Maternal child exam 2

The nurse instructs a child's parent to be cautious because the child is hyperactive and difficult. What assessment would the nurse have performed to confirm the child's behavior? 1 Restlessness 2 Temperament 3 Hypothermic conditions 4 Neurological maturation

Temperament

During their school-age years, children best understand concepts that can be seen or illustrated. The nurse knows this type of thinking is termed as: 1 concrete operations. 2 preoperational. 3 school-age rhetoric. 4 formal operations.

concrete operations.

The nurse is talking to a group of parents about different types of play in which children engage. Which statement made by a parent indicates a correct understanding of the teaching? 1 "Parallel-play children borrow and lend play materials and sometimes attempt to control who plays in the group." 2 "In associative play, children play independently but among other children." 3 "During onlooker play, children play alone with toys different from those used by other children in the same area." 4 "Cooperative play is organized, and children play in a group with other children."

"Cooperative play is organized, and children play in a group with other children."

The nurse finds that a newborn infant weighs approximately 3 kg (7 lb). Approximately how much would the child weigh when he reaches 2.5 years of age? 1 9 kg (20 lb) 2 12 kg (27 lb) 3 15 kg (33 lb) 4 17 kg (38 lb)

12 kg (27 lb)

The nurse finds that a newborn weighs 3 kg (7 lb). By the time the child reaches 2 years, she weighs 12 kg (26 lb). What would be the child's approximate weight by 6 years of age? 1 20-22 kg (44-48 lb) 2 27-29 kg (59-64 lb) 3 30-32 kg (66-70 lb) 4 36-38 kg (79-84 lb)

20-22 kg (44-48 lb)

A child is 50 cm (20 inches) long in the second month of infancy. The nurse checks the baby 2 months later and finds healthy growth in the child. Approximately how long would the baby be at 4 months? 1 52 cm 2 55 cm 3 57 cm 4 60 cm

55 cm

The nurse is speaking to a group in the community about psychosocial development according to Erikson's life-span approach. The nurse instructs the group not to impose too many expectations on a child because the child may develop an inferiority complex. What age group of children is nurse referring to here? 1 1-3 years 2 3-6 years 3 6-12 years 4 12-18 years

6-12 years

The Kohlberg moral development theory states that children are concerned with conformity and loyalty at a stage of their growth. When this stage is correlated with the cognitive development of children, what would the age group be? 1 0-2 years 2 2-7 years 3 7-11 years 4 11-15 years

7-11 years

The nurse assesses a child's cognitive development to determine whether the child has mastered the concept of conservation. In which age group is the concept of conservation usually attained? 1 0-2 years 2 2-7 years 3 7-11 years 4 11-15 years

7-11 years

14. Excessive blood loss after childbirth can have several causes; the most common is: a.Vaginal or vulvar hematomas. b.Unrepaired lacerations of the vagina or cervix. c.Failure of the uterine muscle to contract firmly. d.Retained placental fragments.

: C Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although vaginal or vulvar hematomas, unpaired lacerations of the vagina or cervix, and retained placental fragments are possible causes of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause.

During a home visit, the parent of a 9-year-old child tells the nurse that after coming in from playing outside, the child does not want to do homework. The child feels feverish. What should the nurse tell the child's mother? 1 "Your child has a fever due to impaired thermoregulation." 2 "Your child should play indoor games for 1 hour daily." 3 "A child's body temperature increases after playing." 4 "Your child should drink milk immediately after playing."

A child's body temperature increases after playing."

18. By what age do the head and chest circumferences generally become equal? a. 1 month b. 6 to 9 months c. 1 to 2 years d. 2.5 to 3 years

ANS: C Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference at ages 1 month and 6 to 9 months. Chest circumference is larger than head circumference at age 2.5 to 3 years.

Which health promotion teaching points should a nurse include in a dental teaching plan to help prevent dental caries? (Select all that apply) A. Drink fluoridated water. B. Begin dental hygiene after eruption of both front teeth. C. Schedule regular dental appointments after age 2. D. Dates and locations of free dental clinics. E. Dental caries are preventable.

A, D, E Dental caries is the single most common chronic disease of childhood. Nearly one in five children between the ages of 2 and 4 years has visible cavities. The most common form of early dental disease is early childhood caries, which may begin before the first birthday and progress to pain and infection within the first 2 years of life. Preschoolers of low-income families are twice as likely to develop tooth decay and only half as likely to visit the dentist as other children. Early childhood caries is a preventable disease, and nurses play an essential role in educating children and parents about practicing dental hygiene beginning with the first tooth eruption; drinking fluoridated water, including bottled water; and instituting early dental preventive care.

What has had the greatest impact on reducing infant mortality in the United States? A. Access to high-quality prenatal care B. Decreased incidence of congenital abnormalities C. Better maternal nutrition D. Improved funding for health care

A. Access to high-quality prenatal care Access to and the use of high-quality prenatal care is a promising preventive strategy to decrease early delivery and infant mortality. The improvements in perinatal care, in particular respiratory care and care of the mother-baby dyad before delivery, have had the greatest impact. There has been a decrease in some congenital anomalies such as spina bifida, but this is not the greatest impact. Better maternal nutrition has had a positive influence but not the greatest overall impact. Changes in funding have not had the greatest impact.

When teaching an adolescent mother about risk factors for neonatal death, the most important factor is: A. Low birth weight B. Injuries to the mother during pregnancy C. Newborn obesity D. Chronic illness of the mother

A. Low birth weight LBW, which is closely related to early gestational age, is considered the leading cause of neonatal death in the United States. Injuries are the leading cause of death in children over age 1 year, with the majority being motor vehicle accident (MVA) injuries. Injuries to the mother and chronic illness are not the major causes of neonatal death.

8. The nurse is performing a gestational age and physical assessment on the newborn. The infant appears to have an excessive amount of saliva. The nurse recognizes that this finding: a. is normal. b. indicates that the infant is hungry. c. may indicate that the infant has a tracheoesophageal fistula or esophageal atresia. d. may indicate that the infant has a diaphragmatic hernia.

ANS: C The presence of excessive saliva in a neonate should alert the nurse to the possibility of tracheoesophageal fistula or esophageal atresia

8. In many hospitals new mothers are routinely presented with gift bags containing samples of infant formula. This practice: a. Is inconsistent with the Baby Friendly Hospital Initiative. b. Promotes longer periods of breastfeeding. c. s perceived as supportive to both bottle-feeding and breastfeeding mothers. d. Is associated with earlier cessation of breastfeeding.

ANS: A Infant formula should not be given to mothers who are breastfeeding. Such gifts are associated with earlier cessation of breastfeeding. Baby-Friendly USA prohibits the distribution of any gift bags or formula to new mothers.

23. Rho immune globulin will be ordered postpartum if which situation occurs? a.Mother Rh?2-, baby Rh+ b.Mother Rh?2-, baby Rh?2- c.Mother Rh+, baby Rh+ d. Mother Rh+, baby Rh?2-

ANS: A An Rh?2- mother delivering an Rh+ baby may develop antibodies to fetal cells that entered her bloodstream when the placenta separated. The Rho immune globulin works to destroy the fetal cells in the maternal circulation before sensitization occurs. If mother and baby are both Rh+ or Rh?2- the blood types are alike, so no antibody formation would be anticipated. If the Rh+ blood of the mother comes in contact with the Rh?2- blood of the infant, no antibodies would develop because the antigens are in the mother's blood, not the infant's.

19. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: a.At the time of admission to the nurse's unit. b.When the infant is presented to the mother at birth c.During the first visit with the physician in the unit. d. When the take-home information packet is given to the couple.

ANS: A Discharge planning, the teaching of maternal and newborn care, begins on the woman's admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.

2. What does the nurse teach to parents to prevent sudden infant death syndrome (SIDS)? a. Place the baby on back to sleep. b. Place the baby on side to sleep. c. Not to feed the baby for 3 hours before sleep. d. Place the baby on her stomach to sleep.

ANS: A Feedback A The American Academy of Pediatrics recommends positioning infants on their backs; the slogan to help people remember is "Back to Sleep." B The side-lying position is not recommended for sleep because of the risk of aspiration. C Not feeding the baby for 3 hours before sleep is not a prevention for SIDS. D The prone position is not recommended for sleep due to the risk of aspiration.

10. In the recovery room, if a woman is asked either to raise her legs (knees extended) off the bed or to flex her knees, place her feet flat on the bed, and raise her buttocks well off the bed, most likely she is being tested to see whether she a. Has recovered from epidural or spinal anesthesia b. Has hidden bleeding underneath her. c. Has regained some flexibility. d. Is a candidate to go home after 6 hours.

ANS: A If the numb or prickly sensations are gone from her legs after these movements, she has likely recovered from the epidural or spinal anesthesia.

7. A primiparous woman is to be discharged from the hospital tomorrow with her infant girl. Which behavior indicates a need for further intervention by the nurse before the woman can be discharged? a. The woman leaves the infant on her bed while she takes a shower. b. The woman continues to hold and cuddle her infant after she has fed her. c. The woman reads a magazine while her infant sleeps. d. The woman changes her infant's diaper and then shows the nurse the contents of the diaper.

ANS: A Leaving an infant on a bed unattended is never acceptable for various safety reasons. Holding and cuddling the infant after feeding and reading a magazine while the infant sleeps are appropriate parent-infant interactions. Changing the diaper and then showing the nurse the contents of the diaper is appropriate because the mother is seeking approval from the nurse and notifying the nurse of the infant's elimination patterns.

15. A hospital has a number of different perineal pads available for use. A nurse is observed soaking several of them and writing down what she sees. This activity indicates that the nurse is trying to: a.Improve the accuracy of blood loss estimation, which usually is a subjective assessment. b.Determine which pad is best. c.Demonstrate that other nurses usually underestimate blood loss. d. Reveal to the nurse supervisor that one of them needs some time off.

ANS: A Saturation of perineal pads is a critical indicator of excessive blood loss, and anything done to aid in assessment is valuable. The nurse is noting the saturation volumes and soaking appearances. It is' possible that the nurse is trying to determine which pad is best, but it is more likely that the nurse is noting saturation volumes and soaking appearances to improve the accuracy of blood loss estimation. Nurses usually overestimate blood loss, if anything.

21. Which breastfeeding patient is most likely to have severe afterbirth pains and request a narcotic analgesic? a.Gravida 5, para 5 b.Woman who is bottle-feeding her first child c. Primipara who delivered a 7-lb boy d. Woman who wishes to breastfeed as soon as her baby is out of the neonatal intensive care unit

ANS: A The discomfort of afterpains is more acute for multiparas because repeated stretching of muscle fibers leads to loss of uterine muscle tone. Afterpains are particularly severe during breastfeeding, not bottle-feeding. The uterus of a primipara tends to remain contracted. The nonnursing mother may have engorgement problems. The patient whose infant is in the NICU should pump regularly to stimulate milk production and ensure that she will have an adequate milk supply when the baby is strong enough to nurse.

4. The laboratory results for a postpartum woman are as follows: blood type, A; Rh status, positive; rubella titer, 1:8 (EIA 0.8); hematocrit, 30%. How would the nurse best interpret these data? a. Rubella vaccine should be given. b. A blood transfusion is necessary. c. Rh immune globulin is necessary within 72 hours of birth. d.A Kleihauer-Betke test should be performed.

ANS: A This client's rubella titer indicates that she is not immune and that she needs to receive a vaccine. These data do not indicate that the client needs a blood transfusion. Rh immune globulin is indicated only if the client has a negative Rh status and the infant has a positive Rh status. A Kleihauer-Betke test should be performed if a large fetomaternal transfusion is suspected, especially if the mother is Rh negative. The data do not provide any indication for performing this test.

24. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is: a. a normal finding. b. an abnormal finding; the child needs referral to an ophthalmologist. c. a sign of a possible visual defect; the child needs vision screening. d. a sign of small hemorrhages, which usually resolve spontaneously.

ANS: A A brilliant, uniform red reflex is an important normal and expected finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.

A major nursing intervention for an infant born with myelomeningocele is to: a. Protect the sac from injury. b. Prepare the parents for the child's paralysis from the waist down. c. Prepare the parents for closure of the sac at around 2 years of age. d. Assess for cyanosis.

ANS: A A major preoperative nursing intervention for a neonate with a myelomeningocele is protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system infection. The long-term prognosis in an affected infant can be determined to a large extent at birth with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse would assess for multiple potential problems in this infant, the major nursing intervention would be to protect the sac from injury.

The abuse of which of the following substances during pregnancy is the leading cause of cognitive impairment in the United States? a. Alcohol c. Marijuana b. Tobacco d. Heroin

ANS: A Alcohol abuse during pregnancy is recognized as one of the leading causes of cognitive impairment in the United States.

Baby-friendly hospitals mandate that infants be put to breast within what time frame after birth? a.1 hour b.30 minutes c.2 hours d. 4 hours

ANS: A Baby-friendly hospitals mandate that the infant be put to breast within the first hour after birth (BFHI, 2010). The ideal time to initiate breastfeeding is within the first 1 to 2 hours after delivery. In many countries this is the norm; however, the Baby-Friendly Hospital Initiative (BFHI) mandates 1 hour. Ideally an infant should go no longer than 2 hours after delivery before being put to breast. This is much too long to wait to initiate breastfeeding, whether the hospital is baby-friendly or not.

14. The best reason for recommending formula over breastfeeding is that: a. the mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. b. the mother lacks confidence in her ability to breastfeed. c. other family members or care providers also need to feed the baby. d. the mother sees bottle-feeding as more convenient.

ANS: A Breastfeeding is contraindicated when mothers have certain viruses, are undergoing chemotherapy, or are using/abusing illicit drugs. A lack of confidence, the need for others to feed the baby, and the convenience of bottle-feeding are all honest reasons for not breastfeeding, although further education concerning the ease of breastfeeding and its convenience, benefits, and adaptability (expressing milk into bottles) could change some minds. In any case the nurse must provide information in a nonjudgmental manner and respect the mother's decision. Nonetheless, breastfeeding is definitely contraindicated when the mother has medical or drug issues of her own.

10. According to the recommendations of the American Academy of Pediatrics on infant nutrition: a. infants should be given only human milk for the first 6 months of life. b. infants fed on formula should be started on solid food sooner than breastfed infants. c. if infants are weaned from breast milk before 12 months, they should receive cow's milk, not formula. d. after 6 months mothers should shift from breast milk to cow's milk.

ANS: A Breastfeeding/human milk should also be the sole source of milk for the second 6 months. Infants start on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, they should receive iron-fortified formula, not cow's milk.

30. A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." The nurse's most appropriate answer is: a. colostrum is high in antibodies, protein, vitamins, and minerals. b. colostrum is lower in calories than milk and should be supplemented by formula. c. giving colostrum is important in helping the mother learn how to breastfeed before she goes home. d. colostrum is unnecessary for newborns.

ANS: A Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary; it will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.

The nurse is providing support to parents at the time their child is diagnosed with chronic disabilities. The nurse notices that the parents keep asking the same questions. The nurse should: a. Patiently continue to answer questions. Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 582 b. Kindly refer them to someone else to answer their questions. c. Recognize that some parents cannot understand explanations. d. Suggest that they ask their questions when they are not upset.

ANS: A Diagnosis is one of the anticipated stress points for parents. The parents may not hear or remember all that is said to them. The nurse should continue to provide the kind of information that they desire. This is a particularly stressful time for the parents; the nurse can play a key role in providing necessary information. Parents should be provided with oral and written information. The nurse needs to work with the family to ensure understanding of the information. The parents require information at the time of diagnosis. Other questions will arise as they adjust to the information.

The parents of a child born with disabilities ask the nurse for advice about discipline. The nurses response should be based on knowledge that discipline is: a. Essential for the child. b. Too difficult to implement with a special-needs child. c. Not needed unless the child becomes problematic. d. Best achieved with punishment for misbehavior.

ANS: A Discipline is essential for the children with disabilities. It provides boundaries within which to test their behavior and teaches them socially acceptable behaviors. It is not too difficult to implement discipline with a special-needs child. The nurse should teach the parents ways to manage the childs behavior before it becomes problematic. Punishment is not effective in managing behavior.

The nurse is caring for a child who has just died. The parents ask to be left alone so that they can rock their child one more time. The nurse should: a. Grant their request. b. Assess why they feel that this is necessary. c. Discourage this because it will only prolong their grief. d. Kindly explain that they need to say good-bye to their child now and leave.

ANS: A The parents should be allowed to remain with their child after the death. The nurse can remove all of the tubes and equipment and offer the parents the option of preparing the body. This is an important part of the grieving process and should be allowed if the parents desire it. It is important for the nurse to ascertain if the family has Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 586 any special needs.

3. A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas: a. increases the risk that the infant will develop allergies. b. helps the infant sleep through the night. c. ensures that the infant is getting iron in a form that is easily absorbed. d. requires that multivitamin supplements be given to the infant.

ANS: A Exposure to cow's milk poses a risk of developing allergies, eczema, and asthma. "Bottle-feeding using commercially prepared infant formulas helps the infant sleep through the night" is a false statement. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and resemble breast milk.

29. Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid? a. A premature infant more easily digests breast milk than formula. b. A glass of wine just before pumping will help reduce stress and anxiety. c. The mother should pump only as much as the infant can drink. d. The mother should pump every 2 to 3 hours, including during the night.

ANS: A Human milk is the ideal food for preterm infants, with benefits that are unique in addition to those received by term, healthy infants. Greater physiologic stability occurs with breastfeeding compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mother's milk ejection reflex. To establish an optimal milk supply, the mother should be instructed to pump 8 to 10 times a day for 10 to 15 minutes on each breast.

Which infant would be more likely to have Rh incompatibility? a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor b. Infant who is Rh negative and whose mother is Rh negative c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor d. Infant who is Rh positive and whose mother is Rh positive

ANS: A If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, all the offspring will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, there is a 50% chance that each infant born of the union will be Rh positive and a 50% chance that each will be born Rh negative.

9. The nurse is discussing storage of breast milk with a mother whose infant is preterm and in the special care unit. What statement would indicate that the mother needs additional teaching? a. "I can store my breast milk in the refrigerator for 3 months." b. "I can store my breast milk in the freezer for 3 months." c. "I can store my breast milk at room temperature for 8 hours." d. "I can store my breast milk in the refrigerator for 3 to 5 days."

ANS: A If the mother states that she can store her breast milk in the refrigerator for 3 months, she needs additional teaching about safe storage. Breast milk can be stored at room temperature for 8 hours, in the refrigerator for 3 to 5 days, in the freezer for 3 months, or in a deep freezer for 6 to 12 months. It is accurate and does not require additional teaching if the mother states that she can store her breast milk in the freezer for 3 months, at room temperature for 8 hours, and in the refrigerator for 3 to 5 days.

With regard to injuries to the infant's plexus during labor and birth, nurses should be aware that: a. If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. b. Erb palsy is damage to the lower plexus. c. Parents of children with brachial palsy are taught to pick up the child from under the axillae. d. Breastfeeding is not recommended for infants with facial nerve paralysis until the condition resolves.

ANS: A If the nerves are stretched with no avulsion, they should recover completely in 3 to 6 months. However, if the ganglia are disconnected completely from the spinal cord, the damage is permanent. Erb palsy is damage to the upper plexus and is less serious than brachial palsy. Parents of children with brachial palsy are taught to avoid picking up the child under the axillae or by pulling on the arms. Breastfeeding is not contraindicated, but both the mother and infant will need help from the nurse at the start.

A common parental reaction to a child with special needs is parental overprotection. Parental behavior suggestive of this includes: a. Giving inconsistent discipline. b. Providing consistent, strict discipline. c. Forcing child to help self, even when not capable. d. Encouraging social and educational activities not appropriate to childs level of capability.

ANS: A Parental overprotection is manifested by the parents fear of letting the child achieve any new skill, avoiding all discipline, and catering to the childs every desire to prevent frustration. The overprotective parents usually do not set limits and or institute discipline, and they usually prefer to remain in the role of total caregiver. They do not allow the child to perform self-care or encourage the child to try new activities.

3. A 3.8-kg infant was delivered vaginally at 39 weeks after a 30-minute second stage. There was a nuchal cord. After birth the infant is noted to have petechiae over the face and upper back. Information given to the infant's parents should be based on the knowledge that petechiae: a. are benign if they disappear within 48 hours of birth. b. result from increased blood volume. c. should always be further investigated. d. usually occur with forceps delivery.

ANS: A Petechiae, or pinpoint hemorrhagic areas, acquired during birth may extend over the upper portion of the trunk and face. These lesions are benign if they disappear within 2 days of birth and no new lesions appear. Petechiae may result from decreased platelet formation. In this situation the presence of petechiae is most likely a soft-tissue injury resulting from the nuchal cord at birth. Unless they do not dissipate in 2 days, there is no reason to alarm the family. Petechiae usually occur with a breech presentation vaginal birth.

What is most descriptive of a school-age childs reaction to death? a. Is very interested in funerals and burials b. Has little understanding of words such as forever c. Imagines the deceased person to be still alive d. Has an idealistic view of the world and criticizes funerals as barbaric

ANS: A The school-age child is very interested in postdeath services and may be inquisitive about what happens to the body. School-age children have an established concept of forever and have a deeper understanding of death in a concrete manner. Toddler may imagine the deceased person to still be alive. Adolescents may respond to death with an idealistic view of the world and criticize funerals as barbaric.

A careful review of the literature on the various recreational and illicit drugs reveals that: a. More longer-term studies are needed to assess the lasting effects on infants when mothers have taken or are taking illegal drugs. b. Heroin and methadone cross the placenta; marijuana, cocaine, and phencyclidine (PCP) do not. c. Mothers should get off heroin (detox) any time they can during pregnancy. d. Methadone withdrawal for infants is less severe and shorter than heroin withdrawal.

ANS: A Studies on the effects of marijuana and cocaine use by mothers are somewhat contradictory. More long-range studies are needed. Just about all of these drugs cross the placenta, including marijuana, cocaine, and PCP. Drug withdrawal is accompanied by fetal withdrawal, which can lead to fetal death. Therefore detoxification from heroin is not recommended, particularly later in pregnancy. Methadone withdrawal is more severe and more prolonged than heroin withdrawal.

10. The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading? a. Birth history b. Present illness c. Chief complaint d. Review of systems

ANS: A The birth history refers to information that relates to previous aspects of the child's health, not to the current problem. The mother's difficult delivery and prematurity are important parts of the past history of an infant. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It would not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth. Sequelae such as pulmonary dysfunction would be included.

With regard to congenital anomalies of the cardiovascular and respiratory systems, nurses should be aware that: a. Cardiac disease may be manifested by respiratory signs and symptoms. b. Screening for congenital anomalies of the respiratory system need only be done for infants having respiratory distress. c. Choanal atresia can be corrected by a suction catheter. d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

ANS: A The cardiac and respiratory systems function together. Screening for congenital respiratory system anomalies is necessary even for infants who appear normal at birth. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are discovered prenatally on ultrasound.

12. With regard to umbilical cord care, nurses should be aware that: a. the stump can easily become infected. b. a nurse noting bleeding from the vessels of the cord should immediately call for assistance. c. the cord clamp is removed at cord separation. d. the average cord separation time is 5 to 7 days.

ANS: A The cord stump is an excellent medium for bacterial growth. The nurse should first check the clamp (or tie) and apply a second one. If the bleeding does not stop, the nurse calls for assistance. The cord clamp is removed after 24 hours when it is dry. The average cord separation time is 10 to 14 days.

A pregnant woman presents in labor at term, having had no prenatal care. After birth her infant is noted to be small for gestational age with small eyes and a thin upper lip. The infant also is microcephalic. On the basis of her infant's physical findings, this woman should be questioned about her use of which substance during pregnancy? a. Alcohol c. Heroin b. Cocaine d. Marijuana

ANS: A The description of the infant suggests fetal alcohol syndrome, which is consistent with maternal alcohol consumption during pregnancy. Fetal brain, kidney, and urogenital system malformations have been associated with maternal cocaine ingestions. Heroin use in pregnancy frequently results in intrauterine growth restriction. The infant may have a shrill cry and sleep cycle disturbances and present with poor feeding, tachypnea, vomiting, diarrhea, hypothermia or hyperthermia, and sweating. Studies have found a higher incidence of meconium staining in infants born of mothers who used marijuana during pregnancy.

1. The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce himself or herself. b. Make the family comfortable. c. Explain the purpose of the interview. d. Give an assurance of privacy.

ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview the nurse should include general conversation to help make the family feel at ease. Next, the purpose of the interview and the nurse's role should be clarified. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.

7. When preparing to administer a hepatitis B vaccine to a newborn, the nurse should: a. obtain a syringe with a 25-gauge, 5/8-inch needle. b. confirm that the newborn's mother has been infected with the hepatitis B virus. c. assess the dorsogluteal muscle as the preferred site for injection. d. confirm that the newborn is at least 24 hours old.

ANS: A The hepatitis B vaccine should be administered with a 25-gauge, 5/8-inch needle. Hepatitis B vaccination is recommended for all infants. If the infant is born to an infected mother who is a chronic carrier, hepatitis vaccine and hepatitis B immune globulin should be administered within 12 hours of birth. Hepatitis B vaccine should be given in the vastus lateralis muscle. Hepatitis B vaccine can be given at birth.

21. Nursing follow-up care often includes home visits for the new mother and her infant. Which information related to home visits is correct? a. Ideally, the visit is scheduled within 72 hours after discharge. b. Home visits are available in all areas. c. Visits are completed within a 30-minute time frame. d. Blood draws are not a part of the home visit.

ANS: A The home visit is ideally scheduled within 72 hours after discharge. This timing allows early assessment and intervention for problems with feedings, jaundice, newborn adaptation, and maternal-infant interaction. Because home visits are expensive, they are not available in all geographic areas. Visits are usually 60 to 90 minutes in length to allow enough time for assessment and teaching. When jaundice is found, the nurse can discuss the implications and check the transcutaneous bilirubin level or draw blood for testing.

Which is the most appropriate nursing intervention to promote normalization in a school-age child with a chronic illness? a. Give child as much control as possible. b. Ask childs peer to make child feel normal. c. Convince child that nothing is wrong with him or her. d. Explain to parents that family rules for the child do not need to be the same as for healthy siblings.

ANS: A The school-age child who is ill may be forced into a period of dependency. To foster normalcy, the child should be given as much control as possible. It is unrealistic to expect one individual to make the child feel normal. The child has a chronic illness. It would be unacceptable to convince the child that nothing is wrong. The family rules should be similar for each of the children in a family. Resentment and hostility can arise if different standards are applied to each child.

33. The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. The rationale for this position is that: a. it prevents cremasteric reflex. b. undescended testes can be palpated. c. this tests the child for an inguinal hernia. d. the child does not yet have a need for privacy.

ANS: A The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its contraction, which pulls the testes into the pelvic cavity. Undescended testes cannot be predictably palpated. Inguinal hernias are not detected by this method. This position is used for inhibiting the cremasteric reflex. Privacy should always be provided for children.

The nurse is talking with the parents of a child who died 6 months ago. They sometimes still hear the childs voice and have trouble sleeping. They describe feeling empty and depressed. The nurse should recognize that: a. These are normal grief responses. b. The pain of the loss is usually less by this time. c. These grief responses are more typical of the early stages of grief. d. This grieving is essential until the pain is gone and the child is gradually forgotten.

ANS: A These are normal grief responses. The process of grief work is lengthy and resolution of grief may take years, with intensification during the early years. The child will never be forgotten by the parents.

16. Nurses providing nutritional instruction should be cognizant of the uniqueness of human milk. Which statement is correct? a. Frequent feedings during predictable growth spurts stimulate increased milk production. b. The milk of preterm mothers is the same as the milk of mothers who gave birth at term. c. The milk at the beginning of the feeding is the same as the milk at the end of the feeding. d. Colostrum is an early, less concentrated, less rich version of mature milk.

ANS: A These growth spurts (10 days, 3 weeks, 6 weeks, 3 months) usually last 24 to 48 hours, after which infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).

22. The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. The most appropriate action is to: a. refer for immediate medical evaluation. b. continue the assessment to determine the cause of neck pain. c. ask the parent when the child's neck was injured. d. record "head lag" on the assessment record and continue the assessment of the child.

ANS: A These symptoms indicate meningeal irritation and need immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag.

What is a priority nursing diagnosis for the preschool child with chronic illness? a. Risk for Delayed Growth and Development related to chronic illness or disability b. Chronic Pain related to frequent injections c. Anticipatory Grieving related to impending death d. Anxiety related to frequent hospitalizations

ANS: A This is the priority nursing diagnosis that is appropriate for the majority of chronic illnesses. Pain is not associated with the majority of chronic illnesses. A chronic illness is one that does not have a cure. It does not mean the child will die prematurely. Frequent hospitalizations are not necessarily required for many chronic illnesses.

During a prenatal examination, the woman reports having two cats at home. The nurse informs her that she should not be cleaning the litter box while she is pregnant. When the woman asks why, the nurse's best response would be: a. "Your cats could be carrying toxoplasmosis. This is a zoonotic parasite that can infect you and have severe effects on your unborn child." b. "You and your baby can be exposed to the human immunodeficiency virus (HIV) in your cats' feces." c. "It's just gross. You should make your husband clean the litter boxes." d. "Cat feces are known to carry Escherichia coli, which can cause a severe infection in both you and your baby."

ANS: A Toxoplasmosis is a multisystem disease caused by the protozoal Toxoplasma gondii parasite, commonly found in cats, dogs, pigs, sheep, and cattle. About 30% of women who contract toxoplasmosis during gestation transmit the disease to their offspring. Clinical features ascribed to toxoplasmosis include hydrocephalus or microcephaly, chorioretinitis, seizures, or cerebral calcifications. HIV is not transmitted by cats. Although suggesting that the woman's husband clean the litter boxes may be a valid statement, it is not appropriate, does not answer the client's question, and is not the nurse's best response. E. coli is found in normal human fecal flora. It is not transmitted by cats.

29. What type of breath sound is normally heard over the entire surface of the lungs, except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular b. Bronchial c. Adventitious d. Bronchovesicular

ANS: A Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate.

The most important nursing action in preventing neonatal infection is: a. Good handwashing. c. Separate gown technique. b. Isolation of infected infants. d. Standard Precautions.

ANS: A Virtually all controlled clinical trials have demonstrated that effective handwashing is responsible for the prevention of nosocomial infection in nursery units. Measures to be taken include Standard Precautions, careful and thorough cleaning, frequent replacement of used equipment, and disposal of excrement and linens in an appropriate manner. Overcrowding must be avoided in nurseries. However, the most important nursing action for preventing neonatal infection is effective handwashing.

An appropriate nursing intervention when providing comfort and support for a child whose death is imminent is to: Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 587 a. Limit care to essentials. b. Avoid playing music near the child. c. Explain to the child the need for constant measurement of vital signs. d. Whisper to the child instead of using a normal voice.

ANS: A When death is imminent, care should be limited to interventions for palliative care. Music may be used to provide comfort for the child. Vital signs do not need to be measured frequently. The nurse should speak to the child in a clear, distinct voice.

A cure is no longer possible for a young child with cancer. The nursing staff recognizes that the goal of treatment must shift from cure to palliation. Which is an important consideration at this time? a. The family is included in the decision to shift the goals of treatment. b. The decision must be made by the health professionals involved in the childs care. c. The family needs to understand that palliative care takes place in the home. d. The decision should not be communicated to the family because it will encourage a sense of Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 591 hopelessness.

ANS: A When the child reaches the terminal stage, the nurse and physician should explore the familys wishes. The family should help decide what interventions will occur as they plan for their childs death.

1. Examples of appropriate techniques to wake a sleepy infant for breastfeeding include: (Select all that apply.) a. unwrapping the infant. b. changing the diaper. c. talking to the infant. d. slapping the infant's hands and feet. e. applying a cold towel to the infant's abdomen.

ANS: A, B, C Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. Slapping the infant's hand and feet and applying a cold towel to the infant's abdomen are not appropriate. The parent can rub the infant's hands or feet to wake the infant. Applying a cold towel to the infant's abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant's face to wake the infant.

Many common drugs of abuse cause significant physiologic and behavioral problems in infants who are breastfed by mothers currently using (choose all that apply): a. Amphetamine. b. Heroin. c. Nicotine. d. PCP. e. Morphine.

ANS: A, B, C, D Amphetamine, heroin, nicotine, and PCP are contraindicated during breastfeeding because of the reported effects on the infant. Morphine is a medication that often is used to treat neonatal abstinence syndrome.

1. Pain should be assessed regularly in all newborn infants. If the infant is displaying physiologic or behavioral cues indicating pain, measures should be taken to manage the pain. Examples of nonpharmacologic pain management techniques include: (Select all that apply.) a. swaddling. b. nonnutritive sucking. c. skin-to-skin contact with the mother. d. sucrose. e. acetaminophen.

ANS: A, B, C, D Swaddling, nonnutritive sucking, skin-to-skin contact with the mother, and sucrose are all appropriate nonpharmacologic techniques used to manage pain in neonates. Acetaminophen is a pharmacologic method of treating pain.

2. A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. What signs and symptoms should the nurse include in her discussion? (Select all that apply.) a. Breast tenderness b. Warmth in the breast c. An area of redness on the breast often resembling the shape of a pie wedge d. A small white blister on the tip of the nipple e. Fever and flu-like symptoms

ANS: A, B, C, E Breast tenderness, breast warmth, breast redness, and fever and flu-like symptoms are commonly associated with mastitis and should be included in the nurse's discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis. It is commonly seen in women who have a plugged milk duct.

4. A nurse is performing an assessment on a school-age child. Which findings suggest the child is receiving an excess of vitamin A? (Select all that apply.) a. Delayed sexual development b. Edema c. Pruritus d. Jaundice e. Paresthesia

ANS: A, C, D Excess vitamin A can cause delayed sexual development, pruritus, and jaundice. Edema is seen with excess sodium. Paresthesia occurs with excess riboflavin.

Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from failure of the primary palate to fuse. Multiple genetic and to a lesser extent environmental factors may lead to the development of a cleft lip or palate. Such factors include (choose all that apply): a. Alcohol consumption. b. Female gender. c. Use of some antiepileptics. d. Maternal cigarette smoking. e. Antibiotic use in pregnancy.

ANS: A, C, D Factors that are associated with the potential development of cleft lip or palate are maternal infections, radiation exposure, corticosteroids, anticonvulsants, male gender, Native American or Asian descent, and smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate

2. Hearing loss is one of the genetic disorders included in the universal screening program. Auditory screening of all newborns within the first month of life is recommended by the American Academy of Pediatrics. Reasons for having this testing performed include: (Select all that apply.) a. prevention or reduction of developmental delay. b. reassurance for concerned new parents. c. early identification and treatment. d. helping the child communicate better. e. recommendation by the Joint Committee on Infant Hearing.

ANS: A, C, D, E New parents are often anxious regarding this test and the impending results; however, it is not the reason for the screening to be performed. Auditory screening is usually done before hospital discharge. It is important for the nurse to ensure that the infant receives the appropriate testing and that the test is fully explained to the parents. For infants who are referred for further testing and follow-up, it is important for the nurse to provide further explanation and emotional support. All other responses are appropriate reasons for auditory screening of the newborn. Infants who do not pass the screening test should have it repeated. If they still do not pass the test, they should have a full audiologic and medical evaluation by 3 months of age. If necessary, the infant should be enrolled in early intervention by 6 months of age.

2. Which data would be included in a health history? (Select all that apply.) a. Review of systems b. Physical assessment c. Sexual history d. Growth measurements e. Nutritional assessment f. Family medical history

ANS: A, C, E, F The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history. Physical assessment and growth measurements are components of the physical examination.

Which are appropriate statements the nurse should make to parents after the death of their child (select all that apply)? a. We feel so sorry that we couldnt save your child. b. Your child isnt suffering anymore. c. I know how you feel. d. Youre feeling all the pain of losing a child. e. You are still young enough to have another baby.

ANS: A, D By saying, We feel so sorry that we couldnt save your child, the nurse is expressing personal feeling of loss or frustration, which is therapeutic. Stating, Youre feeling all the pain of losing a child, focuses on a feeling, which is therapeutic. The statement, Your child isnt suffering anymore, is a judgmental statement, which is nontherapeutic. I know how you feel and Youre still young enough to have another baby are statements that give artificial consolation and are nontherapeutic.

27. Nurses play a critical role in educating parents regarding measures to prevent infant abduction. Which instructions contribute to infant safety and security? select all that apply a.The mother should check the photo ID of any person who comes to her room. b.The baby should be carried in the parent's arms from the room to the nursery. c. Because of infant security systems, the baby can be left unattended in the patient's room. d. Parents should use caution when posting photos of their infant on the Internet. e. The mom should request that a second staff member verify the identity of any questionable person.

ANS: A, D, E Nurses must discuss infant security precautions with the mother and her family because infant abduction continues to be a concern. The mother should be taught to check the identity of any person who comes to remove the baby from her room. Hospital personnel usually wear picture identification patches. On some units staff members also wear matching scrubs or special badges that are unique to the perinatal unit. As a rule the baby is never carried in arms between the mother's room and the nursery, but rather is always wheeled in a bassinet. The infant should never be left unattended, even if the facility has an infant security system. Parents should be instructed to use caution when posting photos of their new baby on the Internet and other public forums.

Which describe avoidance behaviors a parent may exhibit when learning that his or her child has a chronic condition (select all that apply)? a. Refuses to agree to treatment b. Shares burden of disorder with others c. Verbalizes possible loss of child d. Withdraws from outside world e. Punishes self because of guilt and shame

ANS: A, D, E A parent who refuses to agree to treatment, withdraws from the outside world, and punishes self because of guilt and shame is exhibiting avoidance coping behaviors. A parent who shares the burden of disorder with others and verbalizes possible loss of child is exhibiting approach coping behaviors.

5. A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.) a. Elicit one answer at a time. b. Interrupt the interpreter if the response from the family is lengthy. c. Comments to the interpreter about the family should be made in English. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family.

ANS: A, D, E When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English.

25. When caring for a newly delivered woman, the nurse is aware that the best measure to prevent abdominal distention after a cesarean birth is a.Rectal suppositories. b.Early and frequent ambulation. c.Tightening and relaxing abdominal muscles d. Carbonated beverages.

ANS: B Activity will aid the movement of accumulated gas in the gastrointestinal tract. Rectal suppositories can be helpful after distention occurs; however, they do not prevent it. Ambulation is the best prevention. Carbonated beverages may increase distention.

5. A woman gave birth 48 hours ago to a healthy infant girl. She has decided to bottle-feed. During your assessment you notice that both of her breasts are swollen, warm, and tender on palpation. The woman should be advised that this condition can best be treated by: a. Running warm water on her breasts during a shower. b. Applying ice to the breasts for comfort. c. Expressing small amounts of milk from the breasts to relieve pressure. d. Wearing a loose-fitting bra to prevent nipple irritation.

ANS: B Applying ice to the breasts for comfort is appropriate for treating engorgement in a mother who is bottle-feeding. This woman is experiencing engorgement, which can be treated by using ice packs (because she is not breastfeeding) and cabbage leaves. A bottle-feeding mother should avoid any breast stimulation, including pumping or expressing milk. A bottle-feeding mother should wear a well-fitted support bra or breast binder continuously for at least the first 72 hours after giving birth. A loose-fitting bra will not aid lactation suppression. Furthermore, the shifting of the bra against the breasts may stimulate the nipples and thereby stimulate lactation.

1. An adolescent patient appears reluctant to discuss sensitive issues with her parents present. What is the nurse's most appropriate intervention? a. Tell the patient that it is very important to be honest and specific. b. Provide time when the adolescent is alone with the nurse. c. Reassure the patient that anything said in the interview is considered confidential. d. Ask the parents to answer the questions if the patient is not willing to answer.

ANS: B Feedback A Although this statement is true, the adolescent should have time alone with the nurse, if needed, to answer or ask personal questions. B As children reach adolescence, they should be given the option to provide sensitive parts of the history without their parents present. C Although this statement is true, the adolescent should have time alone with the nurse, if needed, to answer or ask personal questions. D This intervention is not appropriate when the patient is present and able to answer questions. In addition, the parents may not know the information needed by the nurse about the adolescent.

The most common cause of pathologic hyperbilirubinemia is: a. Hepatic disease. c. Postmaturity. b. Hemolytic disorders in the newborn. d. Congenital heart defect.

ANS: B Hemolytic disorders in the newborn are the most common cause of pathologic jaundice. Hepatic damage may be a cause of pathologic hyperbilirubinemia, but it is not the most common cause. Prematurity would be a potential cause of pathologic hyperbilirubinemia in neonates, but it is not the most common cause. Congenital heart defect is not a common cause of pathologic hyperbilirubinemia in neonates.

6. Which assessment technique is appropriate to measure the 8-month-old's vital signs during a well-baby check? a. Assess temperature using a rectal thermometer. b. Observe the infant's abdomen when counting respirations. c. Take the infant from the parent's arms to assess pulse. d. Measure blood pressure in the leg.

ANS: B Feedback A Rectal temperatures should be taken as a last resort because children tend to fear intrusive procedures and because of the risk for rectal perforation. The recommended sites for temperature measurement in newborns, infants, and children to age 5 are the axillary or tympanic sites. B Infants usually breathe diaphragmatically, which requires observation of abdominal movement. C For the older infant ( 6 months) and toddler, the nurse may find that having the caregiver hold the baby or toddler decreases fear and distress, thus making it easier for the nurse to conduct the examination. D This infant is too young for blood pressure measurement. The National High Blood Pressure Education Program recommends that blood pressure be measured in children from age 3 through adolescence as part of routine health care visits.

The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: a.place her on a bedpan to empty her bladder. b.massage her fundus. c.call the physician. d.administer Methergine, 0.2 mg IM, which has been ordered prn.

ANS: B There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.

18. As relates to rubella and Rh issues, nurses should be aware that: a.Breastfeeding mothers cannot be vaccinated with the live attenuated rubella virus. b.omen should be warned that the rubella vaccination is teratogenic, and that they must avoid pregnancy for 1 month after vaccination. c.Rh immune globulin is safely administered intravenously because it cannot harm a nursing infant. d.Rh immune globulin boosts the immune system and thereby enhances the effectiveness of vaccinations.

ANS: B Women should understand they must practice contraception for 1 month after being vaccinated. Because the live attenuated rubella virus is not communicable in breast milk, breastfeeding mothers can be vaccinated. Rh immune globulin is administered intramuscularly; it should never be given to an infant. Rh immune globulin suppresses the immune system and therefore could thwart the rubella vaccination.

36. The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as: a. inappropriate, because of child's age. b. a way to establish rapport. c. too distracting, when cooperation is important. d. acceptable, if there is adequate time.

ANS: B A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic.

9. To prevent the abduction of newborns from the hospital, the nurse should: a. instruct the mother not to give her infant to anyone except the one nurse assigned to her that day. b. apply an electronic and identification bracelet to mother and infant. c. carry the infant when transporting him or her in the halls. d. restrict the amount of time infants are out of the nursery.

ANS: B A measure taken by many facilities is to band both the mother and the baby with matching identification bracelets and band the infant with an electronic device that will alarm if the infant is removed from the maternity unit. It is impossible for one nurse to be on call for one mother and baby for the entire shift, so parents need to be able to identify the nurses who are working on the unit. Infants should always be transported in their bassinette, for both safety and security reasons. All maternity unit nursing staff should have unique identification bracelets in comparison with the rest of the hospital. Infants should remain with their parents and spend as little time in the nursery as possible.

7. When the nurse interviews an adolescent, it is especially important to: a. focus the discussion on the peer group. b. allow an opportunity to express feelings. c. emphasize that confidentiality will always be maintained. d. use the same type of language as the adolescent.

ANS: B Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age-group, the focus of the interview should be on the adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently.

12. The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: a. ask her, "Are you sexually active?" b. ask her, "Are you having sex with anyone?" c. ask her, "Are you having sex with a boyfriend?" d. ask both the girl and her parent if she is sexually active.

ANS: B Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone.

28. To prevent nipple trauma, the nurse should instruct the new mother to: a. limit the feeding time to less than 5 minutes. b. position the infant so the nipple is far back in the mouth. c. assess the nipples before each feeding. d. wash the nipples daily with mild soap and water.

ANS: B If the infant's mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need. This will also limit access to the higher-fat "hindmilk." Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.

Kelly, age 8 years, will soon be able to return to school after an injury that resulted in several severe, chronic disabilities. What is the most appropriate action by the school nurse? a. Recommending that Kellys parents attend school at first to prevent teasing b. Preparing Kellys classmates and teachers for changes they can expect c. Referring Kelly to a school where the children have chronic disabilities similar to hers Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 583 d. Discussing with Kelly and her parents the fact that her classmates will not accept her as they did before

ANS: B Attendance at school is an important part of normalization for Kelly. The school nurse should prepare teachers and classmates about her condition, abilities, and special needs. A visit by the parents can be helpful, but unless the classmates are prepared for the changes, it alone will not prevent teasing. Kellys school experience should be normalized as much as possible. Children need the opportunity to interact with healthy peers and engage in activities with groups or clubs composed of similarly affected persons. Children with special needs are encouraged to maintain and reestablish relationships with peers and participate according to their capabilities.

Which best describes how preschoolers react to the death of a loved one? a. The preschooler is too young to have a concept of death. b. A preschooler is likely to feel guilty and responsible for the death. c. Grief is acute but does not last long at this age. d. Grief is usually expressed in the same way in which the adults in the preschoolers life are expressing grief.

ANS: B Because of egocentricity, the preschooler may feel guilty and responsible for the death. Preschoolers usually have some understanding of the meaning of death. Death is seen as a departure or some kind of sleep and they have no understanding of the permanence of death.

25. Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? a. 1 month b. 3 to 4 months c. 6 to 8 months d. 12 months

ANS: B Binocularity is usually achieved by ages 3 to 4 months. Age 1 month is too young for binocularity. If binocularity is not achieved by 6 months, the child must be observed for strabismus.

17. Which tool measures body fat most accurately? a. Stadiometer b. Calipers c. Cloth tape measure d. Paper or metal tape measure

ANS: B Calipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.

Which intervention will encourage a sense of autonomy in a toddler with disabilities? a. Avoiding separation from family during hospitalizations b. Encouraging independence in as many areas as possible c. Exposing child to pleasurable experiences as much as possible d. Helping parents learn special care needs of their child

ANS: B Encouraging the toddler to be independent encourages a sense of autonomy. The child can be given choices about feeding, dressing, and diversional activities, which will provide a sense of control. Avoiding separation from family during hospitalizations and helping parents learn special care needs of their child should be practiced as part of family-centered care. They do not particularly foster autonomy. Exposing the child to pleasurable experiences, especially sensory ones, is a supportive intervention. It does not particularly support autonomy.

Which intervention will encourage a sense of autonomy in a toddler with disabilities? a. Avoid separation from family during hospitalizations. b. Encourage independence in as many areas as possible. c. Expose child to pleasurable experiences as much as possible. d. Help parents learn special care needs of their child.

ANS: B Encouraging the toddler to be independent encourages a sense of autonomy. The child can be given choices about feeding, dressing, and diversional activities, which will provide a sense of control. Avoiding separation from family during hospitalizations, and helping parents learn special care needs of their child should be Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 589 practiced as part of family-centered care. It does not necessarily foster autonomy. Exposing the child to pleasurable experiences, especially sensory ones, is a supportive intervention. It does not promote autonomy.

An infant diagnosed with erythroblastosis fetalis would characteristically exhibit: a. Edema. c. Enlargement of the heart. b. Immature red blood cells. d. Ascites.

ANS: B Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema would occur with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces. The infant with hydrops fetalis displays signs of ascites.

Families progress through various stages of reactions when a child is diagnosed with a chronic illness or disability. After the shock phase, a period of adjustment usually follows. This is often characterized by: a. Denial. c. Social reintegration. b. Guilt and anger. d. Acceptance of childs limitations.

ANS: B For most families, the adjustment phase is accompanied by several responses that are normally part of the adjustment process. Guilt, self-accusation, bitterness, and anger are common reactions. The initial diagnosis of a chronic illness or disability often is often met with intense emotion and characterized by shock and denial. Social reintegration and acceptance of the childs limitations is the culmination of the adjustment process.

With regard to the classification of neonatal bacterial infection, nurses should be aware that: a. Congenital infection progresses slower than nosocomial infection. b. Nosocomial infection can be prevented by effective handwashing; early-onset infections cannot. c. Infections occur with about the same frequency in boy and girl infants, although female mortality is higher. d. The clinical sign of a rapid, high fever makes infection easier to diagnose.

ANS: B Handwashing is an effective preventive measure for late-onset (nosocomial) infections because these infections come from the environment around the infant. Early-onset, or congenital, infections are caused by the normal flora at the maternal vaginal tract and progress more rapidly than nosocomial (late-onset) infections. Infection occurs about twice as often in boys and results in higher mortality. Clinical signs of neonatal infection are nonspecific and similar to noninfectious problems, making diagnosis difficult.

20. The breastfeeding mother should be taught a safe method to remove the breast from the baby's mouth. Which suggestion by the nurse is most appropriate? a. Slowly remove the breast from the baby's mouth when the infant has fallen asleep and the jaws are relaxed. b. Break the suction by inserting your finger into the corner of the infant's mouth. c. A popping sound occurs when the breast is correctly removed from the infant's mouth. d. Elicit the Moro reflex to wake the baby and remove the breast when the baby cries.

ANS: B Inserting a finger into the corner of the baby's mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in "chewing" on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the baby's mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.

2. A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. The nurse can explain to him that beginning solid foods before 4 to 6 months may: a. decrease the infant's intake of sufficient calories. b. lead to early cessation of breastfeeding. c. help the infant sleep through the night. d. limit the infant's growth.

ANS: B Introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. It is not true that feeding of solids helps infants sleep through the night. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.

10. The nurse's initial action when caring for an infant with a slightly decreased temperature is to: a. notify the physician immediately. b. place a cap on the infant's head. c. tell the mother that the infant must be kept in the nursery and observed for the next 4 hours. d. change the formula because this is a sign of formula intolerance.

ANS: B Keeping the head well covered with a cap will prevent further heat loss from the head, and having the mother place the infant skin to skin should increase the infant's temperature. Nursing actions are needed first to correct the problem. If the problem persists after interventions, notification may then be necessary. A slightly decreased temperature can be treated in the mother's room. This would be an excellent time for parent teaching on prevention of cold stress. Mild temperature instability is an expected deviation from normal during the first days as the infant adapts to external life.

With regard to the understanding and treatment of infants born to mothers who are substance abusers, nurses should be aware that: a. Infants born to addicted mothers are also addicted. b. Mothers who abuse one substance likely will use or abuse another, compounding the infant's difficulties. c. The NICU Network Neurobehavioral Scale (NNNS) is designed to assess the damage the mother has done to herself. d. No laboratory procedures are available that can identify the intrauterine drug exposure of the infant.

ANS: B Multiple substance use (even just alcohol and tobacco) makes it difficult to assess the problems of the exposed infant, particularly with regard to withdrawal manifestations. Infants of substance-abusing mothers may have some of the physiologic signs but are not addicted in the behavioral sense. "Drug-exposed newborn" is a more accurate description than "addict." The NNNS is designed to assess the neurologic, behavioral, and stress/abstinence function of the neonate. Newborn urine, hair, or meconium sampling may be used to identify an infant's intrauterine drug exposure.

Which represents a common best practice in the provision of services to children with chronic or complex conditions? a. Care is focused on the childs chronologic age. b. Children with complex conditions are integrated into regular classrooms. c. Disabled children are less likely to be cared for by their families. d. Children with complex conditions are placed in residential treatment facilities.

ANS: B Normalization refers to behaviors and interventions for people with disabilities to integrate into society by living life as people without a disability would. For children, normalization includes attending school and being integrated into regular classrooms. This affords the child the advantages of learning with a wide group of peers. Care is necessarily focused on the childs developmental age. Home care by the family is considered best practice. The nurse can assist families by assessing social support systems, coping strategies, family cohesiveness, and family and community resources.

A nurse is planning palliative care for a child with severe pain. Which should the nurse expect to be prescribed for pain relief? a. Opioids as needed c. Distraction and relaxation techniques b. Opioids on a regular schedule d. Nonsteroidal antiinflammatory drugs

ANS: B Pain medications for children in palliative care should be given on a regular schedule, and extra doses for breakthrough pain should be available to maintain comfort. Opioid drugs such as morphine should be given for severe pain, and the dose should be increased as necessary to maintain optimal pain relief. Techniques such as distraction, relaxation techniques, and guided imagery should be combined with drug therapy to provide the child and family strategies to control pain. Nonsteroidal

The nurse comes into the room of a child who was just diagnosed with a chronic disability. The childs parents begin to yell at the nurse about a variety of concerns. The nurses best response is: a. What is really wrong? Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 579 b. Being angry is only natural. c. Yelling at me will not change things. d. I will come back when you settle down.

ANS: B Parental anger after the diagnosis of a child with a chronic disability is a common response. One of the most common targets for parental anger is members of the staff. The nurse should recognize the common response of anger to the diagnosis and allow the family to ventilate. What is really wrong? Yelling at me will not change things, and I will come back when you settle down are all possible responses, but they are not the likely reasons for this anger.

Excessive blood loss after childbirth can have several causes; however, the most common is: a.vaginal or vulvar hematomas. b.unrepaired lacerations of the vagina or cervix. c.failure of the uterine muscle to contract firmly. d.retained placental fragments

ANS: C Although vaginal or vulvar hematomas are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Although unrepaired lacerations are a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause. Uterine atony can best be thwarted by maintaining good uterine tone and preventing bladder distention. Although retained placental fragments is a possible cause of excessive blood loss, uterine muscle failure (uterine atony) is the most common cause

Lindsey, age 5 years, will be starting kindergarten next month. She has cerebral palsy, and it has been determined that she needs to be in a special education classroom. Her parents are tearful when telling the nurse about this and state that they did not realize that her disability was so severe. The best interpretation of this situation is that: a. This is a sign that parents are in denial. b. This is a normal anticipated time of parental stress. c. The parents need to learn more about cerebral palsy. d. The parents are used to having expectations that are too high.

ANS: B Parenting a child with a chronic illness can be very stressful for parents. There are anticipated times that parental stress increases. One of these identified times is when the child begins school. Nurses can help parents recognize and plan interventions to work through these stressful periods. The parents are not in denial; they are responding to the childs placement in school. The parents are not exhibiting signs of a knowledge deficit or expectations that are too high; this is their first interaction with the school system with this child.

The feeling of guilt that the child caused the disability or illness is especially critical in which child? a. Toddler c. School-age child b. Preschooler d. Adolescent

ANS: B Preschoolers are most likely to be affected by feelings of guilt that they caused the illness/disability or are being punished for wrongdoings. Toddlers are focused on establishing their autonomy. The illness will foster dependency. The school-age child will have limited opportunities for achievement and may not be able to understand limitations. Adolescents are faced with the task of incorporating their disabilities into their changing self-concept.

24. The hormone necessary for milk production is: a. estrogen. b. prolactin. c. progesterone. d. lactogen.

ANS: B Prolactin, secreted by the anterior pituitary, is a hormone that causes the breasts to produce milk. Estrogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Progesterone decreases the effectiveness of prolactin and prevents mature breast milk from being produced. Human placental lactogen decreases the effectiveness of prolactin and prevents mature breast milk from being produced.

19. The earliest age at which a satisfactory radial pulse can be taken in children is: a. 1 year. b. 2 years. c. 3 years. d. 6 years.

ANS: B Satisfactory radial pulses can be used in children older than 2 years. In infants and young children the apical pulse is more reliable. The radial pulse can be used for assessment at ages 3 and 6 years.

1. A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until her infant is crying frantically. On the basis of this information, this woman should feed her infant about every 2.5 to 3 hours when she: a. waves her arms in the air. b. makes sucking motions. c. has hiccups. d. stretches her legs out straight.

ANS: B Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding-readiness cues. Waving the arms in the air, hiccupping, and stretching the legs out straight are not typical feeding-readiness cues.

8. The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined? a. Ask for a detailed listing of symptoms. b. Ask the adolescent, "Why did you come here today?" c. Use what the adolescent says to determine, in correct medical terminology, what the problem is. d. Interview the parent away from the adolescent to determine the chief complaint.

ANS: B The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A listing of symptoms will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him or her to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time.

At the time of a childs death, the nurse tells his mother, We will miss him so much. The best interpretation of this is that the nurse is: a. Pretending to be experiencing grief. b. Expressing personal feelings of loss. c. Denying the mothers sense of loss. d. Talking when listening would be better.

ANS: B The death of a patient is one of the most stressful aspects of a critical care or oncology nurse. Nurses experience reactions similar to those of family members because of their involvement with the child and family during the illness. Nurses often have feelings of personal loss when a patient dies. The nurse is experiencing a normal grief response to the death of a patient. There is no implication that the mothers loss is minimized. The nurse is validating the worth of the child.

35. Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for: a. deep tendon reflexes. b. cerebellar function. c. sensory discrimination. d. ability to follow directions.

ANS: B The finger-to-nose-test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Each sense is tested separately. Although this test enables the nurse to evaluate the child's ability to follow directions, it is used primarily for cerebellar function.

14. During the complete physical examination 24 hours after birth: a. the parents are excused to reduce their normal anxiety. b. the nurse can gauge the neonate's maturity level by assessing the infant's general appearance. c. once often neglected, blood pressure is now routinely checked. d. when the nurse listens to the heart, the S1 and S2 sounds can be heard; the first sound is somewhat higher in pitch and sharper than the second.

ANS: B The nurse will be looking at skin color, alertness, cry, head size, and other features. The parents' presence actively involves them in child care and gives the nurse a chance to observe interactions. Blood pressure is not usually taken unless cardiac problems are suspected. The second sound is higher and sharper than the first.

18. The process whereby parents awaken the infant to feed every 3 hours during the day and at least every 4 hours at night is: a. known as demand feeding. b. necessary during the first 24 to 48 hours after birth. c. used to set up the supply-meets-demand system. d. a way to control cluster feeding.

ANS: B The parents do this to make sure that the infant has at least eight feedings in 24 hours. Demand feeding is when the infant determines the frequency of feedings; this is appropriate once the infant is feeding well and gaining weight. The supply-meets-demand system is a milk production system that occurs naturally. Cluster feeding is not a problem if the baby has eight feedings in 24 hours.

Approach behaviors are coping mechanisms that result in a familys movement toward adjustment and resolution of the crisis of having a child with a chronic illness or disability. What is considered an approach behavior in parents? a. Are unable to adjust to a progression of the disease or condition b. Anticipate future problems and seek guidance and answers c. Look for new cures without a perspective toward possible benefit d. Fail to recognize seriousness of childs condition despite physical evidence

ANS: B The parents who anticipate future problems and seek guidance and answers are demonstrating approach behaviors. They are demonstrating positive actions in caring for their child. Avoidance behaviors include being unable to adjust to a progression of the disease or condition, looking for new cures without a perspective toward possible benefit, and failing to recognize the seriousness of the childs condition despite physical evidence. These behaviors would suggest that the parents are moving away from adjustment or adaptation in the crisis of a child with chronic illness or disability.

The nurse and a new nurse are caring for a child who will require palliative care. Which statement made by the new nurse would indicate a correct understanding of palliative care? a. Palliative care serves to hasten death and make the process easier for the family. b. Palliative care provides pain and symptom management for the child. c. The goal of palliative care is to place the child in a hospice setting at the end of life. d. The goal of palliative care is to act as the liaison between the family, child, and other health care professionals.

ANS: B The primary goal of palliative care is to provide pain and symptom management, not to hasten death or place the child in a hospice setting. Palliative care is provided by a multidisciplinary team whose goal it is to provide active total care for patients whose disease is no longer responding to curative treatment.

2. A new father wants to know what medication was put into his infant's eyes and why it is needed. The nurse explains to the father that the purpose of the erythromycin ophthalmic ointment is to: a. destroy an infectious exudate caused by Staphylococcus that could make the infant blind. b. prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. c. prevent potentially harmful exudate from invading the tear ducts of the infant's eyes, leading to dry eyes. d. prevent the infant's eyelids from sticking together and help the infant see.

ANS: B The purpose of the erythromycin ophthalmic ointment is to prevent gonorrheal and chlamydial infection of the infant's eyes potentially acquired from the birth canal. Prophylactic ophthalmic ointment is instilled in the eyes of all neonates to prevent gonorrheal or chlamydial infection. Prophylactic ophthalmic ointment is not instilled to prevent dry eyes. Prophylactic ophthalmic ointment has no bearing on vision other than to protect against infection that may lead to vision problems.

28. The appropriate placement of a tongue blade for assessment of the mouth and throat is the: a. the center back area of the tongue. b. the side of the tongue. c. against the soft palate. d. on the lower jaw.

ANS: B The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement on the center back area of the tongue elicits the gag reflex. Against the soft palate and on the lower jaw are not appropriate places for the tongue blade.

4. What is an important consideration for the nurse who is communicating with a very young child? a. Speak loudly, clearly, and directly. b. Use transition objects such as a doll. c. Disguise own feelings, attitudes, and anxiety. d. Initiate contact with the child when the parent is not present.

ANS: B Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This facilitates communication with this age child. Speaking loudly, clearly, and directly tends to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children.

12. The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would be inaccurate and provide conflicting information to the patient? a. Women who breastfeed have a decreased risk of breast cancer. b. Breastfeeding is an effective method of birth control. c. Breastfeeding increases bone density. d. Breastfeeding may enhance after birth weight loss.

ANS: B Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of quicker after birth weight loss. Breastfeeding delays the return of fertility; however, it is not an effective birth control method.

With regard to skeletal injuries sustained by a neonate during labor or birth, nurses should be aware that: a. A newborn's skull is still forming and fractures fairly easily. b. Unless a blood vessel is involved, linear skull fractures heal without special treatment. c. Clavicle fractures often need to be set with an inserted pin for stability. d. Other than the skull, the most common skeletal injuries are to leg bones.

ANS: B About 70% of neonatal skull fractures are linear. Because the newborn skull is flexible, considerable force is required to fracture it. Clavicle fractures need no special treatment. The clavicle is the bone most often fractured during birth.

1. The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply) a. The cuff is labeled "toddler." b. The cuff bladder width is approximately 40% of the circumference of the upper arm. c. The cuff bladder length covers 80% to 100% of the circumference of the upper arm. d. The cuff bladder covers 50% to 66% of the length of the upper arm.

ANS: B, C Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. This size cuff will most accurately reflect measured radial artery pressure. The name of the cuff is a representative size that may not be suitable for any individual child. Choosing a cuff by limb circumference more accurately reflects arterial pressure than choosing a cuff by length.

1. An infant boy was born just a few minutes ago. The nurse is conducting the initial assessment. Part of the assessment includes the Apgar score. The Apgar assessment is performed: a. only if the newborn is in obvious distress. b. once by the obstetrician, just after the birth. c. at least twice, 1 minute and 5 minutes after birth. d. every 15 minutes during the newborn's first hour after birth.

ANS: C Apgar scoring is performed at 1 minute and 5 minutes after birth. Scoring may continue at 5-minute intervals if the infant is in distress and requires resuscitation efforts

3. Late in pregnancy, the woman's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include: (Select all that apply.) a. everted nipples. b. flat nipples. c. inverted nipples. d. nipples that contract when compressed. e. cracked nipples.

ANS: B, C, D Flat nipples appear soft, like the areola, and do not stand erect unless stimulated by rolling them between the fingers. Inverted nipples are retracted into the breast tissue. These nipples appear normal; however, they will draw inward when the areola is compressed by the infant's mouth. Dome-shaped devices known as breast shells can be worn during the last weeks of pregnancy and between feedings after birth. The shells are placed inside the bra with the opening over the nipple. The shells exert slight pressure against the areola to help the nipples protrude. The helpfulness of breast shells is debated. A breast pump can be used to draw the nipples out before feedings after delivery. Everted nipples protrude and are normal. No intervention will be required. Cracked, blistered, and bleeding nipples occur after breastfeeding has been initiated and are the result of improper latch. The infant should be repositioned during feeding. Application of colostrum and breast milk after feedings will aid in healing.

3. A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply.) a. Complaints of a sore back b. Asymmetry of the shoulders c. An uneven hemline d. Inability to bend at the waist e. Unequal waist angles

ANS: B, C, E The assessment findings associated with scoliosis include asymmetry of the shoulder and hips, trouser pant leg length appearing shorter on one side, or an uneven hemline on a skirt, indicating unequal leg length. The child may also complain of a sore back. The child is able to bend at the waist adequately.

A nurse is caring for a child who is near death. Which physical signs indicate the child is approaching death (select all that apply)? a. Body feels warm b. Tactile sensation decreasing c. Speech becomes rapid d. Change in respiratory pattern e. Difficulty swallowing

ANS: B, D, E Physical signs of approaching death include tactile sensation beginning to decrease, a change in respiratory pattern, and difficulty swallowing. Even though there is a sensation of heat, the body feels cool, not warm, and speech becomes slurred, not rapid.

When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: a.massage the fundus. b.administer Methergine, 0.2 mg PO, that has been ordered prn. c.assist the woman to empty her bladder. d.recognize this as an expected finding during the first 24 hours following birth.

ANS: C A firm fundus should not be massaged since massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case since it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. This is not a normal finding, and an action is required.

A postpartum woman overhears the nurse tell the obstetrics clinician that she has a positive Homans sign and asks what it means. The nurse's best response is: a. "You have pitting edema in your ankles." b. "You have deep tendon reflexes rated 2+." c. "You have calf pain when the nurse flexes your foot." d. "You have a 'fleshy' odor to your vaginal drainage."

ANS: C Discomfort in the calf with sharp dorsiflexion of the foot may indicate deep vein thrombosis. Edema is within normal limits for the first few days until the excess interstitial fluid is remobilized and excreted. Deep tendon reflexes should be 1+ to 2+. A "fleshy" odor, not a foul odor, is within normal limits.

3. In taking a history from an adolescent girl about diet and nutrition, a nurse specifically asks which question? a. "How frequently do you eat fast food or junk food?" b. "Which carbonated drinks do you drink most often?" c. "Do you have any food restrictions or diet routines?" d. "What are your favorite fruits and vegetables?"

ANS: C Feedback A Asking the frequency of fast food or junk food consumption does not give data about what food is eaten. B Knowing the amount of carbonated drinks provides more useful data. C Adolescents should be asked specifically about their perception of their current weight and behaviors associated with eating disorders, including food restrictions, extreme diet/exercise routines, binging or purging, and the use of laxatives to screen for eating disorders. D Knowing how frequently these foods are eaten provides more useful data.

20. A recently delivered mother and her baby are at the clinic for a 6-week postpartum checkup. The nurse should be concerned that psychosocial outcomes are not being met if the woman: a.Discusses her labor and birth experience excessively. b.Believes that her baby is more attractive and clever than any others. c.Has not given the baby a name. d. Has a partner or family members who react very positively about the baby.

ANS: C If the mother is having difficulty naming her new infant, it may be a signal that she is not adapting well to parenthood. Other red flags include refusal to hold or feed the baby, lack of interaction with the infant, and becoming upset when the baby vomits or needs a diaper change. A new mother who is having difficulty would be unwilling to discuss her labor and birth experience. An appropriate nursing diagnosis could be Impaired parenting related to a long, difficult labor or unmet expectations of birth. A mother who is willing to discuss her birth experience is making a healthy personal adjustment. The mother who is not coping well would find her baby unattractive and messy. She may also be overly disappointed in the baby's sex. The client may voice concern that the baby reminds her of a family member whom she does not like. Having a partner and/or other family members react positively is an indication that this new mother has a good support system in place. This support system will help reduce anxiety related to her new role as a mother.

22. Postpartal overdistention of the bladder and urinary retention can lead to which complications a.Postpartum hemorrhage and eclampsia b.Fever and increased blood pressure c.Postpartum hemorrhage and urinary tract infection d.Urinary tract infection and uterine rupture

ANS: C Incomplete emptying and overdistention of the bladder can lead to urinary tract infection. Overdistention of the bladder displaces the uterus and prevents contraction of the uterine muscle, thus leading to postpartum hemorrhage. There is no correlation between bladder distention and high blood pressure or eclampsia. The risk of uterine rupture decreases after the birth of the infant.

Providing care for the neonate born to a mother who abuses substances can present a challenge for the health care team. Nursing care for this infant requires a multisystem approach. The first step in the provision of this care is: a. Pharmacologic treatment. b. Reduction of environmental stimuli. c. Neonatal abstinence syndrome scoring. d. Adequate nutrition and maintenance of fluid and electrolyte balance.

ANS: C Neonatal abstinence syndrome (NAS) is the term used to describe the cohort of symptoms associated with drug withdrawal in the neonate. The Neonatal Abstinence Scoring System evaluates CNS, metabolic, vasomotor, respiratory, and gastrointestinal disturbances. This evaluation tool enables the care team to develop an appropriate plan of care. The infant is scored throughout the length of stay, and the treatment plan is adjusted accordingly. Pharmacologic treatment is based on the severity of withdrawal symptoms. Symptoms are determined by using a standard assessment tool. Medications of choice are morphine, phenobarbital, diazepam, or diluted tincture of opium. Swaddling, holding, and reducing environmental stimuli are essential in providing care to the infant who is experiencing withdrawal. These nursing interventions are appropriate for the infant who displays central nervous system (CNS) disturbances. Poor feeding is one of the gastrointestinal symptoms common to this client population. Fluid and electrolyte balance must be maintained, and adequate nutrition provided. These infants often have a poor suck reflex and may need to be fed via gavage.

17. If a woman is at risk for thrombus and is not ready to ambulate, nurses may intervene by performing a number of interventions. Which intervention should the nurse avoid?' a.Putting the patient in antiembolic stockings (TED hose) and/or sequential compression device (SCD) boots. b.Having the patient flex, extend, and rotate her feet, ankles, and legs. c.Having the patient sit in a chair. d.Notifying the physician immediately if a positive Homans' sign occurs.

ANS: C Sitting immobile in a chair will not help. Bed exercise and prophylactic footwear may. TED hose and SCD boots are recommended. Bed exercises, such as flexing, extending, and rotating her feet, ankles, and legs, are useful. A positive Homans' sign (calf muscle pain or warmth, redness, or tenderness) requires the physician's immediate attention.

11. Under the Newborns' and Mothers' Health Protection Act, all health plans are required to allow new mothers and newborns to remain in the hospital for a minimum of _____ hours after a normal vaginal birth and for _____ hours after a cesarean birth. a. 24, 73 b. 24, 96 c. 48, 96 d. 48, 120

ANS: C The specified stays are 48 hours (2 days) for a vaginal birth and 96 hours (4 days) for a cesarean birth. The attending provider and the mother together can decide on an earlier discharge.

A primigravida has just delivered a healthy infant girl. The nurse is about to administer erythromycin ointment in the infant's eyes when the mother asks, "What is that medicine for?" The nurse responds: a. "It is an eye ointment to help your baby see you better." b. "It is to protect your baby from contracting herpes from your vaginal tract." c. "Erythromycin is given prophylactically to prevent a gonorrheal infection." d. "This medicine will protect your baby's eyes from drying out over the next few days."

ANS: C With the prophylactic use of erythromycin, the incidence of gonococcal conjunctivitis has declined to less than 0.5%. Eye prophylaxis is administered at or shortly after birth to prevent ophthalmia neonatorum. Erythromycin has no bearing on enhancing vision, is used to prevent an infection caused by gonorrhea, not herpes, and is not used for eye lubrication.

The nurse case manager is planning a care conference about a young child who has complex health care needs and will soon be discharged home. Whom should the nurse invite to the conference? a. Family and nursing staff b. Social worker, nursing staff, and primary care physician c. Family and key health professionals involved in childs care d. Primary care physician and key health professionals involved in childs care

ANS: C A multidisciplinary conference is necessary for coordination of care for children with complex health needs. The family and key health professionals who are involved in the childs care are included. The nursing staff can address the nursing care needs of the child with the family, but other involved disciplines must be included. The family must be included in the discharge conferences, which allow them to determine what education they will require and the resources needed at home. A member of the nursing staff must be included to review the nursing needs of the child.

With regard to central nervous system injuries to the infant during labor and birth, nurses should be aware that: a. Intracranial hemorrhage (ICH) as a result of birth trauma is more likely to occur in the preterm, low-birth-weight infant. b. Subarachnoid hemorrhage (the most common form of ICH) occurs in term infants as a result of hypoxia. c. In many infants signs of hemorrhage in a full-term infant are absent and diagnosed only through laboratory tests. d. Spinal cord injuries almost always result from forceps-assisted deliveries.

ANS: C Abnormalities in lumbar punctures or red blood cell counts, for instance, or in visuals on computed tomography scan might reveal a hemorrhage. ICH as a result of birth trauma is more likely to occur in the full-term, large infant. Subarachnoid hemorrhage in term infants is a result of trauma; in preterm infants it is a result of hypoxia. Spinal cord injuries are almost always from breech births; they are rare today because cesarean birth often is used for breech presentation

13. While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the patient accordingly. Which statement as part of this discussion would be incorrect? a. Breastfeeding requires fewer supplies and less cumbersome equipment. b. Breastfeeding saves families money. c. Breastfeeding costs employers in terms of time lost from work. d. Breastfeeding benefits the environment.

ANS: C Actually less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.

Which measure would be least effective in preventing postpartum hemorrhage? a.Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered b.Encourage the woman to void every 2 hours c.Massage the fundus every hour for the first 24 hours following birth d.Teach the woman the importance of rest and nutrition to enhance healing

ANS: C Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage

1. A 25-year-old gravida 2, para 2-0-0-2 gave birth 4 hours ago to a 9-pound, 7-ounce boy after augmentation of labor with Pitocin. She puts on her call light and asks for her nurse right away, stating, "I'm bleeding a lot." The most likely cause of postpartum hemorrhage in this woman is: a.Retained placental fragments. b.Unrepaired vaginal lacerations. c.Uterine atony. d Puerperal infection.

ANS: C Atony of the uterus, also called uterine atony, is a serious condition that can occur after childbirth. It occurs when the uterus fails to contract after the delivery of the baby, and it can lead to a potentially life-threatening condition known as postpartum hemorrhage This woman gave birth to a macrosomic boy after Pitocin augmentation. The most likely cause of bleeding 4 hours after delivery, combined with these risk factors, is uterine atony. Although retained placental fragments may cause postpartum hemorrhage, this typically would be detected in the first hour after delivery of the placenta and is not the most likely cause of hemorrhage in this woman. Although unrepaired vaginal lacerations may cause bleeding, they typically would occur in the period immediately after birth. Puerperal infection can cause subinvolution and subsequent bleeding; however, this typically would be detected 24 hours after delivery.

20. The nurse administers vitamin K to the newborn for which reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant's being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

ANS: C Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. Vitamin K is provided because the newborn does not have the intestinal flora to produce this vitamin for the first week. The maternal diet has no bearing on the amount of vitamin K found in the newborn. Vitamin K promotes the formation of clotting factors in the liver and is used for the prevention and treatment of hemorrhagic disease in the newborn. Vitamin K is not produced in the intestinal tract of the newborn until after microorganisms are introduced. By day 8, normal newborns are able to produce their own vitamin K.

26. As the nurse assists a new mother with breastfeeding, the patient asks, "If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?" The nurse's best response is that it contains: a. more calories. b. essential amino acids. c. important immunoglobulins. d. more calcium.

ANS: C Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is about the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk. This higher level can cause an excessively high renal solute load if the formula is not diluted properly.

At what age do most children have an adult concept of death as being inevitable, universal, and irreversible? a. 4 to 5 years c. 9 to 11 years b. 6 to 8 years d. 12 to 16 years

ANS: C By age 9 or 10 years, children have an adult concept of death. They realize that it is inevitable, universal, and irreversible. Preschoolers and young school-age children are too young to have an adult concept of death. Adolescents have a mature understanding of death.

16. With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight? a. 10th percentile b. 9th percentile c. 85th percentile d. 95th percentile

ANS: C Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight.

6. A mother expresses fear about changing her infant's diaper after he is circumcised. What does the woman need to be taught to take care of the infant when she gets home? a. Cleanse the penis with prepackaged diaper wipes every 3 to 4 hours. b. Apply constant, firm pressure by squeezing the penis with the fingers for at least 5 minutes if bleeding occurs. c. Cleanse the penis gently with water and put petroleum jelly around the glans after each diaper change. d. Wash off the yellow exudate that forms on the glans at least once every day to prevent infection.

ANS: C Cleansing the penis gently with water and putting petroleum jelly around the glans after each diaper change are appropriate when caring for an infant who has had a circumcision. With each diaper change, the penis should be washed off with warm water to remove any urine or feces. If bleeding occurs, the nurse should apply gentle pressure to the site of the bleeding with a sterile gauze square. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The exudates should not be removed.

2. Which action is most likely to encourage parents to talk about their feelings related to their child's illness? a. Be sympathetic. b. Use direct questions. c. Use open-ended questions. d. Avoid periods of silence.

ANS: C Closed-ended questions should be avoided when attempting to elicit parents' feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.

23. How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day? a. 50 to 65 b. 75 to 90 c. 95 to 110 d. 150 to 200

ANS: C For the first 3 months the infant needs 110 kcal/kg/day. At ages 3 to 6 months the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.

9. As part of Standard Precautions, nurses wear gloves when handling the newborn. The chief reason is: a. to protect the baby from infection. b. that it is part of the Apgar protocol. c. to protect the nurse from contamination by the newborn. d. the nurse has primary responsibility for the baby during the first 2 hours.

ANS: C Gloves are worn to protect the nurse from infection until the blood and amniotic fluid are cleaned off the newborn.

15. With regard to the nutrient needs of breastfed and formula-fed infants, nurses should understand that: a. breastfed infants need extra water in hot climates. b. during the first 3 months breastfed infants consume more energy than do formula-fed infants. c. breastfeeding infants should receive oral vitamin D drops daily at least during the first 2 months. d. vitamin K injections at birth are not needed for infants fed on specially enriched formula.

ANS: C Human milk contains only small amounts of vitamin D. Neither breastfed nor formula-fed infants need to be given water, even in very hot climates. During the first 3 months formula-fed infants consume more energy than do breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the baby's stomach at birth.

15. As related to laboratory tests and diagnostic tests in the hospital after birth, nurses should be aware that: a. all states test for phenylketonuria (PKU), hypothyroidism, cystic fibrosis, and sickle cell diseases. b. federal law prohibits newborn genetic testing without parental consent. c. if genetic screening is done before the infant is 24 hours old, it should be repeated at age 1 to 2 weeks. d. hearing screening is now mandated by federal law.

ANS: C If done very early, genetic screening should be repeated. States all test for PKU and hypothyroidism, but other genetic defects are not universally covered. Federal law mandates newborn genetic screening, but not screening for hearing problems (although more than half the states do mandate hearing screening).

11. When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are: a. unnecessary information because the child is age 3 years. b. an important part of the family history. c. an important part of the child's past growth and development. d. an important part of the child's review of systems.

ANS: C Information about the attainment of developmental milestones is important to obtain. It provides data about the child's growth and development that should be included in the history. Developmental milestones provide important information about the child's physical, social, and neurologic health. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones.

19. With regard to basic care of the breastfeeding mother, nurses should be able to advise her that she: a. will need an extra 1000 calories a day to maintain energy and produce milk. b. can go back to prepregnancy consumption patterns of any drinks, as long as she ingests enough calcium. c. should avoid trying to lose large amounts of weight. d. must avoid exercising because it is too fatiguing.

ANS: C Large weight loss would release fat-stored contaminants into her breast milk. It would also likely involve eating too little and/or exercising too much. A breastfeeding mother need add only 200 to 500 extra calories to her diet to provide extra nutrients for the infant. The mother can go back to her consumption patterns of any drinks as long as she ingests enough calcium, only if she does not drink alcohol, limits coffee to no more than two cups (caffeine in chocolate, tea, and some sodas), and reads the herbal tea ingredients carefully. The mother needs her rest, but moderate exercise is healthy.

8. A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she: a. adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition. b. warms the bottles using a microwave oven. c. burps her infant during and after the feeding as needed. d. refrigerates any leftover formula for the next feeding.

ANS: C Most infants swallow air when fed from a bottle and should be given a chance to burp several times during a feeding and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, and this may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infant's saliva has mixed with it.

32. What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? a. S1, S2 b. S3, S4 c. Murmur d. Physiologic splitting

ANS: C Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves, and both are considered normal heart sounds. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.

25. To initiate the milk ejection reflex (MER), the mother should be advised to: a. wear a firm-fitting bra. b. drink plenty of fluids. c. place the infant to the breast. d. apply cool packs to her breast.

ANS: C Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but this alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.

15. An appropriate approach to performing a physical assessment on a toddler is to: a. always proceed in a head-to-toe direction. b. perform traumatic procedures first. c. use minimal physical contact initially. d. demonstrate use of equipment.

ANS: C Parents can remove the child's clothing, and the child can remain on the parent's lap. The nurse should use minimal physical contact initially to gain the child's cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age-group.

20. Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles

ANS: C Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.

22. Which type of formula is not diluted before being administered to an infant? a. Powdered b. Concentrated c. Ready-to-use d. Modified cow's milk

ANS: C Ready-to-use formula can be poured directly from the can into baby's bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cow's milk is more difficult for the infant to digest and is not recommended, even if it is diluted.

A 16-year-old boy with a chronic illness has recently become rebellious and is taking risks such as missing doses of his medication. The nurse should explain to his parents that: a. He needs more discipline. b. He needs more socialization with peers. c. This is part of normal adolescence. d. This is how he is asking for more parental control.

ANS: C Risk taking, rebelliousness, and lack of cooperation are normal parts of adolescence. If the parents increase the amount of discipline, he will most likely be more rebellious. Socialization with peers should be encouraged as a part of adolescence. It is a normal part of adolescence during which the young adult is establishing independence.

Which age-group is most concerned with body integrity? a. Toddler b. Preschooler c. School-age child d. Adolescent

ANS: C School-age children have a heightened concern about body integrity. They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggestion of injury. Body integrity is not as important a concern to children in the toddler, preschooler, and adolescent age-groups.

6. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: a. ask her why she wants to know. b. determine why she is so anxious. c. explain in simple terms how it works. d. tell her she will see how it works as it is used.

ANS: C School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. A nurse should respond positively to requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification of what will be occurring. The nurse must explain how the blood pressure cuff works so the child can then observe during the procedure.

37. During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? a. Teach the parents appropriate exercises. b. Recheck head control at the next visit. c. Refer the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open.

ANS: C Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.

In caring for the mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: a. The pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. Two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. Alcohol-related neurodevelopmental disorders not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. d. Both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.

ANS: C Some learning problems do not become evident until the child is at school. The pattern of growth restriction persists after birth. Two thirds of newborns with FAS are girls. Although the distinctive facial features of the FAS infant tend to become less evident, the mental capacities never become normal.

13. In the classification of newborns by gestational age and birth weight, the appropriate for gestational age (AGA) weight would: a. fall between the 25th and 75th percentiles for the infant's age. b. depend on the infant's length and the size of the head. c. fall between the 10th and 90th percentiles for the infant's age. d. be modified to consider intrauterine growth restriction (IUGR).

ANS: C The AGA range is large: between the 10th and the 90th percentiles for the infant's age. The infant's length and size of the head are measured, but they do not affect the normal weight designation. IUGR applies to the fetus, not the newborn's weight.

A school-age child is diagnosed with a life-threatening illness. The parents want to protect their child from knowing the seriousness of the illness. The nurse should explain that: a. This will help the child cope effectively by denial. b. This attitude is helpful to give parents time to cope. c. Terminally ill children know when they are seriously ill. d. Terminally ill children usually choose not to discuss the seriousness of their illness.

ANS: C The child needs honest and accurate information about the illness, treatments, and prognosis. Children, even at a young age, realize that something is seriously wrong and that it involves them. The nurse should help parents understand the importance of honesty. The child will know that something is wrong because of the increased attention of health professionals. This would interfere with denial as a form of coping. Parents may need professional support and guidance from a nurse or social worker in this process. Children will usually tell others how much information they want about their condition.

13. When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: a. indicates that they live in poverty. b. is lacking in protein. c. may provide sufficient amino acids. d. should be enriched with meat and milk.

ANS: C The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that contain this combination of foods. It does not indicate poverty. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.

Near the end of the first week of life an infant who has not been treated for any infection develops a copper-colored, maculopapular rash on the palms and around the mouth and anus. The newborn is showing signs of: a. Gonorrhea. c. Congenital syphilis. b. Herpes simplex virus infection. d. Human immunodeficiency virus.

ANS: C The rash is indicative of congenital syphilis. The lesions may extend over the trunk and extremities

Chris, age 9 years, has several physical disabilities. His father explains to the nurse that his son concentrates on what he can rather than cannot do and is as independent as possible. The nurses best Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 581 interpretation of this is: a. The father is experiencing denial. b. The father is expressing his own views. c. Chris is using an adaptive coping style. d. Chris is using a maladaptive coping style.

ANS: C The father is describing a well-adapted child who has learned to accept physical limitations. These children function well at home, at school, and with peers. They have an understanding of their disorder that allows them to accept their limitations, assume responsibility for care, and assist in treatment and rehabilitation. The father is not denying the childs limitations or expressing his own views. This is descriptive of an adaptive coping style.

9. Where in the health history should the nurse describe all details related to the chief complaint? a. Past history b. Chief complaint c. Present illness d. Review of systems

ANS: C The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present. Past history refers to information that relates to previous aspects of the child's health, not to the current problem. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.

17. In assisting the breastfeeding mother position the baby, nurses should keep in mind that: a. the cradle position usually is preferred by mothers who had a cesarean birth. b. women with perineal pain and swelling prefer the modified cradle position. c. whatever the position used, the infant is "belly to belly" with the mother. d. while supporting the head, the mother should push gently on the occiput.

ANS: C The infant inevitably faces the mother, belly to belly. The football position usually is preferred after cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.

A plan of care for an infant experiencing symptoms of drug withdrawal should include: a. Administering chloral hydrate for sedation. b. Feeding every 4 to 6 hours to allow extra rest. c. Swaddling the infant snugly and holding the baby tightly. d. Playing soft music during feeding.

ANS: C The infant should be wrapped snugly to reduce self-stimulation behaviors and protect the skin from abrasions. Phenobarbital or diazepam may be administered to decrease central nervous system (CNS) irritability. The infant should be fed in small, frequent amounts and burped well to diminish aspiration and maintain hydration. The infant should not be stimulated (such as with music) because this will increase activity and potentially increase CNS irritability.

4. A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. An appropriate nursing intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy by this method would be to: a. apply an oil-based lotion to the newborn's skin to prevent dying and cracking. b. limit the newborn's intake of milk to prevent nausea, vomiting, and diarrhea. c. place eye shields over the newborn's closed eyes. d. change the newborn's position every 4 hours.

ANS: C The infant's eyes must be protected by an opaque mask to prevent overexposure to the light. Eye shields should cover the eyes completely but not occlude the nares. Lotions and ointments should not be applied to the infant because they absorb heat, and this can cause burns. The lights increase insensible water loss, placing the infant at risk for fluid loss and dehydration. Therefore, it is important that the infant be adequately hydrated. The infant should be turned every 2 hours to expose all body surfaces to the light.

6. A breastfeeding woman develops engorged breasts at 3 days' after birth. What action would help this woman achieve her goal of reducing the engorgement? The woman: a. skips feedings to let her sore breasts rest. b. avoids using a breast pump. c. breastfeeds her infant every 2 hours. d. reduces her fluid intake for 24 hours.

ANS: C The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not feed adequately and empty the breast, the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.

17. The normal term infant has little difficulty clearing the airway after birth. Most secretions are brought up to the oropharynx by the cough reflex. However, if the infant has excess secretions, the mouth and nasal passages can be cleared easily with a bulb syringe. When instructing parents on the correct use of this piece of equipment, it is important that the nurse teach them to: a. avoid suctioning the nares. b. insert the compressed bulb into the center of the mouth. c. suction the mouth first. d. remove the bulb syringe from the crib when finished.

ANS: C The mouth should be suctioned first to prevent the infant from inhaling pharyngeal secretions by gasping as the nares are suctioned. The nasal passages should be suctioned one nostril at a time. After compression of the bulb it should be inserted into one side of the mouth. If the bulb is inserted into the center of the mouth, the gag reflex is likely to be initiated. When the infant's cry no longer sounds as though it is through mucus or a bubble, suctioning can be stopped. The bulb syringe should remain in the crib so that it is easily accessible if needed again.

3. What is the single most important factor to consider when communicating with children? a. The child's physical condition b. The presence or absence of the child's parent c. The child's developmental level d. The child's nonverbal behaviors

ANS: C The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child's physical condition is a consideration, developmental level is much more important. The parents' presence is important when communicating with young children, but it may be detrimental when speaking with adolescents. Nonverbal behaviors vary in importance based on the child's developmental level.

The nurse is reviewing Erikson's theory about the autonomy versus shame and doubt stage. The nurse is trying to correlate it to Freud's psychosexual theory. Which stage would the nurse review in Freud's theory? 1 Oral 2 Anal 3 Phallic 4 Latency

Anal

7. At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: a. begin solid foods. b. have a bottle of formula after every feeding. c. add at least one extra breastfeeding session every 24 hours. d. start iron supplements.

ANS: C Usually the solution to slow weight gain is to improve the feeding technique. Position and latch-on are evaluated, and adjustments are made. It may help to add a feeding or two in a 24-hour period. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle-feeding may cause nipple confusion and limit the supply of milk. Iron supplements have no bearing on weight gain.

27. The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months d. 6 months

ANS: C Visual fixation and following a target should be present by ages 3 to 4 months. Ages 1 to 2 months are too young for this developmental milestone. If the infant is not able to fix and follow by 6 months of age, further ophthalmologic evaluation is needed.

30. Which term is used to describe breath sounds that are produced as air passes through narrowed passageways? a. Rubs b. Rattles c. Wheezes d. Crackles

ANS: C Wheezes are produced as air passes through narrowed passageways. The sound is similar when the narrowing is caused by exudates, inflammation, spasm, or tumor. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture.

What should the nurse identify as major fears in the preschool child who is hospitalized with a chronic illness (select all that apply)? a. Altered body image b. Separation from peer group c. Bodily injury d. Mutilation e. Being left alone

ANS: C, D, E Bodily injury, mutilation, and being left alone are all major fears of the preschooler. Altered body image and separation from peers are major fears in the adolescent.

A postpartum woman preparing for discharge asks the nurse about resuming sexual activity. Which information is appropriate to include in the patient teaching? Select all that apply. a.Do not perform Kegel exercises to decrease pelvic floor muscle healing time. b.If breastfeeding, sexual interest may be delayed. c.Fatigue may affect interest in sexual activity. d.Sexual activity can usually be safely resumed by 5 to 6 weeks after birth e.Water-soluble lubrication may increase comfort f. The female-on-top position may be more comfortable than other positions.

ANS: C, D, E, F Kegel exercises are usually recommended and can strengthen the pubococcygeal muscle. Breastfeeding mothers often are interested in returning to sexual activity before nonbreastfeeding mothers. The amount of psychologic energy expended by the mother in child care activities may lead to fatigue and decreased interest in sexual activity. Most women can safely resume sexual activity by 5 to 6 weeks after birth. A water-soluble gel or jelly is recommended for lubrication. A position in which the mother has control of the depth of insertion of the penis, such as the female-on-top position may be more comfortable than other positions.

6. A 25-year-old multiparous woman gave birth to an infant boy 1 day ago. Today her husband brings a large container of brown seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup so that his wife can eat it. The nurse's most appropriate response is to ask the woman: a. "Didn't you like your lunch?" b. "Does your doctor know that you are planning to eat that?" c. "What is that anyway?" d. "I'll warm the soup in the microwave for you."

ANS: D "I'll warm the soup in the microwave for you" shows cultural sensitivity to the dietary preferences of the woman and is the most appropriate response. Cultural dietary preferences must be respected. Women may request that family members bring favorite or culturally appropriate foods to the hospital. "What is that anyway?" does not show cultural sensitivity.

The nurse caring for the postpartum woman understands that breast engorgement is caused by: a.Overproduction of colostrum. b.Accumulation of milk in the lactiferous ducts and glands. c.Hyperplasia of mammary tissue. d. Congestion of veins and lymphatics.

ANS: D Breast engorgement is caused by the temporary congestion of veins and lymphatics. Breast engorgement is not the result of overproduction of colostrum. Accumulation of milk in the lactiferous ducts and glands does not cause breast engorgement. Hyperplasia of mammary tissue does not cause breast engorgement.

5. A 4-year-old child has had a tonsillectomy and the nurse is preparing to ask him about his pain. Which technique is the most appropriate method for pain assessment for this patient? a. Asking him if the pain hurts "a little or a lot" b. Asking him to rate the pain on a scale of 0 to 10 c. Using the visual analog scale to rate the pain d. Using the Wong/Baker FACES rating scale

ANS: D Feedback A Using adjectives such as these is not reliable to assess pain in patients of any age. B This scale is appropriate for adolescents and adults, but a child cannot understand the concept of using numbers to rate pain. C This type of scale is appropriate for adults, but a child cannot understand the concept of using a straight line to rate pain. D This tool is appropriate for children who can point to the child's face that best represents how they are feeling.

In a variation of rooming-in, called couplet care, the mother and infant share a room, and the mother shares the care of the infant with: a. The father of the infant b.Her mother (the infant's grandmother). c.Her eldest daughter (the infant's sister). d. The nurse.

ANS: D In couplet care the mother shares a room with the newborn and shares infant care with a nurse educated in maternity and infant car

6. Because a full bladder prevents the uterus from contracting normally, nurses intervene to help the woman empty her bladder spontaneously as soon as possible. If all else fails, the last thing the nurse could try is: a. Pouring water from a squeeze bottle over the woman's perineum. b.Placing oil of peppermint in a bedpan under the woman. c.Asking the physician to prescribe analgesics. d. Inserting a sterile catheter.

ANS: D Invasive procedures usually are the last to be tried, especially with so many other simple and easy methods available (e.g., water, peppermint vapors, pain medication). Pouring water over the perineum may stimulate voiding. It is easy, noninvasive, and should be tried early. The oil of peppermint releases vapors that may relax the necessary muscles. If the woman is anticipating pain from voiding, pain medications may be helpful. Other nonmedical means and pain medication should be tried before insertion of a catheter.

13. Nursing care in the fourth trimester includes an important intervention sometimes referred to as taking the time to mother the mother. Specifically this expression refers to: a. Formally initializing individualized care by confirming the woman's and infant's identification (ID) numbers on their respective wrist bands. ("This is your baby.") b. Teaching the mother to check the identity of any person who comes to remove the baby from the room. ("It's a dangerous world out there. c. Including other family members in the teaching of self-care and child care. ("We're all in this together.") d.Nurturing the woman by providing encouragement and support as she takes on the many tasks of motherhood.

ANS: D Many professionals believe that the nurse's nurturing and support function is more important than providing physical care and teaching. Matching ID wrist bands is more of a formality, but it is also a get-acquainted procedure. "Mothering the mother" is more a process of encouraging and supporting the woman in her new role. Having the mother check IDs is a security measure for protecting the baby from abduction. Teaching the whole family is just good nursing practice.

2. On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a. Begin an intravenous (IV) infusion of Ringer's lactate solution. b. Assess the woman's vital signs c. Call the woman's primary health care provider. d. Massage the woman's fundus.

ANS: D The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss. The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician would be notified after the nurse completes the assessment of the woman.

Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: a.uses soap and warm water to wash the vulva and perineum. b.washes from the symphysis pubis back to the episiotomy. c.changes her perineal pad every 2 to 3 hours d.uses the peribottle to rinse upward into her vagina.

ANS: D These are all appropriate measures. These are all appropriate measures. These are all appropriate measures. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina since debris would be forced upward into the uterus through the still-open cervix.

24. Which nursing action is most appropriate to correct a boggy uterus that is displaced above and to the right of the umbilicus? a.Notify the physician of an impending hemorrhage. b.Assess the blood pressure and pulse. c.Evaluate the lochia. d.Assist the patient in emptying her bladder.

ANS: D Urinary retention may cause overdistention of the urinary bladder, which lifts and displaces the uterus. Nursing actions need to be implemented before notifying the physician. It is important to evaluate blood pressure, pulse, and lochia if the bleeding continues; however, the focus at this point in time is to assist the patient in emptying her bladder.

3. A woman gave birth vaginally to a 9-pound, 12-ounce girl yesterday. Her primary health care provider has written orders for perineal ice packs, use of a sitz bath tid, and a stool softener. What information is most closely correlated with these orders? a.The woman is a gravida 2, para 2. b.The woman had a vacuum-assisted birth. c. The woman received epidural anesthesia. d. The woman has an episiotomy.

ANS: D episiotomy: a surgical cut made at the opening of the vagina during childbirth, to aid a difficult delivery and prevent rupture of tissues. These orders are typical interventions for a woman who has had an episiotomy, lacerations, and hemorrhoids. A multiparous classification is not an indication for these orders. A vacuum-assisted birth may be used in conjunction with an episiotomy, which would indicate these interventions. Use of epidural anesthesia has no correlation with these orders.

4. A after birth woman telephones about her 4-day-old infant. She is not scheduled for a weight check until the infant is 10 days old, and she is worried about whether breastfeeding is going well. Effective breastfeeding is indicated by the newborn who: a. sleeps for 6 hours at a time between feedings. b. has at least one breast milk stool every 24 hours. c. gains 1 to 2 ounces per week. d. has at least 6 to 8 wet diapers per day.

ANS: D After day 4, when the mother's milk comes in, the infant should have 6 to 8 wet diapers every 24 hours. Sleeping for 6 hours between feedings is not an indication of whether the infant is breastfeeding well. Typically infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster fed. The infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.

23. The nurse should expect the anterior fontanel to close at age: a. 2 months. b. 2 to 4 months. c. 6 to 8 months. d. 12 to 18 months.

ANS: D Ages 2 through 8 months are too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes at these earlier ages, the child should be referred for further evaluation.

With regard to hemolytic diseases of the newborn, nurses should be aware that: a. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions frequently are required in the treatment of hemolytic disorders. d. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.

ANS: D An indirect Coombs' test may be performed on the mother a few times during pregnancy. Only the Rh-positive offspring of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers are needed infrequently because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

11. An Apgar score of 10 at 1 minute after birth would indicate a(n): a. infant having no difficulty adjusting to extrauterine life and needing no further testing. b. infant in severe distress who needs resuscitation. c. prediction of a future free of neurologic problems. d. infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth.

ANS: D An initial Apgar score of 10 is a good sign of healthy adaptation; however, it must be repeated at the 5-minute mark.

When attempting to diagnose and treat developmental dysplasia of the hip (DDH), the nurse should: a. Be able to perform the Ortolani and Barlow tests. b. Teach double or triple diapering for added support. c. Explain to the parents the need for serial casting. d. Carefully monitor infants for DDH at follow-up visits.

ANS: D Because DDH often is not detected at birth, infants should be monitored carefully at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is done for clubfeet, not DDH.

At what developmental period do children have the most difficulty coping with death, particularly if it is their own? a. Toddlerhood c. School-age b. Preschool d. Adolescence

ANS: D Because of their mature understanding of death, remnants of guilt and shame, and issues with deviations from normal, adolescents have the most difficulty coping with death. Toddlers and preschoolers are too young to have difficulty coping with their own death. They will fear separation from parents. School-age children will fear the unknown, such as the consequences of the illness and the threat to their sense of security.

Two hours after giving birth a primiparous woman becomes anxious and complains of intense perineal pain with a strong urge to have a bowel movement. Her fundus is firm at the umbilicus and midline. Her lochia is moderate rubra with no clots. The nurse suspects: a.bladder distention b.uterine atony c.constipation d.hematoma formation

ANS: D Bladder distention results in an elevation of the fundus above the umbilicus and deviation to the right or left of midline. Uterine atony results in a boggy fundus. Constipation is unlikely at this time. Increasing perineal pressure along with a firm fundus and moderate lochial flow are characteristic of hematoma formation

11. Which statement concerning the benefits or limitations of breastfeeding is inaccurate? a. Breast milk changes over time to meet changing needs as infants grow. b. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. c. Breast milk/breastfeeding may enhance cognitive development. d. Breastfeeding increases the risk of childhood obesity.

ANS: D Breastfeeding actually decreases the risk of childhood obesity. There are multiple benefits of breastfeeding. Breast milk changes over time to meet changing needs as infants grow. Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. Breast milk/breastfeeding may enhance cognitive development.

31. The nurse must assess a child's capillary refilling time. This can be accomplished by: a. inspecting the chest. b. auscultating the heart. c. palpating the apical pulse. d. palpating the skin to produce a slight blanching.

ANS: D Capillary refilling time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary filling time.

Most parents of children with special needs tend to experience chronic sorrow. This is characterized by: a. Lack of acceptance of the childs limitation. b. Lack of available support to prevent sorrow. c. Periods of intensified sorrow when experiencing anger and guilt. d. Periods of intensified sorrow and loss that occur in waves over time.

ANS: D Chronic sorrow is manifested by feelings of sorrow and loss that recur in waves over time. The sorrow is in response to the recognition of the childs limitations. The family should be assessed in an ongoing manner to provide appropriate support as the needs of the family change. The sorrow is not preventable. The chronic sorrow occurs during the reintegration and acknowledgment stage.

18. When teaching parents about mandatory newborn screening, it is important for the nurse to explain that the main purpose is to: a. keep the state records updated. b. allow accurate statistical information. c. document the number of births. d. recognize and treat newborn disorders early.

ANS: D Early treatment of disorders will prevent morbidity associated with inborn errors of metabolism or other genetic conditions. Keeping records and reporting for statistical purposes are not the primary reason for the screening test. The number of births recorded is not reported from the newborn screening test.

What is the most appropriate response to a school-age child who asks if she can talk to her dying sister? a. You need to speak loudly so she can hear you. b. Holding her hand would be better because at this point she cant hear you. c. Although she cant hear you, she can feel your presence so sit close to her. d. Even though she will probably not answer you, she can still hear what you say to her.

ANS: D Hearing is the last sense to cease before death. Talking to the dying child is important both for the child and for the family. There is no evidence that the dying process decreases hearing acuity; therefore, the sister should speak at a normal volume. The sibling should be encouraged to speak to the child, as well as sit close to the bed and hold the childs hand.

The priority nursing diagnosis for a newborn diagnosed with a diaphragmatic hernia would be: a. Risk for impaired parent-infant attachment. b. Imbalanced nutrition: less than body requirements. c. Risk for infection. d. Impaired gas exchange.

ANS: D Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although the nursing diagnoses of Risk for impaired parent-infant attachment, Imbalanced nutrition: less than body requirements, and Risk for infection may be factors in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia.

34. During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: a. abnormal and requires further investigation. b. abnormal unless it occurs in conjunction with knock-knee. c. normal if the condition is unilateral or asymmetric. d. normal because the lower back and leg muscles are not yet well developed.

ANS: D Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk, not an abnormal finding. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African-American children.

What bacterial infection is definitely decreasing because of effective drug treatment? a. Escherichia coli infection c. Candidiasis b. Tuberculosis d. Group B streptococcal infection

ANS: D Penicillin has significantly decreased the incidence of group B streptococcal infection. E. coli may be increasing, perhaps because of the increasing use of ampicillin (resulting in a more virulent E. coli resistant to the drug). Tuberculosis is increasing in the United States and Canada. Candidiasis is a fairly benign fungal infection.

Human immunodeficiency virus (HIV) may be perinatally transmitted: a. Only in the third trimester from the maternal circulation. b. By a needlestick injury at birth from unsterile instruments. c. Only through the ingestion of amniotic fluid. d. Through the ingestion of breast milk from an infected mother.

ANS: D Postnatal transmission of HIV through breastfeeding may occur. Transmission of HIV from the mother to the infant may occur transplacentally at various gestational ages. Transmission close to or at the time of birth is thought to account for 50% to 80% of cases.

21. When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: a. some form of cancer. b. local scalp infection common in children. c. infection or inflammation distal to the site. d. infection or inflammation close to the site.

ANS: D Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes do not usually indicate cancer. A scalp infection usually does not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed.

A preschooler is found digging up a pet bird that was recently buried after it died. The best explanation for this behavior is that: a. He has a morbid preoccupation with death. b. He is looking to see if a ghost took it away. c. The loss is not yet resolved, and professional counseling is needed. d. Reassurance is needed that the pet has not gone somewhere else.

ANS: D Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 584 The preschooler can recognize that the pet has died but has difficulties with the permanence. Digging up the bird gives reassurance that the bird is still present. A morbid preoccupation with death and the child looking to see if a ghost took it away are expected responses. If they persist, intervention may be required.

26. The most frequently used test for measuring visual acuity is the: a. Denver Eye Screening test. b. Allen picture card test. c. Ishihara vision test. d. Snellen letter chart.

ANS: D The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. Single cards (Denver—letter E; Allen—pictures) are used for children age 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for color vision.

27. When responding to the question "Will I produce enough milk for my baby as she grows and needs more milk at each feeding?" the nurse should explain that: a. the breast milk will gradually become richer to supply additional calories. b. as the infant requires more milk, feedings can be supplemented with cow's milk. c. early addition of baby food will meet the infant's needs. d. the mother's milk supply will increase as the infant demands more at each feeding.

ANS: D The amount of milk produced depends on the amount of stimulation of the breast. Increased demand with more frequent and longer breastfeeding sessions results in more milk available for the infant. Mature breast milk will stay the same. The amounts will increase as the infant feeds for longer times. Supplementation will decrease the amount of stimulation of the breast and decrease the milk production. Solids should not be added until about 4 to 6 months, when the infant's immune system is more mature. This will decrease the chance of allergy formations

16. As part of their teaching function at discharge, nurses should educate parents regarding safe sleep. Which statement is incorrect? a. Prevent exposure to people with upper respiratory tract infections. b. Keep the infant away from secondhand smoke. c. Avoid loose bedding, water beds, and beanbag chairs. d. Place the infant on his or her abdomen to sleep.

ANS: D The infant should be laid down to sleep on his or her back for better breathing and to prevent sudden infant death syndrome. Infants are vulnerable to respiratory infections; infected people must be kept away. Secondhand smoke can damage lungs. Infants can suffocate in loose bedding, and furniture that can trap them. Per AAP guidelines, infants should always be placed "back to sleep" and allowed tummy time to play, to prevent plagiocephaly.

5. Early this morning, an infant boy was circumcised using the PlastiBell method. The nurse tells the mother that she and the infant can be discharged after: a. the bleeding stops completely. b. yellow exudate forms over the glans. c. the PlastiBell rim falls off. d. the infant voids.

ANS: D The infant should be observed for urination after the circumcision. Bleeding is a common complication after circumcision. The nurse will check the penis for 12 hours after a circumcision to assess and provide appropriate interventions for prevention and treatment of bleeding. Yellow exudates cover the glans penis in 24 hours after the circumcision. This is part of normal healing and not an infective process. The PlastiBell remains in place for about a week and falls off when healing has taken place.

5. A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant: a. with his arms folded together over his chest. b. curled up in a fetal position. c. with his head cupped in her hand. d. with his head and body in alignment.

ANS: D The infant's head and body should be in correct alignment with the mother and the breast during latch-on and feeding. Holding the infant with his arms folded together over his chest, curled up in a fetal position, or with his head cupped in her hand are not ideal positions to facilitate latch-on.

While completing a newborn assessment, the nurse should be aware that the most common birth injury is: a. To the soft tissues. b. Caused by forceps gripping the head on delivery. c. Fracture of the humerus and femur. d. Fracture of the clavicle.

ANS: D The most common birth injury is fracture of the clavicle (collarbone). It usually heals without treatment, although the arm and shoulder may be immobilized for comfort.

21. A newly delivered mother who intends to breastfeed tells her nurse, "I am so relieved that this pregnancy is over so I can start smoking again." The nurse encourages the patient to refrain from smoking. However, this new mother insists that she will resume smoking. The nurse will need to adapt her health teaching to ensure that the patient is aware that: a. smoking has little or no effect on milk production. b. there is no relation between smoking and the time of feedings. c. the effects of secondhand smoke on infants are less significant than for adults. d. the mother should always smoke in another room.

ANS: D The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the immunologic properties of breast milk. Research supports that mothers should not smoke within 2 hours before a feeding. The effects of secondhand smoke on infants include sudden infant death syndrome.

On examining a woman who gave birth 5 hours ago, the nurse finds that the woman has completely saturated a perineal pad within 15 minutes. The nurse's first action is to: a.begin an IV infusion of Ringer's lactate solution. b.assess the woman's vital signs. c.call the woman's primary health care provider. d.massage the woman's fundus.

ANS: D The nurse may begin an IV infusion to restore circulatory volume, but this would not be the first action. Blood pressure is not a reliable indicator of impending shock from an impending hemorrhage; assessing vital signs should not be the nurse's first action. The physician should be notified after the nurse completes assessment of the woman. The nurse should assess the uterus for atony. Uterine tone must be established to prevent excessive blood loss.

Nursing interventions to help the siblings of a child with a complex or chronic condition cope include: a. Explaining to the siblings that embarrassment is unhealthy. b. Encouraging the parents not to expect siblings to help them care for the child with special needs. c. Providing information to the siblings about the childs condition only as they request it. d. Suggesting to the parents ways of showing gratitude to the siblings who help care for the child with a disability or chronic condition.

ANS: D The presence of a child with special needs in a family will change the family dynamic. Siblings may be asked to take on additional responsibilities to help the parents to care for the child. The parents should show gratitude, such as an increase in allowance, special privileges, and verbal praise. Embarrassment may be associated with having a sibling with a chronic illness or disability. Parents must be able to respond in an appropriate manner without punishing the sibling. The parents may need assistance with the care of the child. Most siblings are positive about the extra responsibilities. The siblings need to be informed about the childs condition before a nonfamily member does so. The parents do not want the siblings to fantasize about what is wrong with the child.

A pregnant woman at 37 weeks of gestation has had ruptured membranes for 26 hours. A cesarean section is performed for failure to progress. The fetal heart rate (FHR) before birth is 180 beats/min with limited variability. At birth the newborn has Apgar scores of 6 and 7 at 1 and 5 minutes and is noted to be pale and tachypneic. On the basis of the maternal history, the cause of this newborn's distress is most likely to be: a. Hypoglycemia. c. Respiratory distress syndrome. b. Phrenic nerve injury. d. Sepsis.

ANS: D The prolonged rupture of membranes and the tachypnea (before and after birth) both suggest sepsis. An FHR of 180 beats/min is also indicative. This infant is at high risk for sepsis.

Which term best describes a multidisciplinary approach to the management of a terminal illness that focuses on symptom control and support? a. Dying care c. Restorative care b. Curative care d. Palliative care

ANS: D This is one of the definitions of palliative care. The goal of palliative care is the achievement of the highest possible quality of life for patients and their families.

The nurse is talking with the parent of a child newly diagnosed with a chronic illness. The parent is upset and tearful. The nurse asks, With whom do you talk when something is worrying you? This should be interpreted as: a. Inappropriate, because parent is so upset. b. A diversion of the present crisis to similar situations with which parent has dealt. c. An intervention to find someone to help parent. d. Part of assessing parents available support system.

ANS: D This question will provide information about the marital relationship (does the parent speak to the spouse?), alternate support systems, and ability to communicate. These are very important data for the nurse to obtain and an appropriate part of an accurate assessment. By assessing these areas, the nurse can facilitate the identification and use of community resources as needed. The nurse is obtaining information to help support the parent through the diagnosis. The parent is not in need of additional parenting help at this time.

14. Which parameter correlates best with measurements of the body's total protein stores? a. Height b. Weight c. Skin-fold thickness d. Upper arm circumference

ANS: D Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the body's fat content.

Which findings would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? select all that apply a. Postural hypotension b.Temperature of 100.4° F c.Bradycardia—pulse rate of 55 beats/min d.Pain in left calf with dorsiflexion of left foot e. Lochia rubra with foul odor

ANS: D, E Postural hypotension is an expected finding related to circulatory changes after birth A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. These findings indicate a positive Homans' sign and are suggestive of thrombophlebitis and should be investigated. Lochia with odor may indicate infection.

The nurse teaching parents of an adolescent about nutrition will include what important information? A. Adolescents are usually mature enough to make healthy food choices. B. Resources to assist lower income families about obtaining enough protein. C, Behavior problems in this age group are not related to nutritional deficiencies. D. Parental influence has the greatest impact on food choices at this age.

B. Resources to assist lower income families about obtaining enough protein. Lower income families may need resources and information about how to obtain assistance in getting expensive foods such as meats to get enough protein intake. During adolescence, parental influence diminishes and the adolescent makes food choices related to peer acceptability and sociability. Occasionally these choices are detrimental to adolescents with chronic illnesses, such as diabetes, obesity, chronic lung disease, hypertension, cardiovascular risk factors, and renal disease. Families that struggle with lower incomes, homelessness, and migrant status generally lack the resources to provide their children with adequate food intake; nutritious foods, such as fresh fruits and vegetables; and appropriate protein intake. The result is nutritional deficiencies with subsequent growth and developmental delays, depression, and behavior problems. Behavior problems can indeed be related to nutritional deficiencies.

Which parameters should the nurse monitor in the infant with hypothermia to ensure effective care? 1 Hemoglobin levels 2 Blood glucose levels 3 White blood cell count 4 Serum potassium levels

Blood glucose levels

Place the following steps of the nursing process in the proper order of completion when the nurse is caring for a child with pneumonia. (Select all that apply) A. Determine whether antibiotic therapy has been effective by reviewing white blood cell count. B. Administer antibiotics as ordered. C. Listen to the child's breath sounds and monitor vital signs. D. Identify the problem of impaired gas exchange. E. Establish therapeutic goals and prioritize health care provider orders.

C, D, E, B, A

Nurses play an important role in current issues and trends in health care. Which is a current trend in pediatric nursing and health care today? A. The patient is the unit of care for the health care provider. B. Discharge planning begins when the physician writes the order. C. Health promotion resources enable children to achieve their full potential. D. The focus of pediatric health care is trending toward acute hospital care.

C. Health promotion resources enable children to achieve their full potential. Health promotion provides opportunities to reduce differences in current health status among members of different groups and provides a better chance to achieve the fullest health potential. The patient and family is the unit of care for the health care provider. Discharge planning begins when the patient is admitted. The focus of pediatric health care is trending away from acute hospital settings.

What is the most appropriate teaching point to include in a health promotion teaching plan for parents of children age 5 to 14? A. Causes of mechanical suffocation B. Keeping all medications out of children's reach C. Storing firearms in locked cabinets. D. Warning signs of violent crimes.

C. Storing firearms in locked cabinets. Improper use of firearms is the fourth leading cause of death from injury in children 5 to 14. Mechanical suffocation is the leading cause of death from injury in infants. Homicide is the second leading cause of death in 15 to 19 year olds. Poisoning causes a considerable number of injuries in children under 4 years of age.

The signs and symptoms in a nursing diagnosis describe: A. projected changes in an individual's health status, clinical conditions, or behavior. B. an individual's response to health pattern deficits in the child, family, or community. C. a cluster of cues and/or defining characteristics that are derived from patient assessment and indicate actual health problems. D. physiologic, situational, and maturational factors that cause the problem or influence its development.

C. a cluster of cues and/or defining characteristics that are derived from patient assessment and indicate actual health problems. These are the outcomes or goals that are established. This is the definition of the problem statement, the first component of the nursing diagnosis. This is the third part of the nursing diagnosis, the signs and symptoms. This is the definition of etiology, the second component of the nursing diagnosis.

Based on Piaget's theory of cognitive development, what is one basic concept a child is expected to attain during the first year of life? 1 If an object is hidden, that does not mean that it is gone. 2 He or she cannot be fooled by changing shapes. 3 Parents are not perfect. 4 Most procedures can be reversed.

If an object is hidden, that does not mean that it is gone.

Evidence-based practice, a current health care trend, is best described as: A. gathering evidence of mortality and morbidity in children. B. meeting physical and psychosocial needs of the child and family in all areas of practice. C. using a professional code of ethics as a means for professional self-regulation. D. questioning why something is effective and whether there is a better approach.

D. questioning why something is effective and whether there is a better approach. This will assist the nurse in determining areas of concern and potential involvement. It is not possible to meet all needs of the family and child in all areas of practice. The nurse is an advocate for the family. This is part of the professional role and licensure. Evidence-based practice helps to focus on measurable outcomes and the use of demonstrated, effective interventions and questions whether there is a better approach.

The role of the pediatric nurse is influenced by trends in health care. The greatest trend in health care is: A. primary focus on treatment of disease or disability. B. national health care planning on a distributive or episodic basis. C. accountability to professional codes and international standards. D. shift of focus to prevention of illness and maintenance of health.

D. shift of focus to prevention of illness and maintenance of health. Traditionally this is the role of the physician. This is not a major trend. This is an established responsibility, not a trend. Prevention is the current focus of health care, one in which nursing plays a major role.

Which best describes Piaget's cognitive stage of formal operations? 1 Deductive and abstract reasoning 2 Inductive reasoning and beginning logic 3 Transductive reasoning and egocentrism 4 Cause-and-effect reasoning and object permanence

Deductive and abstract reasoning

In what age group should the nurse expect a child to develop gross motor skills? 1 Birth through infancy 2 Early childhood 3 Later childhood 4 Middle childhood

Early childhood

The nurse is assessing a child and asks the child to climb the chairs to check for motor development. What is the age group of the child that the nurse is assessing? 1 Infancy 2 Early childhood 3 Middle childhood 4 Later childhood

Early childhood

A preschool child watches a nurse pour medication from a tall, thin glass to a short, wide glass. Which statement is appropriate developmentally for this age group? 1 The amount of medicine is less. 2 The amount of medicine did not change, only its appearance. 3 Pouring medicine makes the medicine hot. 4 The glass changed shape to accommodate the medicine.

The amount of medicine is less.

A child is assessed and categorized in the industry versus inferiority stage according to Erikson's theory. The nurse compares the child with Freud's psychosexual development theory. At what stage would the child be categorized in Freud's theory? 1 Anal 2 Phallic 3 Latency 4 Genital

Latency

An infant's blood glucose levels are low, and the nurse instructs the mother to perform kangaroo care. Which condition would the nurse have assessed in the child? 1 Irregular sleep patterns 2 Reduced metabolism 3 Improper thermoregulation 4 Impaired maturation

Improper thermoregulation

The nurse is caring for a 2-day-old neonate who is healthy but has a low body temperature. The nurse instructs the infant's mother to place the unclothed infant on her bare chest. Which finding in the infant indicates ineffective management of the infant's condition? 1 Hyperglycemia 2 Metabolic acidosis 3 Body weight of 21 lbs 4 Body weight of 7.5 lbs 00:00:15 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

Metabolic acidosis

What is the corresponding stage of spiritual development of a child who states, "All women with big stomachs have babies"? 1 Mythical-literal 2 Undifferentiated 3 Synthetic-convention 4 Individuating-reflexive

Mythical-literal

The nurse is caring for a child with a genetic disorder and is instructed to not give the child milk or milk products. What type of disorder does this child probably have? 1 Phenylketonuria 2 Sickle cell disorder 3 Down syndrome 4 Turner syndrome

Phenylketonuria

Which intervention should the nurse incorporate to prevent hypothermia in an infant? 1 Give hot milk or hot water to the infant at regular intervals. 2 Place the unclothed, diapered infant in the sun for few hours. 3 Feed the infant formula, which is higher in calories. 4 Put the unclothed, diapered infant on the mother's bare chest.

Put the unclothed, diapered infant on the mother's bare chest.

The nurse finds that an infant with a cleft palate is at risk for obstructive apnea. Which associated findings does the nurse expect? Select all that apply. A Clubfoot B Recessed mandible C Abnormally placed tongue D Congenital amputation E Congenitally sparse hair

Recessed mandible Abnormally placed tongue

The nurse is assessing a child. The nurse asks the parents, "Has your child started sleeping less lately?" Which attribute of temperament is the nurse assessing? 1 Adaptability 2 Distractibility 3 Rhythmicity 4 Activity

Rhythmicity

The nurse is assessing an infant with delayed motor development. The nurse finds that the infant is able to move her neck without support. The ability to perform which activity should develop next in this child? 1 Crawling 2 Creeping 3 Sitting 4 Standing

Sitting

A nurse is knowledgeable about both growth and development. Which assessment finding indicates the child's development is on target? 1 The child has not gained weight for 3 months. 2 The child can throw a large ball but not a small ball. 3 The child's arms are the most rapidly growing part of the child's body. 4 The child can pull herself or himself to her or his feet before the child is able to sit steadily.

The child can throw a large ball but not a small ball.

During assessment of a 7-month-old child, the nurse checks the child's height and weight and compares them with previous assessment records. The nurse finds that the child's height has increased by 1.25 cm, and the weight is 140 g more than in the previous month. What does the nurse infer from this observation? 1 The child is displaying symptoms of Down syndrome. 2 The child's weight is not ideal in relation to height. 3 The child's height and weight are ideal. 4 The child has a calcium deficiency due to malnutrition.

The child's height and weight are ideal.

The nurse assesses a child born to a patient with epilepsy and notices teratogenic effects in the baby. Which factors should the nurse assess to determine the cause of the teratogenic effects? 1 The medication history of the patient 2 The presence of environmental triggers 3 Abnormal CCR5 gene found in the patient 4 A family history of genetic abnormalities

The medication history of the patient

Which statement helps explain the growth and development of children? 1 Development proceeds at a predictable rate. 2 The sequence of developmental milestones is predictable. 3 Rates of growth are consistent among children. 4 At times of rapid growth, there is also acceleration of development.

The sequence of developmental milestones is predictable.

The nurse is caring for two children. The younger child creates complex imaginary stories using dolls and toys. The older child is engaged in building a model airplane. Which stages of development are the children likely in, according to Erikson? 1 The younger child is in the trust versus mistrust stage; the older child is in the initiative versus guilt stage. 2 The younger child is in the industry versus inferiority stage; the older child is in the identity versus role confusion stage. 3 The younger child is in the initiative versus guilt stage; the older child is in the industry versus inferiority stage. 4 The younger child is in the identity versus role confusion stage; the older child is in the trust versus mistrust stage.

The younger child is in the initiative versus guilt stage; the older child is in the industry versus inferiority stage.

The nurse is caring for a newborn who weighs 3 kg (7 lb). The nurse assesses the child 4 years later and notes that the child weighs 13 kg (30 lb). What should the nurse do with this information? 1 This finding is normal; continue to monitor. 2 Instruct the parents to provide supplements. 3 Assess the child for nutritional deficiencies. 4 Talk to the police about parental neglect.

This finding is normal; continue to monitor.

The nurse is assessing a newborn who weighs 3 kg (7 lb). At what growth stage would the child weigh 12 kg (26 lb)? 1 Infancy 2 Toddlerhood 3 Preschool age 4 School age

Toddlerhood

The nurse is teaching a student nurse about a child who only has one X chromosome. What abnormality does the child have? 1 Down syndrome 2 Turner syndrome 3 Fragile X syndrome 4 Contiguous gene syndrome

Turner syndrome

A nurse is examining a toddler and is discussing with the mother psychosocial development according to Erikson's theories. Based on the nurse's knowledge of Erikson, the most age-appropriate activity to suggest to the mother at this stage is to: 1 feed lunch. 2 allow the toddler to start making choices about what to wear. 3 allow the toddler to pull a talking-duck toy. 4 turn on a TV show with bright colors and loud songs.

allow the toddler to start making choices about what to wear.

A patient who is undergoing stem cell therapy asks the nurse about undifferentiated cells. Which response given by the nurse is most appropriate? "These cells:" 1 are able to divide at a very rapid rate." 2 multiply to form any part of the body." 3 can perform specialized functions." 4 are similar to all other cells in the body."

multiply to form any part of the body."