Health Promotion and Maintenance 3

The nurse provides care for infants in the pediatric clinic. When teaching parents about developmental milestones, in which order does the nurse present the information? (Arrange developmental milestones in the proper order. All options must be used.) Responds to own name Pick up-bitesize pieces of cereal Takes deliberate steps when standing Begins drooling Doll's eye reflex disappears

Doll's eye reflex disappears (2-3 months) Begins drooling (4 months) Responds to own name (6-8 months) Takes deliberate steps when standing (9-10 months) Pick up-bitesize pieces of cereal (11 months) [First, the infant loses the doll's eye reflex at 2 to 3 months of age and can follow a moving object briefly. At about 4 months of age, the infant begins drooling as the gums swell and teeth erupt. The infant responds to name by 6 to 8 months of age. The infant will take deliberate steps when held up or after pulling self up to a standing position at 9 to 10 months of age. Lastly, an infant will pick up bite-size pieces of cereal at 11 months and deliberately put them in the mouth.]

During the summer, the nurse visits an assisted living facility for older adult clients. Which observation requires an intervention by the nurse? 1. A resident wears knee-high nylon stockings. 2. A resident wears a long-sleeved knit sweater. 3. A resident wears a rectangular floral neck scarf. 4. A resident wears walking shoes with laces.

1 [1) CORRECT — Knee-high nylon stockings constrict circulation to the extremities and promotes venous stasis. This can cause thrombi and pulmonary emboli. The nurse should encourage the resident to wear compression stockings or to wear simple cotton socks. 2) INCORRECT — The older adult client often experiences impaired tolerance for cold temperatures due to changes in circulation and thinning of the skin. This does not require an intervention. 3) INCORRECT — This does not require an intervention and would only be a concern if aggression or suicide is an issue. Scarves can add cheerfulness and individualization. 4) INCORRECT — This type of shoe is best for preventing falls. Laces ensure shoes can be adjusted properly and securely.]

The nurse is teaching a group of clients who are all over the age of 50 years about the screening tests for colorectal cancer. Which screening recommendation does the nurse include in the teaching? 1. Annual prostate-specific antigen. 2. Fecal occult blood every 3 years. 3. Colonoscopy every 10 years. 4. Barium enema every year.

3 [1) INCORRECT - Prostate-specific antigen is a test which may be used to help screen for prostate cancer. 2) INCORRECT - If fecal occult blood testing is selected as a screening for colorectal cancer, it should be done every year. 3) CORRECT - Clients who are 50 years of age or older should have a colonoscopy every 10 years. 4) INCORRECT - If a barium enema is selected as a screening for colorectal cancer, it should be done every 5 years.]

The nurse provides teaching to a pregnant client about varicose vein prevention. Which client statement indicates that the client needs further teaching? 1. "I cross my ankles." 2. "I wear tight socks." 3. "I elevate my legs." 4. "I change positions hourly."

2 [1) INCORRECT - The client should not cross legs at the thighs. Crossing legs at the ankle is acceptable. 2) CORRECT— Tight fitting socks that leave marks on the skin increase the risk of varicose veins. The nurse will re-teach the the client to wear support hose or elastic stockings and apply them before getting out of bed each morning. 3) INCORRECT - Elevation of the legs higher than 3 to 6 inches above heart level prevents varicose vein formation. 4) INCORRECT - Frequent position changes prevents varicose veins.]

The nurse provides care for a postpartum mother who has stopped breastfeeding her newborn. The client reports painful swollen breasts. Which nursing intervention does the nurse include in the client's plan of care? 1. Wear a snug-fitting supportive bra. 2. Have the client massage the breasts gently. 3. Place warm compresses on the breasts. 4. Expel some breast milk.

1 [1) CORRECT- To relieve the discomfort of breast engorgement, the mother can take mild analgesics such as ibuprofen, wear a supportive bra, and apply ice packs or cabbage leaves to the breasts. 2) INCORRECT- Massage would stimulate breast milk production and increase discomfort. 3) INCORRECT- Warm compresses on the client's breast would stimulate breast milk production and increase discomfort. 4) INCORRECT- Expelling some breast milk would stimulate breast milk production and increase discomfort]

The nurse provides care for a client during a wellness visit. The nurse teaches the client about the effects of stress. Which statement by the client indicates that teaching was successful? 1. "If I do not do something to relieve my stress, I am putting myself at risk for cancer or infection." 2. "My blood sugar level decreases when I am stressed, putting me at risk for hypoglycemia." 3. "Antianxiety medications are the only effective way to reduce stress." 4. "I will sleep my anxiety away."

1 (1) CORRECT— The effects of stress can suppress the immune system increasing the risk for cancer and severe infections. 2) INCORRECT— Blood glucose levels rise in response to stress as cells become resistant to insulin. 3) INCORRECT— A variety of strategies can reduce stress, such as eliminating the stressor or performing relaxation exercises, in addition to antianxiety medications. 4) INCORRECT— Excessive sleeping is a maladaptive coping strategy used to temporarily relieve stress. )

A client experiencing regular contractions reports "water breaking. " Which action does the nurse take first? 1. Auscultate the fetal heart rate. 2. Document the characteristics of the amniotic fluid. 3. Obtain the pH of the amniotic fluid. 4. Notify the health care provider.

1 (1) CORRECT— The priority is assessment of fetal well-being. This is completed by auscultating the fetal heart rate. This heart rate should range from 120 to 160 beats per minute. A heart rate above 160 beats per minute is an early sign of fetal hypoxia. A heart rate below 110 beats per minute is a later sign of fetal hypoxia, which could be caused by prolapse of the umbilical cord. 2) INCORRECT - Documenting the characteristics of the amniotic fluid is not a priority action. The fluid should be pale or straw-colored. Fluid that is green or brown in color should be reported. 3) INCORRECT - Measuring the pH of the amniotic fluid is not a priority action. A nitrazine test for pH is used to differentiate amniotic fluid from urine or other fluids. A normal pH of amniotic fluid is alkaline, or 7 and greater. 4) INCORRECT - The well-being of the fetus should be assessed before contacting the health care provider.)

The nurse prepares to administer the polio vaccine by intramuscular injection to a child. The parent says "I am afraid my child will get polio from the vaccine." Which response by the nurse is best? 1. "The vaccine cannot cause polio because it contains killed virus particles." 2. "The vaccine contains weakened toxins that produce an immune response, not polio." 3. "Do not worry, your child will not get polio from the vaccine." 4. "The vaccine contains live virus, but it is weakened so it will not give your child polio."

1 (1) CORRECT—The polio vaccine administered by the intramuscular route contains inactivated (or killed) polio virus. The organism causes an immune response, but is incapable of reproducing and causing infection. 2) INCORRECT - Toxoid vaccines, such as tetanus, contain weakened toxins that retain the ability to produce an immune response, but they cannot cause polio. 3) INCORRECT - The nurse should educate the parent about the vaccine, not dismiss the parent's concerns by telling the parent not to worry. 4) INCORRECT - The oral polio vaccine, not the polio vaccine administered by intramuscular injection, contains live attenuated vaccine. Live attenuated vaccines contains weakened organisms that produce an immune response, but not illness. However, people who receive the live attenuated vaccine can shed virus and spread the disease to individuals who are immunosuppressed.)

The nurse in the pediatric clinic instructs the parent of a preschool client diagnosed with asthma about preventative care. Which statement by the parent indicates to the nurse that further teaching is necessary? 1. "My child likes sleeping on the bottom bunk. " 2. "My child sleeps on a foam pillow and mattress. " 3. "I wash my child 's hair almost every night. " 4. "My child wears a mask while I vacuum the carpets. "

1 [1) CORRECT— Dust mites are a trigger for asthma. Fabric from bedding on the upper bunk can harbor dust mites. The child is not to sleep or lie down on upholstered furniture. Use furniture that can be wiped with a damp cloth such as wood, plastic, vinyl, or leather. 2) INCORRECT - This is an appropriate action, and encasing the mattress, box springs, and pillow in zippered, allergen-impermeable covers is the best action. 3) INCORRECT - This is an appropriate action if the child plays outside and the pollen count is high. It is best if the child changes clothes after playing outside. 4) INCORRECT - The child should not be in the room when cleaning occurs. It is preferable to remove carpets, but if removal is not possible, then vacuum once or twice per week.]

The nurse provides care to a preschool-age client admitted to the hospital for treatment of a respiratory infection. The client's parents are seated at the client's bedside. As the nurse prepares to perform chest auscultation, the client states, "I'm scared." Which action does the nurse implement? 1. Offer the client an opportunity to play with the stethoscope. 2. Explain to the client that there is no reason to be afraid. 3. Avoid discussing the client's plan of care to prevent escalating any sense of fear. 4. Ask the client's parents to leave the room during the assessment.

1 [1) CORRECT— To help alleviate the preschool client's sense of fear and anxiety, the client should be encouraged to play with medical objects when possible and appropriate. 2) INCORRECT - For clients of all ages, appropriate expression of emotions should be encouraged and validated. Rather than negating an expression of fear, for the preschool client, the nurse may opt to encourage the client to further express emotions by way of drawing a picture. 3) INCORRECT - The preschool client is inquisitive and capable of processing basic information about the plan of care. Prescribed treatments and procedures should be explained to the preschool client using terminology that is appropriate for the client's developmental stage. 4) INCORRECT - Asking the client's parents to leave the room may worsen the client's sense of anxiety and fear. Rather, for the preschool client, parents should be engaged and encouraged to participate in the client's plan of care.]

A nurse assesses a client at a prenatal checkup. The client is at 24 weeks' of gestation. Which finding causes the nurse to be concerned? 1. Facial edema. 2. Skin hyperpigmentation. 3. Lightheadedness. 4. Low back pain.

1 [Facial edema in a pregnant client is not an expected finding and could indicate developing pregnancy - induced hypertension. 1) CORRECT- Facial edema would most concern the nurse because it is an indication the client might be developing preeclampsia. Other findings the nurse should monitor for are elevated blood pressure, headache, visual disturbances, hyperactive reflexes, and right upper quadrant tenderness. 2) INCORRECT - Skin hyperpigmentation is an expected finding of pregnancy. The client should limit exposure to the sun and wear sunscreen when outdoors. 3) INCORRECT - Lightheadedness is an expected finding of pregnancy. The client should maintain adequate fluid intake, change positions slowly, and avoid lying on her side. 4) INCORRECT - Low back pain is an expected finding of pregnancy. The client should maintain good posture, use proper body mechanics, wear supportive shoes with low heels, and sleep on a firm mattress.]

The nurse discusses immunizations with a client in the third trimester of pregnancy. Which information is appropriate for the nurse to include? (Select all that apply.) 1. "Since you are not immune to rubella, you will get immunized after your baby is born. " 2. "If needed, you can get the tetanus vaccine while you are pregnant. " 3. "The pertussis vaccine should not be taken while you are pregnant. " 4. "While pregnant, you should receive the influenza vaccine during flu season. " 5. "If you are not immune to varicella, you should get the vaccination now. "

1, 2, 4 [1) CORRECT - Immunizations with live virus vaccines (such as measles, mumps, rubella, and varicella) are contraindicated during pregnancy because of possible teratogenic effects on the fetus. 2) CORRECT - Inactivated vaccines such as those for tetanus, hepatitis B, and influenza are safe for women who have a risk for developing these diseases. 3) INCORRECT - The Center for Disease Control (CDC) recommends that women who have not been previously vaccinated against pertussis receive the vaccine during the third or late second trimester. 4) CORRECT - Inactivated vaccines such as those for tetanus, hepatitis B, and influenza are safe for women who have a risk for developing these diseases. 5) INCORRECT - Immunizations with live virus vaccines (such as measles, mumps, rubella, varicella, and smallpox) are contraindicated during pregnancy because of possible teratogenic effects on the fetus.]

The nurse provides teaching to the parents of a newborn. Which parent statement requires an intervention by the nurse? (Select all that apply.) 1. "Since our baby seems to prefer formula to breast milk, I will stop breastfeeding." 2. "We will feed our baby formula until my breast milk comes in." 3. "If our baby continues to suck after the feeding, we can use a pacifier to soothe our baby." 4. "We will not give our baby a pacifier, due to an increased risk of sudden infant death syndrome (SIDS)." 5. "I will call the health care provider's office if my baby does not have at least six wet diapers per day." 6. "I will not worry if our baby's bowel movements are sticky and black at first."

1, 2, 4 [Pacifiers are encouraged since they help soothe the newborn, reduce the incidence of sudden infant death syndrome. 1) CORRECT — The nurse should recommend that the parents not offer formula if breastfeeding. The newborn may become confused and refuse breast milk. 2) CORRECT — Parents planning to breastfeed should not offer formula. The newborn will obtain nutrient-rich colostrum before the breast milk comes in. 3) INCORRECT — This is a correct statement, and the parents need no further teaching. 4) CORRECT — Pacifier use is associated with a reduced risk of SIDS, not an increased risk. 5) INCORRECT — This is a correct statement, and the parents need no further teaching. 6) INCORRECT — This is a correct statement describing meconium stools.]

The nurse provides care for a client on the second day postpartum. The client begins to experience breast engorgement. Which actions are appropriate for the nurse to implement? (Select all that apply.) 1. Instruct the client to express some milk to relieve the distention. 2. Remove the client 's bra to relieve pressure from the sensitive breasts. 3. Apply ice packs to the breasts between feedings. 4. Decrease fluid intake for 24 hours. 5. Increase the frequency of breastfeedings.

1, 3, 5 (1) CORRECT - The mother can express milk to get the milk flow started and soften the areola. The client may use a breast pump or manually express milk. 2) INCORRECT - The client should wear a well-fitting bra for support and comfort. 3) CORRECT- Cold applications between feedings and heat just before feedings may help to reduce discomfort and engorgement. 4) INCORRECT - To maintain milk supply, the mother needs to drink adequate fluid. 5) CORRECT - The client should feed more often —every 1½ to 2 hours. )

The nurse reviews the developmental milestones for a 20-month-old client. Which statements made by the parent indicate to the nurse that the family is ready for toilet training? (Select all that apply.) 1. "Diapers are usually dry when waking up from a nap." 2. "Wearing wet or dirty diapers does not bother my child." 3. "I am looking forward to taking the next 2 weeks off." 4. "Sitting still for 2 to 3 minutes is not a problem." 5. "Bowel movements occur any time during the day." 6. "Dressing and undressing are a favorite activity."

1, 3, 6 [Ready to be toilet trained? Client need to demonstrate bladder sphincter control and have the musculoskeletal status ability to adjust or remove clothing independently. Should begin when the child is interested in the potty chair or toilet. 1) CORRECT - Having dry diapers after a nap indicates the ability to stay dry when asleep. This is an indication the client is ready for toilet training. 2) INCORRECT - Tolerating a wet or dirty diaper does not indicate readiness for toilet training. A toddler indicates readiness by wanting the wet or soiled diaper to be changed immediately. 3) CORRECT - Parents have to have the time to devote to toilet training. This is an indication the family is ready for toilet training. 4) INCORRECT - The client should be able to sit on the toilet for 5 to 10 minutes without getting off for toilet training to be successful. 5) INCORRECT - Having regular bowel movements indicates readiness for toilet training. 6) CORRECT - The child needs the fine motor skills to be able to pull clothing up and down for toilet training to be successful. This is an indication the client is ready for toilet training.]

The nurse provides care for clients in the outpatient clinic. After testing positive for Chlamydia trachomatis, the client and spouse returned to the clinic for counseling. Which question is most important for the nurse to ask? 1. "Have you engaged in sexual activity with anyone else?" 2. "What is your understanding about the disease transmission?" 3. "Do you have questions about how the diagnosis was made?" 4. "What medications and substances are you allergic to?"

2 (1) INCORRECT - All sexual partners should be treated. The nurse may want to avoid asking this question while the couple is together. 2) CORRECT - It is most important for the nurse to assess the client's understanding first, as a part of educating the client. 3) INCORRECT - The nurse assesses current understanding, provides updated teaching, and then asks the client for clarifying questions. The diagnosis is performed using a tissue culture or enzyme immunoassay test. 4) INCORRECT - The client is treated with azithromycin or doxycycline. The nurse asks about allergies at the time that these medications are prescribed. It is not the priority in this scenario.)

The outpatient clinic nurse administers a tuberculin skin test (TST) to four adult clients. The nurse anticipates which client will likely demonstrate a false-positive response to the TST? 1. A client who received a herpes zoster (shingles) vaccine last week. 2. A client who received a bacille Calmette-Guerin (BCG) vaccine 1 month ago. 3. A client who regularly takes corticosteroid medication. 4. A client who was recently diagnosed with AIDS.

2 (1) INCORRECT - Recent administration of a live virus vaccine (including for prevention of herpes zoster [shingles], measles, and mumps) may cause a false-negative, not false-positive, response to a TST. The Centers for Disease Control and Prevention (CDC) recommends either administering the live virus vaccine on the same day as the TST or waiting 4-6 weeks after administration of the live virus vaccine to perform the TST. 2) CORRECT— Clients who receive a BCG vaccine, which prevents against the development of tuberculosis (TB), may demonstrate a false-positive response to a TST. 3) INCORRECT - Corticosteroid medications suppress the immune response. Clients who take corticosteroid medications are likely to demonstrate a false-negative, not false-positive, response to a TST. 4) INCORRECT - AIDS is characterized by profound suppression of the immune system. Clients diagnosed with AIDS are likely to demonstrate a false-negative, not a false-positive, response to a TST.)

The nurse assess a client who is at 24 weeks' gestation. Which finding causes the nurse to be most concerned? 1. Fetal heart rate of 130 to 140 beats per minute. 2. Fundal height at three fingers below the umbilicus. 3. Fetal movements felt faintly on lower part of abdomen. 4. The woman reports backache and leg cramps when sleeping.

2 (1) INCORRECT - The fetal heart rate at term ranges between a low of 110 to 120 beats/min and a high of 150 to 160 beats/min. The rate is higher in early gestation and slows as term approaches. 2) CORRECT- The fundus is expected to reach the umbilicus around 20 weeks and should be increasing in height above the umbilicus after 20 weeks. A fundal height of three fingers below the umbilicus indicates a fetal problem and would be a priority concern. 3) INCORRECT - Fetal movement, felt by the mother, is first perceived at 16 to 20 weeks' gestation as a faint fluttering in the lower abdomen. 4) INCORRECT - The pressure of the uterus on blood vessels impairs circulation to legs, causing muscle strain and fatigue that results in leg cramps. The enlarging uterus also alters the center of gravity, resulting in lordosis (exaggeration of lumbosacral curve), which causes backache in 45 to 59% of pregnant women.)

The nurse provides care for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red bleeding on the dressing. Which action is the first action for the nurse to take? 1. Put a clean, loose-fitting diaper on the newborn . 2. Apply gentle pressure to the penis. 3. Notify the health care provider. 4. Assess the newborn's pulse and blood pressure.

2 [1) INCORRECT - Since pressure is needed, you do not want a loose-fitting diaper on the newborn. 2) CORRECT - If excessive bleeding occurs, gentle pressure is applied to the site. 3) INCORRECT - If pressure does not alleviate the bleeding, the nurse will notify the health care provider, who may apply Gelfoam or epinephrine or may suture the small blood vessels. 4) INCORRECT - This provides more assessment data, but the nurse has already identified the issue as excessive bleeding. Obtaining this information does not stop the bleeding or protect the client from harm. ]

The nurse teaches a client newly diagnosed with latent tuberculosis (TB). Which statement by the client indicates that further teaching is needed? 1. "I'm glad I can't spread TB to anyone else right now." 2. "I'm glad I don't have to take any medication." 3. "My immune system stopped the TB from growing." 4. "The bacteria that cause TB can become active later."

2 [Latent disease is most likely to become active when the client experience periods of stress, lowered immunity, or prolonged illness. Prescriptions such as steroids or immunosuppressants can pose a risk to this client. The client is taught ways to stay healthy overall and advised to let any prescribing health care provider know about the latent TB infection. Standard treatment is 9 months of daily isoniazid. 1) INCORRECT- Clients with latent TB infection have no symptoms and do not spread TB to others. 2) CORRECT - Latent TB, if not effectively treated, can become active later and cause disease. Therefore, the statement by the client indicating that medication is not needed demonstrates the need for further teaching. 3) INCORRECT- With latent TB, the client's immune system stopped bacterial growth, causing the bacteria to become inactive in the body. 4) INCORRECT- With latent TB, the client's immune system stops bacterial growth, causing the bacteria to become inactive in the body. However, if not effectively treated, active TB can develop years later if the client's immune system weakens.]

A nurse prepares to perform blood pressure screenings at a health fair in the local community center. Which part of the preparation receives the most attention? 1. Ensure that there will be several quiet rooms near the main gathering area. 2. Collect blood pressure cuffs of varied sizes. 3. Arrange low-cholesterol snacks for participants. 4. Procure booklets that explain hypertension in simple language.

2 [preparation receives the most attention: since the blood pressure screening is being held for a variety of people, should prepare to have different blood pressure cuff sizes, will make measurement accurate. 1) INCORRECT— This may be useful to enhance the examiner's ability to hear the Korotkoff sounds and also to engage in discussion with participants. However, there is another answer that is a higher priority. 2) CORRECT — Having blood pressure cuffs of varied sizes is essential to ensure accurate blood pressure readings. People attending the fair almost certainly will vary in arm size. A cuff that is too small will produce a falsely high reading, while a cuff that is too large will produce a falsely low reading. The nurse will ensure the ability to obtain accurate readings. 3) INCORRECT— This may help attract people to have their blood pressure taken, but another action is a higher priority. 4) INCORRECT— Having written materials for later review is appreciated by many people, but another action is a higher priority.]

The nurse performs a 1-minute Apgar score for a newborn. Assessment reveals a crying newborn, heart rate of 138 beats/min, respiratory rate of 47 breaths/min without distress, arms and legs flexed, cough during suctioning, and pink torso with acrocyanosis. Which Apgar score does the nurse assign this newborn? 1. 6. 2. 7. 3. 8. 4. 9

3 [1) INCORRECT - This is not the correct score. 2) INCORRECT - This is not the correct score. 3) CORRECT - The Apgar score is based on five signs that indicate the physiologic state of the neonate: a heart rate above 100 equals a score of 2. A respiratory effort with a good cry equals a score of 2. For muscle tone, some flexion equals a score of 1. For reflex irritability, coughing during suctioning equals a score of 2. For skin color, acrocyanosis equals a score of 1. The total Apgar score for this newborn is 8. 4) INCORRECT - This is not the correct score. ]

The nurse reviews health promotion practices with a client. Which statement indicates that additional teaching is necessary? 1. "All of my meals should include foods recommended in each group of the food pyramid." 2. "I should limit my use of alcoholic beverages." 3. "Occasional exercise prevents obesity and high blood pressure." 4. "Minimizing exposure to sun and using lotions with sunscreens help prevent skin lesions."

3 [1) INCORRECT — Well-balanced meals help promote health. 2) INCORRECT — Limiting the intake of alcoholic beverages prevents alcohol-related illnesses. 3) CORRECT — Regular, moderate exercise prevents obesity and helps regulate blood pressure. 4) INCORRECT — Minimizing sun exposure and using sunscreen lotion reduces the risk of skin lesions and skin cancer.]

The nurse provides care for a pregnant adolescent client during the first antepartum visit. The nurse prepares a teaching plan for the client. Which instruction is most important for the nurse to include in the plan? 1. Inform the client of the benefits of breastfeeding. 2. Instruct the client to watch for the danger signs of preeclampsia. 3. Advise the client of the importance of consistent prenatal care. 4. Discuss with the client the need for increased iron in the diet.

3 [Adolescent client is still growing and physically developing, with the addition of a pregnancy, the adolescent's body may respond in unpredicatbale way, the only way to keep a close eye on the developing fetus and the impact this fetus has on the adolescent client is to conduct frequent and thorough assessments of fetal and client health throughout gestation. 1) INCORRECT - Although this is important information, it is not the priority information to convey during the first visit. 2) INCORRECT - Preeclampsia does not occur until after 20 weeks' gestation. This is not the priority information to convey on the first visit. 3) CORRECT - Early and regular prenatal care is the best way to ensure a healthy outcome for both mother and child. This is key information to convey during the first visit. 4) INCORRECT - Although the client may need to increase her iron intake, depending on laboratory values, this is not the priority information to convey on the first visit. ]

The office nurse meets with a high-school graduate who will be starting at a residential college in the fall. It is most important for the nurse to address which immunizations? 1. Diphtheria, tetanus toxoide, and acellular pertusis (DTaP). 2. Pneumococcal. 3. Meningitis. 4. Varicella.

3 [Meningitis is the inflammation of the meninges, which are protective coverings of the brain and spinal cord, that may result in infection caused by bacterial, viral, or fungal pathogens. Age is a factor that influences the risk of developing meningitis. 1) INCORRECT—A booster of the DTaP vaccine is needed 10 years after kindergarten, which is generally around 16 years of age. 2) INCORRECT - The pneumococcal vaccine is recommended primarily for older adults. 3) CORRECT - The meningococcal meningitis vaccine is recommended for college freshmen, especially if the student will be living on campus in residence halls or dormitories. 4) INCORRECT - The varicella or chickenpox vaccine is given to people over 13 years of age if they are susceptible, because they have not had the disease and have not been immunized.]

A 6-month-old infant is brought to the wellness clinic by parents for a routine visit. Which observation requires follow up by the nurse for evaluation of a possible developmental delay? 1. The infant cries and clings to the parent when the nurse is present. 2. The infant's weight has increased from 8 lb (3.6 kg) to 16 lb (7.3 kg) since birth. 3. The infant requires support from the parent in order to sit upright. 4. The infant abducts the extremities and fans the fingers when there is a noise. View Explanation

4 (1) INCORRECT - Crying in the presence of strangers and clinging to a parent or caregiver, which are reflective of stranger anxiety, are normal findings at 5-6 months. Stranger anxiety and associated behaviors peak at approximately 7-8 months. No follow up is needed. 2) INCORRECT - The infant's weight typically doubles by 5-6 months. This observation is a normal finding. No follow up is indicated. 3) INCORRECT - To sit upright, the infant typically will require support until 7-8 months of age. Because this observation is a normal finding, follow up is not needed. 4) CORRECT— The Moro reflex, which is an involuntary startle response, is strongest during first 2 months after birth. This reflex should disappear after approximately 4 months of age. Follow up is indicated, as a persistent Moro reflex may be indicative of altered neurological development. )

A neonate is treated in the newborn nursery for hyperbilirubinemia using phototherapy lights. Which situation requires immediate intervention by the nurse? 1. The parent turns off the phototherapy lights and removes the newborn 's eye patches in preparation for feeding. 2. The parent is worried because the newborn experiences frequent loose, greenish stools and increased urine output. 3. A laboratory technician turns off the phototherapy lights to draw the newborn's blood. 4. The jaundice observed around the newborn 's eyes and nose has begun to disappear.

4 (1) INCORRECT — No intervention is required in this situation. Turning off the light and removing the eye patches before oral feeding is appropriate. 2) INCORRECT — This is an expected finding. Loose, greenish stools and increased urine output reflect increased excretion of bilirubin, which indicates that the phototherapy is working. 3) INCORRECT — This is an appropriate action. Phototherapy lights must be turned off when blood is drawn to ensure accurate bilirubin measurements. 4) CORRECT — This indicates that the eye patches are not adequately placed or are not adequately opaque and are allowing light to enter. With phototherapy, eyes must be completely shielded with patches or an opaque mask in order to prevent exposure to the light, which could result in eye damage, especially to the retina.)

The home health nurse completes an assessment of a newborn. Which finding does the nurse expect during assessment? 1. "Machine-like" heart murmur. 2. Occipital frontal circumference 40 cm. 3. Bulging anterior fontanel at rest. 4. Extrusion reflex.

4 [1) INCORRECT - This indicates patent ductus arteriosus, an acyanotic heart problem. 2) INCORRECT - The normal circumference for a newborn's head is 33 to 35 cm. An enlarged circumference would suggest hydrocephalus or increased intracranial pressure. 3) INCORRECT - The fontanels should not bulge at rest, although they may bulge when the infant is crying. 4) CORRECT - A normal neonate reflex that disappears between 3 to 4 months of age, the extrusion reflex is the tongue moving outward when the tongue is touched.]