Maternal Child Chapter 32

29. A parent is concerned because her son was exposed to varicella at preschool. The nurse would tell this parent that the incubation period for varicella is _____ days.

ANS: 14 to 21 The incubation period for varicella is 2 to 3 weeks, usually 13 to 17 days. DIF: Cognitive Level: Knowledge REF: Page 722, Health Promotion box OBJ: 2 TOP: Varicella KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

30. The nurse demonstrates proper hand hygiene pointing out that the process should take a minimum of ____ seconds.

ANS: 15 Hand hygiene should take a minimum of 15 seconds to complete. DIF: Cognitive Level: Knowledge REF: Page 727, Nursing Tip OBJ: 4 TOP: Hand Hygiene KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

26. The nurse explains that the ______________ test determines the child's susceptibility to tuberculosis.

ANS: Mantoux The Mantoux test is a screening test for the susceptibility to TB. An intradermal injection is given and read 3 days later. An erythema and induration of more than 5 mm is considered a positive reading. DIF: Cognitive Level: Knowledge REF: Page 726 OBJ: 4 TOP: Mantoux KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

31. Children are generally more vulnerable to biological warfare, because their ____________________ are not fully developed.

ANS: immune systems The immune systems of children are not fully developed, which makes them a vulnerable population. DIF: Cognitive Level: Comprehension REF: Page 737 OBJ: 7 TOP: Bioterrorism KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

32. A __________ is a worldwide high incidence of a communicable disease. An ___________ is a sudden increase of a communicable disease in a localized area. _________________ refers to a continuous incidence of a communicable disease expected in a localized area.

ANS: pandemic; epidemic; Endemic A pandemic is a worldwide high incidence of a communicable disease. An epidemic is a sudden increase of a communicable disease in a localized area. Endemic refers to a continuous incidence of a communicable disease expected in a localized area. DIF: Cognitive Level: Knowledge REF: Page 725 OBJ: 1 TOP: Key Terms KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

28. The school nurse recognizes the presence of macules, papules, vesicles, pustules, and scabs on the child as the particular sign of the communicable disease of _________________.

ANS: varicella (chickenpox) Varicella has the distinctive sign of showing several types of skin lesions at the same time. DIF: Cognitive Level: Comprehension REF: Page 722, Health Promotion box OBJ: 2 TOP: Varicella KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

27. The nurse uses a diagram showing how the wood tick acts as a(n) ______________ in the transmission of Lyme disease.

ANS: vector A vector is an insect or animal that carries a communicable disease. DIF: Cognitive Level: Comprehension REF: Page 725 OBJ: 4 TOP: Vector KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

17. An adolescent is taking tetracycline for a sexually transmitted disease. What would the nurse stress when providing instruction about this medication? a. Finish all of the medication. b. Get plenty of fresh air and sunlight. c. Take the medication with food. d. Take an antacid if the medication causes an upset stomach.

ANS: A The nurse would teach the adolescent to take all of the prescribed medication to avoid making the microorganism resistant to tetracyclines. DIF: Cognitive Level: Comprehension REF: Page 740, Table 32-3 OBJ: 9 TOP: Sexually Transmitted Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

21. Why would a female adolescent with STDs resist reporting the condition? (Select all that apply.) a. She is reluctant to name contacts. b. She is embarrassed. c. She doubts confidentiality. d. She doesn't want to take the medication. e. She dreads the pelvic examination.

ANS: A, B, C, E Adolescents are uncomfortable about the pelvic examination and require a lot of support. Adolescents doubt the confidentiality of the agency and are reluctant to name contacts. DIF: Cognitive Level: Comprehension REF: Page 739-740 OBJ: 9 TOP: Reporting STDs KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

14. The nurse is preparing to administer immunizations at a well-child clinic. Which method of administration will the nurse implement? a. DTaP subcutaneously b. Hib vaccine prepared in a separate syringe c. Varicella intramuscularly d. Varicella 1 week after the MMR vaccine

ANS: B Hib vaccine must be given in a separate syringe from other vaccines administered at the same time. DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6 OBJ: 6 TOP: Hib KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

19. Which is an example of an opportunistic infection? a. Measles b. Pneumocystis jiroveci c. Clostridium difficile d. Smallpox

ANS: B Pneumocystis jiroveci is the most common of opportunistic diseases. DIF: Cognitive Level: Knowledge REF: Page 741 OBJ: 1 TOP: Opportunistic Diseases KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

22. What sources are examples of acquired immunity? (Select all that apply.) a. Gamma globulin b. The disease c. Maternal antibodies d. The vaccine e. Immune globulin

ANS: B, D Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination. Gamma globulin is simply a support to the immune system. Immune globulin is receiving the antibodies from some other source, giving the person an immediate immunity but one that does not last. DIF: Cognitive Level: Knowledge REF: Page 726 OBJ: 1 TOP: Acquired Immunity KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

5. What type of precautions are necessary when caring for a toddler with varicella? a. Contact b. Protective c. Airborne infection d. Large droplet infection

ANS: C Airborne-infection precautions are used for patients with conditions such as tuberculosis, varicella, and rubella. Small airborne particles caught on floating dust in the room can be inhaled from anywhere in the room. DIF: Cognitive Level: Application REF: Page 722, Health Promotion box OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

11. An infant is hospitalized for RSV bronchiolitis. Which type of precautions would the nurse use when caring for the infant? a. Large-droplet infection precautions b. Airborne-infection precautions c. Contact precautions d. Protective precautions

ANS: C Contact precautions are used when the condition transmits organisms via skin-to-skin contact or indirect touch of a contaminated fomite. DIF: Cognitive Level: Application REF: Page 726-727 OBJ: 4 TOP: Medical Asepsis and Standard Precautions KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

9. The mother of a newborn asked the nurse, "When will my baby get the hepatitis B vaccine?" When will the nurse explain the first dose of Comvax should be given to infants born to a hepatitis B-positive mother? a. Within 12 hours after birth b. Within 2 weeks after birth c. Within 1 month after birth d. Within 2 months after birth

ANS: A The American Academy of Pediatrics recommends that Comvax, the only thimerosal-free hepatitis B vaccine, should be used for infants born to HBsAg-positive mothers within 12 hours of birth. DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6 OBJ: 4 TOP: Immunization Schedule KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

6. Which statement assures the nurse that parents understand how long a child who has varicella is contagious? a. "My child should stay home from school for 6 days after the pox appear." b. "My child can return to school when the rash fades." c. "My child must stay away from other children until all of the lesions have healed." d. "My child is contagious as long as he has a fever."

ANS: A The child with varicella is contagious for 6 days after the appearance of the rash. DIF: Cognitive Level: Comprehension REF: Page 722, Health Promotion box OBJ: 2 TOP: Common Varicella KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

13. The nurse is planning to administer immunizations at a well-child visit when a parent reports the 18-month-old child is allergic to eggs. Which vaccine would be contraindicated? a. Influenza b. Inactivated polio vaccine c. Diphtheria, tetanus, acellular pertussis d. Hepatitis B

NS: A The influenza vaccine should not be given to children who are allergic to eggs. DIF: Cognitive Level: Knowledge REF: Page 729 OBJ: 6 TOP: Nurse's Role in Immunizations—Allergy KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

ANS: B, D Acquired immunity is acquiring the antibodies by way of having the disease or having the vaccination. Gamma globulin is simply a support to the immune system. Immune globulin is receiving the antibodies from some other source, giving the person an immediate immunity but one that does not last. DIF: Cognitive Level: Knowledge REF: Page 726 OBJ: 1 TOP: Acquired Immunity KEY: Nursing Process Step: N/A MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

ANS: A, B, C, E All the options are the expected inoculations of a healthy 2-month-old with the exception of MMR. Mumps, measles, rubella are not expected until the child is 1 year old. DIF: Cognitive Level: Knowledge REF: Page 733, Figure 32-6 OBJ: 6 TOP: Inoculations for a 2-Month-Old KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

25. The nurse is assisting with an admission assessment of a child with scarlet fever. Which actions will the nurse expect to implement? (Select all that apply.) a. Obtain a throat culture. b. Encourage ambulation. c. Assess for desquamation. d. Initiate droplet precautions. e. Administer isoniazid.

ANS: A, C A diagnosis of scarlet fever would indicate throat culture and assessment for desquamation. Bed rest with quiet activity is indicated. Droplet precautions would not be implemented for scarlet fever. Isoniazid is administered for tuberculosis. DIF: Cognitive Level: Application REF: Page 724, Health Promotion box OBJ: 2 TOP: Scarlet Fever KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

4. Which finding would lead the nurse to delay the administration of DTaP for an infant? a. Diarrhea b. Temperature of 40.5° C (105° F) from the previous inoculation c. Teething d. Traveling to Europe in a week

ANS: B A contraindication to giving the DTaP vaccine is a 40.5° C (105° F) temperature following the previous vaccination. DIF: Cognitive Level: Application REF: Page 731 OBJ: 6 TOP: Immunizations KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. How would the nurse document a rash that has erythematous, circular raised lesions? a. Macular b. Papular c. Vesicular d. Pustular

ANS: B A papule is a circular, reddened elevated area on the skin. DIF: Cognitive Level: Knowledge REF: Page 727 OBJ: 2 TOP: Rashes KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

12. A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response for the nurse to make when the child asks, "Why do you have to wear a gown and mask when you are in my room?" a. "Nurses and doctors wear gowns and masks because you have a condition that could be spread to others." b. "The gown and mask are to protect you because you could get an infection very easily." c. "I'm wearing this because there are a lot of bacteria in the hospital." d. "I might look scary but you won't need this after you have had medication for 24 hours."

ANS: B Protective isolation is used for patients who are not communicable but have a lowered resistance and are highly susceptible to infection. DIF: Cognitive Level: Application REF: Page 727 OBJ: 3 TOP: Protective Isolation KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

20. A child is admitted to the pediatric unit with a diagnosis of cellulitis on the right upper thigh. Patient history reveals the child had a 2-cm laceration on the right thigh prior to infection. When explaining the chain of infection, how does the nurse identify this laceration? a. Reservoir b. Portal of entry c. Portal of exit d. Cector

ANS: B The chain of infection refers to the way in which organisms spread and infect the individual. A portal of entry is a route by which the organisms enter the body (e.g., a cut in the skin). A portal of exit is the route by which the organisms exit the body (e.g., feces or urine). A reservoir for infection is a place that supports the growth of organisms (e.g., standing, stagnant water). A vector is an insect or animal that carries and spreads a disease. DIF: Cognitive Level: Comprehension REF: Page 725 OBJ: 1 TOP: Chain of Infection KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

18. The nurse explains to the parents that their child is in the prodromal stage of varicella. What does this mean? a. The child is now immune to varicella. b. The child has varicella but has not yet broken out. c. The child is infected with varicella but is not contagious. d. The child does not have varicella but has been exposed to it.

ANS: B The prodromal stage is the initial stage of the communicable disease in which the child is infected and contagious but does not yet have outward signs of the disease. DIF: Cognitive Level: Comprehension REF: Page 725 OBJ: 1 TOP: Prodromal Period KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

2. An 8-year-old asks the nurse how she got the antibodies that kept her from getting whooping cough. What is the nurse's best explanation? a. "You received borrowed antibodies from another person who had whooping cough." b. "You were given a tiny case of whooping cough and then you made your own antibodies." c. "An immunization strengthened antibodies you were born with." d. "You received only temporary borrowed antibodies and you need to have another shot every 5 years."

ANS: B Vaccines contain live weakened or dead organisms not strong enough to cause disease but they stimulate the body to develop an immune reaction and antibodies. This is active acquired immunity. DIF: Cognitive Level: Comprehension REF: Page 728, Table 32-1 OBJ: 4 TOP: Vaccines KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation

24. The nurse is explaining to a family about disaster preparedness. What will the nurse instruct the family to prepare in a disaster kit in case of emergency? (Select all that apply.) a. Small television b. Vital documents c. Nonperishable food d. Pet food e. Blankets

ANS: B, C, D, E The nurse can assist families to prepare for natural disasters, such as hurricanes or floods, or manmade disasters, such as bioterrorist attacks or bombings. The American Medical Association (AMA) office guidelines for preparing a family and community disaster plan state that the family should keep several days' supply of food, water, pet food, warm clothing, blankets, copies of vital documents, and toiletries on hand. A battery-powered radio and extra medications, eyeglasses, and basic first aid supplies are also essential. DIF: Cognitive Level: Knowledge REF: Page 738-739 OBJ: 8 TOP: Disaster Preparedness KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

7. Which statement made by a sexually active adolescent girl indicates an understanding of the prevention of sexually transmitted diseases? a. "I always douche after intercourse." b. "I think you can get a vaccination for STDs now." c. "I insist that my partner wear a condom." d. "I am protected because I take the pill."

ANS: C The use of condoms to prevent STDs is not considered 100% effective but is recommended for sexual intercourse. DIF: Cognitive Level: Comprehension REF: Page 739, Nursing Tip OBJ: 9 TOP: Sexually Transmitted Diseases KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

10. A 10-year-old child is diagnosed with Hepatitis A. What is the most likely way the child contracted this disease? a. Came in contact with infected blood b. Came in contact with droplets in the air c. Was bitten by a mosquito or a tick d. Ate shrimp while in Mexico

ANS: D Hepatitis A results from ingestion of contaminated water or shellfish. DIF: Cognitive Level: Comprehension REF: Page 723, Health Promotion box OBJ: 3 TOP: Hepatitis A KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

15. A child was sent to the school nurse because of a rash. The nurse noted the rash was present on the trunk, extremities, and face. The child's cheeks were bright red. With what is the nurse aware this type of rash is consistent? a. Measles b. Roseola c. Varicella d. Fifth disease

ANS: D In fifth disease, the child has a generalized rash and the cheeks have a slapped-cheek appearance. DIF: Cognitive Level: Comprehension REF: Page 722, Health Promotion box OBJ: 2 TOP: Fifth Disease KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

16. What statement leads the nurse to determine that a child's parent understands information related to tick bites? a. "I'll have my son wear dark clothing on his hike." b. "We should all get the Lyme disease vaccine before our trip." c. "I'll get a prescription for amoxicillin to take with us." d. "We will wear long pants and long-sleeved shirts in the woods."

ANS: D People should keep skin covered by wearing protective clothing in wooded areas to prevent tick bites. DIF: Cognitive Level: Application REF: Page 724, Health Promotion box OBJ: 4 TOP: Prevention of Tick Bites KEY: Nursing Process Step: Evaluation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

1. Which classification of medication would make a child most susceptible to an opportunistic infection? a. Anticonvulsant b. Beta-adrenergic agent c. Antibiotic d. Corticosteroid

ANS: D Steroids are immunosuppressive drugs that make the child very susceptible to opportunistic infections. DIF: Cognitive Level: Knowledge REF: Page 725 OBJ: 3 TOP: Effect of Steroids KEY: Nursing Process Step: Data Collection MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

8. What is the priority nursing diagnosis for a hospitalized infant who is HIV positive? a. Risk for injury b. Altered nutrition c. Impaired skin integrity d. Risk for infection

ANS: D The infant who is HIV positive has impaired immunologic functioning and is at high risk for infection. DIF: Cognitive Level: Application REF: Page 742-743, NCP 32-1 OBJ: 10 TOP: Human Immunodeficiency Virus KEY: Nursing Process Step: Nursing Diagnosis MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control