising appropriate activities for the child during the time that activity is limited and weight bearing is not allowed. Surgery with supporting rods is used to treat scoliosis. The child will not have passive range-of-motion exercises nor knee joint exercises in the treatment of this disease.

8. Which assessment finding indicates to the nurse that a newborn has hip subluxation? A) Inward rotation of the right foot B) Inability of the right hip to abduct C) Crying on straightening of the right leg D) Drawing of the legs underneath while prone

Ans: B Feedback: If the hip joint seems to lock short of this distance of 180 degrees, hip subluxation is suggested. Inward rotation of the right foot, crying when straightening the leg, or drawing the legs underneath when prone does not indicate hip subluxation.

11. A new mother is distraught because the baby has a white discharge coming from the breasts. What should the nurse explain to the mother about this discharge? A) It is caused by exposure to cool air. B) It is caused by the mother's hormones. C) The baby may need chromosomal studies. D) It is a sign that the baby has a pituitary tumor.

Ans: B Feedback: In both female and male infants, the breasts may be engorged because of the influence of maternal hormones during pregnancy. At times, the breasts of newborn babies secrete a thin, watery fluid termed witch's milk. As soon as the hormones are cleared from the infant's system in about a week, the engorgement and any fluid that is present will subside. The discharge from the baby's breasts is not caused by exposure to cold air. The baby does not need chromosomal studies nor is this a sign that the baby has a pituitary tumor.

10. The parents of a newborn are concerned that something is wrong with the newborn's eyesight. What should the nurse instruct the parents as being an expected finding in the newborn? A) Produces tears when he cries B) Follows a light to the midline C) Has a white rather than a red reflex D) Follows the finger a full 180 degrees

Ans: B Feedback: Instruct parents that the newborn cannot follow an object past the midline or appears to lose track of objects easily so there is nothing wrong with the eyesight. The newborn will not produce tears because the lacrimal ducts are not fully functioning. The parents will not be able to assess for a red reflex. The infant will not be able to follow a finger for a full 180 degrees.

13. The parents of a terminally ill child do not want the child dying in the hospital. What can the nurse suggest to help these parent's needs? A) Admit to a long-term care facility. B) Have hospice provided through home care. C) Discharge the child to home right before death. D) Have family stay with the child around-the-clock in the hospital.

Ans: B Feedback: Many families prefer that a child die at home, surrounded by family and familiar possessions, rather than in a hospital. For many children, hospice care is furnished as part of home care, so that they are not separated from their families. This would be the best suggestion for the nurse to make to the parents of the dying child. A long-term care facility is similar to a hospital and would not meet the family's needs. Discharging the child to home prior to death will not meet the needs of the family. Having the family stay with the child around-the-clock in the hospital definitely will not meet the family's needs.

7. The nurse instructs the parents of a child with Guillain-Barré syndrome on care that will be needed once the child is discharged home. Which statement made by the parents indicates that teaching has been effective? A) "We need to be sure to change our child's body position at least twice a day." B) "Our child might experience weakness even after recovering from the illness." C) "It will take about 10 days for our child to be back normal and return to school." D) "This disease affects the heart and lungs, so our child will have limited ability going forward."

Ans: B Feedback: Most children recover completely, without any residual effects of the syndrome; although, some may continue to have minor problems such as residual weakness. To prevent muscle contractures and effects of immobility, turning and repositioning every 2 hours is important in addition to passive range-of-motion exercises about every 4 hours. It will take longer than 10 days for the child to recover and return to school. This disease does not directly affect the heart and lungs. There should be minimal residual disability going forward.

7. The mother of a toddler experiencing stomach pain insists that the child be admitted to find out the cause of the pain. The child has been in the emergency room three other times in the past 6 months for the same complaint. What other information should alert the nurse to investigate the situation further? A) The mother is a single parent. B) The mother is in nursing school. C) The child has a 1-year-old sister. D) The child verbalizes abdominal pain when the mother is not present.

Ans: B Feedback: Munchausen syndrome by proxy refers to a parent who repeatedly brings a child to a health care facility and reports symptoms of illness when the child is well. A parent might report symptoms such as abdominal pain in a child. Because of these symptoms, the child is submitted to needless diagnostic procedures or therapeutic regimens. The parent usually has some degree of medical or child care knowledge obtained through formal education. Being a single parent, having siblings, and the child verbalizing abdominal pain when the mother is not present are not indications of this syndrome.

11. The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem? A) "Once the infection clears up, the baby will be fine." B) "We will need to plan for special care to help with learning disabilities." C) "In a few months, more brain tissue will grow to fill in the hollow areas in the brain." D) "In a few months, the baby will need to have physical therapy to train muscles to work."

Ans: B Feedback: Periventricular leukomalacia (PVL) is abnormal formation of the white matter of the brain and is caused by an anoxic episode that interferes with circulation to a portion of the brain. Phagocytes and macrophages invade the area to clear away necrotic tissue. What is left is an abnormality in the white matter of the brain seen as a hollow space. Once the condition has occurred, there is no therapy. Infants may die of the original insult; they may be left with long-term effects such as learning disabilities or cerebral palsy. The parents will need to plan for special care to help with the infant's learning disabilities. The baby does not have an infection. Brain tissue will not grow to fill in the hollow areas. There is no therapy for the condition, and there is no information to support that physical therapy will be beneficial.

13. The nurse decides to spend extra time with a pregnant patient in the prenatal clinic in efforts to determine if the patient is a victim of intimate partner violence. What caused the nurse to make this plan prior to assessing the patient? A) Patient chatting with another patient in the waiting room B) Patient wearing a long sleeved jacket on a hot summer day C) Patient periodically looking at a wrist watch to check the time D) Patient unconsciously rubbing the abdomen while reading a magazine

Ans: B Feedback: Pregnant maltreated patients may demonstrate typical behaviors that reveal violence. A patient may dress inappropriately for warm weather, wearing long-sleeved blouses to cover up bruises on the neck or arms. A patient who is talking with another patient, checking the time on a wrist watch, and rubbing the abdomen while reading a magazine are not behaviors that indicate intimate partner violence.

6. While making a home visit, the nurse suspects that a child is experiencing psychological maltreatment. What did the nurse observe in the home? A) Scolding one child for playing with matches B) Belittling the child in front of the nurse and other siblings C) Punishing one child for crossing the street without assistance D) Asking one child to perform a song on the piano for the nurse

Ans: B Feedback: Psychological maltreatment includes constant belittling a child. Children who are psychologically maltreated this way are likely to have difficulty becoming emotionally confident adults. This type of maltreatment is the most difficult form of maltreatment to detect because it may occur only in the home. Scolding for using matches, punishment for crossing the street without assistance, and asking to perform a song on the piano are not observations that support psychological maltreatment.

7. The nurse completes a physical assessment of a newborn. Which finding should the nurse identify as being abnormal? A) Abdomen slightly protuberant B) Clear drainage at the base of the umbilical cord C) Bowel sounds present at two to three per minute D) Liver palpable 2 cm under the right costal margin

Ans: B Feedback: The base of the cord should not appear wet. A moist or odorous cord can indicate an infection or a patent urachus that will drain urine at the cord site until it is surgically repaired. Normal newborn abdominal assessment findings include slightly protuberant in shape, presence of bowel sounds, and 2 cm of the liver palpable under the right costal margin.

8. A preadolescent girl with scoliosis is prescribed a body brace. What should the nurse teach the child about the purpose of the brace? A) Prevents torticollis B) Improves spinal stability C) Corrects spinal curvature D) Prevents herniation of a spinal disk

Ans: B Feedback: The goal of mechanical bracing is to maintain spinal stability and prevent further progression of the deformity until bone growth is complete. Bracing will not prevent torticollis, correct the curvature, or prevent herniation of a spinal disk.

15. A patient who has just given birth to her first baby asks the nurse for help with breastfeeding. Which nursing diagnosis would be the most appropriate for the patient at this time? A) Powerlessness B) Health-seeking behaviors C) Readiness for enhanced coping D) Anxiety related to breastfeeding

Ans: B Feedback: The new mother is asking the nurse for help with breastfeeding, which supports the nursing diagnosis of health-seeking behaviors. The patient requesting help with breastfeeding does not indicate powerlessness, readiness for enhanced coping, or anxiety related to breastfeeding.

8. An adolescent recovering from a spinal cord injury calls out for help. The patient's face is bright red, and the patient is experiencing a severe headache. What is the first thing that the nurse should do for this patient? A) Administer mouth-to-mouth resuscitation. B) Assess if the urinary retention catheter is blocked. C) Massage the lower extremities to cause vasodilation. D) Lower the head of the bed to increase cerebral circulation.

Ans: B Feedback: The patient is demonstrating signs of autonomic dysreflexia, which include extreme hypertension, tachycardia, flushed face, and severe occipital headache. This can occur if the patient's bladder is allowed to fill. The resultant sensory stimulation relayed to the damaged cord can initiate a powerful sympathetic reflex reaction. The nurse should assess that the patient's urinary catheter is not obstructed, so urine can flow freely and reduce the sensory stimulation. The patient is talking, so mouth-to-mouth resuscitation is not necessary. Massaging the lower extremities and lowering the head of the bed will not relieve the sensory stimulation caused by the blocked urinary catheter.

15. The nurse caring for children on a pediatric oncology care area delays entering some of the children's rooms unless to provide medication or perform a procedure. Which stage of the grieving process is influencing this nurse's ability to provide patient care? A) Anger B) Denial C) Bargaining D) Depression

Ans: B Feedback: There is a danger that a nurse who is in a stage of denial may care for children by avoiding going into a child's room unless an important procedure must be done. Nurses who are angry might provide care that is sharp and abrupt. Bargaining is promising to do something in exchange for the child not dying. Nurses who are in the depression stage may be ineffective caregivers because problem solving and decision making becomes a chore.

11. A school-age child with a supracondylar fracture of the humerus has been placed in a partial cast with the elbow region wrapped with an elastic bandage. What should the nurse explain to the parents and child regarding the reason for this type of casting approach? A) Encourages healing B) Ensures edema does not press on the nerves C) Keeps the bones of the forearm in alignment D) Provides additional stability until the bone heals

Ans: B Feedback: With an elbow fracture, the arm will be flexed and put into a cast. In this position, the radial artery and nerve can be compressed at the elbow, causing nerve injury or severe impairment of circulation. In some situations, a cast is applied incompletely for 24 hours, the elbow portion being splinted and wrapped with elastic bandages. After 24 hours, when edema has subsided and the chance of compression is less, the rest of the arm is then casted. The use of an elastic wrap at the elbow is not used to encourage healing, keep the bones in alignment, or provide additional stability.

8. The school district is planning an educational program for high school students to reduce the incidence of rape. When planning this program, which information should the school nurse include? (Select all that apply.) A) Carry a weapon or mace at all times. B) When leaving school after dark, walk on the street. C) Lock car doors when waiting in it and after parking it. D) Keep all doors and windows locked when home alone. E) Avoid taking illegal substances when in social situations.

Ans: B, C, D, E Feedback: Guidelines to prevent rape in adolescents include walking on the street when it is dark, locking car doors when waiting in it and after parking it, keeping all doors and windows locked when home alone, and avoid talking illegal substances such as Rohypnol when in social situations. Students should be cautioned about carrying weapons or mace because these items can be used against them.

13. During a home visit, a new mother tells the nurse that her nipples are sore from breastfeeding. What should the nurse instruct the mother at this time? (Select all that apply.) A) Insert plastic liners into the nursing bra. B) Apply lanolin to nipples after air exposure. C) Expose the nipples to air so the nipple dries. D) Position the baby differently for each feeding. E) Massage a few drops of breast milk to the areola.

Ans: B, C, D, E Feedback: To help with sore nipples from breastfeeding, the nurse should instruct the mother to apply lanolin to nipples after air exposure, expose the nipples to air so the nipple dries, position the baby differently for each feeding, and massage a few drops of breast milk to the areola. The mother should be discouraged from inserting plastic liners into the nursing bra because these prevent air from circulating around the breast.

2. The nurse manager of an urban health care clinic is designing a series of presentations for staff to address the 2020 National Health Goals to reduce child maltreatment and intimate partner violence. Which topics should the manager include in these presentations? (Select all that apply.) A) Caring for victims of rape B) Indications of child neglect C) Recognizing victims of violence D) Environments where rape occurs E) Manifestations of child maltreatment

Ans: B, C, E Feedback: Nurses can help the nation achieve the 2020 National Health Goals to reduce child maltreatment and intimate partner violence by identifying children or women in school or health care agency settings who have been maltreated, neglected, or a victim of violence. Caring for rape victims and environments where rape occurs are not strategies to achieve the 2020 National Health Goals to reduce child maltreatment and intimate partner violence.

2. The nurse is explaining the process of breast milk production with a patient pregnant with her first child. What should the nurse include when providing this teaching? (Select all that apply.) A) Breast milk is thin, yellow, and watery. B) For the first 3 to 4 days, the breast milk is colostrum. C) Uterine cramping is a contraindication to breastfeeding. D) True breast milk comes in by the 10th day after giving birth. E) Most mothers have breast milk by the first day after giving birth.

Ans: B, D Feedback: For the first 3 to 4 days after delivery, the breast milk is colostrum. The consistency changes to true breast milk by the 10th postpartum day. Colostrum is thin, yellow, and watery. Uterine cramping occurs as a result of oxytocin released during breastfeeding and is not a contraindication to breastfeeding but an expected occurrence. Most mothers do not have breast milk by the first day after giving birth.

3. The nurse is planning a program for a community that focuses on the 2020 National Health Goals for neurologic health. Which topics should the nurse include in this presentation? (Select all that apply.) A) Ensuring a diet adequate in vitamins and protein B) Use of helmets for bicycle and motorcycle safety C) Learning the signs and symptoms of inflammatory disorders D) Practicing good hand washing technique and infection control E) Importance of proper emergency care to protect the head and neck

Ans: B, D, E Feedback: Nurses can help the nation achieve the 2020 National Health Goals through helping prevent neurologic injury by educating children and parents about the use of helmets for bicycle and motorcycle safety, by administering and teaching paramedical personnel to administer safe care at accident scenes so children's heads and necks are protected, and by decreasing the possible spread of bacterial meningitis through good hand washing and infection control precautions in hospitals. Interventions about diet and manifestations of inflammatory disorders will not help achieve the 2020 National Health Goals.

10. The nurse visits the foster home of a newborn with failure to thrive syndrome. Which observation indicates a successful outcome for this child's care? A) Birth mother has stopped visiting the child. B) Birth father comes by the home to bring toys. C) Child eagerly takes a bottle and is gaining weight. D) Child is crying and has bruises over the lower legs.

Ans: C Feedback: A successful outcome for the care of a child with failure to thrive syndrome would be that the child shows interest in bottle feedings and begins to gain weight. The child crying and having bruises over the legs could indicate physical abuse or another medical problem. The mother not visiting the child indicates ongoing psychological issues with the mother bonding with the child. The father bringing toys does not indicate that the care of the child has been successful. The father's bonding with the child cannot be determined by this action of bringing toys.

12. The nurse assesses a newborn's Apgar score at birth and documents that it is normal. Which score did the nurse most likely record? A) 1 B) 4 C) 8 D) 13

Ans: C Feedback: An Apgar score between 7 and 10 indicates that the infant scored as high as 70% to 90% of all infants at 1 and 5 minutes after birth and is adjusting well to extrauterine life. A score of 4 to 6 indicates a guarded condition, and the newborn may need clearing of the airway and supplementary oxygen. A score <4 indicates serious danger of respiratory or cardiovascular failure, and the newborn needs resuscitation. Ten is the maximum number on the Apgar scoring system.

1. The nurse is caring for an infant born with a congenital anomaly. Which of the following factors is likely to have the most influence on the mother's ability to cope with the infant's handicap? A) The mother's age B) The gender of the infant C) The parent's amount of support D) The fact that this is a mental and not a physical challenge

Ans: C Feedback: Availability of support people to help the mother cope with the infant's handicap will have a major influence. A family that has few close friends and lives some distance from relatives is apt to have more difficulty adjusting to illness in a child than a family that has close support people. People who can locate secondary support systems in their community usually do better than parents who are without these resources. The mother's age, gender of the infant, and type of handicap will not have the most influence on the mother's ability to cope with the infant's needs.

1. A 3-month-old infant is diagnosed with failure to thrive. For which cause should the nurse include interventions when planning care for this patient? A) A reaction to severe stress B) Limited calcium metabolism C) Poor parent-child relationship D) Interference with gastrointestinal absorption

Ans: C Feedback: Failure to thrive is a syndrome in which an infant falls below the 5th percentile for weight and height on a standard growth chart or is falling in percentiles on a growth chart. One category of this syndrome occurs because of a disturbance in the parent-child relationship, resulting in maternal role insufficiency or a nonorganic cause. Failure to thrive is not caused by a reaction to severe stress, limited calcium metabolism, or interference with gastrointestinal absorption.

14. In which position should the nurse place a newborn to administer oxygen by bag and mask? A) Trendelenburg B) On the back with the neck slightly flexed C) On the back with the head slightly extended D) Position is unimportant as long as the tongue is pulled forward.

Ans: C Feedback: If a newborn does not draw in a first breath spontaneously following gentle stimulation, place the infant under a radiant heat warmer in a "sniffing" position, which is the head slightly tipped back. Trendelenburg is not a recommended position since this increases intracranial pressure. Flexing the neck could occlude the airway. The position is very important; the tongue will not occlude the airway if the correct position is used.

2. An 18-month-old child is admitted with signs of increased intracranial pressure. What should the nurse observe when assessing this patient? A) Numbness of fingers and decreased temperature B) Increased pulse rate and decreased blood pressure C) Increased temperature and decreased respiratory rate D) Decreased level of consciousness and increased respiratory rate

Ans: C Feedback: Manifestations of increased intracranial pressure include increased body temperature and decreased respiratory rate. Pulse rate slows, and the blood pressure increases.

7. A terminally ill child is awake at 2 AM and continues to put on the call light. What should the nurse do regarding this child's behavior? A) Provide with a sleeping aid. B) Encourage the child to sleep. C) Sit with the child until sleep comes. D) Put on the television and dim the lights.

Ans: C Feedback: Many children assume that they will die at night. A child may talk more freely at night about fears or an unfulfilled life ambition than during the day. Children may also be more frightened at night and enjoy having someone sit beside them until they fall asleep. The nurse should not provide with a sleeping aid. Encouraging the child to sleep will not meet the child's needs at this time. Putting on the television with dim lights in the room will not meet the child's needs at this time.

14. During a home visit with a family, the nurse learns that the oldest adolescent son has been arrested for shoplifting and has been skipping school for months. Which information within the family's health history could help explain this child's behavior? A) Father works out of the home. B) Mother works out of the home. C) Adolescent did not die as expected as a child. D) Parents have other children that need time and attention.

Ans: C Feedback: Parents who engage in anticipatory grief but the child does not die may have problems reversing the feelings. The parents begin to treat the child in a cold, unfeeling way. This child is a vulnerable child or a fragile child and may develop behavioral problems later such as shoplifting. It is unknown if this child's behavior is linked to the mother and father working outside of the home or if the behavior is because of the other children's needs.

8. A preterm infant is receiving oxygen to maintain respiratory status. When assessing this patient, at which level should the nurse maintain oxygenation to prevent retinopathy of prematurity? A) 40 mmHg B) 50 mmHg C) 100 mmHg D) 180 mmHg

Ans: C Feedback: When blood Po2 levels rise to higher than 100 mmHg, the risk of retinopathy of prematurity increases. All preterm infants who receive oxygen must have blood oxygen levels monitored by pulse oximeter, transcutaneous oxygen saturation, or blood gas monitoring so the blood Po2 level can be kept within normal limits. Oxygenation at 40 mmHg or 50 mmHg is not sufficient for the infant. Oxygenation at 180 mmHg is too high and can predispose the infant to develop retinopathy of oxygenation.

6. The nurse is caring for a preschool-age child recovering from a lumbar puncture. What should the nurse do to ensure the patient does not develop a spinal headache? A) Measure temperature every hour. B) Restrict fluids for 2 hours after the procedure. C) Elevate the head of the bed to a 30-degree angle. D) Take the pillow away and have the patient lie flat in bed.

Ans: D Feedback: A child may develop a headache after a lumbar puncture as a result of the reduction in CSF volume or invasion of a small air pocket during the puncture. The nurse should encourage the child to lie flat for at least 30 minutes. The child's blood pressure, pulse, and respirations should be assessed for changes that indicate an increase in intracranial pressure. The child should drink a glass of fluid after the procedure to help prevent cerebral irritation caused by air rising in the subarachnoid space and to help increase the amount of CSF. The head of the bed should be flat and not elevated to a 30-degree angle.

3. The community nurse is caring for a family who has a child with a long-term illness. At which point in life should the nurse anticipate the parents having the least difficult time accepting the child's condition? A) On the child's first birthday B) The day the child starts kindergarten C) The day the child is toilet trained D) The day the child would have graduated college

Ans: D Feedback: A child's illness usually appears to be more acute at times when the child would normally reach developmental milestones. When the child does not reach these traditional milestones, it reminds parents about their child's illness in a particularly painful way. The first birthday, starting kindergarten, and being toilet trained are momentous occasions for families raising children. The family may or may not view attending college as a priority.

11. During a child's last stage of dying, the parents ask if the child is able to hear. What should the nurse respond to the parents? A) "No, now that she is semicomatose, she is unable to hear you." B) "No one really knows, so it is a good idea not to speak too loudly." C) "Yes, she is able to hear and fully comprehend everything that is said." D) "Yes, she can hear and may also understand most of what is being said."

Ans: D Feedback: A loss of consciousness occurs as children grow closer and closer to death; although, they may remain perfectly alert until seconds before death. Because hearing is one of the last senses lost, the nurse may need to remind family members and other health care personnel that the child may not be able to respond but may be able to hear. Continue to explain procedures to unconscious children as if they were conscious because they undoubtedly do hear. Never make any comment in the child's presence that would not be made if the child were alert.

9. Which patient's physical assessment finding of a school-age child should the nurse question as a potential indication of abuse? A) A thin, tall appearance B) A scald burn on the chest C) A maculopapular rash on the buttocks D) Linear abrasions on his ankles and wrists

Ans: D Feedback: Abrasions or ecchymotic areas on the wrists or ankles may be present if the child was tied to a bed or against a wall. Being thin and tall is not an indication of abuse. A scald burn on the chest could have occurred while eating a meal at home. A rash on the buttocks is not an indication of physical abuse.

14. A new mother asks the nurse how to determine if the baby is receiving enough breast milk. What response should the nurse make to the mother? A) "The infant should not become constipated." B) "The infant should sleep at least 3 hours between feedings." C) "You need to weigh the infant before and after each feeding." D) "The infant should gain weight and have six wet diapers daily."

Ans: D Feedback: Acceptable criteria during the first week of life are wetting six to eight diapers within 24 hours or losing no more than 10% of birth weight. After the first week, weight gain and voiding six to eight times each 24 hours are good criteria to use. The infant will not become constipated when ingesting breast milk. Sleeping is individual for each baby and cannot be used to determine an adequate nutritional intake. Weighing the infant before and after feedings is not recommended.

10. A new mother asks the nurse to explain the difference between breastfeeding and formula when feeding a newborn. What should the nurse respond as an advantage of breastfeeding for the infant? A) Breast milk leads to firmer stools, increasing bowel tone. B) It takes less effort for an infant to suck at a breast than from a bottle. C) Breast milk is more difficult to digest, so it makes the infant feel fuller longer. D) Breast milk contains antibodies and decreases the possibility of gastrointestinal illnesses.

Ans: D Feedback: Breast milk contains secretory immunoglobulin A (IgA), which binds large molecules of foreign proteins, including viruses and bacteria, keeping them from being absorbed from the gastrointestinal tract. Breast milk does not cause firmer stools. It takes more effort for the infant to suck at a breast than at a bottle. Breast milk is less difficult for the baby to digest.

16. The nurse is visiting a new mother who has been home with a new infant for 4 days. Which observation indicates that the mother's home environment was inadequately assessed prior to being discharged from the hospital? A) Baby has a changing area. B) Kitchen has a refrigerator. C) Windows are covered with screens. D) Baby sleeps with the mother in bed.

Ans: D Feedback: Evidence that an inadequate home environment assessment was performed as baby is sleeping with the mother. The American Academy of Pediatrics recommends newborns have their own crib as a step toward preventing sudden infant death syndrome. The baby having a changing area, the kitchen has a refrigerator, and the windows are covered with screens indicate that the home environment is adequate to support the needs of a newborn.

2. A school-age child with pauciarticular juvenile arthritis has extreme pain upon waking in the morning. Which intervention should the nurse suggest the parents try to help the child with the pain? A) Encourage bed rest until the pain is gone. B) Perform isotonic exercises until the pain is gone. C) Provide 325 mg of aspirin immediately on arising. D) Encourage a warm bath each morning before school.

Ans: D Feedback: Heat reduces pain and inflammation in joints and increases comfort and motion. Heat can be applied by the use of a heating pad or warm water soaks for 20 to 30 minutes. Bed rest will not help reduce the pain. Isotonic exercises will not reduce the pain and could make the pain worse. Aspirin taken on an empty stomach could lead to gastric irritation. The dose of 325 mg may also be too high for the child.

9. The nurse is inspecting a male newborn's genitalia. Which action should the nurse avoid when conducting this assessment? A) Inspecting the genital area for irritated skin B) Inspecting if the urethral opening appears circular C) Palpating if testes are descended into the scrotal sac D) Retracting the foreskin over the glans to assess for secretions

Ans: D Feedback: In most male newborns, the foreskin slides back poorly from the meatal opening, so the nurse should not try to retract it. The nurse should inspect the area for irritated skin, inspect the urethral opening, and palpate the testes in the scrotal sac.

12. The nurse notes that a chronically ill child has not been seeing the health care provider for several months, although monthly checkups and blood work are needed to help maintain the illness. What should the nurse realize as a reason for the child missing appointments? A) The parents have been too busy to bring the child. B) The family does not have the money to pay for multiple visits. C) The child is afraid of having the blood drawn, so the parents do not bring him. D) The parents are having a difficult time grieving with the idea of the child's illness.

Ans: D Feedback: Most parents of a chronically ill child adhere well to instructions and keep health care appointments consistently. Sometimes, however, parents do not follow this pattern. This inability to adhere usually is related to their stage of adjustment to the illness. As long as denial, anger, bargaining, or depression is functioning, coming in for health care or evaluation is viewed as a major demand. Each visit is more of a reminder of the child's illness than a time of reassuring health assessment. This behavior does not indicate that the parents are too busy. There is no enough information to determine if the visits are cost prohibitive for the family. There is no enough information to determine if the child is afraid of having blood tests performed.

8. The nurse is caring for a preschool-age child who is aware of impending death. What behavior should the nurse expect the child to demonstrate at this time? A) Outbreaks of anger B) Verbalization of feelings C) Bargaining for another chance D) Fear of being separated from parents

Ans: D Feedback: Preschoolers fear separation. If able to grasp the concept of dying, this child's major worry is being alone and separated. These children may need someone to stay with them constantly to reassure them that they are loved and people are caring for them. Anger, verbalization of feelings, and bargaining are not behaviors typically associated with a preschool age-child who is facing death.

4. A new mother is ambivalent about breastfeeding and agrees to do it for at least 3 months. What response should the nurse provide to the patient at this time that would support the 2020 National Health Goals? A) Breastfeeding helps the mother return to prepregnancy weight faster. B) Three months is the recommended time frame for the baby's nutrition. C) Breast milk can be donated so that preterm infants can have additional nutrition. D) Six months to 1 year of age is the best time frame to support the baby's growth needs.

Ans: D Feedback: Six months to 1 year of age is one of the 2020 National Health Goals for breastfeeding. Although breastfeeding can help the mother return to prepregnancy weight, this is not a 2020 National Health Goal for breastfeeding. Three months is not the recommended time frame for the baby's nutrition. Breast milk can be donated; however, this is not a 2020 National Health Goal for breastfeeding.

5. The parents of a child with a thoracic-level spinal injury are anxious to learn the long-term prognosis for their child and ask if the child will walk again. How should the nurse respond to the parents? A) "Damage usually progresses after the first week." B) "It is most unlikely that your son will ever walk again." C) "What has the physician said about your son's recovery?" D) "It will be several weeks before an answer to your question is possible."

Ans: D Feedback: Spinal injuries result when the spinal cord becomes compressed or severed by the vertebrae; further cord damage can result from hemorrhage, edema, or inflammation at the injury site as the blood supply becomes impeded. Predictions of useful body function cannot be made accurately at the time of the injury. Three phases of recovery must first take place. The nurse cannot accurately say that damage will progress after the first week. The nurse has no way of knowing if the child will walk again. The nurse can answer the parent's question without finding out what the physician has said about the child's recovery.

4. A postpartum patient is upset that the baby was born with a congenital port-wine birthmark on the skin of the upper part of the right side of the face. What should the nurse explain to the mother about this birthmark? A) "The birthmark is a part of a syndrome that can be cured with medication." B) "The birthmark can be removed surgically so the child will develop normally." C) "The birthmark is a concentration of melanin in the skin and causes cosmetic problems." D) "The baby may have some numbness on the left side of the body because of the birthmark."

Ans: D Feedback: Sturge-Weber syndrome is characterized by a congenital port-wine birthmark on the skin of the upper part of the face that follows the distribution of the first division of the fifth cranial nerve. Because of involvement of the meningeal blood vessels, blood flow can be sluggish, and anoxia may develop in some portions of the cerebral cortex. The child will develop symptoms of numbness on the side opposite the lesion from destruction of motor neurons. This syndrome cannot be cured with medication. Removing the birthmark with surgery will not correct the long-term effects of the problem. The birthmark is not caused by a concentration of melanin in the skin. This problem has the potential to cause more than cosmetic health problems.

7. A pregnant patient had decided to breastfeed the infant but, after delivery, tells the nurse that formula feeding would be the best choice for her now. What nursing diagnosis should the nurse use to plan this patient's care? A) Anxiety B) Ineffective coping C) Imbalanced nutrition D) Risk for impaired parenting

Ans: D Feedback: The mother has decided to forgo breastfeeding for formula feeding. This decision could place the mother at risk for impaired parenting because of the need to formula feed the infant. The mother's decision does not support the diagnoses of anxiety and ineffective coping. It is unlikely that the infant will have imbalanced nutrition related to formula feeding.

1. When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn's respiratory rate? A) 12 to 16 breaths/min B) 16 to 20 breaths/min C) 20 to 30 breaths/min D) 30 to 60 breaths/min

Ans: D Feedback: The respiratory rate of a newborn in the first few minutes of life may be as high as 80 breaths/min. Because respiratory activity is established and maintained over the next hour, this rate will settle to an average of 30 to 60 breaths/min. Respiration rates less than 30 breaths/min should be reported to the health care provider for evaluation.

12. The nurse is assisting a new mother begin breastfeeding. Which action is the most appropriate for the nurse to take at this time? A) Positioning the infant near her breast and stroking his cheek to encourage him to suck B) Stressing that breastfeeding is a normal process and will need minimal help learning it C) Cautioning her not to allow the infant to grasp the areola of her breast to prevent soreness D) Encouraging her to lie on her side and help the baby become wide awake by talking to him

Ans: D Feedback: When a mother is first attempting to breastfeed, lying on the side with a pillow under the head is a good position to use because it relieves fatigue and allows the infant to rest on the bed and not on the mother. Stroking the cheek will cause the infant to turn away from the breast. Infants should grasp the nipple areola with the mouth. Most new mothers need some instruction and help.

12. A preadolescent weighing 99 lb is prescribed carbamazepine (Tegretol) 10 mg/kg per 24 hours in two divided doses. How much medication will the nurse provide the patient for one dose? (Enter numeric response only.)

Ans: 225 mg Feedback: The nurse needs to first determine the patient's weight in kilograms by dividing 99 lb by 2.2 or 99 / 2.2 = 45 kg. Next, the nurse is to multiply the prescribed dose of 10 mg by the body weight in kilograms or 10 × 45 = 450. If the child is to receive 450 mg of the medication in 24 hours, divide this total by 2 to determine that the child is to receive 225 mg for each dose.

8. A child with extensive burns is permitted to eat. Which nutrient should the nurse ensure is of a high amount when the child's meals are being prepared? A) Fats B) Protein C) Minerals D) Carbohydrates

Ans: B Feedback: To supply adequate calories for increased metabolic needs and spare protein for repair of cells after a burn injury, the diet is high in calories and protein. The diet does not need to be high in fat, minerals, or carbohydrates.

6. The nurse documents that a newborn has a normal head-to-body proportion. What did the nurse document in the baby's medical record? A) Head one half of total length B) Head one sixth of total length C) Head one fourth of total length D) Head one eighth of total length

Ans: C Feedback: A newborn's head usually appears disproportionately large because it is about one fourth of the total body length. The newborn's head is not one half, one sixth, or one eighth of the total body length.

5. The parents of a 6-year-old have just been told that their child will die shortly. At which age does the nurse realize that children are capable of understanding death? A) 3 years B) 6 years C) 9 years D) 12 years

Ans: C Feedback: As children near 8 or 9 years of age, they begin to appreciate that death is permanent. Younger children are not able to conceptualize the permanence of death. A 12-year-old child is able to conceptualize the permanence of death.

1. The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this patient? A) Glucose water B) 20 calories per ounce C) 22 calories per ounce D) Iron supplemented

Ans: C Feedback: The caloric concentration of formulas used for preterm infants is usually 22 calories per ounce compared with 20 calories per ounce for a term baby. Glucose water will not provide the infant with adequate calories. Iron supplementation will depend on laboratory values.

5. The nurse is caring for a child with a broken wrist that has just been placed in a cast. The nurse would elevate the arm to: A) To prevent edema B) To promote healing C) To discourage infection D) To ensure proper bone alignment

Ans: A Feedback: If an extremity has been casted, keep it elevated with a pillow to prevent edema in the fractured area. Elevating a casted extremity does not promote healing or discourage infection. The cast will ensure proper bone alignment.

6. A child who knows about a terminal disease tells the nurse of plans to recover and become a doctor to cure everyone in the whole world. What is the child demonstrating to the nurse? A) Anxiety about the illness B) Bargaining stage of grief C) Immature magical thinking D) Poor opinion of the care received

Ans: B Feedback: Bargaining, a stage of the grief process, is attempting to work out a deal to prevent death from occurring. This child is not demonstrating anxiety, immature thinking, or a poor opinion of the care that has been received.

14. The nurse is assessing pupil size and reaction to light in a child with a cervical neck injury. Which cranial nerve is the nurse assessing in this patient? A) II (optic) B) III (oculomotor) C) IV (trochlear) D) VI (abducens)

Ans: B Feedback: Cranial nerve III (oculomotor) provides motor control and sensation for eye muscles and the upper eyelid. To determine the functioning of this nerve, the nurse would assess pupillary size and reaction to light. Cranial nerve II controls vision. Cranial nerve IV controls the movement of major eye muscles. Cranial nerve VI controls the movement and muscle sense of the eye.

16. During a routine health visit, the mother of a 6-month-old baby mentions that she would like to begin weaning the baby from breastfeeding. What teaching should the nurse provide to the mother at this time? A) Apply heat to the breasts to suppress breast milk production. B) Discontinue gradually by omitting one breastfeeding session a day. C) Instead of breastfeeding the baby, pump the breasts to reduce pressure. D) Provide a bottle of regular milk to supplement one breastfeeding session.

Ans: B Feedback: When weaning, breastfeeding should be discontinued gradually by first omitting one breastfeeding a day and substituting a formula feeding. Heat to the breasts does not suppress milk production. Pumping the breasts will continue milk production. If weaning before 12 months, the baby should be weaned to formula and not whole milk.

5. Before discharging a school-age child being treated for a snake bite, the nurse instruct ways to prevent additional bites in the future. Which statement indicates that teaching provided to this child has been effective? A) "I should wear long pants when out of doors." B) "I should look at rocks before touching them." C) "I should poke a snake with a stick before touching it." D) "I should spray a snake with water before picking it up."

Ans: B Feedback: Common safety rules to avoid snake bites include being aware that snakes like to sit in the sun on warm rocks. The child should look at a rock before touching it to prevent a snake bite. Wearing long pants will not necessarily prevent snake bits. Snakes should not be poked or sprayed with water. Snakes should be identified in underbrush and under rocks. Snakes should also be identified by sound and markings.

9. The nurse calculates that a child with a burn injury is to receive 3,600 ml of intravenous fluid over the next 24 hours. How much of this fluid should the nurse provide to the patient during the first 8 hours? A) 900 ml B) 1,200 ml C) 1,800 ml D) 2,700 ml

Ans: C Feedback: Fluid is administered rapidly for the first 8 hours after the injury or half of the 24-hour load and then more slowly for the next 16 hours or the second half. If the child is to receive 3,600 ml of fluid over 24 hours, half of the amount, or 1,800 ml, should be infused over the first 8 hours. The remaining 1,800 ml should be infused over the next 16 hours.

11. An 8-year-old child is being treated for tonic-clonic seizures. What should the nurse emphasize when teaching the parents about this disorder? A) The child should maintain an active lifestyle. B) Immediately provide medication if a seizure begins. C) Have the child carry a padded tongue blade with her at all times. D) Ensure quiet time late in the day, when seizure activity is most likely to occur.

Ans: A Feedback: As a rule, children with seizures should attend regular school and participate in physical education classes and active sports. Antiseizure medication is ineffective during a seizure because most medication needs to achieve a therapeutic level to be effective. Padded tongue blades are not used in people with a seizure disorder. There is no specific time of day when a seizure can occur.

3. During a home visit, the nurse learns that a new mother is experiencing breast engorgement. What should the nurse recommend to help alleviate this problem? A) Discontinuing breastfeeding for 24 hours B) Having her apply lanolin cream to each breast C) Encouraging her to continue regular breastfeeding D) Decreasing her fluid intake to below 500 ml per 24 hours

Ans: C Feedback: A common suggestion to relieve breast engorgement is to empty the breasts of milk by having the infant suck more often or at least continue to suck as much as before. Breastfeeding should not be discontinued. Applying cream to the breasts will not help with engorgement. The mother does not need to be placed on a fluid restriction.

2. The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases? A) Creases on two thirds of the foot B) Heel creases but no anterior creases C) Longitudinal but no horizontal creases D) Creases covering one fourth of the foot

Ans: A Feedback: The foot of a term newborn has many crisscrossed lines on the sole, covering approximately two thirds of the foot. If these creases cover less than two thirds of the foot or are absent, it suggests the infant is preterm.

8. The nurse is evaluating a new mother's ability to breastfeed her infant. Which criteria indicate that the mother is able to breastfeed independently? (Select all that apply.) A) Nipples are everted. B) Breasts are soft and nontender. C) Mother holds the nipple in the baby's mouth. D) Baby swallows spontaneously and frequently. E) Nurse places pillows under the baby for support.

Ans: A, B, D Feedback: The LATCH breastfeeding charting system is used to measure a mother's ability to breastfeed independently. Criteria that indicate the mother can breastfeed independently include everted nipples, breasts are soft and nontender, and the baby swallows spontaneously and frequently. The mother having to hold the nipple in the baby's mouth and the nurse assisting with positioning indicate the mother is not independent in breastfeeding.

11. The school nurse is planning a presentation to be given during the next parent/teacher conference to include the 2020 National Health Goals to prevent unintentional injuries in children. What should the nurse include in this presentation? (Select all that apply.) A) Legal aspects of child abuse B) Recognize signs of self-injury C) Provide information on home safety D) Ways to determine intentional injuries E) Emphasize safety with sports activities

Ans: B, C, D, E Feedback: Nurses can help the nation achieve the 2020 National Health Goals to prevent unintentional injuries in children by providing counseling on safety precautions to parents and children and always help assess whether injuries were unintentional or could be child maltreatment or self-injury. The legal aspects of child abuse would not be appropriate for this presentation.

13. The nurse is caring for a child with a closed head injury. The child's blood pressure is 120/58 mmHg, and intracranial pressure is 16 mmHg. What is this child's cerebral perfusion pressure? (Enter numeric value only. Calculate to the nearing hundredth decimal point.)

Ans: 84.67 Feedback: Cerebral perfusion pressure is calculated by subtracting the mean intracranial pressure from the mean arterial pressure or MAP - ICP = CPP. To calculate mean arterial pressure, the nurse should subtract the diastolic blood pressure from the systolic blood pressure and divide the result by 3 and then add that sum to 80. For this patient, the MAP would be calculated as being (120 - 58) / 3 + 80 = 100.67. To calculate the cerebral perfusion pressure, take the value of the mean arterial pressure and subtract the child's intracranial pressure or 100.67 - 16 = 84.67. The child's cerebral perfusion pressure is 84.67.

12. The nurse is preparing to administer activated charcoal to a 4-year-old child who accidentally ingested a family member's heart medication. What should the nurse do to reduce the discomfort from this treatment? A) Insert a nasogastric tube. B) Mix the charcoal in milk. C) Obtain an order for an indwelling urinary catheter. D) Bring an intravenous infusion for fluid replacement.

Ans: A Feedback: Activated charcoal absorbs toxic substances that have been swallowed to prevent them from being absorbed by the stomach. The drug is provided as a powder that must be mixed with water, and not milk, and administered orally or through a nasogastric tube. The solution feels gritty and tastes disagreeable, so it may be difficult to swallow. A nasogastric tube will help decrease the child's discomfort when taking the medication. This medication does not require an indwelling urinary catheter or intravenous infusion for fluid replacement.

10. A preadolescent child with ataxia-telangiectasia is demonstrating an exacerbation of choreoathetosis. What should the nurse do to help this patient? A) Provide comfort measures. B) Assist the patient to walk several times a day. C) Encourage the patient to increase independence. D) Recommend transferring the patient to a rehabilitation facility.

Ans: A Feedback: Ataxia-telangiectasia is a primary immunodeficiency disorder that results in progressive cerebellar degeneration. Telangiectasia or red vascular markings appear on the conjunctiva and skin at the flexor creases. Neurologic symptoms caused by the degeneration process can usually be detected in early infancy when developmental milestones are not met. Children develop an awkward gait when they begin to walk. Choreoathetosis or rapid, purposeless movements may develop. Unfortunately, there is no effective treatment, and children with this disorder often die in late adolescence of infection, respiratory failure, or a malignant brain tumor. The nurse should provide comfort measures when caring for this child. The patient may not be able to walk. It is an unrealistic expectation for this child to increase independence. A rehabilitation facility is not going to help with the long-term prognosis of this disorder.

6. A school-age child comes into the emergency clinic complaining of knee pain that started while playing soccer. What will the nurse most likely observe when assessing this child's knee? A) Edema B) Erythema C) Contusions D) Mottled skin

Ans: A Feedback: Participation in sports such as soccer is a frequent cause of knee injuries in children and usually involves the ligaments surrounding the knee. Immediately after the injury, the child reports severe pain in the knee, and localized edema becomes evident. Erythema, contusions, and mottled skin are not associated with a knee injury caused by participation in a sport.

9. The nurse is caring for an 8-month-old baby diagnosed with spastic cerebral palsy. Which assessment finding supports this medical diagnosis? A) The child has a strong Moro reflex when startled. B) The child bears weight on both feet when held upright. C) The child cries when held in a ventral suspension position. D) The child holds the back very straight when in a sitting position.

Ans: A Feedback: Spasticity is excessive tone in the voluntary muscles that results in loss of upper motor neurons. A child with spastic cerebral palsy has hypertonic muscles, abnormal clonus, exaggeration of deep tendon reflexes, abnormal reflexes such as a positive Babinski reflex, and continuation of neonatal reflexes, such as the tonic neck reflex, well past the age at which these usually disappear. If infants with this disorder are held in a ventral suspension position, they arch their backs and extend their arms and legs abnormally. They tend to assume a "scissors gait" because tight adductor thigh muscles cause their legs to cross when held upright. This involvement may be so severe it leads to a subluxated hip. Posture when in a sitting position is not remarkable for this health problem.

7. A preadolescent child sprains the right ankle while inline skating. What should the nurse instruct the child and parents about the care that the child will need at home? (Select all that apply.) A) Apply ice pack for 20-minute intervals. B) Apply ice pack on the ankle for 4 to 7 days. C) Keep wrapped in an elastic bandage. D) Remind to use crutches to walk for 3 to 4 days. E) Apply heat to the ankle beginning the first day after injury.

Ans: A, B, C, D Feedback: Interventions to help with a sprain include applying ice pack for 20-minute intervals, applying ice pack on the site for 4 to 7 days, wrapping with an elastic bandage, and using crutches to walk for 3 to 4 days after the injury. Heat is not applied to a sprain.

15. During a routine well-child visit, the mother of a preadolescent patient asks the nurse to explain signs of sexual abuse. The mother is concerned because an older male neighbor has been making comments and overtly admiring the child when playing outdoors. What information should the nurse provide to the mother? (Select all that apply.) A) Child reports abdominal pain. B) Child has a change in school performance. C) Child demonstrates anxiety or trouble sleeping. D) Child does not want to be left alone with a certain adult. E) Child spends a great deal of time with peer-group friends.

Ans: A, B, C, D Feedback: Signs of sexual maltreatment include vague reports of abdominal pain, a change in school performance, anxiety or trouble sleeping, and not wanting to be left alone with a certain adult. Spending time with peer-group friends is an expected preadolescent behavior and is not a sign of sexual maltreatment.

14. The nurse is caring for a preschool-age child who survived near drowning. Which interventions should the nurse plan to promote optimum respiratory functioning for this patient? (Select all that apply.) A) Turn and reposition every 2 hours. B) Administer antibiotics as prescribed. C) Auscultate lung sounds every 2 to 4 hours. D) Monitor cardiac rhythm and blood pressure. E) Encourage deep breathing and incentive spirometry every hour.

Ans: A, B, C, E Feedback: After a near drowning, the child should be turned every 2 hours. The child is usually prescribed prophylactic antibiotic therapy to prevent pneumonia. Lung sounds should be auscultated frequently for adventitious sounds. Deep breathing and incentive spirometry should be encouraged every hour help to aerate the lungs fully and prevent the accumulation of fluid, which promotes infection. Monitoring cardiac rhythm and blood pressure are not interventions specifically for respiratory functioning.

13. A school-age child is brought to the emergency department after being hit in the mouth with a baseball bat during Little League. The child has lost two deciduous teeth, and one permanent front tooth is loose. What care should the nurse prepare to provide to this patient? (Select all that apply.) A) Administer prescribed oral antibiotic. B) Wash the deciduous teeth with saline to be wired into place. C) Instruct the parents and the child that the jaw will need to be wired shut. D) Explain that an X-ray may be done to make sure that the jaw was not fractured. E) Explain that a chest X-ray will be done to make sure that other teeth are not in the lungs.

Ans: A, D Feedback: With dental fractures, deciduous teeth may not be replaced. If the blow to the teeth was extensive, an X-ray may be done to ensure that the upper or lower jaw is not fractured. The patient will be prescribed an oral antibiotic. The jaw does not need to be wired shut unless it is fractured. A chest X-ray would be done if the missing teeth are unaccountable.

10. The nurse notes that a child with a burn injury is prescribed daily debridement. What should the nurse instruct the child and parents about the purpose of this treatment? A) Relieves pain B) Prevents infection C) Maintains mobility of extremities D) Decreases the need for skin grafts

Ans: B Feedback: Debridement is the removal of necrotic tissue on which microorganisms could thrive from a burned area to reduce the possibility of infection. Debridement does not relieve pain but rather is a very painful procedure. Debridement does not influence extremity mobility. The need for skin grafts depends on the depth of the burned tissue.

4. The nurse is completing the health history for the parents of school-age child admitted with a ruptured spleen. For which activity should the nurse assess as the possible cause for this child's injury? A) Shooting pool B) Skateboarding C) Playing baseball D) Playing basketball

Ans: B Feedback: In children, the spleen is the most frequently injured organ when there is abdominal trauma. Frequent causes of injury include skateboard accidents. Injuries to the spleen are not associated with shooting pool or playing baseball or basketball.

15. The nurse is planning care for a preschool-age child diagnosed with meningitis. What should the nurse identify as a priority goal for this patient's care? A) Inspect the teeth for obvious caries. B) Reduce the pain related to nuchal rigidity. C) Provide an opportunity for therapeutic play. D) Increase stimulation opportunities to prevent coma.

Ans: B Feedback: Meningitis is an infection of the cerebral meninges. Pathologic organisms spread to the meninges. Once organisms enter the meningeal space, they multiply rapidly and then spread throughout the CSF to invade brain tissue through the meningeal folds, which extend down into the brain itself. A child with meningitis usually has an upper respiratory tract infection prior to the development of meningitis. Then the child will become increasingly irritable because of an intense headache with sharp pain when bending the head forward. Reducing the pain caused by neck pain would be the priority goal for this patient's care. Inspecting the teeth, providing opportunities for play, and increasing stimulation would not be priority goals for this patient.

15. A 3-year-old child is brought to the emergency department after swallowing batteries taken from a grandparent's hearing aids. The parents believe that two batteries were swallowed. What should the nurse explain to the parents regarding the care that the child will need at this time? A) Activated charcoal so that the child will vomit the batteries B) Preparation for an emergency endoscopy to remove the batteries C) Oxygen to ensure that the child's blood is thoroughly oxygenated D) Emergency intubation to ensure that the child has an adequate airway

Ans: B Feedback: Objects that do not digest such as batteries need to be removed by endoscopy as soon as possible because they can lead to bowel perforation or volvulus from the acid within the object. Activated charcoal is used for accidental poisoning. The child is not demonstrating signs of respiratory distress and will not need oxygen or emergency intubation.

1. A 2-year-old child is diagnosed with lead poisoning caused by eating paint chips from a windowsill. What measure should the nurse instruct the parents to prevent this from occurring in the future? A) Teaching their daughter that paint is not an edible substance B) Not allowing their daughter any milk products during daylight hours C) Covering the windowsills with paneling to prevent her from reaching them D) Administering ipecac syrup the next time they see her eat a paint chip

Ans: C Feedback: Active interventions need to begin to prevent further lead exposure such as removal of the child from the environment containing the lead source or removal of the source of lead from the child's environment. Removal of the lead source is not an easy task in homes because simple repainting or wallpapering does not necessarily remove the source of peeling paint adequately. After some months, the new paint will begin to peel because of the defective paint underneath. The walls must therefore be covered by paneling or dry wall or other solid protective material. The child is 2 years old and will not understand that paint is not edible. Milk products will not prevent future episodes of lead poisoning. Syrup of ipecac will not help with the metabolism of lead from paint chips.

3. An infant is brought to the emergency department with acetaminophen poisoning. Which medication should the nurse expect to administer to this child? A) Iron B) Deferoxamine C) Acetylcysteine D) Dexamethasone

Ans: C Feedback: In the emergency department, acetylcysteine, a mucolytic agent and also the specific antidote for acetaminophen poisoning, will be administered. Acetylcysteine prevents hepatotoxicity by binding with the breakdown product of acetaminophen so that it will not bind to liver cells. Iron, deferoxamine, and dexamethasone are not used as antidote for acetaminophen poisoning.

2. A child with a head injury is demonstrating signs of cognitive deficits. The parents are concerned about how well the child will recover. Which nursing diagnosis should the nurse identify as the most appropriate for the family at this time? A) Anxiety related to extent of required hospitalization B) Risk for long-term learning deficits related to head injury C) Parental fear related to outcome after head injury in child D) Ineffective coping related to care of a child with a head injury

Ans: C Feedback: The parents are concerned if the child will recover. The most appropriate nursing diagnosis would be parental fear related to outcome after head injury. The parents are not demonstrating anxiety related to the hospitalization. Even though the child is demonstrating cognitive deficits at this time, this can change. The recovery from a head injury is unpredictable so deficits can resolve. The parents are not providing care to the child at this time, so there is no evidence of ineffective coping related to the care of a child with a head injury.