W5 Quiz 1

The nurse is discussing the principles of hospice care to the family of a terminally ill pediatric client. Which parental statement would the nurse clarify as a misconception?

"My son will still receive aggressive treatments for a cure." ✓

A 14-year-old boy has come to his primary care physician's office for a routine well-child visit with his mother. Which statement by the mother should the nurse prioritize for further investigation after noting the father has a history of alcoholism?

"Our next door neighbor is older than my son, and he drinks when they hang out together." ✓

When caring for a child who is dying, which statement by the child leads the nurse to believe that the topic of death needs to be discussed further?

"The bogeyman is going to come and fly me away." ✓

A new mother of a newborn girl calls the clinic in a panic, concerned about the blood- tinged soiled diaper. What is the best response from the nurse?

"This can be from the sudden withdrawal of your hormones. It is not a cause for alarm." ✓

The newborn weighing 6 lb 6 oz (2856 g), now weighs 5 lbs 14 oz (2632 g), 2 days later. Which response should the nurse prioritize to address the mother's concerns about the weight loss?

"This is a normal response." ✓

A graduate nurse has provided care for a pediatric client who has died. Which statement to the family would require further discussion between the graduate nurse and the registered nurse (RN) mentor?

"This reminds me of the time my aunt died." ✓

The mother calls the nurse to check her baby after noting the right side of the body is dark red while the left side of the baby is pale. Which question to the mother should the nurse prioritize when assessing the situation?

"Was the baby recently crying?" ✓

The caregiver of a 3-year-old boy presents at the receptionist desk and reports her child nauseated. In interviewing the child's caregiver, which question should the nurse prioritize when starting the assessment?

"Why did you decide to bring your son to the clinic today?" ✓

A young mother is concerned for her baby and asks the nurse if her baby is okay. What is the best response if the nurse notes: RR 66, nostrils flaring, and grunting sounds during respiration?

"Your baby is having a little trouble breathing. I'll let the RN know." ✓

The LPN is preparing to assist the RN with the initial admissions assessment of the newborn. The nurse should explain to the new mother that this will be completed in what time frame after birth?

2 hours ✓

The young mother is nervous about discharge with her first child. The nurse encourages the mother by pointing out various instructions, including to call her health care provider if the newborn does not void within which time period?

24 hours 12 hours

The nurse receives a report from labor and delivery on an infant and mother couplet. Which reported Apgar score will the nurse prioritize for close observation for the entire transition period?

5 at 1 minute; 6 at 5 minutes ✓

A 2-year-old child with a 3-day history of diarrhea is brought to the urgent care by the caregiver. The nurse determines the child's temperature is within the normal range after assessing which measurement?

96.6°F (35.8°C) ✓

Which physical assessment data would the nurse find concerning and would warrant reporting to the physician?

A blood pressure of 128/80 in a preschool-aged child ✓

The parents of a newborn are concerned that the different procedures are causing pain for their newborn. Which action should the nurse prioritize to address the parent's concerns?

Advocate and use effective treatment methods that cause no pain or less pain. ✓

An 8-month-old infant in being held by her mother and the nurse needs to obtain her vital signs. Which approach would most likely ensure accurate readings?

Allow the mother to continue to hold the infant, listen to the child's heart rate, count respirations by the abdominal rise, then take an axillary temperature.

The parents of a newborn male are questioning the nurse concerning the pros and cons of a circumcision. Which disadvantage should the nurse point out to these parents?

Anesthetic may not be effective during the procedure ✓

The nurse notes the following on a newborn's assessment: poor muscle tone, jitteriness, and temperature 97.0 F (36.1 C), HR 120 bpm, RR 26 breathes per minute, and blood pressure 60/40 mm Hg. Which nursing action should the nurse prioritize?

Assess the infant's blood sugar. ✓

The nurse is assisting with the physical exam on a 2-year-old child. The nurse predicts the order of the exam will be in which sequence?

Back and extremities; head and neck; then the eyes, ears, nose, and mouth ✓

The parents of a terminally ill child ask the nurse how to have a conversation about illness. Which is the most appropriate concept for the nurse to base the response?

Be direct, using age-appropriate language the child can understand. ✓

The nurse is observing an infant and notes that the infant is restless, wide-awake but quiet. The mother reports that her baby often is awake for hours at a time and is very fidgety. How would the nurse respond to her observation?

Because the mother reports that the infant's behavior is normal, there is no need for further observation. ✓

The nursing student is preparing to explain the appropriate steps for assessing an infant. The instructor determines the student's presentation is successful after illustrating which location as appropriate for obtaining an apical pulse?

Between the sternum and the left nipple ✓

The nurse has completed an assessment on a 1-day-old newborn. Which finding should the nurse prioritize?

Blood sugar 42 mg/dL ✓

The nurse is caring for a child in the emergency department who is on a cardiac monitor. Which nursing action should the nurse prioritize?

Confirm the alarms are set with maximum and minimum settings. ✓

The parents are concerned their newborn appears to be cold all the time. The nurse should point out the infant is best helped by which primary method in the first few days?

Brown fat store usage ✓

A 30-minute-old newborn starts crying in a high-pitched manner and cannot be consoled by the mother. Which action should the nurse prioritize if jitteriness is also noted and the infant is unable to breastfeed?

Check blood glucose. ✓

The nurse is teaching a prenatal class illustrating the steps that are used to keep families safe. The nurse determines the session is successful when the parents correctly choose which precaution to follow after the birth of their infant?

Check the identification badge of any health care worker before releasing baby from room. ✓

The emergency room nurse is caring for a family who lost an adolescent in a violent car accident. Which initial nursing action best helps the family's grieving process?

Cleaning and making the deceased presentable to the family ✓

The nurse is conducting a preadmission class for a group of parents on the safety features that are utilized to help prevent infant abduction. The nurse should prioritize which factor as most essential to ensure the program's success?

Cooperation by the parents with the hospital policies ✓

The nurse is preparing discharge instructions for the parents of a male newborn who is to be circumcised before discharge. Which instruction should the nurse prioritize?

Cover the glans generously with petroleum jelly. ✓

As part of an admission to the pediatric floor, the nurse gathers a lifestyle history. What components would be included in this part of the client history? Select all that apply.

Custody of the child if parents are divorced ✓ Habits such as thumb sucking or nail biting ✓ The child's grade in school ✓

A toddler is brought to the pediatric clinic by the caregiver because the child 'doesn't feel well.' As the nurse interviews the caregiver about why the client is there, which goal is the nurse prioritizing at this point?

Determining the chief complaint ✓

The nurse is assessing a newborn's vital signs and notes the following: HR 138, RR 42, temperature 97.7 F (36.5 C), and blood pressure 78/40 mm Hg. Which action should the nurse prioritize?

Document normal findings. ✓

The nurse is assisting new parents adjust to the birth of their first child. The parents appear hesitant to pick up the baby, stating they are afraid they will make the baby cry. What is the best response if the nurse discovers the infant is lying relatively still with eyes wide open, looking at the parents?

Encourage the parents to pick up the baby ✓

A new mother is learning how to change the diaper on her newborn and becomes concerned after observing a rash on the trunk of the infant. Which response should the nurse prioritize?

Explain this is normal. ✓

The nurse is escorting the newborn to the transition nursery for the initial assessment and care. The nurse is prepared to carefully monitor the infant during the transition period, which occurs at which time interval?

First 6 to 12 hours ✓

The nurse is caring for a child admitted with a head injury and is conducting the ongoing assessment. The nurse prepares to utilize the Glasgow coma scale to achieve which priority nursing intervention?

Have a comparison of the child's status from one check to another ✓

The parents are bonding with their newborn when the nurse notes the infant's axillary temperature is 97.2 F (36.2 C) an hour after birth. Which intervention should the nurse prioritize for this family?

Help the mother provide kangaroo care. ✓

The LPN assists the RN while performing the Ortolani maneuver on a newborn. When asked by the mother the reason for this maneuver, which is the best response from the nurse?

Hip for dislocation ✓

The nurse is assessing a 5-month-old infant at a well-child visit. In measuring and weighing the child, the nurse will prioritize which action?

Hold one hand within 1 inch (2.54 cm) of the child. ✓

The nurse is preparing the nursing care plan for a newborn who was born via a cesarean delivery. Which diagnosis should the nurse prioritize?

Ineffective airway clearance related to mucus and secretions ✓

Which result should the nurse prioritize for further action?

Infant C - 48 mg/dL ✓

The nurse is caring for a newborn after the parents have spent time bonding. As the nurse performs the assessment and evidence-based care, which eye care will the nurse prioritize?

Instill 0.5% ophthalmic erythromycin. ✓

The nursing instructor is teaching a class on the physiologic properities involved with the birthing process. The instructor determines the session is successful when the students correctly match surfactant with which function?

It keeps alveoli from collapsing with breaths. ✓

The nurse is conducting an assessment on a newborn and witnesses a startled response with the extension of the arms and legs. The nurse should document this as which response?

Moro ✓

The nurse is responding to an infant crying and notes it is very high pitched and shrill. The nurse predicts this is most likely related to which situation?

Neurologic dysfunction ✓

The nurse is initiating the assessment of a new child to the pediatric clinic. The nurse will prioritize which section of the assessment in the beginning?

Obtaining biographical data ✓

The nurse is teaching new parents how to clear the secretions from their infant's mouth and nose. The nurse determines they are prepared when they correctly perform which initial step?

Position the newborn on side with head slightly below body; use a bulb syringe to clear mouth. ✓

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system?

Pressure changes occur and result in closure of the ductus arteriosus. ✓

The nurse is conducting a prenatal class explaining the various activities which will occur within the first 4 hours after birth. The nurse determines the session is successful when the couples correctly choose which reason for the use of an antibiotic ointment?

Prevent infection of the umbilical cord ✓

Which technique will best foster the initial communication between the nurse and a school-aged child recently told of a cancer diagnosis?

Provide supplies for the child to draw a picture. ✓

The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered?

Redness at the base of the umbilical cord ✓

The nurse is caring for a new mother and newborn in a rooming-in unit and watches the mother put the infant in its bed, lying on its side, propped up with a pillow. The nurse should point out that this position can increase the risk of which situation?

Sudden infant death syndrome ✓

A mother observes the office nurse charting her son's height and weight on a growth chart and asks the nurse the purpose of plotting this information for her child. The nurse would reply with which explanation?

The height and weight of each client is plotted on a growth chart at each visit to note how the child is growing and compare the growth to the norm.

The nurse is preparing new parents and their infant for discharge by answering questions and presenting basic discharge instruction. Which explanation should the nurse provide when questioned about the infant's yellow hue?

The tint is due to jaundice. ✓

The mother of 2-year-old triplets is anxious and worried because one of the trio does not seem to be developing at the same rate as the other two. Which assessment finding would lead the nurse to question the need for further diagnostic testing for this child?

The tops of her ears are below the corners of her eyes. ✓

The nurse is admitting to the intensive care unit a child who arrives on cardiac monitor, pulse oximeter, and an IV infusion. As the nurse begins collecting data on the child, which nursing interventions should the nurse prioritize?

Verify that the alarms on the monitor are still properly set. ✓

The parents of a 1-day-old newborn are concerned the infant is cold and shivering. Which action should the nurse prioritize to best prevent heat loss?

Warm all surfaces and objects that come in contact with the newborn. ✓

The nurse is giving a newborn his first bath. What should the nurse prioritize?

Wash off all traces of blood and leave the vernix in place. ✓

The nurse is preparing to assess the pulse on a newborn who has just arrived to the nursery after being cleaned in the labor and birth suite and swaddled in a blanket. Which action should the nurse prioritize?

Wear clean gloves. ✓

The nurse is teaching a prenatal class and illustrating some of the basic events that will happen right after the birth. The nurse should point out which action will best help the infant maintain an adequate body temperature?

Wrap the infant in a warm, dry blanket. ✓

The nurse is interviewing the mother of a child who is at the local clinic. When asked why she brought her toddler in today, she replies that he has been running a fever and coughing a lot since last weekend. This information would be noted in the chart as what data?

chief complaint ✓

The nurse walks into a client's room and notes a small fan blowing on the mother as she holds her infant. The nurse should explain this can result in the infant losing body heat based on which mechanism?

convection ✓

The nurse is explaining to new parents the various injections their newborn will receive before being discharged home. Which injection should the nurse teach the parents about that will help decrease the incidence of hepatic disease later in life?

hep B ✓

The nurse is conducting an assessment on a newborn male and the parents' question why the nurse is using a penlight to examine the scrotal sac. The nurse should point out this helps to eliminate which potential disorder?

hydrocele ✓

The infant born at 5 a.m. has moved to the transition phase and is progressing well. The nurse documents a HR 130, RR 42, axillary temperature 99.5 F (37.5 C), and blood pressure 60/40 at 6:45 a.m. When should the nurse plan to reassess the infant's vital signs?

in 30 minutes ✓

The African American parents are spending time with their newborn after the nurse brings the baby back from the transition nursery. The parents are horrified to note that their infant's buttocks appears bruised and demand to know what happened. The nurse should explain this is related to which factor?

mongolian spots ✓

The nurse notes a newborn has a temperature of 97.4 F (36.3 C) on assessment. The nurse takes action to prevent which complication first?

respiratory distress ✓

The new mother is holding her infant, speaking softly and gently stroking the baby's face. She giggles and asks the nurse why the baby turns toward her finger when she strokes the cheeks. The nurse should explain that this is which common newborn reflex?

rooting ✓

An infant born via a cesarean delivery appears to be transitioning well; however, the nurse predicts that she will note which common assessment finding in this infant?

tachypnea ✓

The nurse prepares to give the first bath to a newborn and notes a white cheese-like substance on the skin. The nurse should document this as which substance?

vernix ✓

The nurse is preparing the delivery room before the birth occurs. What supplies would the nurse have available to care for the newborn? Select all that apply.

Identification bands ✓ Suction equipment ✓ Warmer bed ✓

The nurse asks the parents of a child about the family health history. The father asks the nurse why she needs his information. The nurse would explain that the family health history is gathered for what reason?

Identifying risk factors in families decreases the child's risk of developing the same conditions or health problems. ✓

The nursing instructor is monitoring the nursing students as they role-play conducting assessments on children and their caregivers. The instructor determines the session is successful after witnessing the students collect the necessary subjective data during which portion of the assessment process?

Interviewing the child's caregiver ✓

The nurse is explaining to the new parents the various substances which will be administered to their newborn within a few hours of birth. Which explanation should the nurse prioritize as the best rationale for administering vitamin K?

Provides blood clotting factors ✓