Chapter 18 Foundations:Conception through Adulthood PrepU

The pregnant young adult asks the nurse when she will be able to hear the fetal heart beat. Which is the nurse's best response?

"At your 12-week appointment, you will be able to hear the heart beat by Doppler."

A father is concerned because his 3-year-old daughter has been using the bathroom independently for the past 6 months but has had a few "accidents" since her hospitalization. Which of the following is the nurse's best response?

"Her regressive behaviors are a reaction to being hospitalized."

Today you are caring for Jerry, a 3-year-old boy, who is admitted with a respiratory infection. His mother, Mrs. Baker, is a single parent and works. She can only be with Jerry during the late afternoon and evening. Today she tells you that Jerry has been toilet trained for a year and she is very surprised and disappointed that he is wetting and soiling his bed now. Your best reply would be which of the following?

"His regression is normal and is related to stress."

The mother states to the nurse, "My 4-year-old daughter keeps saying she is going to marry her father when she grows up. Should I be concerned about this behavior?" Which is the nurse's best response?

"It is normal behavior for a 4-year-old to be attracted to her father."

The mother of a girl 6 years of age is exasperated at her daughter's persistent enuresis. How can the nurse best respond to this mother's concern?

"Most children outgrow their bedwetting at around your daughter's age or shortly after."

Today the pediatric clinic nurse gets Mrs. Johnson and her 20-month-old son, Jackson, settled in an exam room. Mrs. Johnson tells the nurse that the biggest problem she faces now is Jackson's refusal to let her out of his sight. "He screams and cries if he thinks I am gone". She asks if she should be concerned about this. Your best reply is which of the following?

"Separation anxiety is normal at 18 to 24 months."

You are teaching a "Preschool Childcare" class and Tiffany, one of the parents, asks when her toddler will have all of her baby teeth. Which of the following responses would be appropriate?

3 years

When a nurse is working on a pediatric unit, which of the following clients would the nurse know has the greatest need for good nutrition?

5 month old

A neonate has a heartbeat of 92 beats/minute, good respiratory effort, active motion, a vigorous cry, a pink body, and blue extremities. Based upon these findings, what Apgar score will this neonate receive?

8

A nurse is assessing toddlers in a community health care clinic. Which toddlers would the nurse refer for follow-up care?

A 2-year-old who cannot kick a ball. A 1-1/2-year-old whose arms and legs are not increasing in length. A 1-year-old who does not pick up small objects with fingers.

A nurse is assessing neonates in a hospital nursery. Which neonates are exhibiting normal characteristics? (Select all that apply.)

A neonate displays the Moro and stepping reflex. A neonate eliminates urine and stool. A neonate exhibits both an active crying state and a quiet alert state. The neonate inherits a transient immunity from infections from the mother.

A 2 year old tells the nurse that she "needs a Band-Aid" where she had an injection. Which of the following interventions is the best nursing action?

Apply a Band-Aid upon request

Of the following components of psychosocial development in the neonate and infant, which one facilitates emotional linkage between a baby and caregiver?

Bonding

Which of the following statements explains how pregnancy affects the growth and development of the adolescent?

Affects the normal physical and maturation processes

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops soon after conception. An accurate statement from you about the embryonic stage would be which of the following?

All basic organs are established here

You are teaching a "care of the infant" class and Kelly, one of the members, asks what kinds of physical things her infant be learning to do in the first year. Which of the following responses would be appropriate? Choose all that apply.

Ambulation may start Crawl on all fours Stack building blocks

The nurse is teaching child safety and nutrition to a group of young parents at a public health clinic. In answer to a question about childhood obesity, the nurse talks about the incidence of childhood obesity related to ethnic background. The nurse informs the group that although the incidence of obesity has risen by 50% in Caucasian children, it has risen more significantly in which of the following ethnic groups? Choose all that apply.

American Indian African American Hispanic American

A nurse is teaching parents of preschoolers about normal development for this age group. Which teaching points would the nurse include? (Select all that apply.)

By 6 years of age, the preschooler's head is close to adult size. The preschooler's body is less chubby and more coordinated. The preschooler is able to skip, jump, and throw a ball.

Sexual abuse leads to serious health problems in adulthood. Which of the following does the nurse understand is the rationale for this?

Causes an imbalanced stress reaction and immune system

You are teaching a "care of the infant" class and Adrianne, one of the members, asks what kinds of physical changes will be happening to her infant during the first year. Which of the following responses would be appropriate? Choose all that apply.

Deciduous teeth begin to erupt Heart doubles in weight Body temperature stabilizes Birth weight usually triples by 1 year

A nurse is counseling pregnant women about the detrimental effects of smoking and drinking on a fetus. During what stage of development is the fetus most susceptible to these teratogens?

Embryonic stage

The nurse is caring for a female client 15 years of age who is hospitalized with a fractured ankle. Her father tells the nurse that this happened during a gymnastics lesson. He goes on to explain that every six or eight months it seems his daughter is trying something different; right now it is gymnastics. You know that this behavior fits with which of the following theorist's developmental tasks for adolescents?

Eric Erikson

The nurse is teaching a health and yoga class to a group of young adults. He is aware that the developmental tasks for this age group are centered around which of the following?

Establishing an intimate relationship and family

A nurse is instructing a group of adolescents and young adults about safety. Which of the following topics should be included?

Explaining that sports injuries are major causes of fatalities Reviewing the use of protection during sexual activity Instructing them about the dangers of bullying and gang involvement

Which of the following nursing activities is the most significant in assisting with transitioning from the adolescent to the young adult age group?

Facilitating healthy family relationships

Which would be an expected reaction from a 5 year old when his 3-month-old infant sibling dies from Sudden Infant Death Syndrome (SIDS)?

Guilt he may have caused the death

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops soon after conception. An accurate statement from you about the zygote and preembryonic stage would be which of the following?

Has a total of three distinct cell layers

Sleep habits have been implicated in cases of sudden infant death syndrome (SIDS). What instructions will the nurse provide to new parents related to positioning their infant for sleeping?

Healthy infants to up age 6 months should be positioned on their backs on a firm surface.

A school nurse is aware of the importance of creating and carrying out interventions that resonate with the developmental tasks of the adolescent population. Such interventions should appeal to adolescents' prioritization of their what?

Identity

A nurse is teaching a parenting class for parents with infants. What is an example of an appropriate teaching point for this developmental age?

If choking occurs, give back blows and chest thrusts or CPR.

Today you are caring for Amy, a 10-year-old, who is admitted for a fractured wrist (suffered during a soccer game) repair. She talks a lot about how well she is doing in school this year and her mother agrees. As you assess her developmental health, you know that Amy is well on the way to achieving which of the following according to Erik Erikson?

Industry

The school nurse is asked by the teacher to see Angela and her mother today. Angela is a 9-year-old who is in the 3rd grade. Angela has great difficulty with reading; she is one year behind her age group because she repeated her kindergarten year. The teacher's report indicates that Angela is becoming very withdrawn and depressed; the mother concurs. According to Erik Erikson's developmental theory, Angela is at risk for developing which of the following self-concepts?

Inferiority

The clinic nurse is seeing a female client 18 years of age who needs to renew her asthma prescription. The client tells the nurse that she is going to another state in a few weeks to attend college and will be living in a dorm. The nurse recommends which of the following while the client is being seen in the clinic?

Meningococcal vaccine

A school-aged child is attentive to following the rules at school, respects his teachers, and views justice as a means of fair play. These are characteristics of which type of development typical of this age group?

Moral development

The nurse is caring for a male client 17 years of age who was admitted to the intensive care unit with a gunshot wound to his head. He and his 17-year-old girlfriend had carried out a suicide pact. She died at the scene and Brett survived. The nurse recalls what she has read about the nation's teenagers and suicide. Which of the following are correct? Choose all that apply.

More prevalent in teenagers than other age groups Males succeed at suicide more often Third leading cause of death in ages 15 to 24 Females attempt suicide more often

While providing education to a young adult during an annual health exam, the nurse discusses health problems common during this stage of development. What is the most common cause of mortality during this stage?

Motor vehicle crashes

You are teaching a "care of the newborn" class and Jan, one of the members, asks a question about how newborns tolerate pain. Her baby is a male and she is concerned about how the circumcision will be done. Kate, another member, says that newborns do not feel pain, so not to worry. Which of the following is your best response?

Neonates feel touch and pain.

Which of the following topics for the client education of a pregnant woman should the nurse prioritize in an effort to promote healthy fetal development?

Nutrition

Accurate instruction regarding the typical growth and development patterns for adolescents would include which of the following guidelines?

Peer relationships characterize the adolescent years.

A school nurse is teaching a sexuality class to 5th- and 6th-grade girls. She talks about secondary sexual characteristics and explains that these are which of the following? Choose all that apply

Presence of body hair Breast development Facial hair growth in boys Voice changes in boys

Which of the following nursing interventions should the nurse perform when caring for an infant with fetal alcohol syndrome? Select all that apply.

Provide adequate nutrition Participation in developmental program Promote bonding with parents Monitor weight and head circumference

After assessing a female adolescent, a nurse collects the following data: development of breast tissue, growth spurt in height and weight, appearance of axillary hair, and initiation of menarche. Which stage of sexual development does this data confirm?

Pubescence

The nurse observes a hospitalized preschooler who clings excessively to his mother and uses infantile speech patterns. This child is exhibiting what type of behavior?

Regression

A toddler's mother exits the room to talk to the physician in the hallway. The nurse caring for the toddler notes that the child starts to cry when he no longer sees his mother in the room. He soon stops crying and appears saddened and depressed. The nurse recognizes this behavior as which of the following?

Separation anxiety

The nurse is conducting a preoperative assessment of a girl 5 years of age who is scheduled for surgery later that day. The nurse should be aware that the client's imminent surgery is likely to cause what?

Separation anxiety and fear of pain.

An 18 year old with a chronic illness tells the school nurse that he has recently started using marijuana with his friends on weekends. Which of the following should be the nurse's next action?

Teach him about effects of marijuana on his illness and potential complications with marijuana use

A nurse is counseling adolescents in a group home setting. Which statements accurately describe the cognitive and psychosocial development of this age group? (Select all that apply.)

The concept of time and its passage enables the adolescent to set long-term goals. According to Piaget, adolescence is the stage when the cognitive development of formal operations is developed. According to Havighurst, more mature relationships with boys and girls are achieved by the adolescent.

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops after the first trimester. An accurate statement from you about the fetal stage would be which of the following?

The heartbeat can be heard

Which of the following characteristics of a neonate would be reflected in her Apgar score?

The infant's hands and feet appear blue.

When assessing the health of a neonate, the nurse should be aware that:

The neonate hears and turns toward sound and can smell and taste.

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops soon after birth. An accurate statement from you about neonatal development would be which of the following?

The neonate is able to hear and turn toward sound

The nurse is caring for Michelle, a 15-year-old female, who was admitted for a concussion suffered while playing hockey. Her parents are at her bedside and appear very concerned about her. She ignores them for the most part and spends her time texting her hockey friends. Which of the following describes how her behavior is related to Erik Erikson's theory of growth and development?

The peer group acts as the greatest influence

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks about the advantages of breastfeeding. An accurate statement from you about breastfeeding would be which of the following?

Transient immunity is provided by breast milk

A nurse is choosing activities for a toddler who is hospitalized for tests. Which toy would be most appropriate for this patient?

Tricycle

You are working with a nursing student today, whose focus and goal for the day is to assess the developmental stages of his patients. The two of you are caring for a group of pediatric patients that includes a 2-year-old, a 7-year-old, and a 16-year-old. You and the student discuss Erik Erikson's development theory and you ask the student to put the following tasks and stages in chronological order.

Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority Identity versus role confusion Intimacy versus isolation

While teaching a sex education class to a group of preadolescents, the school nurse explains that human growth and development begins at which of the following events?

When ovum is fertilized by sperm

The nurse is teaching a class to pregnant adolescents and young adults. What does the nurse explain is the most important reason for breastfeeding instead of bottle feeding?

breastfeeding provides protection against infections

When counseling the young adult considering pregnancy, what does the nurse teach the client about nutrition?

foods high in folic acid help to prevent neural tube defects

At which stage of the pregnancy is the developing fetus most at risk for developing congenital anomalies?

embryonic stage

A 6-month-old infant visits the pediatric clinic for a well-baby checkup. The infant's father asks what the common health problems are for this age. The nurse's reply includes:

food allergies.

The school nurse is concerned about nutrition for school-age children. Which meal plan should be selected for a nutritious lunch?

grilled chicken with celery and carrot sticks and apple slices