Data Collection EAQ
A nurse suspects that a newborn has toxoplasmosis, one of the TORCH infections. How and when may it have been transmitted to the newborn? Correct1 In utero through the placenta 2 In the postpartum period through breast milk 3 During birth through contact with the maternal vagina 4 After the birth through a blood transfusion given to the mother
1 In utero through the placenta Toxoplasmosis is caused by a parasitic protozoon that is acquired from inadequately cooked contaminated food or through handling of infected cat feces; the most common form of transmission to the newborn is by way of placental perfusion when in utero. There is no evidence that toxoplasmosis is transmitted in breast milk. The newborn does not contract toxoplasmosis from the maternal genital tract during the birth process. There is no evidence that toxoplasmosis is transmitted in blood transfused into the mother.
What must the LPN observe first when planning to promote mother-infant attachment? Correct1 Mother-infant interaction 2 Mother-father interaction 3 The infant's physical status 4 The mother's ability to care for her infant
1 Mother-infant interaction The extent and quality of the mother-infant interaction is believed to be a predictor of positive or negative attachment behavior . Mother-father interaction, the infant's physical status, and the mother's ability to care for her infant are also assessed but are not as significant as mother-infant interaction.
Which condition is an example of a deformation that affects a child's growth and development? 1 Cleft lip Correct2 Club foot 3 Ectodermal dysplasia 4 Congenital amputation
2 Club foot Congenital anomalies can affect a child's growth and development. There are many types of congenital anomalies. A deformation such as a club foot occurs due to extrinsic mechanical force on developing tissue. A cleft lip is an example of a malformation. Ectodermal dysplasia occurs due to abnormal organization of cells. Congenital amputation is an example of disruption.
The nurse is collecting data from a 6-year-old child during a well-child visit. After interacting with the child's mother, the nurse suspects that the child requires psychiatric screening. Which statement by the mother supports the nurse's conclusion? 1 "My child cheats in games to win." 2 "My child steals red colored objects." Correct3 "My child still wets the bed at night." 4 "My child is jealous of his younger brother."
3 "My child still wets the bed at night." Bedwetting is an abnormal behavior in a 6-year-old child. It may be caused by stress or fear and a psychiatric evaluation may help determine the root of the problem. A 6-year-old child is still learning about appropriate behaviors and to monitor his or her emotions. For this reason it is natural to see a child cheating to win a game, stealing attractive objects, or feeling jealous when a younger sibling receives attention. These behaviors do not warrant psychiatric evaluation.
Which stage of psychosocial development should an individual successfully master to achieve self-control and willpower, according to Erikson's theory? 1 Trust versus mistrust 2 Initiative versus guilt 3 Industry versus inferiority Correct4 Autonomy versus shame and doubt
4 Autonomy versus shame and doubt In the autonomy versus shame and doubt stage, the child becomes more independent and develops autonomy by making choices. Limiting the choices and enacting harsh punishment leads to feelings of shame and guilt. Therefore, the individual who succeeds at this stage will achieve self-control and willpower. Success in the trust versus mistrust stage results in faith and optimism in the individual. The successful resolution of the initiative versus guilt stage results in direction and purpose. Failure during the industry versus inferiority stage results in the development of a sense of inadequacy and inferiority.
A nurse reviews the history of a client who is hospitalized with a diagnosis of urinary calculi and identifies which factor may have contributed to the development of the calculi? 1 Increased fluid intake 2 Urine specific gravity of 1.017 Correct3 History of hyperparathyroidism 4 Jogging 3 miles a day
Correct3 History of hyperparathyroidism Hyperparathyroidism results in high serum calcium levels; as the blood is filtered through the nephron, precipitates of calcium may form calculi. Increased fluid intake will discourage stone formation by preventing stagnation of urine. A urine specific gravity of 1.017 is within the expected range of 1.010 to 1.030 and will not increase the risk of developing urinary calculi. A jogging schedule of 3 miles daily reduces the risk of developing urinary calculi; activity improves glomerular filtration and inhibits calcium from leaving the bone.
The nurse sees a 4-year-old girl with a webbed neck and short stature. What could be the probable finding in genetic testing? 1 The child has mutated chromosome 47 with XXX inheritance. 2 The child has mutated chromosome 47 with XYY inheritance. Correct3 The child has mutated chromosome 45 with XO inheritance. 4 The child has mutated chromosome 48 with XXXY inheritance.
3 The child has mutated chromosome 45 with XO inheritance. Webbed neck and short stature are characteristic features of Turner's syndrome. The child may have mutated chromosome 45 with XO inheritance. Children with triple X or superfemale chromosomal abnormality may have mutated chromosome 47 with XXX inheritance. This condition is manifested as impaired language and mental capacity. Children with mutated chromosome 47 with XXY inheritance may have Jacobs XYY chromosomal abnormality, which is associated with normal sexual development and aggressive sexual tendencies. Children with mutated chromosome 48 with XXXY inheritance may be tall with deficient secondary sex characteristics. This condition is called Kleinfelter syndrome.
The nurse is caring for a client who has been diagnosed with glomerulonephritis. What initial urinary finding supports this diagnosis? 1 Anuria 2 Dysuria 3 Polyuria Correct4 Hematuria
4 Hematuria Blood in the urine (hematuria) and red blood cell casts are classic manifestations of the onset of glomerulonephritis because of the increased permeability of the vascular bed in the kidneys. Suppression of urine formation (anuria) is not an initial manifestation of glomerulonephritis; oliguria may be present. Pain or burning on urination (dysuria) is indicative of cystitis, not glomerulonephritis. Excessive urination (polyuria) does not occur as an initial change with glomerulonephritis; polyuria and nocturia may occur later with chronic glomerulonephritis when the renal structures are destroyed.
A preschooler insists on having breakfast alone, even though the child is unable to eat properly. Which stage of psychosocial development best describes the behavior of this child? 1 Initiative vs. guilt 2 Trust vs. mistrust 3 Industry vs. inferiority Correct4 Autonomy vs. shame and doubt
Correct4 Autonomy vs. shame and doubt Autonomy vs. shame and doubt is a stage in which the child gains some basic control over self and environment. Therefore, this behavior of the child to eat alone without help from the parent indicates that the child is in the autonomy vs. shame and doubt stage. Success at this stage results in sense of self-control, adequacy, and willpower. In the initiative vs. guilt stage, the child becomes purposeful and directive. Trust vs. mistrust is a stage in which the child develops attachment to the mother. Developing social, physical, and learning skills is the characteristic feature of the industry vs. inferiority stage of psychosocial development.
A client who has been taking diuretics is admitted to the hospital with hypokalemia. For which clinical findings should the nurse assess the client? 1 Hyperactive reflexes 2 Bounding, irregular pulse 3 Nausea, vomiting, and diarrhea Correct4 Leg weakness and muscle cramps
Correct4 Leg weakness and muscle cramps Muscular weakness and cramps may occur with hypokalemia because impulse conduction of skeletal muscles is impaired. An adequate level of potassium is necessary for effective functioning of the sodium-potassium pump. Hyperactive reflexes indicate hyperkalemia, not hypokalemia. The pulse is weak and irregular with hypokalemia because of an impaired conduction system in cardiac muscle. Diarrhea is caused by hyperkalemia, not hypokalemia.
