206-Exam 4
At what age does the birth rate usually double? a. 8 mo b. 6 mo c. 9 mo d. 12 mo
b
What is the correct amount of wet diapers a mature infant should produce each day? a. 1-2 b. 3-5 c. 6-8 d. 9-10
c
The nurse is watching a group of infants playing in an infant room at day care. When analyzing the developmental characteristics exhibited, which infant would the nurse identify as being approximately 3 months of age? a. infant picking up a toy and moving it between hands b. infant crawling to obtain a book c. infant playing peek-a-boo with a caregiver d. infant lying prone with a colorful toy in front
d
What client health history concern does the registered nurse (RN) identify when the healthcare provider orders methylergonovine (methergine) 0.2 mg every 4 hours for 5 doses to control early postpartum hemorrhage not responding to intravenous oxytocin? a. client's history of pancreatitis b. client's history of bronchitis c. client's history of asthma d. client's history of hypertension
d
What educational point presented by the registered nurse (RN) to the mother of a 30 weeks gestational newborn best explains the cause of respiratory distress syndrome (RDS)? a. "This is just what happens in the lungs of the baby that is born too early; just part of the way the body works." b. "This is a rare occurrence, even at 30 weeks gestation, but try not to worry; everything will be fine." c. "Because of the baby's age, the lungs are bigger than the chest cavity which keeps the lungs from expanding the way they need to." d. "Because the baby's lungs are not mature they are not able to produce the needed amount of surfactant which helps the lungs expand and fill with air easily."
d
What is Eriksons stage for toddlers? a. initiative vs. guilt b. identity vs. role conflict c. industry vs. inferiority d. autonomy vs. shame & doubt
d
The nurse correctly recognizes the sac protruding from the back that contains a portion of the spinal cord and nerves as which defect? a. Spina bifida occulta b. Myelomeningocele c. Encephalocoele d. Omphalacele
b
The nurse is assessing the motor skills of an infant who is 9 months old. Which motor skills should the nurse prepare to assess in an infant achieving normal growth and development milestones? a. startles then cries when hearing a loud noise b. is eating cereal with the thumb & index finger c. moves from prone to sitting to standing position d. can stand and walk around furniture
b
Which of the following conditions should the nurse include when discussing risk factors for UTI with a new nurse? SATA a. epidural anesthesia b. urinary bladder catheterization c. frequent pelvic exams d. Hx of UTI e. vaginal birth
a, b, c, d
Which of the following pts should the nurse recognize as the greatest risk for a development of a postpartum infection? a. a pt who experienced a precipitous labor less than 3 hrs in duration b. a pt who had premature rupture of membranes and prolonged labor c. a pt who delivered a large for gestation age infant d. a pt who had a boggy uterus that was not well contracted
b
The registered nurse (RN) is caring for a 26 year-old woman who delivered six hours ago and identifies which client labor/delivery factor that increases the woman's risk of developing early postpartum hemorrhage? Select all that apply. a. spontaneous labor/delivery b. placenta delivered intact c. labor lasted 22 hours d. 50 minutes third stage of labor e. woman delivering twins
c, d, e
Which assessment finding indicates a lack of improvement for the postpartum woman diagnosed with endometritis who has received antibiotic therapy for 48 hours? Select all that apply. a. increase in amount of lochia rubra b. decrease in abdominal tenderness c. presence of a heart rate of 116 d. oral temperature of 101 F (38.3 C) e. presence of foul-smelling lochia
c, d, e
A nurse is assessing a postpartum pt who is experiencing tearfulness, insomnia, lack of appetite, & feeling of letdown. Which of the following conditions are associated with these manifestations? a. postpartum fatigue b. postpartus psychosis c. letting go phase d. postpartum blues
d
A nurse is caring for a postpartum pt that delivered their 3rd baby 2 days ago. Which of the following manifestations indicate postpartum depression? SATA a. fatigue b. insomnia c. euphoria d. flat affect e. delusions
a, b, d
During a wellness visit for a 2 month old client, the nurse understands that which of the following developmental milestones should be met at this age? Select all that apply. a. Less head lag b. Kicking both feet c. Rolls from front to back d. Grabs object voluntarily e. Smiles/coos when seeing a familiar face
a, b, e
A nurse is performing a developmental screening on a 10 mo old. Which of the following fine motor skills should the nurse expect the pt to perform? SATA a. grasp a rattle by the handle b. try building a 2 block tower c. use a crude pincer grasp d. place objects into a container e. walk with one hand held
a, c
A nurse is assisting an assessment of a 32 week gestation newborn. The newborn weighs 1,100g. Which of the following findings are expected in the newborn? SATA a. lanugo b. long nails c. weak grasp reflex d. translucent skin e. plump face
a, c, d
A nurse working the postpartum unit is assessing a pt who was admitted for a suspected DVT. Which of the following clinical findings should the nurse expect? SATA a. calf tenderness to palpitation b. mottling of the effected extremity c. elevated temp d. area of warmth e. nausea
a, c, d
A nursing instructor is on the postpartum unit and is reviewing risk factors for postpartum hemorrhage with a group of nurses. Which of the following factors should the nurse include in their teaching? SATA a. precipitous delivery b. obesity c. inversion of the uterus d. oligohydraminos e. retained placental fragments
a, c, e
A nurse is caring for a pt who postpartum psychosis. Which of the following actions is the nurses priority? a. reinforce the need to take antipsychotic med as rx b. ask the pt if they have thoughts of harming themselves or their infant c. monitor the infant for indications of failure to thrive d. review the pts medical record for hx of bipolar disorder
b
A nurse is providing education about introducing new foods to the parents of a 4 mo old. The nurse should recommend that the parents introduce what food first? a. strained yellow veggies b. iron-fortified cereals c. pureed fruits d. whole milk
b
A new mother is concerned about the risk of her 6-month-old aspirating and choking. Which of the following should the nurse recommend to her? Select all that apply. a. don't prop up the baby's bottle when feeding him b. use only clothing without decorative buttons c. allow only toys that fit inside a toilet paper roll d. offer only unbuttered popcorn e. use only pacifiers that have 2 piece construction and small flange
a, b
A 12-month-old seen at a walk-in clinic weighed 8 pounds 4 ounces (3750 g) at birth. Weight now is 20 pounds 8 ounces (9300 g). The nurse determines: a. the child weighs less than expected for age b. the child weighs more than expected for age c. the child weighs the expected amount for age d. the weight assessment is bluntly inaccurate
a
A nurse is caring for a preterm newborn with respiratory distress syndrome. Which of the following should the nurse monitor to evaluate the newborn's condition following admin of synthetic surfactant? a. oxygen saturation b. body temp c. bilirubin level d. HR
a
A nurse is providing health promotion education to a family of an 11-month-old infant who is eating "finger foods." The nurse knows the parents understand the risk of infant choking when they state which response below? a. I can feed our baby Cheerios b. I can feed our baby popcorn c. I can feed our baby raisins d. I can feed our baby lollipops
a
A nurse is providing health promotion education to a family of an infant at the family birth center. The nurse knows the parents need more education when they state which response? a. I will switch to whole milk when by infant is around 6 months of age b. I will introduce soft foods for my infant around 6 months of age c. I will give my infant a drinking cup gradually around 6 months of age d. I will introduce new foods one at a time
a
A nurse is talking to and making facial expressions at a 9-month-old baby girl during a routine office visit. What is the most advanced milestone of language development that the nurse should expect to see in this child? a. The infant says "da-da" when looking at her father b. The infant squeals with pleasure c. The infant coos, babbles, and gurgles d. The infant imitates her father's cough
a
A staff nurse is talking about Piaget's theory with a nursing student. Infants are in the sensorimotor stage of cognitive development during which object permanence is mastered. An example of an infant displaying this ability is: a. look for a toy in her crib at the last place she saw it b. shaking a rattle to enjoy the sound c. pushing a spoon from her high chair tray to the floor d. smiling at herself in the mirror
a
The nurse conducting a 6-month well-baby check-up assesses for the presence/absence of the asymmetric tonic neck reflex. At this age the reflex: a. should have disappeared b. should be pronounced and easy to elicit c. is expected to appear within 1 month d. is a protective reflex and retained for life
a
The nurse expects to make which observation during a wellness check of an 18 month old child? a. The client can jump in place with both feet. b. The client can walk up steps with alternating feet. c. The client can ride a tricycle. d. The client can use scissors.
a
The nurse in a community clinic is caring for a 6-month-old infant and parent. Which nursing intervention is priority? a. monitoring the infant's weight and height b. encouraging a more frequent feeding schedule c. obtaining the infant's current feeding pattern d. recommending higher-calorie solid foods
a
The nurse is assessing the preschool child and recognizes which finding is indicative of hip dysplasia? a. Limp with a pelvic tilt b. Failure to walk c. Walking with the knees together d. Walking on the inside of the feet
a
The nurse is conducting a physical examination of an 8-month-old infant. Which observation may be cause for concern about the infant's neurologic development? a. the infant displays an asymmetric tonic neck reflex (fencing reflex) b. the infant grasps a finger when its placed in the palm c. the infant's toes hyperextend when the Botton of the foot is stroked d. the anterior fontanel is open and easily palpated.
a
The nurse should identify which of the following findings as an early indication of hypovolemia caused by hemorrhage in a postpartum pt? a. decreased BP & increased pulse b. dizziness & increased RR c. cool, clammy skin & pale mucus membranes d. altered mental status & LOC
a
What action shows an example of Erik Erikson's developmental task for the infant? a. The infant cries and the caregiver picks the child up. b. The infant cries when they have a wet diaper. c. The infant smiles as people walk past the crib. d. The infant plays the game peek-a-boo.
a
Which developmental milestone would the nurse expect an 11-month-old infant to have achieved? a. sitting independently b. walking independently c. building a tower of 4 blocks d. turning a door knob
a
Which of the following antepartum complication should the nurse understand is a risk factor of DIC? a. preeclampsia b. thrombophlebitis c. placenta previa d. hyperemesis gravidarum
a
Which of the following is a typical causative agent of mastitis? a. staphylococcus aureus b. chlamydia trachomatis c. klebisella pneumonia d. clostridium perfinges
a
A nurse is proving teaching about dental care and teething to the parent of a 9 mo old. Which statement by the parent indicates an understanding of the teaching? a. I can give my baby a warm teething ring to relieve pain b. I should clean by baby's teeth with a cool, wet wash cloth c. I can give ibuprofen for up to 5 days while my baby is teething d. I should place diluted juice in the bottle my baby drinks while they fall asleep
b
A nurse is teaching a new nurse about neonatal abstinence syndrome. Which of the following statements by the new nurse indicates an understanding of the teaching? a. the newborn will have decreased muscle tone b. the newborn will have a continuous high-pitched cry c. the newborn will sleep 2-3 hrs after feeding d. the newborn will have mild tremors when disturbed
b
A nurse on a home visit is providing safety tips to a family of a 1-week-old infant. Which of the following statements by the parents indicates the need for further teaching? a. we will place our infant in a rear-facing car seat in the back of the car b. we will position our infant on his side for sleeping c. we will swaddle our son to keep him quiet and warm to sleep d. we will give our son a pacifier before placing him in his crib
b
Babbling or being able to say words such as "Mama" or "Dada" is typical for which age? a. 5 months b. 9 months c. 10 months d. 12 months
b
If the infant is following a normal pattern of dentition, the child would most likely have how many teeth by the age of 14 months? a. 4 b. 6-12 c. 14-18 d. 24
b
The caregivers of an infant state that their child cries when her mother leaves for even a short amount of time. What might the nurse suggest as a way to console the infant and develop a sense of security when the child's primary caregiver is out of sight? a. Pick the child up as soon as she begins to cry. b. Play peek-a-boo with the child when happy. c. Slowly increase the amount of time allowed to cry before being picked up. d. Give her dolls and stuffed animals so she learns to distract herself.
b
The clinic nurse assesses which fine motor skill will be typically present in a 10 month old client? a. Prone to sitting position b. Beginning to use the pincer grasp c. Fully developed 2 finger pincer grasp d. Transfer object from one hand to another
b
The infant weighs 7 lb 4 oz (3,300 g) at birth. If the infant is following a normal pattern of growth, what would be the expected weight for this child at the age of 12 months? a. 14lb 8oz b. 21lb 12oz c. 25lb d. 28lb 40z
b
The nurse allows the 2-year old client to choose the hospital gown they would like to wear and the toy they want to take to the playroom. Which stage of Erikson's psychosocial developmental theory is the nurse addressing with these interventions? a. Trust versus Mistrust b. Autonomy versus Shame and Doubt c. Initiative versus Guilt d. Industry versus Inferiority
b
Which action by the nurse is a priority in a newborn just birthed with a myelomeningocele? a. Place the patient in supine with his legs slightly raised b. Cover the myelomeningocele with a moist sterile dressing c. Place the patient in a side-lying position with his legs raised d. Prepare the patient for immediate surgery; notify the provider.
b
A nurse is assessing a pt with postpartum depression. The nurse should expect which of the following manifestations? SATA a. paranoia that their infant will be harmed b. concerns about lack of income to pay bills c. anxiety about assuming a new role as a mother d. rapid decline in estrogen & progesterone e. feeling of inadequacy with the new role as a mother
b, c, d, e
Which clinical manifestation alerts the registered nurse (RN) to the development of respiratory distress syndrome (RDS) in a 32 week gestational age neonate 3 hours after delivery? Select all that apply. a. respiratory rate of 24 b. periods of apnea c. substernal retractions d. grunting respirations e. nasal flaring
b, c, d, e
Which vaccine will the registered nurse (RN) working in a pediatric clinic prepare to administer to a 4 year-old child preparing to begin pre-kindergarten? Select all that apply. a. human papillomavirus (HPV) b. measles, mumps, and rubella (MMR) c. varicella vaccine d. polio vaccine (IPV) e. diphtheria-tetanus-acellular pertussis (DTaP)
b, c, d, e
What vaccines should the nurse plan to admin to 4mo old at their WCC visit? SATA a. MMR b. IPV c. PCV d. Var e. RV
b, c, e
A nurse is assessing a 12 mo old at their WCC (well child check). Which of the following findings should the nurse report to the HCP? a. closed anterior fontanel b. 6 teeth c. birth weight doubled d. birth length increased 50%
c
A nurse is caring for an infant with a high bilirubin level and is receiving phototherapy. Which of the following is the priority finding in the newborn? a. conjunctivitis b. bronze skin discoloration c. sunken fontanels d. maculopapular skin rash
c
A nurse is teaching pt who breastfeeds and has developed mastitis. Which of the following responses should the nurse make? a. limit the amount of time the infant nurses from each breast b. nurse the infant only on the unaffected breast until it resolves c. completely empty each breast at each feeding or use a pump d. wear a tight fitting bra until lactation has ceased
c
The mother of a 16-month-old infant comes into the clinic and asks the nurse, "When will my baby play with toys by moving them from one hand to the other?" The nurse's response is based on knowledge that transferring objects from one hand to the other is normally accomplished by what age? a. 17 weeks b. 20 weeks c. 28 weeks d. 36 weeks e. 48 weeks
c
The nurse is reviewing the diet of an 8-month-old infant with the mother who reveals she has been using evaporated milk to make the formula. Which additional ingredient should the nurse ensure she is including in the formula? a. Vitamin D b. Vitamin E c. Iron d. Calcium
c
The nurse takes a call from a concerned mother whose infant received routine immunizations the day before and now has a temperature of 101oF (38.3oC), is fussy, and pulling at the injection site. The mother wants to know what she should do. Which is the best response from the nurse to this mother? a. you need to bring the baby to the ER to be sure he is not having an allergic reaction b. all babies have similar reactions but you should call back if he is still fussy in 24 hrs c. this is a common reaction. Give your child Tylenol, cuddle him, and apply a cool compress to the infection site d. you can give your child ice-cold fluids and cover the infection site so that he doesn't scratch the site and get it infected
c
A nurse assesses a 9 month old child during a wellness check. Which findings should the nurse report to the health care provider (HCP) for a follow up developmental screening? Select all that apply a. The client is unable to pick up a small cookie with the thumb and index finger. b. The client is unable to crawl up stairs. c. The client is unable to roll from front to back. d. The client is unable to "babble" words. e. The client is unable to transfer a rattle from one hand to another.
c, d, e
Realizing that late postpartum hemorrhage is a risk, which educational point will the registered nurse (RN) provide to the postpartum woman prior to her discharge home? Select all that apply. a. how to monitor abdominal tone and when to call the healthcare provider b. how to monitor vaginal odor and when to call the healthcare provider c. how to monitor the fundus and when to call the healthcare provider d. how to monitor color of lochia and when to call the healthcare provider e. how to monitor amount of lochia and when to call the healthcare provider
c, d, e
A nurse is providing discharge teaching to a pt with a UTI. Which of the following statements indicates the pt understands the teaching? SATA a. I will perform perineal care & apply a perineal pad in a back to front direction b. I will drink grape juice to make my urine more acidic c. I will drink large amounts of fluid to flush the bacteria from my urinary tract d. I will begin breastfeeding again after I finish the antibiotic e. I will take Tylenol for any pain or discomfort
c, e
A nurse is caring for a pt that is 42 weeks pregnant and in labor. The pt asks the nurse what to expect because the baby is post mature. Which of the following statements should the nurse make? a. your baby will have excess body fat b. your baby will have flat areola without breast buds c. your baby's heels will easily move to his ears d. your baby's skin will have a leathery appearance
d
A nurse is planning care for a pt who is postpartum experiencing thrombophlebitis. Which of the following nursing interventions should the nurse include in the plan of care? a. apply cold compress to affected extremity b. massage the affected extremity c. allow the pt to ambulate d. measure leg circumference
d
The infant weighs 6 lb 8 oz (2,950 g) at birth. If the infant is following a normal pattern of growth, what would be an expected weight for this child at the age of 12 months? a. 10lb 8oz b. 13lb c. 15lb 4oz d. 19lb 8oz
d
The new nurse needs more guidance about hydrocephalus and its correction when she makes which statement? a. "Mannitol will decrease fluid from the brain and cause it to go in the vascular space." b. "Avoiding flexing the patient will reduce raising his intracranial pressure." c. "Low Fowler position with neck stabilization is needed to reduce ICP." d. "Suctioning needs to be done frequently to reduce his secretions and pressure."
d
The nurse anticipates which orthopedic device will be utilized after surgical correction of hip dysplasia? a. TLSO brace (thoracic lumbar sacral orthosis brace) b. Pavlik harness c. Serial casting d. Spica cast
d
The nurse is educating a new parent regarding nutritional needs for the newborn. Which statement is accurate and should be taught regarding the nutritional needs of a newborn? a. Growth during newborn stage is slow, so fewer calories are needed then when the infant is older. b. Cow's milk is similar to breast milk in terms of calories and nutrients and is appropriate for the newborn. c. Newborns require additional water to supplement their diet if they are only formula feeding. d. Formula is designed to provide similar amounts of calories as breast milk would provide.
d
What stage according to Erikson is an 8 month old infant in? a. industry vs. inferiority b. autonomy vs. shame & doubt c. initiative vs. guilt d. trust vs. mistrust
d
When assessing a 6-month-old infant, which symptom will the nurse bring to the health care provider's attention? a. absent grasp reflex b. rolls from back to side c. balances head when sitting d. presence of Moro embrace reflex
d
Which of the following vaccines is recommenced for the newborn at birth? a. hepatitis A vaccine b. pneumococcal vaccine c. inactivated poliovirus vaccine d. hepatitis B vaccine
d
Which vitamin or nutrient is essential in preventing neural tube defects during pregnancy? a. Vitamin C b. Calcium c. Vitamin D d. Folic acid
d