pass point health promotion and maintenance

the anteroposterior diameter is normally equal that of the lateral diameter (a ratio of 1:1)

As the infant reaches toddlerhood, the anteroposterior diameter becomes less than the lateral diameter.

The nurse should tell the client that applying an emollient immediately after taking a bath or shower prevents evaporation of water from the hydrated epidermis, the skin's upper layer.

. An emollient does not affect the rate of skin cell growth. An emollient minimizes cracking of the epidermis, not the dermis (the layer beneath the epidermis). An emollient does not prevent skin inflammation.

For the most accurate measurement, the nurse should place the infant in a supine position and then measure recumbent height.

. Measuring recumbent height with the infant lying on the side would yield an inaccurate result. Measuring recumbent height with the infant prone would yield an inaccurately long result because it includes the length of the foot. Measuring standing height with the infant held upright would also yield an inaccurate result, at least until the child no longer needs assistance to stand up straight.

Most children with asthma can participate in sports if the asthma is controlled.

Physical activities are beneficial to asthmatic children, physically and psychosocially. Most children with asthma can engage in school and sports activities that are geared to the child's condition and within the limits imposed by the disease. The coach and other team members need to be aware of the child's condition and know what to do in case an attack occurs. Those children who have exercise-induced asthma usually use a short-acting bronchodilator before exercising.

mother to best support her 4-year-old child's developmental needs?

Playing kick ball requires the preschooler to use a variety of motor skills, can help channel energy, and meets developmental needs.

The child entering school is moving into a new environment after having experienced security at home.

Unhappiness with resulting feelings of insecurity is a normal response to the lost sense of security.

Birth weight usually doubles by age 6 months and triples by age 1 year.

Watchful waiting or no action is detrimental to the infant's growth and development. Comparison to other children is not helpful. Asking about the child's eating habits will help the nurse get a better understanding of potential causes of the low birth weight. The parents should be advised that the birth weight is below normal.

A child's parents play a key role in the development of the child's spirituality.

What is important is not so much what parents teach a child about God and religion, but rather what the child learns about God, life, and self from the parent's behavior.

While the nurse is assessing the fundus of a multiparous client who gave birth 24 hours ago, the client asks, "What can I do to get rid of these stretch marks?" Which response would be most appropriate? "They usually fade to a silvery-white color over a period of time." "You will need to use a specially prescribed cream to help them disappear." "As long as you don not get pregnant again, the marks will disappear completely." "If you lose the weight you gained during pregnancy, the marks will fade to a pale pink."

1 Stretch marks, or striae gravidarum, are caused by stretching of the tissues, particularly over the abdomen. After birth, the tissues atrophy, leaving silver scars. These skin pigmentations will not disappear completely. The striae gravidarum may reappear as pink streaks if the client becomes pregnant again. Special creams are not warranted because they are not helpful and may be expensive. Weight loss does not make the marks disappear. Striae gravidarum tend to run in families.

Elderly clients who fall are most at risk for which injuries? humerus fractures pelvic fractures c ervical spine fractures wrist fractures

2 Elderly clients who fall are most at risk for pelvic and lower extremity fractures. These injuries are devastating because they can seriously alter an elderly client's lifestyle and reduce functional independence. Wrist fractures usually occur with falls on an outstretched hand or from a direct blow. Such fractures are commonly found in young men. Humerus fractures and cervical spine fractures aren't age-specific.

A nurse is completing an admission assessment. The nurse asks the client about social support systems and the client asks the nurse to explain social support systems. Which statement describes a social support system? "It is a source of payment options to aid in the hospital bill of the client." "It is a group of friends and colleagues at home and in the community that help a client in times of need." "It is a health care system with a variety of educators available in the community." "It is a group of health care providers who are available to assist with care needed for the client's family."

2 Support systems can be family members as well as community members who are available to assist with any need of the client. Health care systems are support systems of health care. Health care providers are also part of the health care support system. Support systems are not payment options.

The recommended fasting blood sugar level in a pregnant client with diabetes is 60 to 90 mg/dl (3.3 to 5.0 mmol/L).

A fasting blood sugar level of 45 mg/dl (2.5 mmol/L) is low, and may result in symptoms of hypoglycemia. A blood sugar level below 120 mg/dl (6.7 mmol/L) is a recommended one-hour postprandial value. A blood sugar level above 136 mg/dl (7.6 mmol/L) in a pregnant client indicates hyperglycemia.

Performing weight-bearing exercise increases bone health.

A sedentary lifestyle increases the risk of developing osteoporosis. Estrogen is needed to promote calcium absorption. The recommended daily intake of calcium is 1,000 mg, not 300 mg.

"It is normal to have eye crossing in the newborn period."

During the first few months of life, an infant's eyes may wander and appear to be crossing. As the eye muscles mature, between 2 and 3 months of age, both eyes will focus on the same thing. No intervention is necessary, as crossing of the eyes is normal in the first few months of life.

The best way for the nurse to determine a client's learning preference is to ask questions relating to how the client likes to learn.

For example, the nurse should ask the client if he or she prefers to read a brochure, watch a video, or listen to a podcast. Asking the client to read something would help the nurse determine the ability to read but not the client's learning preferences. Asking the client about education level and whether he or she likes to read might help the nurse determine at what level to present the information, but not about the client's learning preferences. Asking the client about literacy and/or health literacy may be viewed as insensitive by the client. Additionally, it would not provide the nurse with the client's learning preferences.

Which method would the nurse use to identify the educational needs of clients in a senior center? Conduct focus group interviews and have the clients fill out a survey.

Initial gathering of information from the clients using a survey would help identify individual clients' needs and interests. Focus groups will also help generate discussion of needs and common concerns. This gathering of information on risk identification can then help individualize interventions. The other choices are not enough for the families or caregivers to determine the needs of the seniors because they need to have a voice. Discussing with caregivers does not allow for individual consideration.

The client who is on a progressive exercise program at home after a myocardial infarction should be taught to monitor the heart rate and take the pulse at the end of each walk.

The heart rate can be expected to increase with exercise, but the client should not increase the exercise if the heart rate increases more than about 25 bpm from baseline or exceeds 100 to 125 bpm. The nurse should also teach the client to discontinue exercise if chest pain occurs. The number of steps and the time to walk a mile are not determining factors for increasing the amount of exercise as long as the heart rate remains within range. The respirations may increase, but do not determine the ability to increase the exercise unless the client becomes short of breath.

A 36-year-old female is scheduled to receive external radiation therapy and a cesium implant for cancer of the cervix and is asking about the effects of the radiation on sexual relations during and after the radiation therapy. The nurse should inform the client about which potential effect of radiation therapy on sexuality? "You will experience vaginal relaxation after treatment is completed." "You will be able to have sexual intercourse while the implant is in place." "You will have vaginal dryness after treatment is completed." "You will continue to have normal menstrual periods during treatment."

3 Radiation fields that include the ovaries usually result in premature menopause. Vaginal dryness will occur without estrogen replacement. There should be no sexual intercourse while the implant is in place. Cesium is a radioactive isotope used for therapeutic irradiation of cancerous tissue. There is no documentation to support vaginal relaxation after treatment. Because the client will have premature menopause, she will not have normal menstrual periods.

A multigravid client is admitted at 4-cm dilation and is requesting pain medication. The nurse gives the client an opioid agonist-antagonist. Within 5 minutes, the client tells the nurse she feels like she needs to have a bowel movement. What should the nurse do first? Have naloxone hydrochloride available in the birthing room. Prepare for birth. Document the client's relief due to pain medication. Complete a vaginal examination.

4 The feeling of needing to have a bowel movement is commonly caused by pressure on the receptors low in the perineum when the fetal head is creating pressure on them. This feeling usually indicates advances in fetal station and that the client may be close to birth. The nurse should respond initially to the client's signs and symptoms by completing a vaginal exam to validate current effacement, dilation, and station. If the fetus is ready to be born, having the room ready for the birth and having naloxone available are important. Naloxone completely or partially reverses the effects of natural and synthetic opioids, including respiratory depression. Documenting pain relief takes time away from the vaginal examination, preparing for birth, and obtaining naloxone. The birth may be occurring rapidly. Being prepared for the birth is a higher priority than documentation for this client.

Adolescents are worried about appearing different from their peers

Adolescents have a strong need to belong, and they seek social approval from their peers. Knowing this information will help the nurse construct an effective teaching plan. According to Piaget, adolescents are at the formal operations stage and are capable of deductive, reflective, and hypothetical reasoning. According to Erikson's stages of psychosocial development, adolescence is the stage of identity versus role confusion. During this stage, the adolescent strives to establish a sense of identity. There is no reason to think the adolescent will be uncooperative. Many people find video tutorials useful, but a return demonstration is the best way to ensure the client understands and is able to follow the instructions. The nurse can assess the client's abilities without the client requiring supervision at home.

A 7-year-old child is brought to the clinic by a parent for a school physical. When the child is prepared for examination, which interventions should the nurse provide to ensure the child's comfort?

At this age in the early school-age years, the child is still comfortable with a parent's presence in the examination room and is not generally given the option. It is important for the child's comfort and to decrease anxiety to explain the use of each piece of equipment prior to using it. During the school-age years, the child should be allowed to keep their underpants on along with the gown. Gaining distraction with bright objects would be used for an infant.

Children are capable of mastering the skills required for flossing when they reach 9 years of age.

At this age, many children are able to assume responsibility for personal hygiene. She is not too young to assume this responsibility, and she should not have been expected to assume this responsibility much earlier. It is not likely that she is exaggerating; this is an expected behavior at this age.

The screening protocol recommended by the American and Canadian Cancer Societies for early detection of cancer in asymptomatic people includes:

Beginning at age 50, men and women should have fecal occult blood testing, flexible sigmoidoscopy, or colonoscopy every year until age 75 unless determined otherwise by a health care provider (HCP). A diet low in saturated fat and high in fruit and fiber is not a screening protocol but is good dietary advice for all clients.

A 2-year-old tells his parent he is afraid to go to sleep because "the monsters will get him." What should the nurse tell the parent to do?

Behavior problems related to sleep and rest are common in young children. Consistent rituals around bedtime help to create an easier transition from waking to sleep. Allowing a child to sleep with his parents commonly creates more problems for the family and child and does not alleviate the problem or foster autonomy. Increasing activity before bedtime does not alleviate the separation anxiety in the toddler and causes further anxiety. Allowing him to stay up later than his normal time for bed will increase his anxiety, make it more difficult for him to fall asleep, and do nothing to lessen his fear.

Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it necessary for placental expulsion.

Blood loss during birth is almost always estimated because it provides a valuable indicator for possible hemorrhage. A blood loss of 1,000 mL is considered hemorrhage.

A couple visiting the infertility clinic for the first time states that they have been trying to conceive for the past 2 years without success. After a history and physical examination of both partners, what would be the most appropriate outcome for the couple to accomplish by the end of this visit?

By the end of the first visit, the couple should be able to identify potential causes and treatment modalities for infertility. If their evaluation shows that a treatment or procedure may help them to conceive, the couple must then decide how to proceed, considering all of the various treatments before selecting one. Treatments can be difficult, painful, or risky. The first visit is not the appropriate time to decide on a treatment plan because the couple needs time to adjust to the diagnosis of infertility, a crisis for most couples. Although the couple may be in a hurry for definitive therapy, a thorough assessment of both partners is necessary before a treatment plan can be initiated. The success rate for achieving a pregnancy depends on both the cause and the effectiveness of the treatment, and in some cases it may be only as high as 30%. The couple may desire information about alternatives to treatment, but insufficient data are available to suggest that a specific treatment modality may not be successful. Suggesting that the couple consider adoption at this time may inappropriately imply that the couple has no other choice. If a specific therapy may result in a pregnancy, the couple should have time to consider their options. After a thorough evaluation, adoption may be considered by the couple as an alternative to the costly, time-consuming, and sometimes painful treatments for infertility.

A safe level of alcohol intake during pregnancy hasn't been established. Therefore, authorities recommend that pregnant women abstain from alcohol entirely.

Excessive alcohol intake has serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth restriction, short palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may predispose the client to complications in early pregnancy.

The nurse in the emergency department is caring for a preschool-age child with a fractured humerus. The child is crying and screaming, "I hate you!" Which action would be most appropriate?

Explaining to the parents that this is a normal reaction under the circumstances is most appropriate. The child's outburst is related to the child's fears of the unknown. The child is scared and anxious and needs the parents for support. Asking the parents to wait outside would only add to the child's fear and anxiety. The reaction is normal for a child her age and does not usually call for a change in staff assignments. Asking the parents to discipline their child for her behavior is inappropriate. The nurse needs to handle the situation.

To gain a preschooler's cooperation, the most appropriate strategy is for the nurse to show trust and express faith in the child's ability to cooperate even with an unpleasant procedure.

Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.

School-age children delight in riddles and jokes.

Mastery of the ambiguities of language and of sentence structure allows the school-age child to manipulate words, and telling riddles and jokes is a way of practicing this skill. Children who suffer from inadequate attention from parents tend to demonstrate abnormal behavior. Peer influence is less important to school-age children, and while the child may learn the joke from a friend, he is telling the joke to master language. Watching television does not influence the extent of joke telling.

A sudden gush of dark blood, a lengthening of the umbilical cord, a smaller uterus, and changing of the uterus to a round or spherical shape are impending signs of placental separation.

Pushing effort from the client is not a reliable indicator for impending placental separation, nor is it necessary for placental expulsion.

Soft, washable toys are appropriate for infants, who tend to place everything in their mouths.

Soft, washable toys are appropriate for infants, who tend to place everything in their mouths. These toys are not harmful. Plastic toys cannot be manipulated by a child of this age, and the child would put the car in the mouth, which may not be safe due to small parts that may be swallowed or aspirated. Games and puzzles are too advanced for a 5-month-old, and the child could put the pieces in the mouth and swallow them. Some stuffed animals have eyes that can be swallowed or aspirated.

During the transition phase of labor, the client may fear being left alone, but the support person may need a break. During this time, it is critical that the nurse remain with the client, provide relief for the support person, and keep the client aware of where her support person is.

The best action is to use the call bell and ask another nurse to assist in locating the client's partner, as this allows the nurse to remain with the client and keep the client informed. Given that the client is multiparous and 9 cm dilated, her transition phase should last approximately an hour and her second stage (which begins with cervical dilation at 10 cm and ends with the birth) will likely last fewer than 30 minutes. Therefore, birth will be approximately 1-2 hours from this point, and the answer of 4-5 hours is incorrect. It is not appropriate to call the health care provider at this stage, and the nurse should not leave the client alone to do so.

A nurse should administer an I.M. injection to a 6-month-old infant in the vastus lateralis muscle.

The nurse should give the injection in the ventrogluteal area only in a child who has been walking for about 1 year. The deltoid and gluteus maximus muscles aren't appropriate injection sites in children.

School-aged children enjoy board games and are commonly intense about following rules.

Their play can become emotional. Adequate rest is of utmost importance during the acute stage of rheumatic fever. Therefore, playing a game with another child probably would be too strenuous. Such diversional activities as reading a book, playing with a doll, and watching television would be more satisfactory.

Lightening occurs

about 1 to 2 weeks before the beginning of labor

Subconjunctival hemorrhage results from

damage of capillaries around the eye seen in blunt eye trauma. Impaired vision, eye pain, and hyphema can be manifestations of blunt eye trauma. A nasal fracture can cause subconjunctival hemorrhage and nasal pain (not eye pain). A basilar skull fracture can cause subconjunctival hemorrhage and impaired vision. It can result in abnormal pupil size but is unlikely to cause eye pain or hyphema.

To assess the frequency of the client's contractions, the nurse should assess the interval from

the beginning of one contraction to the beginning of the next contraction. The duration of a contraction is the interval between the beginning and the end of a contraction. The acme

While examining an 11-month-old child, the nurse notes that the child can stand independently but cannot walk without support. How should the nurse intervene? Do nothing because this is a normal finding in a child this age. Initiate a consultation with a developmental specialist. Tell the mother that the child may have a developmental delay. Recommend the child uses a walker at home.

1 An 11-month-old child is expected to cruise but not necessarily walk without support. Use of a walker at home are not recommended because they may tip and increase the risk for falls. A developmental specialist consult is not necessary. Even if the child's development in walking is slow, this fact is not sufficient data to make the nurse suspect developmental delay.

Which food should the nurse teach a client with heart failure to limit when following a 2-gram sodium diet? canned tomato juice apple hamburger whole wheat bread

1 Canned foods and juices such as tomato juice are typically high in sodium and should be avoided in a sodium-restricted diet. Canned foods and juices in which sodium has been removed or limited are available. The nurse should teach the client to read labels carefully. Apples and whole wheat breads are not high in sodium. Hamburger would have less sodium than canned foods or tomato juice.

The nurse is assessing a 5-year-old client and wants to gain the client's cooperation. Which actions are appropriate for the nurse? Save the more intimidating or intrusive parts of the assessment, such as eyes, ears, and genitalia, until the end of the assessment. Tell the child not to be afraid because it will not hurt. Tell the child that prizes are given for good behavior. Perform a head to toe assessment, just as for an adult.

1 It will be of no benefit to tell the child not to be afraid. Instead work to develop trust. Begin the assessment with growth and developmental assessments such as building with blocks or drawing. Save the more intrusive and frightening parts of the assessment until the end, after trust and rapport has been developed. Prizes may be given, but should be given no matter the behavior of the child.

The nurse lifted up a neonate from the bassinet. The neonate became startled, extended the arms with hands open and started crying. What intervention would be most appropriate for the nurse? Document the finding as a normal response. Give the neonate a pacifier. Do a complete neurological examination. Contact the health care provider.

1 The Moro or startle reflex is present in all neonates up until 3 to 4 months of age. It has three components: spreading out the arms (abduction), pulling the arms in (adduction), and crying. With the arms outstretched, the palms of the hands are up and open with the thumbs being flexed. This reflex occurs as a response to a sudden loss of support. It is a normal response, so the nurse would document as such. There is no need to notify the health care provider or do a neurological exam. A pacifier will not prevent the Moro reflex but it may help soothe the neonate after being startled. Even though it is a caring intervention it is not the most important. The most important is to know if the reflex is present or absent.

The client had an ostomy created 3 days prior. The nurse is planning to teach the client how to empty the ostomy pouch. What is the best time for the nurse to conduct the teaching? the time that the nurse and client mutually agree upon just prior to the end of the nurse's shift at the time the nurse perceives he or she will have time to conduct the teaching before the client's lunch

1 The time to conduct the teaching should be mutually agreed upon by the nurse and client in order for the teaching to be most effective. Performing the teaching just prior to the end of the nurse's shift does not take into account when the client would feel most comfortable with the teaching. While it is important that the nurse has the time to conduct the teaching, it is also important that the client feels it is a good time for the teaching to occur. Conducting the teaching right before lunch does not take into account the client's feelings on when is a good time for the teaching to occur. Additionally, if the client is hungry, attention to the teaching might be hindered. Teaching is most effective when it occurs during a mutually agreed upon time.

During the toddler years, food preferences and appetite are changeable.

A child may enjoy one food for several days in a row, then suddenly refuse to eat it again for days. Attempts to alter such food fads are met with resentment and obstinacy.

A client has given birth to an 8 lb 2.5 oz (3,700 g) infant. A newborn infant requires 110 to 120 cal/kg/day. What is the minimum number of calories per day this neonate requires? Record your answer using a whole number.

A newborn infant requires 110 to 120 calories/kg/day. It is important in newborns to calculate fluid and caloric requirements exactly, rather than rounding up or down. There are no differences in caloric requirements for males versus females. Because the question asks about the minimum, base the calculation on 110 calories/kg/day. First find the weight in kilograms: 3700 g = 3.7 kg. Now find the daily minimum calories: 3.7 kg × 110 calories/kg/day = 407 calories/day.

What data indicates to the nurse that placental detachment is occurring?

An abrupt lengthening of the cord, an increase (not a decrease) in the number of contractions, and an increase (not a decrease) in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus. Relaxation of the uterus is not an indication for detachment of the placenta.

Annual Papanicolaou testing is a screening to detect potential precancerous and cancerous cells in the endocervical canal of the female reproductive system.

HPV causes genital warts, which are associated with an increased incidence of cervical cancer. Recurrent candidiasis, pregnancy before age 20, and use of oral contraceptives do not increase the risk of cervical cancer.

Hyphema and vision impairment both suggest potential damage to the iris and should be addressed immediately.

Hyphema occurs when blood vessels in the iris are damaged and blood seeps into the anterior chamber of the eye, causing pain, blurry vision, and a pink-coloring of vision. An orbital fracture could cause inward displacement of the globe of the eye. The globe of this client's eye is not displaced, but imaging will be needed after the initial treatment to determine if a fracture is present. Ecchymosis (black eye) and swollen eyelids are minor injuries that can be addressed once more serious injuries are assessed and treated.

Between 24 and 28 weeks' gestation, the client is evaluated for gestational diabetes. A 50-g glucose load is administered, and the plasma glucose levels are checked at 1 hour.

If the results are more than 130-140 mg/dL (7.2-8 mmol/l), such as with this client, further testing such as the 3-hour glucose tolerance test is needed to determine gestational diabetes. The American Diabetes Association says that if the fasting glucose is greater than 95mg/dL (5.3 mmol/L) and the glucose level at 1 hour is greater than 180 mg/dL (10 mmol/L), the 3-hour test is not warranted, because this is a definitive diagnosis of gestational diabetes. A definitive diagnosis would need to be made before the nurse can give diet instructions or teach insulin administration.

The nurse is evaluating an infant for auditory ability. What is the expected response in an infant with normal hearing? blinking and stopping body movements when sound is introduced

In response to hearing a noise, normally hearing infants blink or startle and stop body movements. Shy and withdrawn behaviors are characteristic of older children with hearing impairment. Squealing occurs in 90% of infants by age 4 months. Most infants can say "da-da" by age 9 months.

The symptoms of osteoarthritis most commonly result from "wear and tear"—excessive and prolonged mechanical stress on the joints.

Increased weight increases stress on weight-bearing joints. Therefore, an obese client with osteoarthritis should be encouraged to lose weight.

The school nurse is counseling a female client who is concerned about an incident that occurred at a school dance. The young client describes becoming drowsy and disoriented after drinking punch and waking up hours later in the back of a stranger's car. What is the most appropriate advice for the nurse to give the adolescent? "It's possible that you were raped and will need information on pregnancy testing."

It is highly likely that the punch contained flunitrazepam, a date rape drug. It is colorless, odorless, and tasteless. The effects are drowsiness, impaired motor skills, and amnesia, making the victim an easy target for rape.

The mother says that the infant's primary care provider recommends certain foods, but the infant refuses to eat them after breastfeeding. How should the nurse suggest that the mother alter the feeding plan? Allow the infant to nurse for a few minutes and then offering solid foods.

It is typical for an infant just starting on solid foods to spit them out because the infant does not know how to swallow them. Also, the infant is hungry and is accustomed to having milk to satisfy that hunger. It is generally recommended that an infant be given some milk first and then offered solid foods.

Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not unusual for clients to exhibit a loss of control or irritability.

Leg tremors, nausea, vomiting, and an urge to bear down also are common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia has been given; however, it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when the client begins bearing-down efforts.

Tubal ligation, a female sterilization procedure, involves ligation (tying off) or cauterization of the fallopian tubes through a small abdominal incision (laparotomy).

Reversal of a tubal ligation is not easily done, and the pregnancy success rate after reversal is about 30%. After a tubal ligation, the client may engage in intercourse 2 to 3 days after the procedure. The ovaries are not generally removed during a tubal ligation. An oophorectomy involves removal of one or both ovaries.

A 2-year-old child usually can kick a ball forward.

Riding a tricycle is characteristic of a 3-year-old child. Tying shoelaces is a behavior to be expected of a 5-year-old child. Using blunt scissors is characteristic of a 3-year-old child. Add a Note

STIs are most prevalent among teenagers and young adults.

STIs are most prevalent among teenagers and young adults, and nearly two thirds of all STIs occur in people younger than 25 years. The incidence of STIs is increasing due to multiple sex partners and sexual activity at a younger age. STIs affect men and women of all backgrounds and economic levels.

what types of activities the 3-year-old child should be able to do ride a tricycle

The nurse should expect the child to ride a tricycle because at age 3 gross motor development and refinement in eye-hand coordination enable a child to perform such an action. The fine motor skills required to lace shoelaces and the gross motor skills required for throwing a ball overhanded and jumping rope develop around age 4.

A primiparous client diagnosed with cystitis at 48 hours postpartum who is receiving intravenous ampicillin asks the nurse, "Can I still continue to breastfeed my baby?" What should the nurse tell the client? "You can continue to breastfeed as long as you want to do so."

The client can continue to breastfeed as often as she desires. Continuation of breastfeeding is limited only by the client's discomfort or malaise. Antibiotics for treatment are chosen carefully so that they avoid affecting the neonate through breast milk. Drugs such as sulfonamides, nitrofurantoin, and cephalosporins usually are not prescribed for breastfeeding mothers. Manual pumping of the breasts is not necessary.

client has breast engorgement and should instruct the client to perform which measure?

The client should be instructed to express milk from the nipples either by hand or with a breast pump to stimulate milk flow and relieve the engorgement. As soon as the areola is soft, the client should begin to breastfeed. Frequent feedings with complete emptying of the breasts should alleviate engorgement.

teaching plan for a primiparous client who asks about weaning her neonate?

The client should wean the infant gradually, eliminating one feeding at a time. The baby can be weaned to a bottle (formula) anytime the mother desires; she does not have to breastfeed for 4 months. Most infants (and mothers) develop a "favorite feeding time," so this feeding session should be eliminated last. The client may wish to begin weaning with daytime feedings when the infant is busy.

A client to the emergency department with reports of acute GI distress, bloody diarrhea, weight loss, and fever. A family history of what would be significant to this client's diagnosis? ulcerative colitis

The client's symptoms are suggestive of ulcerative colitis, and a family history of ulcerative colitis, particularly if the relative affected is a first-degree relative, is a risk factor. A family history of peptic ulcers, celiac disease, or appendicitis would not be a risk factor.

What should the nurse teach the client with neutropenia to avoid? using suppositories or enemas

The neutropenic client is at risk for infection, especially bacterial infection of the respiratory and gastrointestinal tracts. Breaks in the mucous membranes, such as those that could be caused by the insertion of a suppository or enema tube, would be a break in the first line of the body's defense and a direct port of entry for infection. The client with neutropenia is encouraged to wear a HEPA filter mask and to use an incentive spirometer for pulmonary hygiene. The client needs to know the importance of completing meticulous total body hygiene daily, including perianal care after every bowel movement, to decrease the flora at normal body orifices. The client also needs to know the importance of performing oral care after every meal and every 4 hours while the client is awake to decrease the bacterial buildup in the oropharynx.

The mother of a 10-year-old girl with diabetes asks the nurse's advice about whether or not her child, who has always been compliant with treatment, should be allowed to go trick-or-treating on Halloween with several friends. The nurse should tell the mother: "Yes, she needs to be with friends and do the things other children do."

The nurse should advise the mother to allow the child to go trick-or-treating. Children need to be treated like their peers. Sheltering them from all temptation does not allow them the opportunity to develop coping strategies for dealing with the restraints made necessary by their disease.

"Research suggests that vaccinations are helpful to prevent the spread of influenza."

The nurse should base the answer in science and evidence. The nurse should not focus on potential trouble with management, as this may seem threatening. While the effectiveness is limited to the targeted strains, this is not the most relevant information in the scenario. Healthcare professionals are prioritized for flu vaccines along with those with risk factors.

No matter how far the client's pregnancy has progressed by the time of the first prenatal visit, the nurse should teach about danger signs during pregnancy so the client can identify and report them early, helping to avoid complications.

The nurse should discuss other topics just before they're expected to occur. For example, the nurse should teach about labor techniques near the end of pregnancy; signs and symptoms of pregnancy shortly before they're anticipated, based on the number of weeks' gestation; and any tests a few weeks before they're scheduled.

While assessing the fundus of a multiparous client on the first postpartum day, the nurse performs handwashing and dons clean gloves. What should the nurse do next? -Place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus.

The nurse should place the nondominant hand above the symphysis pubis and the dominant hand at the umbilicus to palpate the fundus. This prevents uterine inversion and trauma, which can be very painful to the client. The nurse should ask the client to assume a supine, not side-lying, position with the knees flexed. The fundus can be palpated in this position, and the perineal pads can be evaluated for lochia amounts. The fundus should be massaged gently if the fundus feels boggy. Vigorous massaging may fatigue the uterus and cause it to become firm and then boggy again. The nurse should ask the client to void before fundal evaluation. A full bladder can cause discomfort to the client, the uterus to be deviated to one side, and postpartum hemorrhage.

A parent brings a child to the clinic with symptoms of weight loss, paleness, fatigue, and not growing. What question about the child's environment should the nurse ask the parent based on these symptoms? "How old is the house that you live in?"

The nurse should suspect lead poisoning in this situation. Many of the symptoms are the same as other illnesses, but the key is living in the older home. Lead poisoning occurs through older lead pipes and drinking water from those pipes. Lead is also found in the dirt in areas surrounding homes where lead pipes and lead paint have been used. The symptoms of lead poisoning include weight loss, being tired all the time, difficulty concentrating, and abdominal pain. The concern for living near a hydroelectric facility would be methylmercury poisoning. The symptoms of this would include lack of coordination, speech impairments and muscle weakness. The type of pets in the home could indicate symptoms of a disease such as asthma. The concern for being a single parent would be one of financial need and not being able to purchase nutritious foods for the child.

While a 31-year-old multigravida at 39 weeks' gestation in active labor is being admitted, her amniotic membranes rupture spontaneously. The client's cervix is 5 cm dilated, the presenting part is at 0 station, and the electronic fetal heart rate pattern is reassuring. What should the nurse do first?

The nurse's first action when membranes rupture spontaneously is to check the odor, consistency, and volume of the amniotic fluid. Because the fetal head is engaged and at 0 station, there is little likelihood of cord prolapse. However, when the fetal head is not engaged, checking for cord prolapse would be the priority when the membranes rupture spontaneously. After rupture of the membranes, vaginal examinations should be kept to a minimum to decrease the chance of infection. Birth is not imminent if the client is 5 cm dilated. However, multigravid clients may progress quickly in labor, especially after rupture of the membranes.

What would the nurse expect to find during the physical examination of a preterm male neonate born at 28 weeks' gestation? thin, wasted appearance

The premature neonate characteristically exhibits a thin, wasted appearance.The premature neonate commonly exhibits a scarcity of scalp hair.In the premature male neonate, testicles are typically high in the inguinal canal and absence of rugae on the scrotum is typical.

taking-in phase

The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by the responsibilities of caring for the neonate while still fatigued from childbirth. Taking-hold is the next phase, when the mother has rested and she can think and learn mothering skills with confidence. During the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate. Depression may occur during this stage.

the taking-hold phase

The taking-in phase is the period after birth characterized by the women's dependency and passivity with others. Maternal needs are dominant and talking about the birth is an important task. The new mother follows suggestions, is hesitant about making decisions, and is still preoccupied with her needs. The taking-hold phase is the period after birth characterized by a woman becoming more independent and most interested in learning how to care for her infant. Learning how to be a competent parent is an important task. The letting-go phase is an interdependent phase after birth in which the mother and family move forward as a family system, interacting together.

Helping the client function at his or her best is most appropriate and realistic.

There is no known cure for Parkinson's disease. Parkinson's disease progresses in severity, and there is no known way to stop its progression. However, many clients live for years with the disease: and it would not be appropriate to start planning terminal care at this time.

When dealing with a crying client, the best approach is to talk to the caregiver first then to the toddler.

This approach helps the client get used to the nurse before attempting any procedures. It also gives the client an opportunity to see that the caregiver trusts the nurse. Ignoring the crying and screaming may be the second step. The nurse should encourage the caregiver to hold the client because it will likely help the situation. The last resort is to bring in assistance so the procedure can be completed quickly.

Molding occurs with vaginal births and is commonly seen in newborns.

This is especially true with primigravid clients experiencing a lengthy labor process. Parents need to be reassured that it is not permanent and that it typically lasts a day or two before resolving. Molding rarely is present if the fetus is in a breech or brow presentation. Surgical intervention is not necessary.

Slight relaxation and increased mobility of the pelvis are normal during pregnancy and are caused by the ovarian hormone relaxin.

This may cause the pregnant woman to feel unstable while walking, which has definite safety implications for a long-distance runner. The symphysis pubis may also separate. While some may, not all muscles weaken, and long bones do not increase in density. The spinal column does not flatten; rather, as the fetus grows, there is increased fetal weight and the maternal belly protrudes causing lordosis (in the lumbar region, an abnormal forward curvature of the spine).

Toddlers have temper tantrums in their attempt to develop autonomy.

Toddlers should be left alone as long as they are safe during a tantrum. Moving the child to a time-out chair or punishing the child reinforces the behavior and is to be avoided. Attempting to talk to the toddler also reinforces the behavior. Additionally, at this cognitive level, toddlers do not understand as well as older children do.

Early pregnancy classes, which typically focus on maternal nutrition, minor discomforts of pregnancy, and newborn nutrition, are appropriate for clients seeking early obstetric care

Typically, couples begin attending these classes during the first trimester. This allows the woman to incorporate proper nutritional guidelines into her diet. The couple then has ample time to decide the method of choice for feeding the newborn. Most clients make the decision to breastfeed or bottle-feed by the sixth month of pregnancy.

Which nursing approach is most helpful to a client with Parkinson disease who is experiencing a freezing of gait with difficulty initiating movement? Tell the client to march in place.

When a freezing gait occurs, having the client march in place or step over actual lines, imaginary lines, or objects on the floor can promote walking. Instructing the client to take one step backward and two steps forward may also stimulate walking. Pulling the client forward can cause imbalance. The nurse does not instruct the client to use a wheelchair. The client obtains much exercise as possible; having the client remain still does not help the client obtain the momentum needed to walk.

The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders.

X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait, whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia.