Intro to maternity and pediatrics Chap 2, Intro to maternity and pediatrics Chap 3, Intro maternity and pediatric Chap 4, Intro to maternity and pediatric Chap 5, Intro to maternity and pediatric Chap 6, Intro to maternity and pediatrics Chap 7, Intr...

The nurse caring for a preterm infant will record the intake and output. The nurse is aware that what is the optimum output for this infant?

1 to 3 mL/kg/hr R: The optimum output for a preterm infant is 1 to 3 mL/kg/hr.

The nurse includes in the care plan for a Hispanic family to encourage visits from the ____________ ____________, or _______________ for a healing ceremony.

folk healer, curandero R: Hispanics have faith in the effect of the curandero and are soothed by the ceremonies.

The nurse reviews Accolate and Zyflo, which are _______________ _______________; they are capable of blocking the inflammatory response as well as providing bronchodilation.

leukotriene modifiers R: The leukotriene modifiers are capable of blocking the inflammatory response and can also provide bronchodilation.

A womans prepregnant weight is determined to be average for her height. What will the nurse advise the woman regarding recommended weight gain during pregnancy?

25 to 35 pounds R: The recommended weight gain for a woman of normal weight before pregnancy is 25 to 35 pounds.

At what point in prenatal development do the lungs begin to produce surfactant?

25 weeks R: During week 25, the alveoli begin to produce surfactant, which enables the alveoli to stay open for adequate lung oxygenation to occur.

The nurse is measuring the vital signs of a full-term newborn. Which finding is abnormal?

An apical pulse rate of 178 beats/min R: The normal range for a newborns pulse rate is 110 to 160 beats/min. A pulse rate outside of this range should be reported.

The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?

High-pitched cry R: There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.

An adolescents parent comments, My son seems so preoccupied with his appearance these days. Is this normal? What is the nurses best response?

His preoccupation with his looks is quite normal R: Preoccupation with self-image is normal and accounts for the constant primping of adolescents.

The nurse is reading a pregnant patients history and physical. What information does the nurse recognize might indicate the need for a cesarean delivery? (Select all that apply.) a. History of childhood rickets b. Immobile coccyx c. Prepregnant weight of 100 pounds d. Avid horse rider e. Pelvic fracture 3 years ago

History of childhood rickets Immobile coccyx Pelvic fracture 3 years ago R: Pelvic conditions that may predispose to a cesarean delivery are childhood rickets, pelvic fracture, and immobile coccyx.

How often should a child who has a continuous intravenous infusion should be assessed?

Hourly R: The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

A 16-year-old excitedly tells his parents that he was offered a part-time job. Which response represents an effective problem-solving approach for his parents?

How do you think you will manage your school work and a job? R: An effective approach to help adolescents learn to solve problems is for parents to guide them in exploring alternatives.

The parent of a toddler tells the nurse, My daughters appetite has decreased. Thank goodness she loves to drink milk. What is the most appropriate response by the nurse?

How much milk does she drink in a day? R: Milk should be limited to 24 ounces a day. Too few solid foods can lead to dietary deficiencies of iron.

What will the nurse expect when assessing the anterior fontanelle of a healthy, full-term newborn?

Open and diamond shaped R: The anterior fontanelle is diamond shaped and located at the junction of the two parietal and two frontal bones. It should not be raised or sunken, and it closes between 12 and 18 months of age.

At her 6-week postpartum checkup, a woman states, I am wondering about birth control. I used oral contraceptives before, and Im breastfeeding now. Can I use the pill again? What is the nurses best response?

Oral contraceptives can be taken once lactation is well established R: Oral contraceptives decrease breast milk production and are contraindicated until lactation is well established. Women who breastfeed their infants usually will not ovulate for 10 weeks and do not need contraception until that time.

What will the nurse tell parents of a child with a positive throat culture for group A hemolytic streptococcus that the treatment is most likely to be?

Oral penicillin for 10 days R: When a throat culture is positive for group A beta-hemolytic streptococcus, penicillin is administered for 10 days even if symptoms are alleviated before the medication is finished.

A mother tells the nurse, My 11-month-old son is not as active as my other children were at this age. He is the youngest of four and the older children love to dote on him. Which factor is influencing this childs language development?

Ordinal position R: Motor development of the youngest child may be prolonged if the child is babied by others in the family.

The nurse is caring for an Rh-negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?

She has had an Rh-positive infant and is pregnant with an Rh-positive fetus R: The only woman with antibodies against the Rh-positive infant is the Rh-negative woman who has had one Rh-positive child and is now pregnant with another.

At what age does an infants birth weight triple?

1 year R: The infant usually triples his or her birth weight by about 12 months of age.

Parents of an infant inform the nurse they are planning home preparation of solid foods. What directions should the nurse provide? (Select all that apply.) a. Boil foods in a large amount of water. b. Do not freeze foods. c. Add 1 teaspoon of salt per cup. d. Puree food in electric blender. e. Add sugar sparingly.

.d. Puree food in electric blender. e. Add sugar sparingly. R: Home-prepared infant food can be strained and pureed in an electric blender. Sugar should be added sparingly. Food should be boiled in small amounts of water and not over cooked to avoid destroying nutrients. Foods may be frozen in ice cube trays and defrosted for use.

After the membranes have ruptured, the nurse should assess the fetal heart rate (FHR) for ________ minute(s).

1 R: The FHR is checked for 1 full minute to ensure that the infant is not in distress from cord compression resultant from the lost buoyancy.

The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide?

1.4 R: 600,000_mL 5 mL 150,000 = 1.25 mL This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an infant.

The nurse is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters of the obstetric conjugate?

10 to 10.5 R: The obstetric conjugate is approximately 1.5 to 2 centimeters shorter than the diagonal conjugate.

During the second prenatal visit, the nurse attempts to locate the fetal heartbeat with an electronic Doppler device. How early might fetal heart tones be detected with an electronic Doppler device?

10 weeks R: The fetal heartbeat can be detected as early as 10 weeks of pregnancy using a Doppler device.

A couple just learned they are expecting their first child and are curious if they are having a boy or a girl. At what point of development can the couple first expect to see the sex of their child on ultrasound?

10 weeks gestational age R: The fetal period begins at the ninth week, and by the tenth week the external genitalia are visible to ultrasound examination.

The school nurse is planning a program for girls about the physical changes of puberty. Toward what age girl should this program be directed?

10 years R: Because puberty can occur in girls as early as age 10 years, instruction must be given by that age.

The nurse explains that Bryants traction is reserved for children who weigh less than _____ pounds.

30 R: Bryants traction is a skin traction used in the treatment of orthopedic disorders of young children who weigh less than 30 pounds. Greater weight would cause excessive counterbalance and injury to soft tissues.

The normal volume of amniotic fluid is approximately _______________ mL at 37 weeks gestation.

1000 R: The volume of amniotic fluid steadily increases from about 30 mL at 10 weeks of pregnancy to 350 mL at 20 weeks. The volume of fluid is about 1000 mL at 37 weeks. In the latter part of pregnancy the fetus may swallow up to 400 mL of amniotic fluid per day and normally excretes urine into the fluid.

The nurse advises the parents of a 6-year-old to try and ensure at least ______ hours of sleep daily for the child.

11 R: The 6-year-old school-age child needs at least 11 hours of sleep.

The nurse is instructing a Lamaze class on abdominal breathing and tells a patient that her baseline respiratory rate is 22 breaths per minute. What should be the patients rate while performing slow breathing?

11 R: The range of respirations should be no lower than half of the base rate and no more rapid than double the base rate.

The mother of a 7-year-old pediatric patient asks the nurse about her childs sleep requirement. What is the most accurate response by the nurse?

11 to 13 hours a night R: Sleep patterns vary with age. The neonate sleeps 8 to 9 hours per night and naps an equal amount of time during the day. The 2-year-old may sleep 10 hours during the night and have only one short daytime nap. The 7-year-old usually requires 11 to 13 hours of sleep and rarely has a daytime nap. These patterns may be altered by cultural practices.

After instilling nose drops, the nurse will keep the infant in the head down position for at least _________ seconds.

30 R: The retained position for 30 seconds to 1 minute allows the nose drops to enter deeply into the nostril.

What is the earliest age at which the infant should be able to walk independently?

12 to 15 months R: For the majority of children, the milestone of walking alone is achieved between 12 and 15 months.

The nurse stresses the need for using a sunscreen with a Sun Protection Factor (SPF) of at least _____.

15 R: A sunscreen with an SPF of at least 15 is recommended to block sun rays that cause cancer.

When planning an activity for a 3-year-old, the nurse bases the plan on the average attention span of _____ minutes.

15 R: The average attention span of the preschooler is about 15 minutes.

The nurse weighs a saturated perineal pad and finds it to weigh 15 grams. The nurse is aware that this indicates a blood loss of _____ mL.

15 R: The weight of 1 g in a perineal pad is equal to 1 mL of blood loss.

An infants birth weight is 7 pounds, 8 ounces. What can the nurse project the weight to be at 6 months?

15 pounds R: An infant usually doubles his or her birth weight by 5 to 6 months.

The order reads, Give ampicillin oral suspension 400 mg PO every day. The vial reads, Ampicillin 125 mg/5 mL. The nurse will give a dose of ______ mL.

16 mL

Which child would have the most difficulty in coping with separation from parents because of hospitalization?

16-month-old child R: Separation anxiety occurs after age 6 months and is most pronounced in the toddler.

A female patient reports her menstrual cycle consistently occurs every 32 days. What day of her cycle can the woman anticipate ovulation?

18 R: Ovulation occurs when a mature ovum is released from the follicle about 14 days before the onset of the next menstrual period.

At her initial prenatal visit a woman asks, When can I hear the babys heartbeat? At what gestational age can the fetal heartbeat be auscultated with a specially adapted stethoscope or fetoscope?

18 weeks R: The fetal heartbeat can be heard with a fetoscope between the 18th and 20th weeks of pregnancy.

The nurse in a pediatricians office is preparing to do a developmental assessment on a 3-month-old infant who was born at 36 weeks. The nurse knows that the infant should be evaluated in what month of achievement to adjust for the preterm birth?

2 R: The growth and development of a preterm infant are based on the current age minus the number of weeks before term that the infant was born.

How many hours should toddlers be able to stay dry for the nurse to suggest they are ready to begin bladder training?

2 R: If the toddler is mature enough to retain urine for 2 hours, bladder training can be effective.

A mother asks the nurse how much food should be offered to her 2-year-old. What is a good rule of thumb for serving size (in tablespoons) per year of age?

2 R: The rule of thumb for serving sizes is to offer 1 tablespoon of each food group per year of age.

Of what is the normal umbilical cord comprised?

2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus R: The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus.

When does the posterior fontanelle close?

2 to 3 months R: The posterior fontanelle closes between 2 and 3 months of age.

The nurse is educating a class of expectant parents about fetal development. What is considered fetal age of viability?

20 weeks R: By 20 weeks of gestation, the lungs have matured enough for the fetus to survive outside the uterus (age of viability).

The pediatric nurse is caring for child that weighs 15 kilograms and calls the physician for an order for Acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates ordering?

225 mg R: Acetaminophen is commonly used for the relief of mild to moderate pain in infants and children. The maximum dose is 15 mg/kg/dose for infants and children, with a maximum of 5 doses in 24 hours.

What is the total number of chromosomes contained in a mature sperm or ovum?

23 R: Gametes (sex chromosomes) contain 23 chromosomes.

Which situation would cause the nurse to suspect a hearing impairment?

24-month-old toddler who communicates by pointing R: The child who is not making verbal attempts by 18 months should undergo a complete physical examination.

The nurse is planning to explain the use of time-outs to the parent of a 3-year-old. How many minutes will the nurse indicate is appropriate for a child of this age?

3 R: Timing for time-out is usually based on 1 minute per year of age.

The nurse is checking for capillary refill on a child in Bryants traction. How long does it take for the toe to regain color if adequate perfusion is assessed?

3 seconds R: Capillary refill in 3 seconds or less is determined to be indicative of adequate perfusion.

What foods would be a healthy choice for an adolescent who just finished playing in a strenuous sports game?

A bagel and skim milk R: A bagel provides a rapid supply of carbohydrates to the muscles, and skim milk provides a slow release of carbohydrates to the muscles.

The nurse reminds the prenatal patient that she should add ________ kcal to her daily intake to nourish the fetus.

300 R: The recommended dietary intake increase is 300 kcal a day.

What does the nurse calculate the basal metabolic index (BMI) of an 8-year-old child who is 48 inches tall (1.2 meters) and weighs 100 pounds (45.4 kg) to be?

32.4 R: The formula for BMI calculation is weight in kg divided by height in meters (squared):45.4 (weight in kg) divided by 1.4 (1.2 squared) = 32.4. A BMI of over 30 is classified as obese.

A full-term newborn weighs 3600 grams at birth. What would the nurse expect the newborn to weigh in grams 3 days later?

3300 R: In the first 3 to 4 days of life, a newborn generally loses 5% to 10% of his or her birth weight.

The nurse clarifies that a fetus has enough surfactant to breathe on its own at the age of _____ weeks.

34 R: Surfactant begins to appear at the age of 24 weeks and is adequate to support life at the age of 34 weeks.

The physician has ordered phenytoin syrup 20 mg PO bid for a child who weighs 15 pounds. The PDR states that 10 mg/kg/day is the maximum daily dose. The safe daily dose of this medication is _____ mg.

34mg R: 15 pounds = 6.8 kilograms; 6.8 10 mg = 68 mg maximum daily dose, making the bid doses 34 mg each

The nurse arrives at the start of a shift on the labor unit to find a census of four patients in active labor. Which laboring patient should the nurse attend to first?

35-year-old multigravida with history of precipitate R: A precipitate birth is completed in less than 3 hours. Labor often begins abruptly and intensifies quickly, rather than having a more subtle onset and gradual progression. Contractions may be frequent and intense, often from the onset. If the womans tissues do not yield easily to the powerful contractions, she may have uterine rupture, cervical lacerations, or hematoma. Fetal breech presentation, history of cesarean section, and multifetal pregnancy have associated risk factors, but not as immediate as precipitate birth.

The nurse is performing a neurological assessment on a 10-month-old infant using a modified Glasgow Coma Scale. What score will the nurse give if the child is babbling?

4 R: If babbling, the 10-month-old infant receives a score of 4 for responses.

The nurse is assessing a 3-year-old. What is the expected weight gain for this age child?

4 times the birth weight R: The expected weight of a -year-old toddler is four times the birth weight.

How long does sperm remain viable in the female reproductive tract?

4-5 days R: Sperm can remain viable in the reproductive tract of the female for as long as 4 to 5 days.

On day 13 of a 28-day cycle, a womans basal body temperature is 36.5 C (97.7 F). What will her temperature measurement most likely be if ovulation takes place on day 14?

98.1 F R: At the time of ovulation, body temperature will increase slightly, about 0.2 C (0.4 F).

An infants dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record the infants urine output?

44.5 mL R: Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one milliliter of output. 47 2.5 = 44.5 grams = 44.5 mL of urine.

The parent of a 3-month-old infant asks the nurse, At what age do infants usually begin drinking from a cup? What is the nurses most accurate response?

5 months R: The infant can usually drink from a cup when it is offered at about 5 months.

How long should a 4-year-old child recovering from rheumatic fever need to receive monthly injections of penicillin G?

5 years R: Children who recover from rheumatic fever should have a chemoprophylaxis protocol of penicillin G injections (about 200,000 units per dose) for a minimum of 5 years or up to the age of 18 to prevent further bouts of rheumatic fever.

The nurse is assessing a 13-year-old boy. With what do physical changes in the pubertal male begin?

Enlargement of testicles R: In boys, pubertal changes begin with enlargement of the testicles and internal structures.

The nurse is presenting a conference on gene dominance. What does the nurse report as the percentage of children carrying the dominant gene if one parent has a dominant gene and the other parent does not?

50% R: If one parent has a dominant trait and the other does not, then 50% of the children will inherit the trait.

The nurse is aware that by the age of _____, the first permanent teeth erupt.

6 R: At the age of 6, the first permanent teeth erupt: the 6-year molars.

A frustrated patient in labor has been affected by decreased uterine muscle tone and reports, My doctor wont induce my labor because of some silly score. He said I was a 4. What kind of magic number do I need? What is the lowest Bishop score the patient should have prior to induction?

6 R: The Bishop score evaluates the suitability of the patient for a vaginal delivery. A minimum score of 6 is recommended by the American Congress of Obstetricians and Gynecologists (ACOG).

The mother of a 7-month-old reports that the first lower central incisor has erupted. She asks the nurse, How many teeth will he have by his first birthday? The nurse explains that the infant will have how many teeth by 1 year of age?

6 R: The 1-year-old infant usually has about 6 teeth, 4 above and 2 below.

Approximately how old does the nurse assess a large green bruise on the thigh of a 4-year-old to be?

6 days R: Bruises heal in various stages that are indicated according to color; after 5 to 7 days bruise are green.

A child hospitalized for treatment of osteomyelitis complains that he is tired of being sick and wants to know when the antibiotic protocol will end. How long will the nurse indicate that antibiotic therapy will probably last?

6 weeks R: Because osteomyelitis is an infection in the bone, antibiotics are given intravenously for 4 to 6 weeks.

The nurse is planning anticipatory guidance for a caregiver of a preschool-age child. The nurse will explain that permanent teeth begin erupting at what age?

6 years old R: Permanent teeth do not erupt through the gums until the sixth year.

The nurse is caring for a 4-year-old child. What will the nurse expect the childs daily urinary output to be?

600 to 700 mL R: The average daily excretion of urine for a 4-year-old child is 600 to 700 mL.

What does the nurse recognize as an example of Piagets concrete operational thinking?

7-year-old says, I am sick because I have germs in my chest R: The 7-year-olds remark reflecting the cause and effect of germs and illness is an example of operational thinking. All other options are examples of preoperational thought, which is egocentric and symbolic.

The nurse is caring for a 3-year-old who suffered a smoke inhalation injury. How long is this patient at the highest risk for pulmonary edema after exposure?

72 hours R: Pulmonary edema appears in a child with smoke inhalation injury 6 to 72 hours after exposure.

What is the earliest age at which an infant is able to sit steadily alone?

8 months R: The infant can sit alone without support at about 8 months of age.

The nurse is aware that for the 3-month-old who has a surgery time of 2:30 PM, the start order for NPO should be no earlier than ____________________.

8:30 AM R: Periods of NPO should not exceed 4 to 6 hours for pediatric clients because they can become dehydrated very quickly.

After the 3-month-old child with respiratory syncytial virus is given a protocol of antiviral medications, the nurse explains that routine immunizations will need to be delayed for _______ months.

9 R: After a protocol of antiviral medications, the routine immunizations should be delayed because the antiviral medications affect the integrity of the immunizations.

The embryo is termed a fetus at which stage of prenatal development?

9 weeks R: The fetus (third stage of prenatal development) begins at the ninth week and continues until the 40th week of gestation or until birth.

A parent asked the nurse, At what age are children capable of assuming more responsibility for personal belongings? What is the nurses best response based on knowledge of growth and development?

9 years R: The 9-year-old is dependable and assumes more responsibility for personal belongings.

A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, Will I be able to deliver vaginally? What explanation by the nurse is the most appropriate?

A cesarean section is performed when the mother has a total placenta previa. R: A cesarean delivery is done for a partial or total placenta previa.

The nurse must make a room assignment for a 16-year-old with cystic fibrosis. Which roommate would be the most appropriate for this patient?

A 15-year-old with type 1 diabetes mellitus R: Adolescents usually do better in rooms with one or more roommates than in single rooms. The adolescent would do best with a roommate who is closest to his or her age and also lives with a chronic illness.

A 3-month-old infant is diagnosed with developmental hip dysplasia. The nurse knows that what is the usual treatment for an infant with this diagnosis?

A Pavlik harness R: In infants who are more than 2 months of age, longer-term immobilization with a Pavlik harness is required.

A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia?

A change in lochia from pink to bright red should be reported. R: A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported.

Why does a childs fracture heal more rapidly than the adults?

A childs bones have faster callus formation R: Callus forms more rapidly in the child than the adult.

What assessment does the school nurse recognize as the cardinal sign of a hyphema?

A dark-red spot in front of the iris R: A dark red spot in front of the iris is blood that has drained into the anterior chamber as the result of an injury.

At a well-baby visit, parents of a 6-month-old ask when to take the infant for the first dental visit. What is the nurses best response?

A dental visit by 1 year of age is recommended by the American Academy of Pediatric Dentistry R: The Academy of Pediatric Dentistry recommends that the first dental visit occur by 1 year of age.

What should the school nurse recommend when encouraging a heart-healthy diet for a child with high cholesterol?

A fat intake reduction of 25-35% of total calories R: For a child with increased cholesterol a fat reduction of 25-35% of total calories with less than 75 saturated fat and less than 200 mg of cholesterol per day is advised.

Why should the nurse encourage the mother to void during the fourth stage of labor?

A full bladder could predispose the mother to uterine hemorrhage. R: A full bladder immediately after birth can cause excessive bleeding because it pushes the uterus upward and interferes with contractions.

What should the nurse suggest as the most appropriate toy choice for a 3-year-old?

A large construction set R: Large construction sets are suitable toys for the preschool-age child.

Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?

A loud, harsh murmur with a systolic thrill R: A loud, harsh murmur combined with a systolic thrill is characteristic of a ventricular septal defect.

A newly married couple tells the nurse they would like to wait a few years before starting a family. Which statement made by the man indicates an understanding about sexual activity and pregnancy?

A man can secrete semen before ejaculation. R: Semen may be secreted during sexual intercourse before ejaculation.

A parent states, My 7-year-old really wants a dog. His 10-year-old brother has allergies to animal dander. I dont know what to do. What type of pet should the nurse suggest as the best choice?

A poodle, which does not shed, making it a good choice for people with allergies R: The poodle does not have a shed cycle and so it may be the least offensive pet for the allergic child.

What is the best choice for fluid replacement that the nurse can offer a child who has just had a tonsillectomy?

A popsicle R: Small amounts of clear liquids can be offered to the child. Synthetic fruit juices are not as irritating as natural juices. A popsicle is usually well-tolerated.

An ultrasound confirms that a 16-year-old girl is pregnant. How does the need for prenatal care and counseling for adolescents different from other age populations?

A pregnant adolescent is experiencing two major life transitions at the same time. R: The pregnant adolescent must cope with two of lifes most stress-laden transitions simultaneously: adolescence and parenthood.

A pregnant woman inquires about exercising during pregnancy. What information should the nurse include when planning to educate this woman?

A regular schedule of moderate exercise during pregnancy is beneficial. R: In general, moderate exercise several times a week, from the 8th week through delivery, is advised during pregnancy.

The nurse is planning care of an adolescent. What psychosocial task does the nurse understand is important for the adolescent to develop?

A sense of identityd. A sense of involvement R: Psychosocial milestones that must be accomplished during adolescence include the five Isimage of self, identity, independence, interpersonal relationships, and intellectual maturity.

The nurse observes that a 2-year-old is able to use a spoon steadily at mealtime. What does self-feeding help to develop in the toddler?

A sense of independence R: By the end of the second year, toddlers can feed themselves. This helps them to develop a sense of independence.

What should a woman expect after insertion of an intrauterine device (IUD)?

A string should be felt in the vagina R: A woman should feel for the string periodically, especially after her period, to confirm the presence of the IUD.

The nurse observes on the fetal monitor a pattern of a 15-beat increase in the fetal heart rate that lasts 15 to 20 seconds. What does this pattern indicate?

A well-oxygenated fetus R: Accelerations in the fetal heart rate suggest that the fetus is well oxygenated.

The nurse is providing care to a child with Down syndrome. What body system has the highest risk of congenital anomaly in a child with Down syndrome?

Cardiovascular system R: Down syndrome children are prone to deformities of the cardiovascular system.

Through what does the infant born with hypoplastic left heart syndrome acquire oxygenated blood?

An atrial septal defect R: Because the right side of the heart must take over pumping blood to both the lungs and systemic circulation, the ductus arteriosus must remain open to shunt the oxygenated blood from the lungs.

After delivery, a mother asks the nurse about newborn screening tests. The nurse explains that what is the optimal time for testing for phenylketonuria?

After 2 to 3 days R: Blood tests for phenylketonuria should be obtained 48 to 72 hours after birth. The newborn will have had enough time to ingest protein through feedings, and the chance of false-negative results will be reduced.

At what age is a woman who becomes pregnant for the first time described as an elderly primip?

After 35 years old R: A woman over the age of 35 who becomes pregnant for the first time is described as an elderly primip.

What will the nurse teach parents when giving instructions for acute conjunctivitis?

Clear drainage from the inner to the outer aspect of the eye R: Eye secretions are always cleared from the inner canthus downward and away from the opposite eye (inner to outer direction).

What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant?

Apical R: Apical pulses are advised for children under age 5 years.

A 13-year-old girl tells the nurse she is concerned because she has not had her first menstrual period. What is the best initial response from the nurse?

Age of first menstrual cycle varies R: Puberty is easily recognized in girls by the onset of menstruation. The first menstrual period is called the menarche. It commonly occurs about age 12 or 13 years, but this varies. It may occur as early as age 10 years or as late as age 15 years.

The nurse is assessing a preterm infant. To what does the infants level of maturation refer?

Ability of the organs to function outside of the uterus R: Level of maturation refers to how well developed the infant is at birth and the ability of the organs to function outside of the uterus.

The nurse is discussing toilet training with parents. What behavior by the child would identify toilet training readiness?

Able to communicate that he or she is wet R: Children are ready for toilet training when they can communicate in some fashion that they are wet or need to urinate or defecate.

When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block?

Abnormal clotting R: An epidural block is not used if a woman has abnormal blood clotting.

The ___________ is a period of years during which the womans ability to reproduce gradually declines.

Climacteric R: The climacteric is a period of years during which the womans ability to reproduce gradually declines.

What is the best suggestion by the nurse when parents ask, When is the best time to begin to prepare a 5-year-old for surgery and hospitalization?

About 4 days before surgery R: Parents should prepare children for procedures and hospitalization a few days in advance.

What will the nurse explain to a 12-year-old patient when describing what characterizes nocturnal emissions?

Absence of sperm in ejaculate R: Nocturnal emissions, also known as wet dreams, occur without sexual stimulation and contain no sperm. Testosterone levels are constant until midlife.

A parent reports that her child has begun to do poorly at school and experiences episodes where he appears to be staring into space. Of which type of seizure is this behavior a characteristic?

Absenceb. Akineticc. Myoclonicd. Complex partial R: Absence seizures are characterized by transient loss of consciousness where the child appears to stare blankly, and may last only a few seconds.

The nurse is providing sexual education to a group of high school students. What will the nurse explain is the most effective choice of birth control for preventing pregnancy and sexually transmitted diseases?

Abstain from sex R: Abstinence is 100% effective in preventing pregnancy and sexually transmitted diseases.

A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home health nurse make the first priority?

Activity restriction R: Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and enhancing fetal oxygenation.

Which hormone is responsible for converting the endometrium into decidual cells for implantation?

Progesteron R: At high levels, progesterone maintains the endometrial lining for implantation of the zygote.

The anxious parent asks if there is a danger of her 2-year-old child becoming addicted to the opioid pain reliever. What is the nurses most helpful response?

Addiction is rare in children when opiates are given for pain R: Addiction is rare in children.

A postpartum patient experiences anaphylactic shock. What is the most likely cause?

Allergy R: Anaphylactic shock is caused by allergic responses to drugs administered. Cardiogenic shock may be caused by pulmonary embolism or hypertension. Hypovolemic shock could be caused by blood clotting disorders.

The nurse is educating a pregnant patient who expects to breastfeed. The nurse knows that when a patient breastfeeds, which portions of the breast secrete milk?

Alveoli R: The alveoli secrete milk.

After an amniotomy, the umbilical cord becomes compressed. The nurse prepares the patient for an instillation of a bolus of warm sterile saline into the uterus, which is called ____________________.

Amnioinfusion R: A warm saline bolus is instilled in the uterus to float the fetus to relieve pressure on the cord.

What nursing assessment should be reported immediately after an amniotomy?

Amniotic fluid is watery and pale green. R: Amniotic fluid should be clear. Green fluid indicates the fetus has passed meconium, which is associated with fetal compromise.

The parent of a 3 -year-old child tells the nurse, My daughter points instead of speaking whenever she wants me to get something for her, but she understands me when I ask her to do something. Based on the parents comment, what does the nurse suspect?

An expressive language delay R: An expressive language delay is suspected when the child understands spoken language but is not talking.

A nurse is planning to teach couples about the physiology of the sex act. What correct information will the nurse provide?

An ovum must be fertilized within 24 hours of ovulation. R: After ovulation, the egg lives for only 24 hours. Sperm must be available during that time if fertilization is to occur.

In what situation will the physician order RhoGAM?

An unsensitized Rh-negative mother has an Rh-positive infant R: The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-positive infant.

The nurse explains that the term _______________ refers to a sex role that incorporates both male and female traits.

Androgynous R: Sex roles that involve male and female qualities lead to better human functioning.

Fathers go through phases similar to the expectant mother. Place the following phases in order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Focus phase b. Announcement phase c. Adjustment phase

Announcement phase Adjustment phase Focus phase R: For fathers, the announcement phase begins when pregnancy is confirmed. The second phase of the fathers response is the adjustment phase. The third phase of the fathers response is the focus phase, in which active plans for participation in the labor process, birth, and change in lifestyle result in the partner feeling like a father.

A 13-year-old girl has been hospitalized for the past week. When discussing the girls feelings about her illness, what would the nurse expect the girl to express as her biggest concern?

Appearance R: Illness during early adolescence (12 to 15 years) is seen mainly as a threat to body image.

What does the nurse consider as an appropriate snack for a 2-year-old child?

Applesauce R: Applesauce is a healthy and safe snack food for the toddler. The toddler is at risk for choking on foods such as grapes, hot dogs, and popcorn.

What assessment made by the nurse would lead the nurse to suspect hip dysplasia?

Asymmetrical gluteal folds R: The gluteal folds are asymmetrical because the head of the femur has slipped out of the acetabulum. There is also limited abduction of the affected side, and when the legs are flexed the affected leg seems to be shorter.

Which nursing action would facilitate rapport with a child and the childs parents during the admission process?

Answer questions in a calm and matter-of-fact way R: The nurse tries not to appear rushed. A matter-of-fact attitude must be maintained regardless of the childs condition.

The nurse is discussing preschoolers sexual curiosity with the parent. What statement by the mother leads the nurse to determine that the mother understands the information?

Answer their questions when they ask R: Parents should provide sex education at the time the child asks about sex.

When the nurse reads in the history and physical of a pregnant patient that she has a platypelloid pelvis, the nurse is aware that this pelvis has a narrow _____________ diameter, making a vaginal birth unlikely.

Anteroposterior R: The platypelloid pelvis is very narrow from front to back (anteroposterior). The shape of this pelvis makes vaginal delivery unlikely.

A patient is being seen by her health care provider for a suspected vaginal infection. What will the nurse include when educating this patient on factors that affect the vaginal pH? (Select all that apply.) a. Antibiotic therapy b. Frequent douching c. Exercise d. Jet lag e. Use of vaginal sprays

Antibiotic therapy Frequent douching Use of vaginal sprays R: The vagina is self-cleansing and during the reproductive years maintains a normal acidic pH of 4 to 5. The self-cleansing activity may be altered by antibiotic therapy, frequent douching, and excessive use of vaginal sprays, deodorant sanitary pads, or deodorant tampons.

During a postpartum assessment, a woman reports her right calf is painful. The nurse observes edema and redness along the saphenous vein in the right lower leg. Based on this finding, what does the nurse explain the probable treatment will involve?

Anticoagulants for 6 weeks R: Anticoagulant therapy is continued with heparin or warfarin (Coumadin) for 6 weeks after birth to minimize the risk of embolism.

The nurse is providing an informational session on oral contraceptives. Which of the following decrease effectiveness of oral contraceptives?

Anticonvulsants for treatment of epilepsy R: Anticonvulsants decrease the effectiveness of oral contraceptives.

What part of the fetal body derives from the mesoderm?

Muscles R: The mesoderm is responsible for the development of muscles. Nails and oil glands derive from the ectoderm. The lining of the bladder derives from the endoderm.

What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant?

Apply a cloth diaper R: Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left undiapered on a cloth pad.

A parent is concerned because her infant has a diaper rash. What is the best action the nurse would advise the parent to implement?

Apply a protective ointment on the area R: A protective ointment can be applied when the skin in the diaper area appears pink and irritated.

Which intervention will the nurse implement when suctioning a tracheostomy?

Apply suction for no more than 15 seconds R: Suctioning should be limited to 15 seconds.

The nurse is providing instructions about how to treat a sprained ankle. What statement by the mother does the nurse recognize as indicative of a need for additional teaching?

Apply warm compresses to the ankle for the first 24 hours R: Heat is not a treatment for soft tissue injuries. The principles of managing soft tissue injuries are rest, ice, compression, and elevation.

Postoperative nursing care of the infant following surgical repair of a cleft lip would include?

Applying elbow restraints to protect the surgical area R: Elbow restraints are used postoperatively to prevent the infant from damaging the operative area.

Which intervention would be helpful in relieving morning discomfort associated with juvenile rheumatoid arthritis?

Applying moist heat packs upon awakening R: Application of moist heat, with a compress or by tub bath upon awakening, will help to lessen stiffness.

Parents of a 5-year-old child tell the nurse they are concerned about their childs speech development by stating, No one can understand him but us. What clinical classification of speech disorder does the nurse suspect?

Articulation disorder R: When parents are the only people to understand their preschool child, an articulation disorder is suspected. (See Table 18-3.)

____________ is a preschoolers idea that the world and all of its contents are created by people.

Artificialism R: Artificialism is the belief that all things in the world have been created by people.

What intervention is appropriate for a nurse assessing a preadolescent child for scoliosis?

Ask the child to bend forward at the waist and observe the childs back for asymmetry R: The nurse looks at the back as the child bends forward for general body alignment and asymmetry.

A school-age child becomes frustrated with a school assignment and says, I cant do this! What is the most developmentally supportive response from the parent?

Ask, What is it that is so difficult? R: Helping the child focus on the problem that is keeping him from mastery can limit frustration. Quitting or having someone else finish is detrimental to the development of industry.

How will the nurse safely ensure tube placement when preparing to initiate a gavage feeding?

Aspirate stomach contents R: When the preterm infant is gavage fed, the contents of the stomach should be aspirated before the feeding is started. Aspiration of the stomach contents ensures tube placement and also allows the nurse to assess the amount of feeding in the stomach.

What will the nurse teach the parents of a child with a low platelet count to avoid?

Aspirin R: Aspirin interferes with platelet function and should be avoided to prevent the risk of prolonged bleeding.

What nursing action will the nurse implement for a preterm infant who is being gavage fed and has a bloody stool?

Assess for abdominal distention R: Bloody stools, abdominal distention, diarrhea, and bilious vomitus are signs of necrotizing enterocolitis. Specific nursing responsibilities include measuring the abdomen and listening to bowel sounds.

A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest?

Diabetes mellitus R: Large (macrosomic) infants over 9 pounds are linked to gestational diabetes.

What is the most important nursing intervention during the fourth stage of labor?

Assess for hemorrhage. R: Immediately after giving birth, every woman is assessed for signs of hemorrhage.

The new mother who had a vaginal delivery yesterday has a white blood cell count of 30,000 cells/dL. What action should the nurse implement?

Assess the patient further R: The patient should be assessed further for other signs of infection because a white blood cell (WBC) count of 20,000 to 30,000 cells/dL is normal in the early postpartum period.

On admission, a child with leukemia has widespread purpura and a platelet count of 19,000/mm3. What is the priority nursing intervention?

Assessing neurological status R: When platelets are low, the greatest danger is spontaneous intracranial bleeding. Neurological assessments are therefore a priority of care.

What intervention will the nurse caring for a child in Bucks skin traction implement?

Assist the child to be pulled up in bed R: Bucks traction is a type of skin traction that relies on the childs weight as counterbalance. The child must be kept with head elevated no more than 20 degrees and pulled up in bed, and the feet should not touch the bed surface or the foot of the bed.

The nurse is caring for a woman who had a cesarean birth yesterday. Varicose veins are visible on both legs. What nursing action is the most appropriate to prevent thrombus formation?

Assist the woman with ambulation for short periods of time R: Early ambulation and range-of-motion exercises are valuable aids to prevent thrombus formation in the postpartum woman.

The general appearance of the adolescent tends to be awkward, that is, long-legged and gangling; this growth characteristic is termed _______________ because different body parts mature at different rates.

Asynchrony R: The general appearance of the adolescent tends to be awkward, that is, long-legged and gangling; this growth characteristic is termed asynchrony because different body parts mature at different rates.

A parent brings a 6-month-old infant to the pediatric clinic for her well-baby examination. Her birth weight was 8 pounds, 2 ounces. What will the nurse weighing the infant today would expect her weight to be?

At least 16 pounds R: Birth weight is usually doubled by 6 months of age.

What is the most appropriate statement from the nurse when coaching the laboring woman with a fully dilated cervix to push?

At the beginning of a contraction, take two deep breaths and push with the second exhalation. R: When the cervix is fully dilated, the woman should take a deep breath and exhale at the beginning of a contraction, and then take another deep breath and push while exhaling.

The nurse is planning a safety program for high school students. To what will the nurse relay that most accidental deaths in adolescence are related?

Automobiles R: The chief safety hazard for the adolescent is automobiles.

The nurse is planning to teach parents about prevention of Reyes syndrome. What information would the nurse include in this teaching?

Avoid giving salicylate-containing medications to a child who has viral symptoms R: Prevention of Reyes syndrome includes educating parents not to give aspirin-containing medication to children with viral symptoms.

What would the nurse include when planning postoperative teaching for a child who has had a tympanostomy with insertion of tubes?

Avoiding getting water in the earsd. Cleaning the ear canal with cotton-tipped applicator R: After a tympanostomy, care should be taken to avoid getting water in the ears.

Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury?

Diapers and wipes are stacked at the foot of the crib R: Disposable diapers and supplies must be kept out of the infants reach to prevent accidental suffocation.

The nurse urges the mother of a 6-month-old to get her child inoculated with Haemophilus influenzae type B. What does this immunization protect against?

Bacterial meningitis R: H. influenzae type B and conjugated pneumococcal vaccines have decreased the incidence of bacterial meningitis.

The nurse explains that the _____________ ___________ is a tool used to determine the gestational age of a neonate based on appearance and neuromuscular criteria.

Ballard Score R: The Ballard Score is a standardized method to determine gestational age based on external characteristics and neurological development.

What important focus of nursing care for the dying child and the family should the nurse implement?

Families should be made aware that hearing is the last sense to stop functioning before death R: Hearing is intact even when there is a loss of consciousness.

A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurses most appropriate action?

Baptize the newborn R: If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infants forehead while saying, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. If there is any doubt as to whether the infant is alive, the baptism is given conditionally: If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit. The physician is attending to the patients immediate health needs.

The nurse conducting a sex education class for junior high students describes some cultural rites celebrating the entry to adulthood. What information would the nurse include? (Select all that apply.) a. Bar mitzvah b. Displays of bravery c. Receiving part of their inheritance d. Ritual circumcision e. Displays of self-defense

Bar mitzvah Displays of bravery Ritual circumcision Displays of self-defense R: Some cultures celebrate the entry to adulthood with rites such as displays of strength, bravery, self-reliance, and self-defense. Ritual circumcisions and bar and bat mitzvahs are also entry rites to adulthood. Lack of such rituals can sometimes confuse young people because there is no evidence of acceptance as an adult.

__________________ occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.

Barotrauma R: Barotrauma occurs when there is a change in the atmospheric pressure between the internal body systems and the surrounding environment.

What type of play is most appropriate when planning care for a child with moderate intellectual deficiency?

Be adjusted to mental age rather than chronological age R: The nurse must consider the childs mental age rather than her chronological age when selecting toys for play.

What guideline should an adult follow when speaking to a toddler?

Be at eye level with the child R: Being at eye level is helpful to hold the childs attention and is especially important when the child is frightened.

What should the nurse explain to the parent of a child with exercise-induced asthma about when to inhale Cromolyn?

Before exercise to prevent attacks R: Anti-inflammatory inhalants are taken before exercise to prevent attacks. These drugs can do nothing for the attack in progress. They are meant to be used as prophylactic therapies.

What should the nurses first action be when postpartum hemorrhage from uterine atony is suspected?

Begin massaging the fundus while another person notifies the physician R: When the uterus is boggy, the nurse should immediately massage it until it becomes firm.

Below what blood glucose level is the newborn considered hypoglycemic?

Below 40 mg/dL R: A blood glucose level of less than 40 mg/dL is considered hypoglycemic. If the screening sample is below 40 mg/dL, a venous sample will be drawn. After the blood has been drawn, the infant should be fed to prevent a further drop.

The pediatric clinic nurse receives lab results on several newborn patients. Which of the following should be brought to the physicians attention first?

Bilirubin of 15 R: A bilirubin of 15 is elevated and requires further immediate investigation.

A(n) _________________________________ consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amniotic fluid.

Biophysical profile R: A biophysical profile consists of a group of five fetal assessments: fetal heart rate and reactivity (the NST), fetal breathing movements, fetal body movements, fetal tone (closure of the hand), and volume of amniotic fluid.

What will the nurses instructions for a new mother to care for the infants umbilical cord include?

Fastening the diaper low to allow for air circulation R: Diaper placement below the umbilical stump allows for drying by air circulation.

A woman in labor has had an epidural block for pain relief. The nurse will be assessing carefully for what associated side effect of this type of regional anesthesia?

Bladder distention R: A side effect of an epidural block is urine retention because the anesthesia interferes with the womans ability to have an urge to void. The patient may have to be catheterized.

The nurse would observe a child for frequent swallowing after a tonsillectomy and adenoidectomy (T&A). What might this indicate?

Bleeding from the surgical site R: Hemorrhage is the most common postoperative complication. Blood trickling down the back of the childs throat could cause frequent swallowing.

A mother reports that she and her husband have had one child together, but both have children from previous marriages living in their home. The nurse will base the care planning on what type of family?

Blended R: A blended family involves the remarriage of persons with children.

An infant is experiencing dyspnea related to patent ductus arteriosus (PDA). What does the nurse understand regarding why dyspnea occurs?

Blood is circulated through the lungs again, causing pulmonary circulatory congestion R: When PDA is present, oxygenated blood recycles through the lungs, overburdening the pulmonary circulation.

What assessment should be taken immediately after the anesthesiologist administers an epidural block to a laboring woman?

Blood pressure R: Blood pressure is checked every 5 minutes when the epidural block is first begun. Bladder assessment is also important but not an initial assessment.

What finding would the nurse expect when measuring blood pressure on all four extremities of a child with coarctation of the aorta?

Blood pressure lower in the legs than in the arms R: The characteristic symptoms of coarctation of the aorta are a marked difference in blood pressure and pulses between the upper and lower extremities. Pressure is increased proximal to the defect and decreased distal to the coarctation.

What does the nurse explain that a ventricular septal defect will allow?

Blood to shunt left to right, causing increased pulmonary flow and no cyanosis R: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.

A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction?

Blow in short breaths. R: If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down.

What finding would the nurse assessing the neurovascular status of a child in Russell traction report immediately?

Bluish coloration of skin R: Cyanosis or pallor noted in an extremity is an indication of circulatory impairment.

During the physical examination for the first prenatal visit, it is noted that Chadwicks sign is present. What is Chadwicks sign?

Bluish or purplish discoloration of the vulva, vagina, and cervix R: Chadwicks sign is the purplish or bluish discoloration of the cervix and vagina.

A patient with gestational hypertension is exhibiting all of the signs below. What should the nurse report immediately?

Blurred vision R: Visual disturbances indicate worsening pregnancy-induced hypertension and must be reported promptly for effective intervention to prevent preeclampsia and convulsion.

What fear is unique to the preschool period?

Bodily harm R: The fear of bodily harm, particularly the loss of body parts, is unique to this stage.

The parents of a 3-month-old infant with cystic fibrosis (CF) want to know how their child got this disease, because no one in either of their families has CF. What is the nurses best response based on the understanding of CF?

Both parents are carriers of the CF gene R: Cystic fibrosis is an inherited disease. Both parents must be carriers of the CF gene for the child to have the disease.

What would the nurse assess for in a preterm infant receiving an intravenous infusion containing calcium gluconate?

Bradycardia R: The infant receiving intravenous calcium gluconate should be monitored for bradycardia.

A preterm infant has a yellow skin color and a rising bilirubin level. The nurse knows that this infant is at risk for what?

Brain damage R: The higher the bilirubin level and the deeper the jaundice, the greater is the risk for neurological damage.

A child is admitted to the hospital because she had a seizure. Her parents report that for the past few weeks she has had headaches, with vomiting, that are worse in the morning. What does the nurse suspect?

Brain tumor R: The signs and symptoms of a brain tumor are related to its size and location. Most tumors create increased intracranial pressure (ICP) with the hallmark symptoms of headache, vomiting, drowsiness, and seizures.

A 10-year-old girl asks the nurse, What is the first sign of puberty? What is the correct nursing response?

Breast development R:The first outward change of puberty in girls is the development of breasts at about 10 to 11 years of age.

The nurse instructed a postpartum woman about storing and freezing breast milk. What statement by the woman leads the nurse to determine that the teaching was effective?

Breast milk can be stored in glass containers R: Breast milk can be safely stored in glass or clear hard plastic containers.

A 4-week postpartum patient with mastitis asks the nurse if she can continue to breastfeed. What is the nurses most helpful response?

Breastfeeding can continue unless there is abscess formation R: The woman with mastitis can continue to breastfeed unless an abscess forms.

A primipara tells the nurse, My afterpains get worse when I am breastfeeding. What is the most appropriate nursing response?

Breastfeeding releases a hormone that causes your uterus to contract. R: Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus.

A nursing student is observing prenatal exams in the office setting. The health care provider informs the student that the fetal position is LSA. The student interprets this as a ____________________ presentation.

Breech R: LSA is the abbreviation for Left Sacrum Anterior. This is a breech presentation.

Parents of a newborn with a unilateral cleft lip are concerned about having the defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time?

By 3 months of age R: A cleft lip is repaired by 3 months of age when weight gain is established and the infant is free of infection.

The nurse is caring for a patient who is not certain if she is in true labor. How might the nurse attempt to stimulate cervical effacement and intensify contractions in the patient?

By helping the patient to ambulate in the room R: Ambulation will stimulate effacement and intensify contractions if the patient is in true labor.

When a woman is admitted to the labor and delivery unit, she tells the nurse that she is anxious about delivery, the welfare of her infant, and how quickly she will recover. How can anxiety affect labor?

By reducing blood flow to the uterus R: Excessive anxiety reduces uterine blood flow, making uterine contractions less effective, and creates muscle tension that counteracts the expulsion powers of contractions.

A laboring patient requests hot and cold applications be applied to her abdomen for pain control. How will this intervention act to control pain?

By stimulation of large nerve fibers R: The gate control theory explains how pain impulses reach the brain for interpretation. It supports several nonpharmacological methods of pain control. According to this theory, pain is transmitted through small-diameter nerve fibers. However, the stimulation of large-diameter nerve fibers temporarily interferes with the conduction of impulses through small-diameter fibers. Techniques to stimulate large-diameter fibers and close the gate to painful impulses include massage, palm and fingertip pressure, and heat and cold applications.

A patient asks the nurse when her infants heart will begin to pump blood. What will the nurse reply?

By the end of week 3 R: The fetal heart begins to pump by week 3 of gestation.

A parent remarks, My 18-month-old daughter carries her blanket around everywhere. Is this normal? What is the best explanation a nurse who has an understanding of toddler development might give?

Carrying her favorite blanket is self-consoling behavior R: Favorite possessions and repetitive rituals are self-consoling behaviors for the toddler.

A child is brought to the emergency department after he fell and hit his head on the ground. Which nursing assessment suggests the child has a concussion?

Cannot remember what happened to himd. Pupils react sluggishly to light R: A concussion is a temporary disturbance of the brain that is immediately followed by a period of unconsciousness. It is accompanied often by a loss of memory of the events that occurred immediately before, during, or after the injury.

What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient?

Calcium gluconate R: Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a woman receives magnesium sulfate.

The nurse assesses a positive Homans sign when the patients leg is flexed and foot sharply dorsiflexed. Where does the patient report that the pain is felt?

Calf of the leg R: A pain in the calf of the leg when the leg is flexed and the foot is dorsiflexed is a positive Homans sign. Homans sign is suggestive of a deep vein thrombosis.

The teaching plan for the use of a dry powder inhaler for the treatment of asthma should include the warning to rinse the mouth after inhaling the powder. What does this prevent?

Candidiasis R: Inhalant powders can cause candidiasis (yeast) infection of the mouth.

A 21-year-old college student has come to see the nurse practitioner for treatment of a vaginal infection. Physical assessment reveals inflammation of the vagina and vulva, and vaginal discharge has a cottage cheese appearance. With what are these findings consistent?

Candidiasis R: The signs and symptoms of candidiasis include inflammation of the vagina and vulva and a cottage cheese appearance to the vaginal discharge.

A 4-year-old child tells the nurse she will not eat peas because they are green. Of what is this an example?

Centering R: The tendency to concentrate on a single outstanding characteristic of an object while excluding other features is known as centering.

What type of development is the nurse assessing when an infant can lift his or her head before he or she can sit?

Cephalocaudal R: Cephalocaudal development proceeds from head to toe.

While inspecting a newborns head, the nurse identifies a swelling of the scalp that does not cross the suture line. How would the nurse refer to this finding when documenting?

Cephalohematoma R: A cephalohematoma is caused by a collection of blood beneath the periosteum of the cranial bone. It does not cross the suture line.

The nurse explains that ___________ is a procedure in which an incompetent cervix is sutured closed to prevent its opening when the fetus presses against it.

Cerclage R: Cerclage is the procedure that sutures the cervix closed to prevent its opening when the fetus presses against it.

The nurse coaches the primigravida not to bear down until the cervix is completely dilated. What may premature bearing down cause?

Cervical laceration R: Bearing down against a cervix that is not dilated can cause edema and laceration to the cervix.

The nurse is discussing cervical mucus changes with a woman who wishes to use natural family planning methods. What information about cervical mucus at ovulation will the woman indicate to the nurse, demonstrating that learning has taken place?

Cervical mucus enhances the motility of the sperm R: Around the time of ovulation, the slippery, clear cervical mucus enhances the motility of the sperm.

The parents of a newborn girl express concern about the infants vaginal discharge, which appears to be bloody mucus. What does the nurse explain as the cause?

Cessation of female sex hormones transferred in utero from mother to infant R: Blood-tinged mucus discharged from the vagina is caused by hormonal withdrawal from the mother at birth.

What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied?

Change the childs position frequently R: The childs position must be changed frequently to relieve pressure and promote circulation.

What should the nurse implement for security purposes when bringing the infant from the nursery to the mother?

Check the band number of the infant with that of the mother R: The nurse should check the band number of the infant with that of the mother by asking the mother to verbally read the number.

One hour postdelivery the nurse notes the new mother has saturated three perineal pads. What is the most appropriate nursing action?

Check the fundus for position and firmness. R: Increased lochia may indicate hemorrhage. The fundus should be assessed for firmness. One pad an hour is an acceptable rate for immediate postdelivery.

What will the nurse include when caring for a child in Bucks extension?

Checking for skin irritation from traction equipment R: The skin exposed to frequent friction may break down.

The initial treatment for cleft lip is a surgical repair known as ______________.

Cheiloplasty R: The initial treatment for cleft lip is a surgical repair known as cheiloplasty.

The nurse explains that the ____________________ can sense the oxygen concentration in the blood and signal the brainstem to increase respiration.

Chemoreceptors R: Chemoreceptors can sense the oxygen concentration of the blood and signal the brainstem to increase and deepen respirations to keep an adequate supply of oxygen in the circulating volume.

What assessment made by the school nurse would lead to the suspicion of strabismus?

Child covers one eye to read the chalkboard R: Indicators of strabismus include covering one eye to see, tilting the head to see, and missing objects in attempts to pick them up. Although headaches may be associated with amblyopia, this symptom is too vague to point suspicion to any disorder.

On entering the room of a child in Bucks traction, the nurse makes all of the following observations. Which observation requires a nursing intervention?

Childs heels are placed firmly against the foot of the bed R: Bucks traction is dependent on the child as a counterweight. The heels should be elevated above the level of the foot of the bed.

A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient?

Chorioamnionitis R: Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken.

What is the embryonic membrane that contains finger like projections on its surface, which attach to the uterine wall?

Chorion R: The chorion is a thick membrane with finger like projections (villi) on its outermost surface.

What is the result of a deficiency of factor IX?

Christmas disease R: Christmas disease, or hemophilia B, is caused by the deficiency of factor IX.

The child receiving a transfusion complains of back pain and itching. What is the best initial action by the nurse?

Clamp off blood and keep line open with normal saline R: If a blood transfusion reaction occurs, the first action is to stop the blood infusion, keep the line open with normal saline, and notify the charge nurse.

What would the nurse include in a teaching plan about mouth care of a child receiving chemotherapy?a. Use commercial mouthwash.b. Clean teeth with a soft toothbrush.c. Avoid use of a Water-Pik.d. Inspect the mouth weekly for ulcerations.ANS: BA soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection. Water-Pik is useful for toughening gums.

Clean teeth with a soft toothbrush R: A soft toothbrush reduces capillary damage and mucous membrane breakdown and prevents bleeding and infection. Commercial mouthwashes may kill oral flora that combat infection. Water-Pik is useful for toughening gums.

What instruction should the nurse teach the postpartum woman about perineal self-care?

Cleanse with warm water in a squeeze bottle from front to back. R: Cleansing from front to back prevents contamination from the rectal area.

The nurse tells a woman who is trying to conceive to check her cervical mucus for changes. What will she expect the characteristic of cervical mucus to be a few days before ovulation?

Clear and slippery R: Within a few days of ovulation, cervical mucus will become clear and slippery to aid the passage of sperm into the cervix.

The nurse shares the information and timelines recorded on the interdisciplinary outline of care for a child. What is this document?

Clinical pathway R: This document is the clinical pathway, which is a broad outline of interdisciplinary plan of care with specific timelines.

The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, Why do my childs fingertips look like that? On what understanding does the nurse base a response?

Clubbing occurs as a result of chronic hypoxia R: Clubbing of the fingers develops in response to chronic hypoxia.

A nurse assessing welts on the body of a 2-year-old Vietnamese child should consider the skin lesions might be the result of the cultural practice of __________.

Coining R: Some Vietnamese place heated coins on the body to cure disease. This practice leaves welts that are sometimes mistaken for child abuse.

What nursing care should be provided to a woman with a third-degree laceration immediately after delivery?

Cold pack to the perineum R: Ice is applied to the perineum to reduce bruising and edema.

______________ is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant.

Colic R: Colic is characterized by periods of unexplained irritability and crying in a healthy, well-fed infant.

When the CSF is obstructed in the subarachnoid space rather than in the ventricles, the resulting hydrocephalus is diagnosed as ____________________ hydrocephalus.

Communicating R: Communicating hydrocephalus occurs when the CSF is obstructed in the subarachnoid space rather than in the ventricles.

The nurse recognizes the signs of ____________________ syndrome in a child in 90-90 traction when the toes are pale and edematous and have a very slow capillary refill.

Compartment R: When a limb is in traction or has been cast, the caregiver must check for adequate perfusion of the limb. Compartment syndrome occurs when the attendant edema from the injury or the traction compromises the circulation. This is an emergency and must be corrected before permanent damage can occur.

What activity would the nurse choose to meet Eriksons developmental task of industry when caring for a 7-year-old?

Completing a 50-piece jigsaw puzzle R: In the developmental period of late childhood, children are striving to develop a sense of industry. The completion of a jigsaw puzzle is industrious play.

Put the steps of nasal bulb suctioning for the newborn in the correct order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Clean bulb syringe. b. Release pressure. c. Insert narrow portion into nose. d. Compress ball of bulb syringe. e. Remove and empty into receptacle.

Compress ball of bulb syringe. Insert narrow portion into nose. Release pressure. Remove and empty into receptacle. Clean bulb syringe. R: First the ball of the bulb syringe is compressed, and then the narrow portion is inserted into the nose. The pressure is released, and the syringe is removed and emptied into the receptacle. The bulb syringe is cleaned and stored at the end of the procedure.

While caring for a postpartum patient who had a vaginal delivery yesterday, the nurse assesses a firm uterine fundus and a trickle of bright blood. How does the nurse most likely feel and react to this finding?

Concerned and reports a probable cervical laceration R: The bright trickle of blood with a firm uterus suggests a cervical laceration.

Which stage of cognitive development is a 9-year-old child in according to Piaget?

Concrete operations R: School-age children are in the concrete operations stage of cognitive development.

The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse?

Confirm the identity with the charge nurse, make a new bracelet, and give the medicine R: After confirmation of the childs identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

The nurse understands that as adolescents strive for individuality, the strongest need of any adolescent in society is that of _______________.

Conformity R: For all of the stress from coming of age as an individual in his own right, the adolescent also has an equal drive for conformity.

Why is the postterm neonate at risk for cold stress?

Fat stores have been used in utero for nourishment R: Fat stores have been used in utero for nourishment during the extended pregnancy.

When the nurse asks a 10-year-old Native American if he is ready to go to therapy, he does not answer immediately. How does the nurse interpret this response?

Considering the answer in silence R: Native Americans value silence. They need to sit and consider matters before replying to questions.

The nurse is counseling a lactating mother about diet. What would the nurse include with this information?

Consume 500 more calories than her usual prepregnancy diet R: To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories each day over her prepregnancy diet.

The mother of a 7-month-old states, The baby is eating food now. Should I give him regular milk, too? What is the nurses best response?

Continue breast milk or iron-fortified formula until 1 year of age R: Whole milk should not be introduced before 1 year of age. Low-fat milk should not be introduced before 2 years of age.

When a small group of preschool-age children were playing house, each child was pretending to be a particular family member. What type of play does the nurse recognize these children are participating in?

Cooperative R: In cooperative play, children play with each other, each taking a specific role.

When the preschooler who is hospitalized for surgery to correct a poorly healed fracture says, My doctor is going to unscrew my bent arm and screw on a new one, the nurse should ________________ this misconception.

Correct R: All misconceptions that a youngster has about procedures should be corrected.

The parents of a child diagnosed with cystic fibrosis ask the nurse what caused this disorder. What is the most appropriate response?

Cystic fibrosis is a metabolic defect R: Inborn errors of metabolism include a number of inherited diseases that affect body chemistry. There may be an absence or a deficiency of a substance necessary for cell metabolism. The deficient substance is usually an enzyme. Almost any organ of the body may be damaged. Examples of inborn errors of metabolism include cystic fibrosis and phenylketonuria (PKU). In disorders of the blood, there is a reduced or missing blood component or an inability of a component to function adequately. Sickle cell disease, thalassemia, and hemophilia fall into this category. Chromosomal abnormalities number in the thousands. Most involve some type of mental retardation, and others are incompatible with life. The newborn with Turners syndrome or Klinefelters syndrome may have impaired physical growth and sexual development. Malformations at birth include several types of structural defects.

A child is diagnosed with nonparalytic strabismus. How will this disorder most likely be corrected?

Corrective lenses R: In nonparalytic strabismus the refractory error is usually corrected with eyeglasses.

The nurse explains to a patient in preterm labor that what may be ordered by the physician to accelerate fetal lung maturity?

Corticosteroids R: Surfactant production can be increased by administering corticosteroids to the mother before delivery.

The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the most appropriate nursing intervention?

Count respirations and report a rate of less than 12 breaths/min. R: Excessive magnesium sulfate may cause respiratory depression.

Where are the secretions responsible for nourishing sperm excreted from?

Cowpers gland R: The Cowpers gland secretions nourish the sperm.

The nurse is teaching the parents of a young child with iron deficiency anemia about nutrition. What food would the nurse emphasize as being a rich source of iron?

Cream of Wheat R: Good nutritional sources of iron include boiled egg yolk, liver, green leafy vegetables, Cream of Wheat, dried fruits, beans, nuts, and whole-grain breads.

The nurse explains that the second process of self-mobility an infant learns is seen at the age of 9 months, when the infant begins to ___________.

Creep R: At 7 months the infant begins to crawl, using arms and dragging trunk and legs. At 9 months the infant begins to creep, holding his or her trunk above the floor. The next self-mobility activity is cruising, where the child walks from one piece of furniture to the next before it begins to walk independently.

The nurse is assessing development in a 9-month-old infant. What would the nurse expect to observe?

Creeping along the floor R: The 9-month-old tries to creep, has developed pincer movement, and can grasp a spoon without keeping food on it.

What contraction duration and interval does the nurse recognize could result in fetal compromise?

Duration longer than 90 seconds, interval shorter than 60 seconds R: Persistent contraction durations longer than 90 seconds or contraction intervals less than 60 seconds may reduce fetal oxygen supply.

The component of development that programs the genetic code into the nucleus of the cell is ____________.

DNA R: The DNA programs the genetic code to the nucleus of the cell to be replicated.

Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the __________ __________ .

Dancing reflex R: Prancing movements of the legs, seen when an infant is held upright on the examining table, are termed the dancing reflex.

The nurse observes a childs position is supine with his arms and legs rigidly extended and the hands pronated. How does the nurse identify this posture?

Decerebrate R: In decerebrate posturing, arms are extended along the side of the body and hands are pronated. This posture indicates brainstem function only.

What intervention might the nurse suggest as helpful for the child with enuresis?

Decreasing fluid intake after the evening meal R: If a child is experiencing enuresis, liquids after dinner should be limited and the child should routinely void before going to bed.

What would the nurse include in planning teaching to parents of a child with Legg-Calv-Perthes disease about the long-term effects of this disease?

Degenerative arthritis may develop later in life R: Marked distortion of the head of the femur may lead to an imperfect joint or to degenerative arthritis of the hip later in life.

The parents of a hospitalized toddler are upset because she seems more interested in her toys when they come to visit her. In which stage of separation anxiety is the toddler?

Denial R: In the stage of denial or detachment, the child appears to deny the need for the parents and becomes uninterested in their visits.

Place the stages of dying in the usual order as detailed by Kbler-Ross (1975). Put a comma and space between each answer choice (a, b, c, d, etc.) a. Bargaining b. Acceptance c. Denial d. Anger e. Reaching out to help others f. Depression

Denial Anger Bargaining Depression Acceptance Reaching out to help others R: The stages of dying as detailed by Kbler-Ross (1975)denial, anger, bargaining, depression, acceptance, and reaching out to help otherscan be applied to parents and siblings as well as to the sick child. (Nurses may also respond with similar feelings.) It is important to accept and support each participant at whatever stage has been reached and to refrain from directing progress.

The nurse is going to use a bulb syringe to clear mucus from a newborns nose and mouth. What is the nurses first action?

Depress the bulb before inserting the syringe tip into the mouth R: The bulb is depressed, and then the tip is inserted into the mouth and then the nose. The depression is slowly released, creating the suction.

Using a diagram, the nurse demonstrates the sequence of the mechanisms of labor. Place the seven mechanisms of labor in sequential order. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Extension b. Engagement c. Descent d. Flexion e. Expulsion f. Internal rotation g. External rotation

Descent Engagement Flexion Internal rotation Extension External rotation Expulsion R: The process by which a normal vaginal delivery is accomplished requires the infant to make the descent into the birth canal, engage, flex and internally rotate, and extend and externally rotate to be expelled.

A woman has had persistent lochia rubra for 2 weeks after her delivery and is experiencing pelvic discomfort. What does the nurse explain is the usual treatment for subinvolution?

Dilation and curettage R: Medical treatment for subinvolution is selected to correct the cause. Treatment may include dilation of the cervix and curettage to remove retained placental fragments from the uterine wall.

The gradual transfer of behavioral control from the parent to the child is accomplished through _________________.

Discipline R: Through discipline the parent gradually gives up behavior self-control to the child.

During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy?

Dizygotic twins R: Dizygotic twins always have two amnions and two chorions (placentas).

The nurse compared the birth weight of a 3-day-old with her current weight and determined the infant had lost weight. What is the most appropriate intervention by the nurse?

Do nothing because this is a normal occurrence R: It is typical for the newborn to lose 5% to 10% of his or her birth weight in the first 3 to 4 days of life. No change in the plan of care is needed.

A 16-month-old child is attending a well-child visit at a pediatric clinic. Which assessment would indicate the biggest cause for concern?

Does not walk independently R: A child should be walking independently by 16 months old. It is normal for a child this age to prefer finger feeding and to be limited to single words. Many children do not climb steps until 24 months of age.

What will the nurse advise when a woman asks what she can do to reduce the discomfort of hot flashes?

Dress in layers of cotton clothing R: Cotton allows easier passage of air than synthetic fabrics. Layering allows the woman to take off or put on clothes when symptoms occur.

The nurse encourages a Puerto Rican family to bring food to a child because he is not eating the food served on his hospital tray. What can the nurse expect the child to eat?

Dried beans mixed with rice R: A common food choice of Americans of Puerto Rican descent is dried beans mixed with rice.

A woman is prescribed to take alendronate (Fosamax) for osteoporosis postmenopause. What information will the nurse provide when educating this patient on alendronate (Fosamax)?

Drink 8 oz. of water following dosage R: Alendronate (Fosamax) may be prescribed. Esophageal and gastric irritation are common side effects of alendronate, and the woman should be instructed to drink 8 ounces of plain water and sit upright for 30 minutes after taking the drug and before eating a meal. Weight-bearing exercises such as walking, hiking, stair climbing, and dancing are advisable. High-impact exercises should be avoided.

The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is sweating profusely. What does the nurse recognize as the cause of these symptoms?

Drug toxicity R: The symptoms described are the signs of theophylline toxicity.

The nurse is caring for an infant born at 43 weeks. What would the physical assessment reveal?

Dry, peeling skin R: Loss of vernix caseosa leaves the skin dry, causing peeling.

What is the most appropriate toy for the nurse to select for a normal 2-year-old child?

Dump truck R: The 2-year-old enjoys playing with objects that can be pushed or pulled.

A woman diagnosed with endometriosis reports painful intercourse. What is the appropriate medical term for the nurse to document when describing this symptom?

Dyspareunia R: Dyspareunia is the term for painful sexual intercourse. Dyspnea is shortness of breath. Dysmenorrhea is painful menstruation. Dysrhythmia is irregular heart rhythm.

A newly married couple is seeking genetic counseling because they are both carriers of the sickle cell trait. How can the nurse best explain the childrens risk of inheriting this disease?

Each child has a one in four chance of having the disease and a two in four chance of being a carrier R: The sickle cell gene is inherited from both parents; therefore each offspring has a one in four chance of inheriting the disease.

The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately?

Ear infections R: Children with cleft palate are at risk of ear infections and dental disorders. Parents should be instructed to take the child to the health care provider at the first sign of earache.

A girl tells the nurse that she and her best friend belong to the popular clique. She states, I love Katy Perry, and I want to be a singer. The nurse recognizes the girls statement as characteristic of what time period?

Early adolescence R: Cliques of unisex friends, having a best friend, and hero worship are characteristics of the early adolescent.

A 12-year-old female pediatric patient experienced menarche 3 months ago. Her mother voices concern to the pediatric office nurse regarding the irregularity of her daughters menstrual cycle. What is the nurses best response?

Early cycles are often irregular. R:Early cycles are often irregular and may be anovulatory. Regular cycles are usually established within 6 months to 2 years of the menarche. In an average cycle, the flow (menses) occurs every 28 days, plus or minus 5 to 10 days.

When the nurse tells a pregnant woman that she needs 1200 mg of calcium daily during pregnancy, the woman responds, I dont like milk. What dietary adjustments could the nurse recommend?

Eat more green leafy vegetables. R: For women who do not like milk, other sources of calcium include enriched cereals, legumes, nuts, dried fruits, green leafy vegetables, and canned salmon and sardines that contain bones.

A pediatric patient is scheduled for a noninvasive procedure to determine if his heart is structurally normal and to localize a murmur. What diagnostic test does the nurse anticipate?

Echocardiogram R: Echocardiography is a noninvasive procedure that localizes murmurs and determines if theheart is structurally normal.

The massage technique that stimulates the large-diameter fibers in order to block impulses from the small-diameter fibers is ____________________.

Effleurage R: Effleurage stimulates the large-diameter fibers and blocks the pain impulses from the small-diameter fibers.

The nurse instructs the mother of a 2-year-old who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse?

Egg yolks R: Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement.

The nurse recognizes that when the toddler claims everything in the environment as mine, it is an example of the toddler trait of ____________________.

Egocentrism R: Toddlers are egocentric in that they perceive their world only as it applies to them, such as MY mommy, MY dog, MY car, MY house, MY street. As they mature and have more experience with the world, they come to a more realistic viewpoint.

The nurse confirms that sickle cell trait can be distinguished from sickle cell disease by a lab test called ________________.

Electrophoresis R: The hemoglobin electrophoresis is a blood test to check for different types of hemoglobin in the blood. Hemoglobin is the substance in red blood cells that carries oxygen. Electrophoresis uses an electrical current to separate normal and abnormal types of hemoglobin in the blood. Hemoglobin types have different electrical charges and move at different speeds. The amount of each hemoglobin type in the current is measured. An abnormal amount of normal hemoglobin or an abnormal type of hemoglobin in the blood may mean that a disease is present. A person with sickle cell disease has abnormal hemoglobin S cells.

A(n) _______________ ______________ is a person under the age of 18 who can legally sign for consent for medical treatment for themselves or their children.

Emancipated minor R: A person under the age of 18 who is no longer under the care of his parents authority or a married minor or minors in the military are considered emancipated minors who are accorded the rights of an adult.

What is best for the nurse to suggest to the parents of an overweight 9-year-old to help prevent obesity?

Encourage the child to engage in physical activity for at least an hour a day R: Regular physical activity reduces weight.

The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks gestation. What intervention will the nurse implement before this diagnostic test?

Encourage the patient to drink 1 to 2 quarts of water before the test. R: Ultrasound uses high-frequency sound waves to visualize structures within the body; the examination may use a transvaginal probe or an abdominal transducer; abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination).

What would the nurse guide a labor coach to do to comfort a woman tensing her muscles with contractions?

Encourage the patient to pant. R: Panting relaxes the abdominal wall and distracts the patient. It would not be helpful to offer fluids or to attempt conversation during contractions. Walking intensifies contractions.

The nurse caring for a 4-year-old postoperative patient instructs him to blow bubbles. What nursing intervention is the nurse most likely implementing by using this form of therapeutic play?

Encouraging deep breathing R: Play can also be therapeutic and aid in the recovery process. An example of therapeutic play is the game of having the child blow bubbles to promote deep breathing.

_____________________ is the presence of tissue that resembles endometrium outside the uterus.

Endometriosis R: Endometriosis is the presence of tissue that resembles endometrium outside the uterus.

Five days after a spontaneous vaginal delivery, a woman comes to the emergency room because she has a fever and persistent cramping. What does the nurse recognize as the possible cause of these signs and symptoms?

Endometritis R: Fever after 24 hours following delivery is suggestive of an infection. Severe cramping and fever are manifestations of endometritis.

When describing the female reproductive tract to a pregnant woman, the nurse would explain that which uterine layer is involved in implantation?

Endometrium R:The endometrium is the inner mucosal layer of the uterus that is governed by cyclical hormonal changes. It is functional during menstruation and during the implantation of a fertilized ovum.

What chemical substance(s) produced in the body acts as a natural pain reliever?

Endorphins R: Endorphins are natural body substances that are similar to morphine and may explain why laboring women need smaller doses of analgesia.

Which is the most appropriate nursing action when planning care for a child with cystic fibrosis?

Ensure high-protein, high-calorie diet R: The maintenance of adequate nutrition is essential. The diet is high in protein and calories. Chest physiotherapy should be done between meals. Pancreatic enzyme powder should be given with applesauce or other nonstarch, nonfat, nonprotein food. Children with cystic fibrosis should be weighed daily.

The rate of RBC production is regulated by _________________.

Erythropoietin R: Erythropoietin is a glycoprotein hormone that controls erythropoiesis or red blood cell production.

The parent of a 4 -year-old child tells the nurse, Bedtime is difficult. I cant get my son to go to bed at night. The nurse and the childs mother discuss options. What intervention is the most appropriate choice?

Establish a bedtime routine and use it consistently R: Parents should engage the child in quiet activities before bedtime and establish a ritual that signals readiness for bedtime.

What does the nurse explain can affect the survival of the X- and Y-bearing sperm after intercourse?

Estrogen level R: Estrogen levels and the pH of the female reproductive tract can affect the survival of the X- and Y-bearing sperm as well as their motility.

After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this action prevent heat loss?

Evaporation R: Newborns lose heat quickly after birth as fluid evaporates from their bodies.

How often will the nurse caring for a preterm infant in an incubator record the temperature of the infant and the incubator?

Every 2 hours

A new mother is voicing concern she is breastfeeding her newborn too frequently. How often does the nurse instruct this mother she should expect her newborn to feed?

Every 2 to 3 hours R: Breastfed infants may require feedings at 2- to 3-hour intervals because breast milk is more easily digested. A flexible but regular schedule that provides a rest period between feedings is best for the parent and infant.

A woman calls her health care provider to schedule prenatal visits in an uncomplicated pregnancy. How frequently will the nurse assist the patient to schedule these appointments?

Every 4 weeks until the 7th month, after which appointments will become more frequent R: Monthly visits are scheduled up to 28 weeks, and then visits increase to every 2 to 3 weeks through 36 weeks. From 36 weeks until delivery, visits are weekly.

What classic sign would the nurse, auscultating the breath sounds of a child hospitalized for an acute asthma attack, expect to find?

Expiratory wheezing R: The child experiencing an acute asthma attack wheezes as air moves in and out of the narrowed airways. The expiratory wheeze is most pronounced.

What marks the end of the third stage of labor?

Expulsion of the placenta and membranes R: The third stage of labor extends from the birth of the infant until the placenta is detached and expelled.

What is the best way for the nurse to communicate with a 10-year-old child who has a hearing impairment?

Face the child and speak clearly in short sentences.d. Recognize that the childs ability to communicate will be on a 6-year-old childs level R: The nurse who faces the child and speaks clearly will help the hearing-impaired child in the hospital to develop a healthy personality.

An infant is delivered with the use of forceps. What should the nurse assess for in the newborn?

Facial asymmetry R: Pressure from forceps may injure the infants facial nerve, which is evidenced by facial asymmetry.

The nurse is caring for a laboring patient who is not reporting pain. What sign would alert the nurse of the need for pain relief?

Facial grimacing R: Facial grimacing may be an indicator of unexpressed pain.

What characteristic manifestation does the nurse caring for a child with Duchennes muscular dystrophy document?

Falls frequently and is clumsy R: Frequent falling and clumsiness are clinical manifestations of Duchennes muscular dystrophy.

An 18-month-old child had a surgical repair of a cleft palate and is now allowed to eat a regular diet. What nursing action is the most appropriate?

Feed solid foods with the spoon at the side of the mouth R: The primary concern with feeding is to protect the operative site. The child can be fed with a spoon, but only the side of the spoon is placed into the mouth at the side of the mouth. The spoon must not touch the roof of the mouth.

The nurse providing stimulation to a preterm infant should schedule stimulation not to conflict with __________.

Feeding R: Preterm babies should not be stimulated during feeding so they can focus on sucking and swallowing.

________________________is designed to serve the metabolic needs during intrauterine life and also to permit safe transition to life outside the womb.

Fetal circulation R: Fetal circulation is designed to serve the metabolic needs during intrauterine life and also to permit safe transition to life outside the womb.

What does meconium-stained amniotic fluid indicate when the infant is in a vertex presentation?

Fetal distress R: Green-stained amniotic fluid means that the fetus passed the first stool before birth, and it is an indicator of fetal compromise.

The husband of a woman in labor asks, What does it mean when the baby is at minus 1 station? After giving an explanation, what statement by the husband indicates that teaching was effective?

Fetal head is above the ischial spines. R: Station describes the level of the presenting part in the pelvis. It is estimated in centimeters from the level of the ischial spines. Minus stations are above the ischial spines.

The physician performs an amniotomy on a laboring woman. What will be the nurses priority assessment immediately following this procedure?

Fetal heart rate R: The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes.

A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy?

Fetal heartbeat R: Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner.

A woman had a vaginal delivery two days ago and is preparing for discharge. What will the nurse plan to teach the woman to report to help prevent postpartum complications?

Fever R: Increased temperature is a sign of infection. The other choices are normal in the postpartum period.

What should the nurse closely assess in a child receiving a transfusion?

Fever R: The child receiving a blood transfusion is observed for signs of a transfusion reaction including chills, itching, fever, rash, headache, and back pain.

Place the newborn phases of the sleep-wake states in proper order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Stability phase b. First reactive phase c. Sleep phase d. Second reactive phase

First reactive phase Sleep phase Second reactive phase Stability phase R: At birth the newborn passes through the phases of sleep-wake states as part of the adjustment to life outside of the uterus: first reactive phase, sleep phase, second reactive phase, stability phase.

What emergency action should be implemented for airway obstruction in the infant?

Five back blows followed by five chest thrusts R: Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the infant.

Which hormone initiates the maturation of the ovarian follicle?

Follicle-stimulating hormone R:Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle.

How does the nurse characterize the play of 5-year-old children?

Following rules R: The 5-year-old wants to play by the rules but cannot accept losing. The rules may be very strict or change as the game progresses.

Which statement by a mother may indicate a cause for her 9-month-olds iron deficiency anemia?

Formula is so expensive. We switched to regular milk right away R: Because cows milk contains very little iron, infants should drink iron-fortified formula for the first year of life.

It is determined that the presenting part of the fetus is the buttocks. At delivery the fetuss hips are flexed and the knees are extended. How would the nurse record this presentation?

Frank breech R: When a fetus presents in a frank breech position, the legs are flexed at the hips and extend toward the shoulders.

The nurse assesses a boggy uterus with the fundus above the umbilicus and deviated to the side. What should the nurses next assessment be?

Fullness of the bladder R: Bladder distention can cause uterine atony. The uterus is massaged to firmness and then the bladder is emptied.

The nurse is assessing a school-age child. What will the nurse expect in regard to physical development of this child?

Gain of 5 to 7 pounds per year R: During the school-age period, the average weight gain per year is generally 5.5 to 7 pounds.

The nurse knows that an adolescent may find making a career choice difficult because there is less clarity in ______________ roles.

Gender R: The blurring of gender roles in the United Stateswomen holding jobs as engineers, lawyers, and physicians; and men entering nursing and culinary pursuitshas caused confusion with the selection of a career path.

At what stage is the adolescent considered to be,according to Freuds theory?

Genital R: Freud describes the adolescent period as genital.

The apnea monitor indicates that a preterm infant is having an apneic episode. What is the most appropriate nursing action in this situation?

Gently rub the infants feet or back R: Gently rubbing the infants back, ankles, or feet may stimulate the infant to breathe.

What term describes the age of a neonate that is based on the actual time in utero?

Gestational age R: The gestational age is the age based on the actual time in the uterus.

The nurse explains that the softening of the cervix and vagina is a probable sign of pregnancy. What is the appropriate term for this sign?

Goodells R: Goodells sign is one of the probable signs of pregnancy and describes a softened cervix and vagina.

The child with Duchennes muscular dystrophy must push on his legs and walk up the leg in order to rise to a standing position. The nurse recognizes this characteristic behavior as _______________ maneuver.

Gowers R: Gowers maneuver is a unique way of rising from the floor by walking up the leg in order to get the upper body erect.

A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patients obstetric history using the TPALM system?

Gravida 3, para 10110 R: Refer to TPALM system of identifying gravida and para.

Several hours after delivery the nurse finds a woman crying. The woman says repeatedly, My baby is beautiful, but I was planning on a vaginal delivery. Instead I needed an emergency C-section. What is the most appropriate nursing diagnosis?

Grieving related to loss of expected birth experience R: Women who have cesarean births usually need greater support than those who have vaginal births. They may feel grief, guilt, or anger because the expected course of birth did not occur.

________________________ is the leading cause of perinatal infections that have a high mortality rate.

Group B streptococcus (GBS) R: Group B streptococcus (GBS) is a leading cause of perinatal infections that have a high neonatal mortality rate. The organism can be found in the womans rectum, vagina, cervix, throat, or skin.

What would the nurse include when creating a teaching plan that includes the long-term administration of phenytoin (Dilantin)?

Gums should be massaged regularly to prevent hyperplasia R: Dilantin can cause gum overgrowth, which can be minimized by regular massaging. Dilantin frequently causes drowsiness and should be given with meals at the same time each day.

A pregnant woman asks the nurse, Will I be able to have a vaginal delivery? The nurse knows that which is the most favorable pelvic type for vaginal birth?

Gynecoid R: The gynecoid pelvis is the typical female pelvis and is most favorable for vaginal birth.

The number of years between menarche and the date of conception is known as___________________ age.

Gynecological R: Gynecological age is a term that refers to the number of years between the starting of the menses and the date of conception.

What is the best suggestion by the nurse for an appropriate toy for a hospitalized 6-year-old boy?

Handheld video game R: The 6-year-old child can perform numerous feats that require muscle coordination. At this age, the handheld video game will offer nonaggressive competition.

A mother is concerned because her 10-month-old is lethargic. What is the best action the nurse can advise this mother to implement?

Handle the infant slowly and gently R: Some infants respond to stimulating environments by shutting down. Move and handle infants slowly and gently.

The school nurse is preserving a tooth that was knocked out on the school playground. What will the nurse be especially careful to do?

Handle the tooth only by the crown R: When a permanent tooth is avulsed, the tooth should be picked up by the crown to prevent any further damage to the root and placed in milk until the child can be examined by a dentist.

The nurse explains that an infants prehensile development is progressive and logical. Arrange the development in the order from the simplest to the most complex. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Hands held open most of the time b. Grasps with thumb on one side and three fingers on the other c. Picks up toy with squeeze action d. Thumb and forefinger hold object e. Hands held closed most of the time ANS:E, A, C, B, D The development advances from the newborns closed hands to the open star hands of the older infant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger.

Hands held closed most of the time Hands held open most of the time Picks up toy with squeeze action Grasps with thumb on one side and three fingers on the other Thumb and forefinger hold object R: The development advances from the newborns closed hands to the open star hands of the older infant, to the squeeze action, to a grasp with thumb and fingers, to the pincher movement of thumb and forefinger.

The nurse explains that prior to fertilization each cell is reduced from 46 chromosomes to 23 chromosomes. This is referred to as the __________ number.

Haploid R: When each cell reduces its chromosomes from 46 to 23, it is called the haploid number.

A pregnant woman is experiencing nausea in the early morning. What recommendations would the nurse offer to alleviate this symptom?

Have crackers handy at the bedside, and eat a few before getting out of bed. R: The nurse can recommend eating dry toast or crackers before getting out of bed in the morning to alleviate nausea during pregnancy.

What will children who are unable to express themselves with words often do?

Have tantrums and act out R: Children with delayed communication skills will frequently have tantrums and act out when they are unable to make their needs known.

What is the most appropriate intervention when dealing with occasional aggression in a 4-year-old child?

Have the child take a time-out in the corner for 4 minutes R: Time-out periods, usually lasting 1 minute per year of age, with the child sitting in a chair or corner, are considered an effective disciplinary technique.

A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his favorite bottle. What is the most likely reason for this behavior?

He is dealing with the anxiety of hospitalization by regressing R: Hospitalization is frustrating for toddlers. They show their displeasure when illness restricts satisfaction of their desires. It is not unusual for a toddler who was drinking from a cup to refuse it in the hospital.

A 9-year-old boy is often cranky and irritable, and his school performance has declined. What is the most probable factor causing this behavior?

He sleeps only 6 to 7 hours a night R: The 9-year-old child requires about 10 hours of sleep per night.

Which comment made by a parent of a 1-month-old would alert the nurse about the presence of a congenital heart defect?

He tires out during feedings R: Fatigue during feeding or activity is common to most infants with congenital cardiac problems.

Which assessment of the newborn should be reported?

Head circumference is 5 cm greater than the chest circumference R: The circumference of the head should be less than 2 cm greater than that of the chest. All other listed assessments are within the norm.

What is an abnormal finding in an evaluation of growth and development for a 6-month-old infant?

Head lag present R: The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the child should undergo further evaluation.

What side effect would the nurse instruct a woman to look for when starting hormone replacement therapy (HRT)?

Headache R: Patients initiating HRT are reminded to have regular follow-up care and report headaches, vision changes, symptoms of thrombophlebitis, and cardiac symptoms.

A child is diagnosed with iron deficiency anemia. What will the nurse explain can occur if this disorder goes untreated?

Heart failure R: Untreated iron deficiency anemias progress slowly, and in severe cases the heart muscle becomes too weak to function. If this happens, heart failure follows.

A child develops carditis from rheumatic fever. Which areas of the heart are affected by carditis?

Heart muscle and the mitral valve R: The tissues that cover the heart and heart valves are affected. The heart muscle may be involved and the mitral valve is frequently involved.

__________ refers to standing measurement, whereas _______ refers to measurement while the infant is in a recumbent position.

Height, length R: Height refers to standing measurement, whereas length refers to measurement while the infant is in a recumbent position.

What is the most appropriate nursing action to take when a laboring woman hyperventilates?

Help her breathe into her cupped hands R: Measures to combat hyperventilation include breathing into cupped hands or a paper bag or holding breath for a few seconds. All of these techniques decrease PCO2.

What is the best advice the nurse can offer a parent concerned because her 2-year-old is very active and does not eat much?

Help the child wind down with a quiet activity before mealtime R: Quiet time before meals provides an opportunity for the active toddler to wind down.

Which statement best describes the 3-year-old child?

Helpful, wants to assist with chores R: Three-year-old children are helpful and can assist in simple household chores.

A(n) is a collection of blood within the tissues.

Hematoma R: A hematoma is a collection of blood within the tissues.

After a prolonged labor, a woman vaginally delivered a 10 pound, 3 ounce infant boy. What complication should the nurse be alert for in the immediate postpartum period?

Hematoma R: Delivering a large infant and a prolonged labor are risk factors for hematoma formation.

The nurse shows slides of red blood cells from a child with sickle cell disease, noting that in addition to their sickle shape, the cells contain the abnormal element of ______________ _____.

Hemoglobin S R: Hemoglobin S is the abnormal hemoglobin that makes red blood cells fragile and causes the walls of the cells to collapse, giving them the characteristic sickle shape.

When obtaining a prenatal history on a pregnant patient the nurse notes a family history of sickle cell disease. Given this information, what lab test can the nurse anticipate the physician will order?

Hemoglobin electrophoresis R: Hemoglobin electrophoresis identifies presence of sickle cell trait or disease (in women of African or Mediterranean descent). It is ordered in the first trimester, if indicated.

A child with thalassemia major receives blood transfusions frequently. What is a complication of repeated blood transfusions?

Hemosiderosis R: As a result of repeated blood transfusions, excessive deposits of iron (hemosiderosis) are stored in tissues.

A 48-year-old woman tells the nurse, I missed my period last month. Am I in menopause? The nurse knows that at which point is a woman considered to be menopausal?

Her periods have stopped for 1 year. R: When a womans menstrual periods have stopped for 1 year, she is considered menopausal.

A seventh-grade girl tells the school nurse that her art teacher, a woman, is her hero. What is the most appropriate interpretation of the girls comment?

Hero worship is a normal phenomenon R: School-age children tend to admire their teachers and adult companions. For the 11- to 12-year-old, hero worship is a normal phenomenon.

The nurse is educating a woman diagnosed with Premenstrual Dysphoric Disorder (PMDD). What is the best type of diet for the nurse to recommend?

High carbohydrate, high fiber R: Treatment of PMDD includes a diet rich in complex carbohydrates and fiber (to lengthen effects of the carbohydrate meal).

A woman missed her menstrual period 1 week ago and has come to the doctors office for a pregnancy test. Which placental hormone is measured in pregnancy tests?

Human chorionic gonadotropin R: Human chorionic gonadotropin is the basis for most pregnancy tests. It is detectable in maternal blood as soon as implantation occurs, usually 7 to 9 days after fertilization.

What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid?

Hydrocephalus R: Hydrocephalus is characterized by an increase in cerebrospinal fluid in the ventricles of the brain.

A pregnant patient tells the nurse that she has been nauseated and vomiting. How will the nurse explain that hyperemesis gravidarum is distinguished from morning sickness?

Hyperemesis gravidarum causes dehydration and electrolyte imbalances. R: Dehydration and electrolyte imbalances result from persistent nausea and vomiting associated with hyperemesis gravidarum. Dehydration impairs the perfusion to the placenta.

Several hours into labor, a woman complains of dizziness, numbness, and tingling of her hands and mouth. What does the nurse recognize these symptoms signify?

Hyperventilation R: Hyperventilation is sometimes a problem if a woman is breathing rapidly.

The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess for with this neonate?

Hypoglycemia R: The newborn of a mother with diabetes is prone to hypoglycemia.

The nurse caring for an infant born at 36 weeks of gestation assesses tremors and a weak cry. The nurse is aware that these symptoms indicate what?

Hypoglycemia R: The preterm infant, before 38 weeks, should be assessed for hypoglycemia because the infants glycogen stores are not adequate.

After several hours of labor, a nursing assessment reveals that a womans cervix is 5 cm dilated but contractions are becoming shorter and less frequent. What is this labor pattern considered?

Hypotonic R: The woman with labor dysfunction related to decreased uterine muscle tone begins labor normally, but contractions diminish after the active phase.

The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions?

I clean the perineum from front to back with an antiseptic wipe before I urinate R: To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

The school nurse is educating high school students about guidelines to be followed when participating in sports. Which statement by a student alerts the nurse of the need for further information?

I drink large amounts of fluid when working out R: Fluids lost by sweat must be replaced by drinking small amounts of fluid during a workout. Thirst is one guide for intake. Caffeine and alcohol deplete body water and are to be avoided. Carbohydrates that provide both energy and other nutrients are best for athletes. Protective gear should be worn by all team players in any contact sport.

The nurse suggests the use of I messages to communicate a parents feeling to an adolescent. What is the most appropriate example of an I message?

I feel frightened when you stay out past your curfew R: This is the only statement that associates the parents feelings about the adolescent behavior that is not aggressive or accusatory.

What statement made by a parent indicates correct understanding of infant feeding?

I give the baby any new foods before he takes his bottle R: New solid foods should be introduced before formula or breast milk to encourage the infant to try new foods.

Which statement best corresponds to a preschoolers understanding of hospitalization?

I got sick because I was mad at my brother. R: The preschooler may feel guilty, particularly if an accident happens as a result of mischief on his or her part.

The nurse is educating a group of preschool parents about the importance of safety. Which statement by a parent indicates the need for further education?

I only leave my child in the car for brief moments R: Children must not play in or around the car or be left alone, even for a brief moment, in the car. Preschool children still require a good deal of indirect supervision to protect them from dangers that arise from their immature judgment or social environment. Stairways should be free of clutter and medications kept out of reach.

Which statement indicates a woman understands activity limitations for the management of preterm labor?

I pack a picnic basket and put it next to the sofa so I do not have to get up for food during the day. R: Lengthy activity restrictions are often needed to prevent preterm birth. The nurse can help the woman identify ways to organize necessary activities and maximize rest.

Which statement indicates the mother of an 8-month-old understands infant sleep patterns?

I put the pacifier in the crib so that she can find it when she wakes up R: The parent should assist the infant to develop self-soothing behaviors so that the infant can get back to sleep on her own.

What statement made by a parent indicates an understanding about helping a 13-year-old manage his allowance?

I set amounts he can earn for particular chores R: If money is simply handed out as requested, it is difficult to develop responsibility for finances and money management. The older adolescent is able to get a job. The younger adolescent can earn money by doing particular chores.

The nurse has explained menstruation to a 13-year-old girl. What statement indicates the girl needs additional education?

I should expect heavy bleeding with clots. R: Clots are not normally seen in menstrual discharge. A normal menstrual flow is 30 to 40 mL blood and 30 to 50 mL serous fluid.

What statement indicates the parent understands the guidelines for bathing a newborn?

I should shampoo the head after washing the rest of the body R: The shampoo is done last because the large surface area of the head predisposes the infant to heat loss.

A mother reports that she has a new job and her 12-year-old child is home alone for a time after school. Which statement made by the parent alerts the nurse to a potentially unsafe situation for this child?

I told him that he could invite a few friends after school R: Latchkey children are subject to a higher rate of accidents. Permitting school-age children and their friends to be home alone in an unsupervised environment is an unsafe situation.

The nurse is caring for a patient who is threatening preterm labor and has been given glucocorticoids. What is the purpose of glucocorticoid administration?

Increase fetal lung maturity. R: Glucocorticoids assist with improving the lung maturity of a fetus that is preterm.

What statement by a patients mother leads the nurse to determine she understands instructions about administering an oral antibiotic for otitis media?

I will administer prescribed doses until all the medication is used R: Antibiotic therapy for otitis media is continued until the prescribed amount has been completed, even if symptoms are alleviated.

Which statement indicates the new mother is breastfeeding correctly?

I will alternate breasts when feeding the baby. R: Alternating breasts for feeding increases milk production, particularly hindmilk, which has a higher protein and fat content.

The nurse has discussed with a mother the process of introducing solid foods to her 6-month-old infant. What statement by the mother leads the nurse to determine that learning has taken place?

I will give my infant rice cereal first R: Solid foods are usually introduced at about 6 months of age, starting with rice cereal, which is the least allergenic.

What statement by the patient leads the nurse to determine a woman with mastitis understands treatment instructions?

I will take a warm shower before nursing the baby R: Moist heat promotes blood flow to the area, comfort, and complete emptying of the breast.

An adolescent is diagnosed with Hodgkins disease. Lymph nodes on both sides of her diaphragm have been found to be involved, including cervical and inguinal nodes. Which disease stage is this?

III R: Lymph node regions on both sides of the diaphragm are consistent with a diagnosis of stage III Hodgkins disease.

The nurse notices that the mother of a child with cerebral palsy corrects and redoes many of the things the nurse does for her child. What is the nurses most appropriate response to this mother?

Id love for you to share with me some of the special things you do for your child R: The person who cares daily for the child with a chronic illness can provide information that will best guarantee continuity of care between the home and the hospital.

A pregnant woman states, My husband hopes I will give him a boy because we have three girls. What will the nurse explain to this woman?

If a sperm carrying a Y chromosome fertilizes an ovum, then a boy is produced. R: When a Y-bearing sperm fertilizes an ovum, a male child is produced.

A 2-year-old child has been diagnosed with hemophilia A. What information should the nurse include in a teaching plan about home care?

If bleeding occurs, apply pressure, ice, elevate, and rest the extremity R: When bleeding occurs, the traditional approach is to follow RICE rest, ice, compression, and elevation.

What statement made by a new mother indicates she needs additional information about breastfeeding?

If the baby gets fussy between feedings, I give her a bottle of water. R: Supplemental feedings of formula or water should not be offered to a healthy newborn who is breastfeeding.

The nurse explained how to position an infant with tetralogy of Fallot if the infant suddenly becomes cyanotic. Which statement by the father leads the nurse to determine he understood the instructions?

If the baby turns blue, I will hold him against my shoulder with his knees bent up toward his chest R: In the event of a paroxysmal hypercyanotic or tet spell, the infant should be placed in a knee-chest position.

The nurse advises the nursing mother that the immune globulin that is found in breast milk is ______________.

IgA R: IgA is an immune globulin that is found in breast milk.

What statement by a man considering a vasectomy indicates a need for further information?

Ill need to remain in the hospital for a few days. R: A vasectomy takes about 20 minutes and is performed on an outpatient basis under local anesthesia.

A woman requests a pudendal block to manage her labor pain. What statement by the woman indicates a need for further explanation about the pudendal block?

Im having a contraction. Can I get the pudendal block now? R: The pudendal block does not block pain from contractions and is given just before birth.

The nurse finds a woman crying after she has undergone a dilation and evacuation (D&E) for a missed abortion. What is the most appropriate statement by the nurse?

Im here if you need to talk.d. You are young and strong. I know you can have a healthy pregnancy. R: An effective technique when communicating with a woman experiencing pregnancy loss is to say, Im here if you need to talk. The nurse listens and acknowledges the womans grief.

What statement by an 11-year-old leads the nurse to determine he has moved from the mind set of egocentrism?

Im sorry. I bet that hurt your feelings R: The ability to see anothers point of view indicates moving away from egocentrism into a more altruistic mind-set.

What factor does the nurse explain affects the infants physiological response to medications?

Immature kidney function R: Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of age.

The nurse observes that the infants anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant?

In a semi-Fowlers position R: If the fontanelles are bulging, the child will be positioned in a semi-Fowlers position to promote drainage from the ventricles through the shunt.

The nurse discusses child-proofing the home for safety with the mother of a 9-month-old. Which statement made by the mother would indicate an unsafe behavior?

In the car, she rides in a front-facing car seat R: A rear-facing infant car seat should be used for infants younger than 1 year of age.

The nurse outlines the process of ova being mixed with sperm and then the resulting embryos being returned to the mothers uterus. This process of infertility treatment is ____________ ______________ _________________.

In vitro fertilization R: The in vitro fertilization technique mixes ova with sperm and deposits several of the resulting embryos in the mothers uterus.

The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause?

Inadequate placental nutrition R: The single placenta may not be able to provide adequate nutrition to two fetuses.

In the week before her menstrual period, a woman experiences irritability, anxiety, and difficulty concentrating. What remedy might the nurse suggest to relieve these symptoms?

Include complex carbohydrates and fiber in the diet R: A diet rich in complex carbohydrates and fiber is recommended for premenstrual dysmorphic disorder.

At her regular gynecological examination, a woman tells the nurse that she is concerned about osteoporosis. What suggestion can the nurse make to this patient?

Include more dairy products and green, leafy vegetables in her diet R: Foods rich in calcium include milk, dairy products, and green, leafy vegetables.

A woman is 9 weeks pregnant and experiencing heavy bleeding and cramping. She reports passing some tissue. Cervical dilation is noted on examination. What is the most likely cause of these symptoms?

Incomplete abortion R: Signs and symptoms of an incomplete abortion are similar to those of an inevitable abortion, but some tissue is passed.

The nurse is caring for a 3-year-old with a head injury. Which assessment would lead the nurse to report the probability of increasing intracranial pressure (ICP)?

Increase in blood pressure with an attendant decrease in pulse R: Increasing blood pressure, accompanied by decreasing pulse, and accompanied by unequal pupils are indicators of ICP.

A 14-year-old boy is at the pediatric clinic for a checkup. What physical changes of puberty will the nurse indicate are related to the production of testosterone?

Increase in muscle mass and strength R:Testosterone increases muscle mass, promotes strength and growth of long bones, and enhances production of red blood cells.

What is the best nursing action to implement when late decelerations occur?

Increase oxygen to 10 L/minute R: The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension.

What symptoms of cold stress might the nurse recognize in a preterm infant?

Increased respiratory rate and periods of apnea R: Signs of cold stress include increased respiratory rate with periods of apnea, decreased skin temperature, bradycardia, mottling of skin, and lethargy.

A child has just been diagnosed with acute lymphoblastic leukemia. What is the result of an overproduction of immature white blood cells in the bone marrow?

Increased susceptibility to infection R: An overproduction of immature white blood cells increases the childs susceptibility to infection.

The nurse using the PACE interview guide for persons at risk for substance abuse arrives at a score of 2 for an adolescent patient. How would the nurse interpret this score?

Indication for referral for counseling R: The PACE guide recommends that a score of 2 or higher would suggest the need for a referral for counseling about substance abuse.

The nurse explains that the drug clomiphene (Clomid) is used in infertility treatment. What is the primary action of clomiphene (Clomid)?

Induces ovulation R: Clomiphene (Clomid) induces ovulation. It may also increase sperm production, although this is an unlabeled use.

When asked about her activities, a 10-year-old girl responded, I like school. I play the flute in the school band, and I take tennis lessons. What does the nurse know these activities will help this child develop?

Industry R: The school-age period is referred to by Erikson as the stage of industry. Successful participation in activities facilitates the childs sense of industry.

An infant is hospitalized with RSV bronchiolitis. What is the priority nursing diagnosis?

Ineffective breathing pattern related to airway inflammation and increased secretions R: An ineffective breathing pattern is the priority nursing diagnosis for an infant hospitalized with RSV infection.

The correct term for the child aged 4 weeks to 1 year is ______________.

Infant R: A child between the ages of 4 weeks and 1 year is termed an infant.

Which statement indicates the parents understand when to contact the pediatrician or nurse practitioner?

Infants diaper is not wet after 8 hours R: Decreased or lack of voiding by the newborn should be reported to the pediatrician or nurse practitioner to prevent dehydration.

The nurse is caring for a child with a diagnosis of Kawasaki disease. The childs parent asks the nurse, How does Kawasaki disease affect my childs heart and blood vessels? On what understanding is the nurses response based?

Inflammation weakens blood vessels, leading to aneurysm R: Inflammation of vessels weakens the walls of the vessels and often results in aneurysm.

Assessment of altered skin integrity in the preterm infant is made difficult because of the immature immune system that cannot produce a(n) __________ reaction.

Inflammatory R: The immature immune system cannot produce an inflammatory reaction to show redness or swelling. Without such symptoms, skin integrity is more difficult to assess in the preterm infant.

A pregnant woman is attending her second postpartum visit. Prenatal lab work indicates she is not immune to the rubella virus. What is the most appropriate nursing intervention?

Inform the woman she should receive the vaccine in the hospital after delivery. R: The rubella vaccine is contraindicated during pregnancy. A woman should be instructed to avoid pregnancy for at least 1 month following rubella immunization. It is not necessary to hold all immunizations until 1 month postpartum.

An ________________________ implies that the parent or legal guardian is capable of understanding information given to him or her, including the purpose and risks of the procedure, and voluntarily agrees to that procedure.

Informed consent R: An informed consent implies that the parent or legal guardian is capable of understanding information given to him or her, including the purpose and risks of the procedure, and voluntarily agrees to that procedure.

What does an adolescents peer group serve as related to development?

Initial separation from family R: Being a member of a peer group and communicating with and seeking approval from this group are hallmarks of the first separation from the family.

Why does the woman taking oral hypoglycemic agents to control diabetes mellitus need to take insulin during pregnancy?

Insulin does not cross the placental barrier to the fetus. R: Oral hypoglycemic agents are not used during pregnancy because they can cross the placenta, possibly resulting in fetal birth defects or hypoglycemia.

What will the nurse advise a parent to do when introducing solid foods?

Introduce each new food 4 to 7 days apart R: Only one new food is offered in a 4- to 7-day period to determine tolerance.

A 4-year-old child insists he has more money with a nickel than his father has with a dime. What is this perception, as described in Piagets theory?

Intuition R: The intuitive stage, as described by Piaget, is prelogical thinking that is based on the outside appearance of objects. A nickel is larger than a dime and therefore more valuable.

A 4-year-old begins to cry when his mother tells him it is time for his operation. The nurse understands this is an expected reaction. On which particular fear of the preschooler does the nurse base this understanding?

Invasive procedures R: The preschool-age child is afraid of bodily harm, particularly invasive procedures.

____________ refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition.

Involution R: Involution refers to changes that the reproductive organs, particularly the uterus, undergo after birth to return to their prepregnancy size and condition.

The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention is appropriate for the nurse to implement?

Involve the parents R: It is appropriate to involve the parents when performing a procedure on an infant. Providng a simple explanation, letting the child examine the equipment, and suggesting coping techniques are not appropriate interventions for an infant.

Which assessment finding in a child with meningitis should be reported immediately?

Irregular respirations R: Irregular respirations in conjunction with slowing heart rate and increasing blood pressure are reported immediately because they could indicate increased intracranial pressure.

The nurse explains to the parents of a hospitalized child that their child will receive fentanyl for an upcoming procedure. What advantage of fentanyl will the nurse explain?

It has a rapid onset R: Fentanyl is a drug useful for all ages because of its rapid onset and brief duration.

The nurse is leading a discussion group with parents of adolescents. One parent comments, My son cant do anything without checking with his friends first. My opinion doesnt count anymore. What knowledge in regard to this behavior would the nurse formulate as a response?

It is a normal phenomenon during adolescence R: Parents may need help understanding that the adolescents exaggerated conformity is necessary for moving away from dependence and obtaining approval from persons outside the nuclear family.

The nurse has explained physiological changes that occur during pregnancy. Which statement indicates that the woman understands the information?

My breathing will get deeper and a little faster. R: The pregnant woman breathes more deeply, and her respiratory rate may increase slightly.

What is the nurses best advice to a parent about a preschoolers imaginary friend?

It is common for preschoolers to have imaginary friends R: Imaginary friends are common and normal during the preschool period and serve many purposes, such as relief from loneliness, mastery of fears, and acting as a scapegoat.

Which statement made by a parent indicates an understanding of health maintenance of a child with sickle cell disease?

It is important for my child to drink plenty of fluids R: Prevention of dehydration, which can trigger the sickling process, is a priority goal in the care of a child with sickle cell disease.

The mother of a hospitalized toddler states, He cries when I visit. Maybe I should just stay away. What is the nurses best response?

It is important that you are here. This is a common reaction in children when they are separated from their parents R: During the second stage of separation anxiety (despair), the child is quiet, is not crying, and is sad and depressed. The child will revert to protest when the parent arrives for a visit.

A nurse is teaching a childbirth preparation class. The group is discussing individual expression of labor pain. What statement is accurate about a patients expression of pain?

It is influenced by culture. R: Culture influences how women feel about birth and what is an acceptable response to pain.

The nurse is presenting information on the congentital disorder of hemophilia A. What fact will the nurse include?

It is transmitted by symptom-free females R: Hemophilia A affects mostly males who received the sex-linked recessive trait from a symptom-free female. The defective gene is on the X chromosome.

A woman in the transition phase of labor requests a narcotic analgesic medication for pain relief. What should the nurse explain regarding giving a narcotic analgesic medication at this stage of labor?

It may result in respiratory depression to the newborn. R: The risk of narcotic analgesics is that they cross the placenta and can cause fetal respiratory depression.

A 13-year-old boy states, The girls in my class tower over me. What would be the nurses most informative response?

It may seem that way because girls have a growth spurt 2 years earlier than boys R: Although the age for growth spurts during puberty varies, growth spurts occur 2 years earlier for girls than for boys.

The nurse is planning to teach a woman about perimenopause. What would the nurse include regarding lowered estrogen level?

It raises the level of low-density lipoproteins R: Estrogen increases the amount of high-density lipoproteins that carry cholesterol from body cells to the liver for excretion. With lowered levels of estrogen, low-density lipoproteins increase, causing an increase in the incidence of heart attacks and strokes.

The mother of a 4-month-old infant, born prematurely, asks the nurse if her daughter will always be small for her age. What is the most appropriate nursing response?

It takes about two years for the preterm infant to catch up to a full-term infant R: In the absence of severe birth defects and complications, the growth rate of the preterm newborn nears that of the term infant by about the second year.

The young prenatal patient with gestational diabetes mellitus (GDM) says, I am frightened that I will have to deal with insulin injections for the rest of my life. What is the best response by the nurse?

It will most likely resolve 6 weeks or so after the baby is born. R: GDM usually resolves by 6 weeks after delivery.

Because the diagnosis of rheumatic fever is difficult, an aid used to identify the presence of rheumatic fever is the _____________ _______________.

Jones criteria R: The Jones criteria identify a cluster of symptoms and divide them into major criteria and minor criteria. The formula for making the diagnosis of rheumatic fever is to identify two major criteria in the patient, or one major and two minor criteria.

The nurse encourages the anxious mother of a preterm infant to consider the warming technique of holding the infant between her breasts with skin-to-skin contact under a blanket. This technique is the __________ care method.

Kangaroo R: The kangaroo care method is when the mother places the infant between her breasts for skin-to-skin contact, and then both mother and infant are wrapped in a blanket as a warming technique. This method also facilitates maternal-infant bonding.

Phototherapy is instituted for an infant. What is the most appropriate nursing action for the infant having phototherapy?

Keep the infants eyes covered R: The infants eyes are protected with patches to prevent damage from the high-intensity lights.

A woman is 7 cm dilated, and her contractions are 3 minutes apart. When she begins cursing at her birthing coach and the nurse, what does the nurse assess as the most likely explanation for the womans change in behavior?

Labor has progressed to the transition phase. R: If a woman suddenly loses control and becomes irritable, suspect that she has progressed to the transition stage of labor.

The _________________________, also called the psychoprophylactic method, is the basis of most childbirth preparation classes in the United States.

Lamaze method R: The Lamaze method, also called the psychoprophylactic method, is the basis of most childbirth preparation classes in the United States.

A(n) _______________ is a narrow cone inserted into the cervix to ripen the cervix to increase uterine contractions.

Laminaria R: A laminaria is a narrow cone inserted in the cervix that dilates and ripens the cervix as it absorbs water.

A woman who is 25 weeks pregnant asks the nurse what her fetus looks like. What does the nurse explain is one physical characteristic present in a 25-week-old fetus?

Lanugo covering the body R: By 25 weeks, the body of the fetus is covered with lanugo, the eyes are open, the skin is wrinkled, and the fetus has definite periods of movement and sleeping.

When assessing a neonate born at 38 weeks of gestation, the nurse records his weight as 8 pounds, 10 ounces. What will the nurse consider this newborn?

Large for gestational age R: Term infants over 4000 g (8.8 lb) may be classified as large for gestational age (LGA). For the preterm infant this is less than 38 weeks, for the term infant it is 38 to 42 weeks, and for the postterm infant it is beyond 42 weeks. A late preterm infant, also known as a near-term infant, is born between 34 and 36 weeks.

What information will the nurse provide when educating a woman about the correct use of a diaphragm?

Leave in place for at least 6 hours after intercourse R: To act as a barrier, the diaphragm must be left in place for at least 6 hours after intercourse and can be left in place up to 24 hours.

What nursing action will the nurse implement after feeding an infant with hydrocephalus?

Leave the infant in a side-lying position R: Because children with hydrocephalus are prone to vomiting, the child is fed and then positioned in the side-lying position in a quiet atmosphere to reduce the incidence of vomiting.

Parents express concern about the milia on the face and nose of their infant. What is the nurses most helpful response when instructing the parents?

Leave the milia alone; it will disappear spontaneously. No treatment is needed R: Milia require no treatment. This skin manifestation will disappear spontaneously.

The nurse is aware that ______________ maneuver can assess the position and presentation of the fetus.

Leopolds R: Leopolds maneuver assesses the position and the presentation of the fetus by palpation.

The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called _____________________________ _____________________________.

Leopolds maneuver R: The nurse may assist the health care provider in determining the fetal position and presentation by abdominal palpations called Leopolds maneuver.

What is the best response to a postpartum woman who tells the nurse she feels tired and sick all of the time since I had the baby 3 months ago?

Lets talk about this further. I am concerned about how you are feeling R: If a postpartum woman seems depressed, it is important to explore her feelings to determine if they are persistent and pervasive.

What would the nurse include in teaching when preparing to teach parents about air travel instructions to prevent barotrauma in infants?

Letting the infant nurse during descent R: Encouraging an infant to swallow reduces the pressure in the ears during descent.

In males the follicle-stimulating hormone (FSH) and the luteinizing hormone (LH) from the anterior pituitary stimulate testosterone production in the ________ cells of the testes.

Leydig R: The Leydig cells in the testes are stimulated by the FSH and LH to produce testosterone.

The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia?

Lie flat for several hours. R: The woman would be advised to remain flat for several hours after the block to decrease the chance of postspinal headache.

What would the nurse expect a 4-month-old to be able to accomplish?

Lift head and shoulders R: Because development is cephalocaudal, of these choices, lifting the head and shoulders is the one that the infant learns to do first. The infant can usually sit with support at about 5 months of age and can sit alone at about 8 months.

What instruction would the nurse include when planning anticipatory guidance for parents of a toddler?

Limit-setting should include praise R: Limit-setting should include praise as well as disapproval for undesired behavior.

What organ does the ductus venosus shunt blood away from in fetal circulation?

Liver R: Fetal blood bypasses the liver through the ductus venosus by carrying blood directly to the inferior vena cava.

The nurse is caring for an infant born at 35 weeks of gestation. What physical characteristic might the nurse expect this infant to exhibit?

Loose, transparent skin R: The growth and development of the fetus are abruptly halted by a preterm birth. One of the characteristics of the preterm infant is skin that is loose and transparent.

An 8-year-old child will be hospitalized for several weeks in skeletal traction to treat a fractured femur. What does the nurse realize immobilization in this age-group can generate feelings of in planning care of this child?

Loss of control R: Forced dependency in the hospital, such as immobilization, can result in a feeling of loss of control and loss of security.

The nurse is talking with a parent about tooth eruption. What teeth will the nurse explain are the first deciduous teeth to erupt?

Lower central incisors R: The first teeth to erupt, usually at about 7 months, are the lower central incisors.

The nurse who encourages the gate control theory of pain control would advise a woman in labor and her partner to use which nonpharmacological method of pain management?

Massage R: According to the gate control theory, stimulating large-diameter nerve fibers temporarily interferes with conduction of impulses through small-diameter fibers. Massage is a technique that stimulates large-diameter fibers and closes the gate.

At her 6-week postpartum checkup, a woman mentions to the nurse that she cannot sleep and is not eating. She feels guilty because sometimes she believes her infant is dead. What does the nurse recognize as the cause of this womans symptoms?

Major depression R: Major depression is a disorder characterized by deep feelings of worthlessness, guilt, serious sleep and appetite disturbances, and sometimes delusions about the infant being dead.

The nurse is preparing a community education program on preventive health care for women. What common screening test will the nurse plan on explaining to the women attending the program?

Mammography R: Mammography is a screening test used to detect breast cancer.

After delivery, the nurses assessment reveals a soft, boggy uterus located above the level of the umbilicus. What is the most appropriate nursing intervention?

Massage the fundus. R: A poorly contracted uterus should be massaged until firm to prevent hemorrhage.

The nurse encourages the members of a prenatal class to seriously consider breastfeeding. What does breast milk provide in addition to nourishment for the infant?

Maternal antibodies R: Breast milk provides maternal antibodies to the infant that give the child acquired immunity from some diseases for several months.

The nurse is administering terbutaline (Brethine) to a pregnant woman to prevent preterm labor. The nurse would assess for which adverse effect?

Maternal tachycardia R: Maternal tachycardia is the common negative side effect of terbutaline, which should be corrected with a dose of propranolol.

What signifies the end of puberty for a male?

Mature sperm are formed. R: Puberty ends for a male when mature sperm are formed by the testes.

A woman reports that her last normal menstrual period began on August 5, 2013. What is this womans expected delivery date using Ngeles rule?

May 12, 2014 R: To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary.

______________ is frequently delayed in girls who are involved in activities that require a lean body and a high level of physical activity.

Menarche R: Menarche can be delayed in girls who are involved in such activities as dancing, running, gymnastics, or any activity that requires a lean body.

A group of nursing students plans to teach a class of sixth grade girls about menstruation. What correct information will the nursing students teach to the class?

Menarche usually occurs around 12 years of age. R:The beginning of menstruation, called menarche, occurs at about 12 years of age. Early cycles are irregular and anovulatory.

The nurse clarifies to the parents of a child with spina bifida that their child has a portion of the spinal cord in the sac in addition to the meninges. This type of spina bifida is known as a(n) ____________________.

Meningomyelocele R: A spina bifida that includes a portion of the cord in the sac in addition to the meninges is classified as a meningomyelocele.

The nurse teaches a woman who is 8 weeks pregnant about how rubella can affect the developing fetus. What can result from maternal rubella during pregnancy?

Mental retardation R: Rubella can have devastating effects on the developing fetus. Some effects of rubella on the embryo or fetus include microcephaly, mental retardation, cardiac defects, cataracts, and deafness.

A mother is anxious about her ability to breastfeed after her child is born because of her small breast size. What would be an important point to teach this mother?

Milk is produced in ducts and lobules regardless of breast size. R: Breast size does not influence the ability to secrete milk.

What toy is developmentally appropriate for the nurse to suggest to entertain a 5-year-old child?

Model airport with toy planes R: At this age children are into creative play. The model airport with toy planes is the most developmentally appropriate.

The nurse assesses a 6-inch stain of lochia rubra on a pad that was worn for 2 hours. The nurse would document this as a(n) ________________ amount of lochia.

Moderate R: A 6-inch stain on a pad worn for 2 hours is regarded as a moderate amount of lochia discharge.

Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant?

Mummy R: A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.

Parents of a newborn are worried about dark areas over the sacrum of the newborn. What does the nurse explain this transitory skin discoloration is called?

Mongolian spots R: Bluish skin discoloration over the sacral area of a newborn is a transitory condition called Mongolian spots.

What nursing action is appropriate to prevent possible retinopathy in a preterm infant requiring oxygen therapy?

Monitor arterial oxygen levels with a pulse oximeter R: Use of a pulse oximeter to carefully monitor arterial blood gases in high-risk infants continues to be a priority in the neonatal intensive care unit (NICU).

A father is concerned about how long his preschool-age child will continue sucking his thumb. What is the most helpful response from the nurse?

Most children will stop thumb-sucking naturally by school age R: Most children give up the habit of thumb-sucking by the time they reach school.

A woman asks about resumption of her menstrual cycle after childbirth. What should the nurse respond?

Most nonlactating women resume menstruation about 2 months postpartum. R: Menstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.

What is an appropriate nursing action when a child is experiencing a generalized tonic-clonic seizure?

Move objects out of the childs immediate area R: During a generalized tonic-clonic seizure, the immediate area is cleared to protect the child from injury.

Which statement indicates to the nurse on a postpartum home visit that the patient understands the signs of late postpartum hemorrhage?

My discharge would change to red after it has been pink or white R: When the nurse teaches the postpartum woman about normal changes in lochia, it is important to explain that a return to red bleeding after it has changed to pink or white may indicate a late postpartum hemorrhage.

Which narcotic antagonist is used to reverse narcotic-induced respiratory depression?

Naloxone (Narcan) R: Naloxone (Narcan) is used to reverse respiratory depression caused by narcotics.

A pregnant womans membranes ruptured prematurely at 34 weeks. She will be discharged to her home for the next few weeks. What would the nurse planning discharge instruction teach the woman to do?

Notify her obstetrician if she has a temperature above 37.8 C (100 F). R: For the woman with premature rupture of membranes (PROM) who is not having labor induced right away, teaching combines information about infection and preterm labor. The woman should monitor her temperature and report a temperature greater than 37.8 C (100 F).

During a strenuous labor, the woman asks for some pain remedy for the sudden pain between her scapulae that seems to occur with every breath she takes. What is the best nursing action?

Notify the charge nurse immediately R: Sudden pain between the scapulae during a strenuous labor is an indicator of uterine rupture. This should be reported immediately.

Parents tell the nurse they are frustrated with their toddlers recent behavior and refusal to agree with anything they ask of them. What does the nurse explain as the term for when a toddler tests their own power?

Negativism R: By refusing to eat, dress, sleep, or anything else by saying No, toddlers test their own power to control. Because toddlers are also egocentric, they come to believe that their negativism is absolute. This is especially true if the adults give into it.

On what knowledge would the nurse base a response to a mother who questions, Do you think my baby recognizes my voice?

Neonates can distinguish a mothers voice from other sounds in the first days of life R: The ability to discriminate between a mothers voice and other voices may occur as early as in the first 3 days of life.

The nurse encourages adequate intake of folic acid for women of childbearing age before and during pregnancy. What is folic acid thought to decrease the incidence of in fetal development?

Neural tube defects R: Folic acid can reduce the incidence of neural tube defects such as spina bifida and anencephaly.

When preparing to teach a class about prenatal development, the nurse would include information about folic acid supplementation. What is folic acid known to prevent?

Neural tube defects R: It is now known that folic acid supplements can prevent neural tube defects such as spina bifida.

What nursing action will significantly decrease the risk of serious complications for a child in Bryants traction?

Neurovascular checks are done frequently R: The nurse caring for a child in traction must be alert for Volkmanns ischemia, which occurs when circulation is obstructed.

The mother of a 2-week-old infant tells the nurse, I think the baby is constipated. Ive noticed she strains when she has a bowel movement. What is nurses most helpful response?

Newborns might strain with bowel movements because their muscles arent fully developed R: Straining in the newborn period is normal. It results from underdeveloped abdominal musculature. No treatment is required.

The nurse outlines the phases of the sexual response. Arrange the phases in order of occurrence. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Nipples become erect. b. Involuntary muscle spasms occur. c. Engorgement resolves. d. Heart rate slows. e. Skin flushes.

Nipples become erect. Skin flushes. Involuntary muscle spasms occur. Engorgement resolves. Heart rate slows.

The nurse is caring for a child who has had a ventriculoperitoneal shunt (VP) for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response?

Notify the charge nurse of possible malabsorption R: An increasing abdominal girth in a child with a VP shunt may be indicative of malabsorption of the cerebrospinal fluid (CSF) that is being shunted to the peritoneum.

The 1-day postpartum patient shows a temperature elevation, cough, and slight shortness of breath on exertion. What action should the nurse implement based on these symptoms?

Notify the physician of a possible pulmonary embolism R: Symptoms of early pulmonary embolism may not be dynamic. The cough with shortness of breath and temperature elevation is a clue to this possible complication.

What can the nurse suggests as a good dietary source of zinc for an adolescent who is a vegetarian?

Nuts R: Zinc is essential for growth and sexual maturation in adolescence. Good vegetable sources include nuts, legumes, and wheat germ.

The nurse is assisting with pelvic inlet measurements on a pregnant woman. What measurement will provide the nurse with information about whether the woman can deliver vaginally?

Obstetric conjugate R: This measurement determines if the fetus can pass through the birth canal.

Where the labia majora and the labia minora meet is known as the fourchette or _____________________________.

Obstetrical perineum R: Where the labia majora and the labia minora meet is known as the fourchette or obstetrical perineum. Lacerations in this area often occur during childbirth.

What could the nurse recommend to a childs mother to encourage a toddler to practice independence?

Offer him a choice between two items R: The toddler can be allowed to make choices as the situation warrants, but the number of choices should be limited because too many confuse the toddler.

A parent confides in the school nurse that her 8-year-old twins argue and bicker constantly. What is the best response by the nurse?

Offer reassurance that such behavior is normal for 8-year-olds R: Argumentative and competitive behavior is normal in 8-year-olds.

Which strategy might the nurse use when administering oral medications to a young child who is reluctant?

Offer the child fruit juice after the medication is swallowed R: The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk because the child may develop distaste for it.

What does adolescent acne result from?

Oily skin R: Adolescent acne is the result of overactive sweat glands and oily skin.

_____________________________ is a lower-than-normal amount of amniotic fluid.

Oligohydramnios R: Oligohydramnios is a lower amount than normal of amniotic fluid.

A pulsating structure is felt during a vaginal examination of a woman in labor. How would the nurse position the woman to prevent compression of a prolapsed cord?

On her back with her head lower than the rest of her body R: The Trendelenburg (head down) position displaces the fetus upward to stop compression of the prolapsed cord.

The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient?

On her side to prevent supine hypotension R: The prenatal patient with placenta previa is best placed on her side with a pillow for support. This position not only reduces stress on the placenta but also reduces the possibility of supine hypotension.

A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will assume for this procedure?

On your side with the knees bent and the head close to the knees R: The child is positioned on his or her side with the knees flexed, and the head is brought down close to the flexed knees.

When bathing an infant, what sign does the nurse recognize as a sign of developmental hip dysplasia?

One leg is shorter than the other R: When developmental hip dysplasia is present, the leg on the affected side will appear shorter than the leg on the unaffected side.

The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus?

One umbilical vein R: The umbilical vein transports richly oxygenated blood from the placenta to the fetus.

The nurse reviews the procedure for breast self-examination (BSE) with a 25-year-old woman who has a family history of breast cancer. When reviewing the procedure, when will the nurse indicate as the best time for a woman to perform a breast self-examination?

One week after the beginning of her period R: The best time for BSE is 1 week after the beginning of the menstrual period.

What is the most common site for fertilization?

Outer third of the fallopian tube near the ovary R: Fertilization takes place in the outer third of the fallopian tube, which is closest to the ovary.

Bronchopulmonary dysplasia is the toxic response of the lung to _______ therapy.

Oxygen R: Bronchopulmonary dysplasia is the toxic response of the lung to oxygen therapy.

The hormone responsible for milk let-down or ejection from the breasts is ____________.

Oxytocin R: The milk let-down reflex is caused by the hormone oxytocin.

Massage and putting the infant to the breast of a postpartum patient have been ineffective in controlling a boggy uterus. What will the nurse anticipate might be ordered by the physician?

Oxytocin R: Oxytocin (Pitocin) is the most common drug ordered to control uterine atony.

The nurse in the nursery may use CRIES, PIPP, NIPS, or NPASS as a guide to _____________ assessment.

Pain R: CRIES, PIPP, NIPS, and NPASS are all 10-point-scale pain assessment guides for infants.

An 18-year-old primigravida is 4 cm dilated and her contractions are 5 minutes apart. She received little prenatal care and had no childbirth preparation. She is crying loudly and shouting, Please give me something for the pain. I cant take the pain! What is the priority nursing diagnosis?

Pain related to uterine contractions R: The most important issue for this woman, at this time, is effective pain management.

A 6-year-old sustained a fractured femur and was put in Russell traction 2 days ago. She screams in pain when she raises herself onto the bedpan. Which nursing diagnosis takes highest priority for this child?

Pain resulting from tissue trauma R: Although all of these nursing diagnoses are relevant to the child in traction, pain resulting from muscle spasm and tissue trauma is the highest priority.

The amount of pain a person is willing to endure is referred to as ___________________________.

Pain tolerance R: Pain tolerance is the amount of pain a person is willing to endure. Pain threshold is the point at which pain is perceived. Pain threshold is relatively consistent from person to person, but pain tolerance differs greatly.

A child has an elevated antistreptolysin O (ASO) titer. Which combination of symptoms, in conjunction with this finding, would confirm a diagnosis of rheumatic fever?

Painful, tender joints and carditis R: The presence of two major Jones criteria would indicate a high probability of rheumatic fever.

In the recovery room, the nurse checks the newly delivered womans fundus following a cesarean section. How would the nurse proceed with this assessment?

Palpate from the side of the uterus to the midline R: The fundus is checked gently by walking the fingers from the side of the uterus to the midline.

What will the nurse teach the child with cystic fibrosis to take in order to facilitate digestion and absorption of nutrients?

Pancreatic enzymes R: An oral pancreatic enzyme is given to the child with every meal and with snacks to replace the pancreatic enzymes that the childs body cannot produce.

The nurse observed three toddlers playing side by side with dolls. Closer observation revealed that the children were not interacting with one another. What type of play is this?

Parallel R: Toddlers engage in parallel play. Children play next to, but not with, each other.

What are considered to be functions of the fallopian tubes? (Select all that apply.) a. Passage for sperm to meet ova b. Passage for ovum to uterus c. Safe environment for zygote d. Restriction for only one ovum to enter uterus e. Site for fertilization ANS: A, B, C, EThe fallopian tube provides passage for both sperm and ova, offering an optimum place for fertilization and a safe environment for the zygote.

Passage for sperm to meet ova Passage for ovum to uterus Safe environment for zygote Site for fertilization R: The fallopian tube provides passage for both sperm and ova, offering an optimum place for fertilization and a safe environment for the zygote.

What might the nurse explain as a common treatment for amblyopia?

Patching the good eye to force the brain to use the affected eye R: Early detection and treatment are essential for the child with amblyopia. Treatment includes patching the good eye and using glasses to correct refractive errors.

The nurse reminds the adolescent boy with Ewings sarcoma that he is prohibited from vigorous weight-bearing activities during treatment with radiation to reduce the risk of a(n) _______________ fracture.

Pathological R: The bone has lost its integrity because of the cancer and radiation. Excessive or vigorous weight bearing can cause a pathological fracture of the compromised bone.

The nurse is caring for a woman of Middle Eastern descent on the first postpartum day. Education is provided regarding instruction on use of a sitz bath. What documentation best indicates that the woman has understood the provided instruction?

Patient correctly performed return demonstration R: The nurse may need an interpreter to understand and provide optimal care to the woman and her family. If possible, when discussing sensitive information the interpreter should not be a family member, who might interpret selectively. The interpreter should not be of a group that is in social or religious conflict with the patient and her family, an issue that might arise in many Middle Eastern cultures. It is also important to remember that an affirmative nod from the woman may be a sign of courtesy to the nurse rather than a sign of understanding or agreement.

he nurse is planning a hypertension-prevention program. What should be the main focus of the nurse when presenting information?

Patient education R: The main focus of a hypertension-prevention program is patient education.

A labor dysfunction due to decreased uterine muscle tone occurs in a patient who is dilated to 5 cm with membranes intact. What action by the physician will the nurse anticipate?

Perform an amniotomy. R: Medical treatment for hypotonic labor dysfunction includes an amniotomy as the first remedy if the membranes are intact.

The nurse, caring for a child receiving chemotherapy, notes that the childs abdomen is firm and slightly distended. There is no record of a bowel movement for the last 2 days. What do these assessment findings suggest?

Peripheral neuropathy R: Peripheral neuropathy may be signaled by severe constipation resulting from decreased nerve sensations in the bowel.

What is a unique organization of characteristics that determines an individuals pattern of behavior?

Personality R: One definition of personality states that it is a unique organization of characteristics that determines the individuals typical or recurrent pattern of behavior.

One day after discharge, the postpartum patient calls the clinic complaining of a reddened area on her lower leg, temperature elevation of 37 C (99.8 F), rust-colored lochia, and sore breasts. What does the nurse suspect from these symptoms?

Phlebitis R: The complaints related to the leg are indicative of phlebitis. The other signs are normal in the postpartum patient.

Parents ask the pediatric nurse how school life might influence their growing child. What area of development will the nurse indicate that school affects the least?

Physical development R: Physical development is the least affected by school life. Moral development occurs as they have experience with, and understand, rules and fairness in the school setting. Schools have a profound influence on the socialization of children, who bring to school what they have learned and experienced in the home. Success in school requires an integration of cognitive, receptive, and expressive (language) skills.

A child is sent to the school nurse for assessment because she comes to school every day disheveled, unbathed, and hungry. The assessment does not indicate any bruises or marks on the body. What do these finding indicate?

Physical neglect R: Physical neglect is the failure to provide for the basic physical needs of the child, including food, clothing, shelter, and basic cleanliness.

The patient confesses to eating crushed ice 10 or 12 times daily. The nurse assesses this behavior as __________.

Pica R: Pica is the craving and ingestion of nonfood substances such as clay, crushed ice, and ashes.

How should the nurse intervene to relieve perineal bruising and edema following delivery?

Place an ice pack on the area for 12 hours. R: An ice pack can be placed on the mothers perineum to reduce bruising and edema for 12 hours followed by a warm pack after the first 12 to 24 hours after delivery.

Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?

Position the child on the right side after a feeding R: To prevent regurgitation and aspiration, the child is placed in the Fowlers position or on the right side to promote gastric emptying after a gastrostomy tube feeding.

A nurse is providing prenatal education. The nurse will explain that pregnancy affects glucose metabolism in what way?

Placental hormones increase the resistance of cells to insulin. R: Hormones and enzymes produced by the placenta increase the resistance of cells to insulin.

The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What significant information would the nurse include?

Placing infants on their backs or sides for sleep R: The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS.

The nurse notes that a 4-year-old childs gums bleed easily and he has bruising and petechiae on his extremities. Which lab value is consistent with these symptoms?

Platelet count of 25,000/mm3 R: The normal platelet count is 150,000 to 400,000/mm3. This finding is very low, indicating an increased bleeding potential.

What is the most appropriate activity to recommend to parents to promote sensorimotor stimulation for a 1-year-old?

Play with push-pull toys R: Push-pull toys are appropriate to promote sensorimotor stimulation for a 1-year-old child.

When a 2-year-old returns to her hospital room following a diagnostic procedure, her parents are not available, and the child is crying loudly. Which technique is most appropriate to alleviate the childs distress?

Play with the child using pop-up toys R: Distractions such as blowing bubbles, looking through a kaleidoscope, and playing with pop-up toys may help reduce anxiety and pain.

A 13-year-old girl is diagnosed with functional scoliosis. What does the nurse explain as the cause of this spinal curvature defect?

Poor posture R: Functional scoliosis usually is caused by poor posture, and it is not a spinal disease.

A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele. What is the priority preoperative nursing care of this newborn?

Position prone in an incubator R: The infant is placed prone in a humidified incubator, and the sac is covered with dressings of sterile saline. The infants hips are kept lower than the lesion, and the infant is usually not in diapers.

What is the best intervention for the nurse caring for a child experiencing an acute asthma attack?

Position the child with arms resting on the overbed table R: This position is comfortable and allows maximum use of the accessory muscles for breathing. Sedatives would mask symptoms of increasing air hunger. Carbonated beverages are contraindicated in persons with dyspnea.

A new mother has decided not to breastfeed her newborn. What information will the nurse include when planning to teach the mother about formula feeding?

Positioning the bottle so that the nipple is full of formula during the entire feeding R: The nipple of the bottle should be kept full of formula to reduce the amount of air the infant swallows.

The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to prevent this from happening with the child they are currently expecting. What will the nurse explain as the best way to prevent BPD?

Prevention of preterm birth R: Bronchopulmonary dysplasia (BPD) is a fibrosis, or thickening, of the alveolar walls and the bronchiolar epithelium. It occurs in premature infants (less than 32 weeks) who have abnormal or arrested lung development and receive ventilation and oxygen for more than 28 days to survive. Respiratory distress in the newborn is the major reason why oxygen and ventilators are used for prolonged periods. The main cause of respiratory distress in the newborn is prematurity. Therefore the prevention of preterm births is the best way to prevent BPD.

A woman asks the nurse, How do oral contraceptives prevent pregnancy? What will the nurse explain about the combination of estrogen and progesterone in oral contraceptives?

Prevents ovulation R: Oral contraceptives contain a combination of estrogen and progesterone that suppresses ovulation.

What would the nurse further investigate when assessing patterns of growth in a child?

Previous weight was in the 75th percentile, and present weight is in the 25th percentile R: The child showing a difference of two or more percentile levels from an established growth pattern should undergo further evaluation.

The hormone responsible for milk production is ____________________.

Prolactin R: During pregnancy, the woman secretes high levels of prolactin, the hormone that causes milk production. Following delivery, increased levels of prolactin lead to lactation.

What does the nurse explain is used to soften the cervix with a cervical ripening agent?

Prostaglandin gel insertion R: Prostaglandin gel is inserted in the cervix and the woman remains in bed for 1 to 2 hours, being monitored for uterine contractions.

Put the stages of separation anxiety in order from first to last. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Detachment b. Regression c. Despair d. Protest

Protest Despair Detachment Regression R: The preschool child may feel abandoned by the parents and continues to be subject to separation anxiety. Separation anxiety is manifested by the stages of protest, despair, detachment, and regression.

The nurse is aware that the preterm infant has an increased tendency to bleed due to deficient levels of ________.

Prothrombin R: Preterm infants have deficient levels of prothrombin, which increases the tendency to bleed spontaneously.

A nurse encourages a school-age child to draw a picture after a painful procedure. What is the best rationale for this nursing intervention?

Providing a way for the child to express his feelings R: After treatments, the nurse should encourage children to draw and talk about their drawings or to act out their feelings through puppet play.

A 13-year-old girl tells the school nurse that she is getting fat, especially in her hips and legs. What understanding by the nurse would best guide the response?

Puberty is often preceded by fat deposits in these areas R: Secondary sexual characteristics become apparent before menarche. Fat is deposited in the hips, thighs, and breasts, causing them to enlarge.

The nurse demonstrates how to flush the ventriculoperitoneal shunt by the use of the ____________________ that is in place behind the infants ear.

Pump R: A small pump is part of the VP shunt. The pump is in place behind the childs ear. The shunt can be pumped according to the physicians instructions to maintain flow from the ventricles to the peritoneum.

The pediatric nurse assesses the 9-year-old child who has been diagnosed with diabetes to ensure that he does not come to believe that his disease is a form of _________________.

Punishment R: School-age children may come to believe their illness is a form of punishment for bad behavior or bad thoughts.

Which assessment performed by a nursing student performing a neurovascular check alerts the instructor that further education is necessary?

Pupils R: Neurovascular checks include assessment of pain, pulse, sensation, color, capillary refill, and movement. Pupils are assessed with a neurological check.

he parent of a child with osteomyelitis asks why his child is in so much pain. What will the nurse respond causes the pain experienced with osteomyelitis?

Purulent drainage in the bone marrow R: Osteomyelitis is an infection of the bone. Inflammation produces an exudate that collects under the marrow and cortex of the bone. The vessels are compressed and thrombosis occurs, producing ischemia and pain.

What is the function of contractions during the second stage of labor?

Push the infant out of the mothers body R: The contractions push the infant out of the mothers body as the second stage of labor ends with the birth of the infant.

When auscultating breath sounds of an infant with respiratory syncytial virus, which assessment would the nurse immediately report?

Quiet chest from previous assessment of wheezing R: A quiet chest after assessment of wheezing indicates occlusion of air pathways and impending respiratory arrest. All other options are within normal range for infants undergoing oxygen administration.

In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurses first action?

Record the rate as a normal finding. R: The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy.

The patient remarks that she has heard some foods will enhance brain development of the fetus. The nurse replies that foods high in docosahexaenoic acid (DHA) are thought to enhance brain development. What food can the nurse recommend?

Red meat R: Foods rich in DHA are red meat, flounder, halibut, and soybean and canola oil. Frying fish negatively alters the DHA.

Which observation may cause the nurse to consider the possibility of child abuse when a mother says that her young child fell down the basement stairs?

Red, green, and yellow bruises on his body R: bruises heal, they change color in stages. Different colors of bruises indicate that injuries have not all occurred at the same time. The nurse must consider whether the bruises match the caretakers explanation of what happened.

When the previously potty-trained 3-year-old wets the bed after admission to the hospital, the nurse assesses this event is caused by a____________________ related to the new environment.

Regression R: Regression occurs when a situation causes the person to go back to a less mature manner of coping. Faced with the new situation, in this case a hospital admission, the toddler reverts to an earlier coping mechanism in which potty training has no part. The same regression frequently appears when a new infant is introduced to the family circle, or when a traumatic event such as a death or divorce affects the family

At a prenatal visit, a primigravida asks the nurse how she will know her labor has started. The nurse knows that what indicates the beginning of true labor?

Regular contractions becoming more frequent and intense R: In true labor, contractions gradually develop a regular pattern and become more frequent, longer, and more intense.

What is the Dick-Read method of childbirth preparation based on?

Relaxation techniques R: The Dick-Read method depends on the use of relaxation techniques to reduce the discomforts of labor.

How would the nurse advise a mother to clear the nostrils when her infant has a cold?

Remove nasal secretions with a bulb syringe R: The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe.

What complication can result from untreated respiratory distress in the newborn?

Reopening of the foramen ovale R: Respiratory distress can cause increased pressure in the right ventricle, causing reopening of the foramen ovale.

While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurses initial action?

Reposition the woman on her side. R: Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased.

Which finding would concern the nurse assessing vital signs on a 2-year-old?

Respirations of 36 breaths/min R: In the toddler period, the respiratory rate decreases to 25 breaths/min.

Parents of a 2-month-old infant with Down syndrome are attending a well visit at the pediatric clinic. What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child?

Respiratory care R: The child with Down syndrome has generalized hypotonicity, which caused mucus accumulation and respiratory problems.

When assessing a preterm infant, the nurse observes nasal flaring, sternal retractions, and expiratory grunting. What do these findings indicate?

Respiratory distress syndrome R: Insufficient amounts of surfactant predispose the preterm infant to respiratory distress. The signs manifested by the infant are indicative of respiratory distress.

The nurse is assessing a 1-year-old infant in the pediatric office. What finding should the nurse report to the physician immediately?

Respiratory rate of 60 breaths per minute R: Respirations of a 1-year-old should be 20 to 40 breaths per minute. Increased respiratory rate can lead to distress and should be reported immediately. Pulse rate of 100 to 140 beats/minute is normal. Minimal verbalization and fussy behavior are not emergency situations or abnormal for this age.

___________________ provides trained workers who come into the home for brief periods to relieve parents of the responsibility of caring for the child.

Respite care R: Respite care provides trained workers who come into the home for brief periods to relieve parents of the responsibility of caring for the child.

The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction?

Restlessness R: Restlessness is a primary sign of increased respiratory obstruction.

What type of lochia will the nurse assess initially after delivery?

Rubra R: The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately heavy. Lochia rubra lasts for up to 3 days postpartum.

A primigravida in her first trimester is Rh negative. What will this woman receive to prevent anti-Rh antibodies from forming?

Rh immune globulin at 28 weeks and within 72 hours after the birth of an Rh-positive infant R: An Rh-negative woman would receive Rh immune globulin at 28 weeks of gestation and within 72 hours after the birth of an Rh-positive infant or abortion.

What situation would concern the nurse about the presence of Rh incompatibility?

Rh-negative mother, Rh-positive fetus R: Rh incompatibility can occur only if the mother is Rh negative and the fetus is Rh positive.

________________ is a systemic disease involving the joints, heart, central nervous system (CNS), skin, and subcutaneous tissues. It belongs to a group of disorders known as collagen diseases.

Rheumatic fever (RF) R: Rheumatic fever (RF) is a systemic disease involving the joints, heart, central nervous system (CNS), skin, and subcutaneous tissues. It belongs to a group of disorders known as collagen diseases

After the pregnant woman is admitted to the labor suite, the nurse assesses the position of the infant as ROA; this means that the infants head is _________________.

Right occiput anterior R: Right occiput anterior means that the infants right occiput is toward the anterior aspect of the mothers body.

Which nursing diagnosis would be a priority when preparing a plan of care for a child in a leg cast?

Risk for altered peripheral tissue perfusion R: Casting can lead to compromised tissue perfusion caused by increased pressure from edema or swelling pressing on the tissues. Neurovascular checks are an assessment priority.

The most recent blood count for a child who received chemotherapy last week shows neutropenia. What is the priority nursing diagnosis for this child?

Risk for infection R: The child with neutropenia is at risk for infection.

The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis?

Risk for injury related to hemorrhage. R: In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage.

_________________________ is when toddlers increase their sense of security by making compulsive routines of simple tasks.

Ritualism R: Ritualism is when toddlers increase their sense of security by making compulsive routines of simple tasks.

A mother calls the pediatricians office because her infant is colicky. What is the most helpful measure the nurse can suggest to the mother?

Rock the fussy infant slowly and gently R: One technique the nurse can offer parents of a fussy infant is to rock the infant gently and slowly while being careful to avoid sudden movements.

The nurse offers a variety of fluids to a 5-year-old asthmatic child to compensate for the fluid loss through dyspnea. Which fluids are most appropriate?

Room temperature water R: Room temperature fluids are the best. Carbonated and iced beverages increase spasm. Milk stimulates mucus production.

A first-time mother reports that she is experiencing difficulty breastfeeding her newborn. Which neonatal reflex would the nurse teach the mother to elicit to facilitate breastfeeding?

Rooting R: The rooting reflex causes the infants head to turn in the direction of anything that touches the cheek in anticipation of food.

A nurse instructs a womans labor coach to comfort her by firmly pressing on her lower back. What is this technique?

Sacral pressure R: Sacral pressure refers to firm pressure against the lower back to relieve some of the pain of back labor.

When the fifth-grade class collected geckos in a special aquarium in the classroom, the school nurse cautioned the teacher to be alert for symptoms of ____________________ that can be carried by the reptiles.

Salmonella R: Geckos can infect humans with Salmonella.

What type of relationships are the preferred social interactions for the school-age child?

Same-sex peer groups R: The preferred social interaction of the school-age child is in same-sex peer groups or cliques.

The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention?

School-age child with widening pulse pressure R: A widening pulse pressure can indicate increased ICP; therefore it is the priority. An axillary temperature of 99 F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments.

What should the nurse keep in mind when planning to teach a class on nutrition to fourth-grade students?

School-age children think logically and concretely R: Piaget refers to the thought process of this period as concrete operations, which involves logical thinking and an understanding of cause and effect.

A mother asks the nurse, When will I know my child has entered puberty? What will the nurse state based on an understanding of changes associated with puberty?

Secondary sex characteristics, such as pubic hair, appear. R: Puberty begins when the secondary sex characteristics appear. Puberty ends when mature sperm are formed in the male and when regular menstrual cycles occur in the female.

What tasks would be appropriate to expect of a 5-year-old?

Setting the table with paper plates R: Parents must consider developmental level and safety when asking the 5-year-old child to help with chores.

When caring for the laboring patient, the nurse determines that the fetus is located in the right occiput posterior (ROA). What will the nurse anticipate?

Severe lower back pain R: If the fetal occiput is in a posterior pelvic quadrant, each contraction pushes it against the mothers sacrum, resulting in persistent and poorly relieved back pain (back labor). Labor is often longer with this fetal position.

The _____________________________maintains that every sex education program should present the topic from six aspects: biological, social, health, personal adjustment and attitudes, interpersonal associations, and establishment of values.

Sexuality Information and Education Council of the United States (SIECUS)

A parent comments that her adolescent daughter seems to be daydreaming a lot. What does the nurse understand this behavior to indicate regarding their daughter?

She is mentally preparing for real situations R: Daydreaming allows adolescents to act out in their imaginations what will be said or done in certain situations. This helps them to prepare for and cope with interactions with others.

For what is the decrease in estrogen and progesterone during the menstrual cycle responsible?

Shedding of the endometrium R: The fall in estrogen and progesterone causes the endometrium to break down, resulting in menstruation.

A woman is having a difficult labor because the fetus is presenting in the right occipital position (ROP). What position will the nurse promote to encourage fetal rotation and pain relief?

Sitting up and leaning forward on the over-bed table R: A position that favors fetal rotation and descent and that is helpful for the woman with back labor is to sit or kneel leaning forward on a support.

A child diagnosed with epilepsy had a generalized tonic-clonic seizure that lasted 90 seconds. What would the nurse expect to assess after a generalized tonic-clonic seizure?

Sleepiness R: Following a generalized tonic-clonic seizure, the child may have some confusion and may sleep for a time (postictal lethargy) and then return to full consciousness.

What should the nurse, preparing to collect an admission history from parents who have recently emigrated from Russia, keep in mind?

Smiling is inappropriate in a serious situation R: In Russia, a smile indicates happiness and is inappropriate in a serious or sad situation.

Put the developmental milestones in order from first achieved to last achieved. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Jumps with both feet b. Holds a cup by the handle c. Social smile d. Babbles e. Understands no

Social smile Babbles Understands no Jumps with both feet Holds a cup by the handle R: Social smile: 2 monthsBabbles: 3 monthsUnderstands no: 9 monthsJumps with both feet: 24 monthsHolds a cup by the handle: 36 months

The nurse observes that the legs of a child with cerebral palsy cross involuntarily, and the child exhibits jerky movements with his arms as he tries to eat. The nurse recognizes that he has which type of cerebral palsy?

Spastic R: Spasticity is characterized by tension in certain muscle groups, which makes voluntary movements of muscles jerky and uncoordinated.

The nurse is instructing a man considering a vasectomy. What instruction will the nurse provide to address the postoperative time period?

Sperm will still be ejaculated for a month R: Because sperm are distal to the severed vas deferens, sperm will be in the ejaculate for about a month. A sperm count after that period of time should be performed to confirm the absence of sperm. Intercourse does not have to be delayed, but an alternate method of contraception should be used. Erections and sexual pleasure are not affected by a vasectomy.

Put the embryonic/fetal characteristics in the correct order of occurrence from week 3 to week 36 of gestation. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Subcutaneous fat is present. b. Bone marrow forms blood cells. c. Spinal cord and brain appear. d. Skull and jaw ossify. e. Neural tube closes.

Spinal cord and brain appear Neural tube closes Skull and jaw ossify Bone marrow forms blood cells Subcutaneous fat is present R: Primitive spinal cord and brain appear at 3 weeks. Neural tube closes at 4 weeks. Skull and jaw ossify at 6 weeks. Spleen stops forming blood cells and bone marrow takes over at 29 weeks. Subcutaneous fat is present at 36 weeks.

A pediatric nurse is assisting with the care of a child diagnosed with a fractured femur. What type of fracture would be the most likely to alert the nurse to the possibility of physical abuse?

Spiral fracture R: A spiral fracture of the femur is caused by a forceful twisting motion. When the history of an injury does not correlate with x-ray findings, child abuse should be suspected because spiral fractures can be the result of manual twisting of the extremity.

A father asks why his child with tetralogy of Fallot seems to favor a squatting position. What is the nurses best response?

Squatting increases the return of venous blood back to the heart R: The squatting position allows the child to breathe more easily because systemic venous return is increased.

The nurse is documenting the pediatricians assessment of a female patient. When assessing Tanners stages of breast development there is elevation of papilla only. What stage of development will the nurse document?

Stage 1 R: According to Tanners Stages of Sexual Maturity, Stage 1 (Preadolescent) is elevation of papilla only.

The nurse is advising parents about feeding their infant with phenylketonuria. What formula and/or diet should the nurse suggest?

Substitute Lofenalac for some protein foods R: A synthetic food providing enough protein for growth and tissue repair, but little phenylalanine, is substituted for natural protein foods.

The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, Please give me something. What is the most appropriate pain relief intervention for a woman in precipitate labor?

Stay and breathe with her during contractions. R: The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction.

The nurse observes the patient bearing down with contractions and crying out, The baby is coming! What is the best nursing intervention?

Stay with the woman and use the call bell to get help. R: If birth appears to be imminent, the nurse should not leave the woman and should summon help with the call bell.

What symptom assessed in the newborn shortly after delivery should be reported?

Sternal or chest retractions R: Sternal retractions are evidence that the newborn is in respiratory distress and should be reported immediately.

A woman 2 weeks past her expected delivery date is receiving an oxytocin infusion to induce labor and begins to have contractions every 90 seconds. What is the nurses initial action?

Stop the oxytocin infusion R: Oxytocin is discontinued if signs of fetal compromise or excessive uterine contractions occur.

The nurse explains that testosterone is responsible for males exceeding females in which aspects? (Select all that apply.) a. Strength b. Height c. Mental concentration d. Hematocrit levels e. Agility

Strength Height Hematocrit levels

When intraabdominal pressure increases from laughing or sneezing in a woman with a cystocele, __________ ___________ results.

Stress incontinence R: When intraabdominal pressure increases, such as with laughing, coughing, or sneezing, a woman with a cystocele is said to have stress incontinence.

The nurse explains that a slower than expected return of the uterus to the nonpregnant state is called _______________.

Subinvolution R: Subinvolution is the term applied to the uteruss slower than expected return to a nonpregnant state.

The nurse is advising parents of a 10-year-old boy about the most developmentally supportive experiences for their son. What is the best experience for this child according to Eriksons theory?

Successful performance in Little League R: The child who is successful in activities will feel positively about himself or herself.

What symptom leads the nurse caring for a 5-month-old with viral influenza to suspect the development of Reyes syndrome?

Sudden vomiting without effort R: A child with a viral infection is at risk for Reyes syndrome, the onset of which is effortless vomiting, lethargy, and a change in level of consciousness. A 5-month-old child who sleeps after eating is normal.

The nurse assesses a pregnant woman for pregnancy-induced hypertension. What is the first sign of fluid retention suggestive of this complication?

Sudden weight gain R: Sudden, excessive weight gain is the first sign of fluid retention; facial swelling and swelling of the feet, legs, and hands follow weight gain.

The nurse cautions parents to place their infant in the ______________ position, rather than on his or her stomach, to reduce the risk of sudden infant death syndrome (SIDS).

Supine R: The supine or side-lying position has been found to reduce possible aspiration and is believed to reduce the risk of SIDS.

A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will the nurse maintain for this patient?

Supine R: The adolescent may avoid post lumbar puncture headache by lying flat for some time.

How does Russell traction provide adequate skin traction?

Supplies continuous pull in two directions R: Russell traction is skin traction, similar to Bucks, with a sling positioned under the knee, which prevents subluxation of the tibia. Although the traction interferes with full ROM, the patient can change position without disrupting the continuous pull in two directions.

The nurse is caring for an infant with hydrocephalus. What nursing action is most important for this nurse to implement?

Support the head R: The child with hydrocephalus has a heavy head on a small body with poor muscle tone; the head must be supported when feeding and moving the child to prevent injury to the neck.

What deficiency causes a preterm infant respiratory distress syndrome?

Surfactant R: The production of surfactant, necessary for the absorption of oxygen by the lungs, is deficient in the preterm infant.

A child with rheumatic fever begins involuntary, purposeless movements of her limbs. What does the nurse recognize that this indicates?

Sydenhams chorea R: As the effects of rheumatic fever affect the central nervous system, the child may develop Sydenhams chorea, manifested by involuntary, purposeless movements of the limbs.

____________________ _________ is seen in the play of children who pretend that an empty box is a fort; they create a mental image to stand for something that is not there.

Symbolic functioning R: Symbolic functioning is seen in the play of children who pretend that an empty box is a fort; they create a mental image to stand for something that is not there.

The nurse assessing a child with juvenile rheumatoid arthritis notes the childs right knee and ankle are swollen, warm, and tender. The child has a temperature of 38.8 C (102 F) and abdominal pain. What type of juvenile rheumatoid arthritis do these findings suggest?

Systemic R: The systemic form of juvenile rheumatoid arthritis is associated with an elevated temperature, erythrocyte sedimentation rate (ESR), and C-reactive protein; abdominal pain; and a macular rash.

What is the first sign of hypovolemic shock from postpartum hemorrhage?

Tachycardia R: Tachycardia is usually the first sign of inadequate blood volume.

The patient who is 28 weeks pregnant shows a 10-pound weight gain from 2 weeks ago. What is the nurses initial action?

Take the blood pressure. R: The marked weight gain may be an indication of gestational hypertension. The blood pressure should be assessed before notifying the physician.

Which initial intervention will the nurse suggest to the parents of a child experiencing laryngeal spasm?

Take the child to the bathroom and turn on a hot shower R: The child experiencing laryngeal spasm should be placed in a high-humidity environment, such as the bathroom with a hot shower running. The humidity liquefies secretions and reduces spasm.

On the second postpartum day, a mother bathed her newborn for the first time. She tells the nurse, I dont think I did it right. What postpartum psychological stage is this woman most likely in based on this comment?

Taking hold R: In phase 2, taking hold, the mother begins to initiate action and becomes interested in caring for the infant. In doing so, she may become critical of her performance.

Which statement made by the nurse would teach an adolescent using tampons how to prevent toxic shock syndrome (TSS)?

Tampons should be changed at least every 4 hours R: Tampons should be changed every 4 hours because a blood-soaked tampon is an excellent environment for bacteria.

The mother of a 2-week-old infant tells the nurse that she thinks he is sleeping too much. What is the most appropriate nursing response to this mother?

Tell me how many hours per day your baby sleeps R: Although it is true that newborns sleep a great deal of any 24-hour period, the nurse must find out what the mother means by too much before giving any information.

Three weeks after delivering her first child, a woman tells the nurse, I waited so long for this baby and now that she is here, I cant believe how different my life is from what I expected. What is the best nursing response to the womans statement?

Tell me how things are different R: The nurse may help the woman by being a sympathetic listener. The nurse should elicit the new mothers feelings about motherhood and her infant.

The nurse finds an adolescent with Hodgkins disease crying. The adolescent says, I am so scared. What is the most appropriate nursing response to this comment?

Tell me whats got you scared R: The nurse should encourage the adolescent to express her feelings and concerns.

What symptom reported by a pregnant patient would lead the nurse to suspect pyelonephritis?

Tenderness in the flank area R: Pyelonephritis is a particularly serious infection in pregnancy. Signs and symptoms include high fever, chills, flank pain or tenderness, nausea, and vomiting.

The nurse is educating high school students about puberty. What will the nurse indicate regulates the production of sperm and secretion hormones?

Testes R:The testes have two functions: manufacture of spermatozoa and secretion of androgens.

The nurse is dealing with a preschool-age child with a life-threatening illness. What should the nurse remember the childs concept of death is at this age?

That a person becomes alive again soon after death R: The preschooler views death as reversible and temporary.

When the newborns crib was moved suddenly, the nurse noticed that his legs flexed and arms fanned out, and then both came back toward the midline. How would the nurse interpret this behavior?

The Moro reflex R: The Moro reflex is a normal neonatal reflex. It is elicited when the infants crib is jarred. The infant responds by drawing the legs up, fanning the arms, and then bringing the arms to the midline in an embrace position.

When planning to answer a 16-year-old girls questions about menstruation, the nurse must consider cognitive development. What is developed during adolescence according to Piaget?

The ability to consider hypothetical situations R: According to Piaget, in the formal operations stage adolescents have the ability to think abstractly.

What is the nurses best response to a mother who is voicing concern about the molding of her 2-day-old infant?

The babys head conformed to the shape of the birth canal. It will go away soon R: The newborns head may be out of shape from molding. This refers to the shaping of the fetal head to conform to the size and shape of the birth canal.

A mother tells her 4-year-old child that balls should be played with outside and not inside the house. Why is the child likely to obey the rule?

The child does not want to be punished R: According to Kohlberg, children in the preconventional stage (4 to 7 years) are obedient to their parents for fear of punishment.

What would the nurse assessing growth and development of a 2-year-old child expect to find?

The child jumps with both feet R: The 2-year-old can jump with both feet. The remaining achievements occur after 2 years of age.

Why is the relaxation phase between contractions important?

The contractions can interfere with fetal oxygenation. R: Blood flow from the mother into the placenta gradually decreases during contractions. During the interval between contractions, the placenta refills with oxygenated blood for the fetus.

On a home visit, the nurse notes that the parents require teaching intervention to protect the 15-month-old child who lives there. What observation would lead the nurse to this conclusion?

The dining room table has a tablecloth on it R: A tablecloth presents a safety hazard because the curious toddler will reach up and pull on it. The toddler could be injured if items on the table are moved when the tablecloth is pulled.

The nurse is reviewing the characteristics of Ewings sarcoma. Which statement if made by the nurse indicates correct understanding of this disease?

The disease is sensitive to radiation and chemotherapy R: Ewings sarcoma is sensitive to radiation therapy and chemotherapy. Amputation of the affected extremity is not recommended. This cancer occurs in school-age children and does metastasize.

A new mother is distressed and tearful about the elevated dome over her infants posterior fontanelle. The nurse responds, This condition will resolve itself in a few days. What is the cause?

The effect of the vacuum extractor R: The chignon is due to the effect of the vacuum extractor and will disappear in a few days.

A woman who is 8 weeks pregnant becomes concerned when she has light vaginal bleeding accompanied by abdominal pain. An ectopic pregnancy is confirmed by ultrasound. Which statement indicates that the woman understands the explanation of an ectopic pregnancy?

The embryo is implanted in the fallopian tube. R: Ectopic pregnancy occurs when the fertilized ovum is implanted outside of the uterine cavity.

A parent comments that her infant has had several ear infections in the past few months. Why are infants more susceptible to otitis media?

The eustachian tube is short, straight, and wide R: An infants eustachian tubes are short, wide, and straight, allowing microorganisms easy access to the middle ear.

A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response?

The fundus is assessed by walking fingers from the side of the uterus to the midline. R: Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage.

Parents of a 6-month-old infant ask the nurse why it is necessary to offer iron-rich formula to their child. What is the correct response?

The infant has exhausted maternal iron stores R: Many pediatricians recommend iron-fortified formulas because maternal iron stores decrease by 6 months of age.

A pregnant woman comes to the clinic stating that she has been exposed to hepatitis B. She is afraid that her infant will also contract hepatitis B. What will the nurse explain to this woman?

The infant will be given a single dose of hepatitis immune globulin after birth. R: The infant will be given immune globulin immediately after birth for temporary immunity followed by hepatitis B vaccine. Immunization is not recommended for women who are pregnant.

What is the rationale for placing a preterm infant born at 34 weeks of gestation in an incubator?

The infants temperature control mechanism is immature R: The preterm infant is at risk for heat loss for several reasons, one of which is that the heat regulating center in the brain is immature.

Parents ask the nursery staff what the light does for their jaundiced infant. What is the nurses best response?

The light breaks down bilirubin R: Severe jaundice can cause kernicterus, an accumulation of bilirubin in the brain tissue, which can lead to serious brain damage. The light breaks down excess bilirubin so that it can be excreted.

At 1 and 5 minutes of life, a newborns Apgar score is 9. What does the nurse understand that a score of 9 indicates?

The newborn is in stable condition. R: Apgar scoring is a system for evaluating the infants need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is stable.

Why is a tympanic thermometer considered more accurate than other types of thermometers?

The tympanic membrane shares circulation with the hypothalamus R: The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the hypothalamus share the same circulation.

The parents of an 8-year-old tell the nurse the child wakes the household crying out during his frequent nightmares. What is the nurses most helpful response to explain nightmares?

They are a normal extension of the childs fear of mutilation R: The nightmares experienced by an 8-year-old are an extension of their characteristic fear of mutilation.

The nurse observes a 10-month-old infant using her index finger and thumb to pick up pieces of cereal. What does this behavior indicate the infant has developed?

The pincer grasp R: By 1 year, the pincer-grasp coordination of index finger and thumb is well established.

The mother of a postterm infant asks the nurse why the infant is being watched so closely. What is the nurses most appropriate response?

The placenta does not function adequately as it ages R: Fetal distress may occur in the postterm infant because placental functioning becomes inadequate with maturity.

The parents of a hospitalized 9-month-old infant ask if their preschool child may visit his younger sibling. What understanding would assist the nurse most in formulating a response?

The preschooler needs to visit his infant sister to reassure himself that she is all right R: Siblings are affected by a childs hospitalization. Their ability to cope is influenced by their age, experience, and intactness of the family.

A postpartum woman is not immune to rubella. What will the nurse expect?

The rubella virus vaccine should be administered before discharge. R: The woman who is not immune to rubella is immunized in the immediate postpartum period because there is no danger of her being pregnant.

An adolescent has just had a generalized seizure and collapsed in the school nurses office. When should the nurse should call 911?

The seizure lasts more than 5 minutes R: If there are multiple seizures or if seizures last more than 5 minutes, call 911 because these are indicators of possible status epilepticus, a medical emergency.

The nurse is speaking with a couple trying to conceive a child. What will the nurse remind the couple is a factor that can decrease sperm production?

The testes being too warm R:The scrotum is suspended away from the perineum to lower the temperature of the testes for sperm production.

What does the nurse note when measuring the frequency of a laboring womans contractions?

The time between the beginning of one contraction and the beginning of the next R: The frequency of contractions is the elapsed time from the beginning of one contraction to the beginning of the next contraction.

A 2-year-old child has been crying constantly for his mother since he was hospitalized 3 days ago. What does this behavior suggest?

The toddler feels abandoned by his mother R: Unless toddlers are extremely ill, their grief and sense of abandonment during hospitalization are obvious.

Play that is designed to retrain muscles or improve eye-hand coordination is considered ____________________ play.

Therapeutic R: Therapeutic play, whether at home or in a clinic or rehab center, is designed to retrain muscles, strengthen muscles, or improve eye-hand coordination

What is the nurse primarily concerned about maintaining in the initial care of the newborn?

Thermoregulation R: Thermoregulation is necessary to keep heat loss minimal and oxygen consumption low. Hypothermia can cause cold stress, which leads to hypoxia.

The nurse uses a diagram to demonstrate the fimbriae when teaching nursing students about the female anatomy. What is true about fimbriae?

They are fingerlike projections that capture the ovum. R: Fimbriae are the fingerlike projections from the infundibulum that capture the ovum at ovulation and conduct it into the fallopian tube.

The nurse is caring for a woman in the first stage of labor. What will the nurse remind the patient about contractions during this stage of labor?

They dilate and efface the cervix. R: The first stage of labor describes the time from the onset of labor until full dilation of the cervix.

A patient who received an epidural block asks why her blood pressure is taken so often. What is the nurses best response to explain the frequent blood pressure assessments?

They ensure adequate placental perfusion. R: The hypotension that accompanies an epidural block may cause inadequate perfusion of the placenta, leading to fetal hypoxia.

What is accurate about the characteristics of high-density lipoproteins (HDLs)?

They have little cholesterol R: HDLs have low amounts of triglycerides, large amounts of proteins, low amount of cholesterol, and are excreted via the liver. They have no role in the production of steroids.

What does the nurse explains to parents of a child with febrile seizures?

They occur when the temperature rises quickly R: Febrile seizures occur in response to a rapid rise in temperature, often above 38.8 C (102 F).

The school nurse is counseling a group of adolescent girls. What does the nurse explain about sperm ejaculated near the cervix?

They survive up to 5 days and can cause pregnancy. R: Sperm ejaculated near the cervix can survive up to 5 days and cause pregnancy even before ovulation.

The parents of a 4-year-old boy are concerned because they have noticed him frequently touching his penis. What knowledge would act as the basis for the nurses response?

This behavior indicates a normal curiosity about sexuality R: Masturbation at this age is common and indicates that the preschooler has a normal curiosity about sexuality.

What statement by the parent of a hospitalized toddler leads the nurse to determine the parent understands a hospitalized toddlers need for transitional objects?

This stuffed animal makes him feel secure R: The use of a transitional object such as a blanket or a favorite toy promotes security.

What is the least amount of sensation that one perceives as pain?

Threshold R: Pain threshold is the least amount of sensation that one perceives as pain. Thresholds are different for each individual.

How might the nurse demonstrate the parachute reflex with an infant?

Thrusting the infant downward into the crib R: The infant, when thrust downward in a prone position, will protectively extend the arms.

A mother is concerned because her 9-year-old boy has developed the habit of twitching his eyes and flipping his hair while communicating with anyone. What is the best nursing response to this parent?

Tics appear when a child is under stress R: The child cannot help such actions and should not be scolded for them because they are mainly a result of tension.

A preschool-age child is asked, Why do trees have leaves? Which response would be an example of animism?

To hide behind when they are scared R: Animism describes the tendency of preschool children to attribute human characteristics to nonhuman objects.

The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient?

To prevent convulsions R: Magnesium sulfate is a central nervous system depressant given to prevent seizures.

Parents of a preterm infant come to the NICU every day to see their infant, who is being gavage fed. What will the nurse teaching about stimulating the infant tell the parents?

To stroke the infant during feeding to increase intake R: During gavage feedings, stroking the infant gently can provide stimulation.

The mother of a 4-day-old calls the pediatricians office because she is concerned about her infants skin. Which finding needs to be reported promptly to the childs pediatrician?

Today, the infants skin has a yellowish tinge R: Physiological jaundice becomes evident between the second and third days of life and lasts for about 1 week. Evidence of jaundice is reported and the newborn is evaluated.

Why does day care for the toddler differ from that of the preschooler?

Toddlers have a shorter attention span R: Toddlers have a shorter attention span than preschoolers and are prone to investigate other opportunities in the environment that may put them in harms way. Toddlers are more interested in parallel play.

______________________is a condition in which neck motion is limited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle.

Torticollis R: Torticollis (tortus, twisted, and collium, neck) is a condition in which neck motion is limited and the cervical spine is rotated because of shortening of the sternocleidomastoid muscle. It can be either congenital or acquired and can also be either acute or chronic.

An ultrasound on a woman who is 32 weeks pregnant reveals the placenta implanted over the entire cervical os. What does the nurse understand best describes this condition?

Total placenta previa R: A total placenta previa describes a condition in which the placenta completely covers the cervical opening.

What should the nurse avoid when demonstrating a bath procedure to parents of Vietnamese origin?

Touching the childs head R: The Vietnamese are very sensitive about anyone touching a childs head because that is where consciousness lies.

The nurse instructs the mother that when the neonates stool becomes loose and takes on a greenish-yellow color, this is normal __________ stool.

Transition R: The transitional stool has lost its dark green meconium color and gradually changes to a loose greenish-yellow stool with mucus.

A 17-year-old girl comes to the emergency department complaining of severe pain in her left lower quadrant. An ovarian cyst is suspected. The nurse knows that what confirms this diagnosis?.

Transvaginal ultrasound R: Diagnosis of an ovarian cyst is made by transvaginal ultrasound

The nurse assessing a 2-year-old is satisfied to see that the present weight of the child is _____________ the birth weight.

Triple R: The birth weight has usually tripled by the time the child is 2 years of age.

The nurse cautions that the consumption of as few as ________ alcoholic drink(s) during pregnancy can lead to the loss of fetal brain cells.

Two R: Studies have shown that even as few as two alcoholic drinks consumed during pregnancy can cause loss of fetal brain cells. A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of liquor.

Which is an example of associative play?

Two children playing house, one playing the role of the dad and the other playing the mom R: Associative play allows the preschoolers to use their enlarged vocabulary in play with other children to carry on conversations and describe scenarios for each to play.

30. The nurse is providing an inservice to students beginning their obstetric clinical rotation. Using a diagram, the nurse points out parts of the female pelvis. What will the nurse include? (Select all that apply.) a. Two innominates b. Obstetric conjugate c. Sacrum d. Perimetrium e. Coccyx

Two innominates Sacrum Coccyx R: The bones of the pelvis are two innominates, the sacrum, and the coccyx.

Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops?

Up and back R: For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

Where is the usual location for implantation of the zygote?

Upper section of the posterior uterine wall R: The zygote usually implants in the upper section of the posterior uterine wall.

How would the nurse advise a parent who states, I never know how much food to feed my child?

Use 1 tablespoon of each food for each year of age as a guideline R: A tablespoon of each type of food for each year of age is a good guideline to follow when determining serving sizes.

A parent tells the nurse, Im not sure how to give this medicine to my infant. How would the nurse teach the parent to best administer an oral suspension?

Use an oral syringe and placing the medication in the side of the infants mouth R: An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is placed midway back, at the side of the mouth.

The nurse is caring for a patient diagnosed with hypotonic labor dysfunction. What will the nurse expect when caring for this patient?

Use of frequent position changes R: A woman with hypotonic labor dysfunction will be encouraged to change position frequently to enhance contractions. With hypotonic labor uterine resting tone is decreased and IV fluids are increased. Painful and poorly coordinated contractions occur with hypertonic labor.

What would be an expected finding when assessing language development in a 2-year-old?

Use of two-word sentences R: The 2-year-old should be using two-word sentences.

The school nurse is planning sex education classes for school-age children. What should the nurse be sure to do?

Use simple terms R: Using simple terms is essential but slang and street terms need to be clarified. Apply age-specific information across broad aspects of biological, social, and current attitudes.

A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse?

Use the football hold when breastfeeding R: The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding.

Although the nurse has massaged the uterus every 15 minutes, it remains flaccid, and the patient continues to pass large clots. What does the nurse recognize these signs indicate?

Uterine atony R: Atony describes a lack of normal muscle tone. If the uterus is atonic, then muscle fibers are flaccid and will not compress bleeding vessels.

A pregnant woman, gravida 2, para 1, tells the nurse she desires a VBAC (vaginal birth after cesarean section) with this pregnancy. What is the primary concern regarding complications for this patient during labor and birth?

Uterine rupture R: Nursing care for women who plan to have a VBAC is similar to that for women who have had no cesarean births. The main concern is that the uterine scar will rupture, which can disrupt the placental blood flow and cause hemorrhage. Observation for signs of uterine rupture should be part of the nursing care for all laboring women, regardless of whether they have had a previous cesarean birth.

What symptom presented by a pregnant women is indicative of abruptio placentae?

Vaginal bleeding and back pain R: Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae.

After the examination is completed, the patient asks the nurse why Chadwicks sign occurs during pregnancy. What would the nurse explain as the cause of Chadwicks sign?

Vascular congestion in the pelvic area R: Chadwicks sign is caused by increased vascular congestion in the cervical and vaginal area.

A 3-year-old child with sickle cell disease is admitted to the hospital in sickle cell crisis with severe abdominal pain. Which type of crisis is the child most likely experiencing?

Vaso-occlusive R: Vaso-occlusive crisis, or painful crisis, is caused by obstruction of blood flow by sickle cells, infarctions, and some degrees of vasospasm.

Where is the best site for giving an IM injection to a 15-month-old child?

Vastus lateralis muscle R: The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

Vaginal examination reveals the presenting part is the infants head, which is well flexed on the chest. What is this presentation?

Vertex R: In the vertex presentation, the fetal head is the presenting part. The head is fully flexed on the chest.

A woman is prescribed Coumadin (warfarin) to treat deep vein thrombosis. What will the nurse instruct this woman is the antidote for warfarin overdose?

Vitamin K R: The antidote for warfarin overdose is vitamin K.

An infant with congestive heart failure is receiving digoxin (Lanoxin). What does the nurse recognize as a sign of digoxin toxicity?

Vomiting R: Symptoms of digoxin toxicity include: nausea, vomiting, anorexia, irregularity in pulse rate and rhythm, and a sudden change in pulse.

A woman in labor will receive general anesthesia prior to cesarean section. The nurse reminds the patient that food and fluids need to be restricted for several hours prior to delivery. What will this prevent?

Vomiting and aspiration R: The major adverse effect of general anesthesia is aspiration of stomach contents.

Which behavior reported by a parent of an 18-month-old toddler would the nurse report to the pediatrician as a cause for concern?

Walks by holding onto R: By 18 months, a toddler should have been walking alone for several months. The toddler who walks holding onto furniture should be evaluated by a developmental specialist.

What would the nurse consider an abnormal finding on a musculoskeletal assessment of a 4-year-old child?

Walks on the toesc. Appears to have flat feetd. Swings his arms when walking R: Toe walking after 3 years of age may indicate a muscle problem.

A woman who is 24 weeks pregnant is placed on an intravenous infusion of magnesium sulfate. What side effect should the nurse inform the patient that she might experience?

Warm flush R: Magnesium sulfate is the drug of choice for initiating therapy to stop labor. The patient will notice a warm flush with the initiation of the drug.

What action does the nurse implement to protect newborns from infection while in the nursery?

Wash hands before touching each infant R: Handwashing is the most reliable precaution available to prevent infection. The nurse washes his or her hands between handling different babies.

What is the best nursing action when an 8-year-old child comes to the school nurse with his central incisor in his hand and reports he knocked his tooth out on the water fountain?

Wash off the tooth and place it in a container of milk R: The tooth should be washed off and put in a container of milk to preserve it for possible reimplantation.

Which statement indicates that parents understand how to feed their infant who had a surgical repair for a cleft lip?

We are feeding the baby with a dropper for 2 weeks R: The infant is fed with a dropper until the incision is completely healed, about 1 to 2 weeks after surgery.

Parents of a 10-year-old child diagnosed with an intellectual deficit are sharing multiple approaches they implement in dealing with various challenges. Which of the following a statements by the parents alerts the nurse that they need further instruction?

We dress our son every morning for school R: The mentally handicapped child needs to develop a sense of accomplishment. Caregivers should not take over projects because of their own need to assist or speed up the process.

Which statement indicates that the childs parents understand how to perform respiratory therapy?

We give the aerosol followed by postural drainage before meals R: Postural drainage for the child with CF is done following nebulization. Therapy is best scheduled before meals or at least 1 hour after eating to prevent vomiting.

Why does a 4-day-old infant born at 33 weeks of gestation possibly need to be fed by gavage during the first few days of life?

Weak or absent sucking or swallowing reflex R: When the preterm infants sucking and swallowing reflexes are immature, gavage feedings can be used to promote nutrition.

A new mother states her preference to formula feed her newborn. What will the nurse planning discharge instructions tell her to help suppress lactation and promote comfort?

Wear a well-fitting bra continuously for several days R: When a mother does not wish to breastfeed, a snug bra worn around the clock can help alleviate discomfort from engorgement.

What instruction would the nurse provide to an adolescent who has been fitted with a Milwaukee brace?

Wear the brace over a T-shirt 23 hours a day R: A Milwaukee brace is worn approximately 23 hours a day over a T-shirt, which protects the skin.

The nurse discusses preparation for school with the parents of a 6-year-old girl who will soon be starting first grade. What statement by the girls father leads the nurse to determine that the parents understood the information?

Well have her meet some children who will be in her class. R: To prepare a child for school, parents can arrange for the child to meet other children who will be entering school with her.

An assessment of a childs nutritional status reveals the child is alert, with shiny hair, firm gums, firm mucous membranes, and regular elimination. How would this childs nutritional status be described?

Well nourished R: Well-nourished children show steady gains in height and weight and have shiny hair, firm gums and mucous membranes, and regular elimination.

What would the nurse expect to find when assessing the fundus of the uterus immediately after delivery?

Well-contracted with its upper border at or just below the umbilicus R: Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass, about the size of a grapefruit, at the level of the umbilicus.

The vessels comprising the umbilical cord are cushioned and protected by a substance called _______________________.

Whartons jelly R: Whartons jelly is a substance in the umbilical cord that cushions and protects the vessels.

What will the nurse begin with when asking a patient about drug use during a prenatal history?

What over-the-counter and prescription drugs have you taken in the past 3 months? R: Screening for drug use should begin in a nonthreatening way by asking about prescription and OTC medications and how the information can help provide safe and appropriate prenatal care.

While discussing labor and delivery during a prenatal visit, a primigravida asks the nurse when she should go to the hospital. What is the nurses most informative response?

When membranes have ruptured R: Ruptured membranes are an indication that the woman should go to the hospital or birthing center.

A woman pregnant for the first time asks the nurse, When will I begin to feel the baby move? What is the nurses best response?

You may notice the baby moving around the 4th or 5th month R: Quickening, fetal movement felt by the mother, is first perceived at 16 to 20 weeks of gestation.

A 6-year-old with leukemia asks, Who will take care of me in heaven? What is the best response by the nurse?

Who do you think will take care of you? R: This response gives the child an opportunity to verbalize his or her feelings and concerns, whereas closed responses shut off communication. The asking of a why question is not therapeutic as it calls for justification.

A 3-year-old child, while playing with his favorite toy in the playroom of the pediatric unit, is approached by another child who also wants to play with the same toy. What behavior will the nurse anticipate from this child?

Will become angry and a physical response might ensue R: The 3-year-old child is egocentric and likely will become angry when others attempt to take his or her possessions.

What will the nurse administer with ferrous sulfate drops when providing them to a child on the pediatric unit?

With orange juice R: Vitamin C aids in the absorption of iron, whereas food and milk interfere with the absorption of iron.

Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?

Withholding a dose if the apical heart rate is less than 100 beats/min R: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.

An infant receives surfactant via endotracheal (ET) tube at birth for symptoms of respiratory distress syndrome (RDS). When will the nurse anticipate seeing improvement of lung function?

Within 3 days R: In preterm newborns, surfactant can be administered via ET tube at birth or when symptoms of RDS occur, with improvement of lung function seen within 72 hours.

What statement indicates a woman has correct information about oogenesis?

Women have all of their ova at the time they are born. R: Oogenesis (formation of immature ova) does not occur after fetal development. Females are born with about 2 million immature ova, which rapidly reduce by adulthood.

The mother of an infant born prematurely tells the nurse, The baby is irritable. She cries during diaper changes and feedings. Can you make some suggestions about what I should do to soothe her? What is the most appropriate recommendation to help this parent?

Wrap the infant snugly when you hold them R: A strategy that may be helpful is to swaddle the infant snugly in a light blanket with extremities flexed and hands near the face.

The nurse is caring for a newborn who is being breastfed. What will the nurse expect the stool color to be 2 days after birth?

Yellow R: The stool of a breastfed infant is bright yellow, soft, and pasty.

A 4-year-old asks tearfully if the IM injection will hurt. What is the nurses most effective response?

Yes. It will sting a little R: Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

A parent is concerned about her childrens reaction should their grandmother die. What understanding will guide the nurses response?

Young children often understand that other people die, but do not equate it with themselves R: Between 3 and 4 years of age, the child becomes curious about death and dying. They may realize that others die, but they do not relate death to themselves.

The mother of a 3-year-old tells the nurse that she will be in to visit tomorrow around 12:00 PM. The next morning, the child asks the nurse, When is my mommy coming? What is the nurses best response?

Your mommy will be here when you have lunch R: The toddler and preschooler do not understand time yet. They understand time relationships through activities in their experience, such as naptime and mealtimes.

Organize the developmental stages in the correct order. Put a comma and space between each answer choice (a, b, c, d, etc.) a. Fetus b. Zygote c. Embryo d. Blastocyst e. Morula

Zygote Morula Blastocyst Embryo Fetus R: The development follows these stages: zygote, morula, blastocyst, embryo, and fetus.

What do late decelerations indicate? (Select all that apply.) a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression d. Cord compression e. Head compression

a. A nonreassuring pattern b. Uteroplacental insufficiency c. Fetal heart depression R: This nonreassuring pattern indicates uteroplacental insufficiency and fetal heart compression. Prolonged decelerations indicate cord compression and early decelerations indicate head compressions.

The nurse reports which assessments that suggest a meconium ileus in a newborn? (Select all that apply.) a. Abdominal distention b. Vomiting c. Hiccoughing d. Jaundice e. Absence of stool

a. Abdominal distention b. Vomiting e. Absence of stool R: Distended abdomen, vomiting, and absence of stool are the signs indicating meconium ileus in the newborn.

The nurse instructs a woman taking oral contraceptives to report which possible side effects? (Select all that apply.) a. Abdominal pain b. Weight gain c. Headache d. Eye or visual problems e. Speech disturbances

a. Abdominal pain c. Headache d. Eye or visual problems e. Speech disturbances R: The memory aid ACHES is helpful: Abdominal pain, Chest pain, Headaches, Eye problems, Speech disturbances. Weight gain is an expected side effect of oral contraceptives.

What postpartum exercises should the nurse teach a patient who had a vaginal delivery yesterday? (Select all that apply.) a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises e. Leg lifts

a. Abdominal tighteners b. Head lift c. Pelvic tilt d. Kegel exercises R: Exercises for postpartum involution such as abdominal tighteners, head lifts, pelvic tilts, and Kegel exercises are acceptable. Leg lifts are too strenuous early in the postpartum period.

What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all that apply.) a. Age b. Race c. Vital signs d. Distance to travel e. Level of consciousness

a. Age d. Distance to travel e. Level of consciousness R: The means by which the child is transported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel.

The patient who has been dealing with urge incontinence tells the nurse that the symptoms have gotten worse lately. The nurse reminds the patient that which food(s) and drug(s) can increase incontinence? (Select all that apply.) a. Antihypertensive drugs b. Coffee c. Alcohol d. Diuretics e. NSAIDs

a. Antihypertensive drugs b. Coffee c. Alcohol d. Diuretics R: Foods and drugs that increase the symptoms of urge incontinence are antidepressants, angiotensin converting enzyme (ACE) inhibitors, caffeine, alcohol, and diuretics. NSAIDs do not increase incontinence.

What should be included in the nursing care of a 12-year-old child receiving radiation therapy for Hodgkins disease? (Select all that apply.) a. Application of sunblock b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger e. Preparation for premature sexual development

a. Application of sunblock b. Appetite stimulation c. Conservation of energy d. Provision for expressions of anger R: Sun block should be applied to skin after radiation to prevent burning. Low energy levels produce anorexia and anger in many young patients. Radiation delays the development of secondary sex characteristics and menses.

A woman is diagnosed with a urinary tract infection in the postpartum period. What foods can the nurse encourage to increase the acidity of urine? (Select all that apply.) a. Apricots b. Cranberry juice c. Plums d. Prunes e. Apples

a. Apricots b. Cranberry juice c. Plums d. Prunes R: Apricots, cranberry juice, plums, and prunes can increase the acidity of urine. Apples are not considered to increase acidity of urine

The nurse is caring for a woman with epidural anesthesia for pain control during a vaginal delivery. A risk for injury related to epidural anesthesia has been identified by the nursing staff. What interventions are appropriate for the nurse to implement related to this diagnosis? (Select all that apply.) a. Assess leg movement and sensation before ambulating. b. Administer antibiotic as ordered. c. Observe for signs of impending birth. d. Provide sacral pressure as needed. e. Assess fetal position frequently.

a. Assess leg movement and sensation before ambulating. c. Observe for signs of impending birth. R: To prevent the risk for injury related to epidural anesthesia the nurse should asses for movement, sensation, and leg strength before ambulating, ambulate cautiously with an assistant, assist the woman to change positions regularly, and observe for signs that birth may be near: increase in bloody show, perineal bulging, and/or crowning.

The nurse is aware that a full-term infant is born with which reflexes? (Select all that apply.) a. Blinking b. Sneezing c. Gagging d. Sucking e. Grasping

a. Blinking b. Sneezing c. Gagging d. Sucking e. Grasping R: All listed reflexes are present in the full-term newborn.

Which congenital cardiac defect(s) cause(s) increased pulmonary blood flow? (Select all that apply.) a. Atrial septal defects (ASDs) b. Tetralogy of Fallot c. Dextroposition of aorta d. Patent ductus arteriosus e. Ventricular septal defects (VSDs)

a. Atrial septal defects (ASDs) d. Patent ductus arteriosus e. Ventricular septal defects (VSDs) R: The congenital heart defects that cause increased pulmonary blood flow are ASDs, VSDs, and patent ductus arteriosus.

The nurse considers what rites of passage valued by the adolescent in American society? (Select all that apply.) a. Attaining legal drinking age b. Selection of a career c. Religious affiliation d. Obtaining a drivers license e. High school graduation

a. Attaining legal drinking age d. Obtaining a drivers license e. High school graduation R: Rites of passage are socially recognized milestones that signify adulthood. Legal drinking age, drivers license, and matriculation through high school are such signals. Religious affiliation and selection of a career path do not necessarily signal adulthood.

The nurse is obtaining intake information on a new patient being seen for preconception care and notes a family history of neural tube defects. What interventions can the nurse suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply.) a. Avoid drug use. b. Follow a low-calorie, low-protein diet. c. Take a folic acid supplement every day. d. Exercise daily. e. Maintain bed rest during the first trimester.

a. Avoid drug use. c. Take a folic acid supplement every day. R: The use of drugs during early pregnancy and poor nutrition may contribute to the development of a neural tube defect. The American Academy of Pediatrics (AAP) recommends that all women of childbearing age take a daily multivitamin that contains 0.4 mg of folic acid and continue the intake of folic acid until the twelfth week of pregnancy, when basic neural tube development is completed. Studies have shown that the intake of folic acid before conception dramatically decreases the occurrence of neural tube defects such as spina bifida. Daily exercise and bed rest do not decrease the risk of neural tube anomalies.

What developmental milestone(s) assist the 5-year-old boy toward developing his sexual identity? (Select all that apply.) a. Begins to be less focused on his mother b. Ignores both parents totally c. Regresses to a more infantile level d. Forms a romantic attachment to the mother e. Identifies with the parent of the same sex

a. Begins to be less focused on his mother d. Forms a romantic attachment to the mother e. Identifies with the parent of the same sex R: Children of this age become less focused on the mother as the central person and begin to identify with the parent of the same sex, forming a romantic attachment to the parent of the opposite sex. This little boy might say, Im going to marry my mother. A little girl might say, Im going to marry my daddy.

What factor(s) may trigger abuse in a parent? (Select all that apply.) a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care

a. Being abused as a child b. High self-esteem c. Substance abuse d. Overwhelming responsibility e. Knowledge deficit relative to child care R: All options except high self-esteem are possible triggers for a parent to become abusive.

The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of a crack-addicted mother. What would be the manifestations of this syndrome? (Select all that apply.) a. Body tremors b. Excessive sneezing c. Hyperirritability d. Drowsiness e. Excessive appetite

a. Body tremors b. Excessive sneezing c. Hyperirritability R: The neonate with abstinence syndrome will have tremors, be hyperirritable and wakeful, have excessive sneezing or yawning, and have no appetite.

The school nurse suspects a first grade student has sinusitis. Which symptoms might lead the nurse to this suspicion? (Select all that apply.) a. Child reports tooth pain. b. Severe wheezing is auscultated on inspiration. c. Child reports, I have had a cold for 2 weeks. d. Nurse observes periorbital swelling. e. Halitosis is present.

a. Child reports tooth pain. c. Child reports, I have had a cold for 2 weeks. d. Nurse observes periorbital swelling. e. Halitosis is present. R: The proximity of the sinus to the tooth roots often results in tooth pain when the sinus is infected. The maxillary and ethmoid sinuses are most often involved in childhood sinusitis. Therefore the signs and symptoms of sinusitis in children are different from those in adults, depending on the age of the child and which sinus is fully developed. An acute sinusitis is suspected when an upper respiratory infection lasts longer than 10 days, with a daytime cough. Halitosis is often present. Untreated sinusitis can lead to periorbital cellulitis. Severe wheezing is not indicative of sinusitis.

How does the pain of childbirth differ from other types of pain? (Select all that apply.) a. Childbirth pain is part of a normal process. b. Childbirth pain seldom needs narcotic relief. c. Position changes relieve pain and facilitate delivery. d. Childbirth pain declines following birth. e. Childbirth pain is self-limited.

a. Childbirth pain is part of a normal process. c. Position changes relieve pain and facilitate delivery. d. Childbirth pain declines following birth. e. Childbirth pain is self-limited. R: Childbirth pain differs from other types of pain because it is part of a normal, natural, and expected process, can be relieved by change of position, declines immediately following birth, and is self-limiting. Childbirth pain requires pharmacological management with narcotics in many cases.

What would the nurse include in a teaching plan for the pregnant patient who has iron deficiency anemia and has been placed on iron supplements? (Select all that apply.) a. Citrus fruits enhance absorption of iron. b. Bran products support iron deficiency. c. Milk will disguise the taste of the iron. d. The iron therapy will continue for about 3 months. e. Tea should be avoided while taking iron.

a. Citrus fruits enhance absorption of iron. d. The iron therapy will continue for about 3 months. e. Tea should be avoided while taking iron. R: Calcium, bran, and milk interfere with the absorption of iron. Vitamin C helps with the absorption of iron, the therapy usually lasts 3 months, and the tannic acid in tea does interfere with the absorption of iron.

What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply.) a. Close-set eyes b. Simian creases c. Wide-spaced front teeth d. Protruding tongue e. Curved, small fingers

a. Close-set eyes b. Simian creases d. Protruding tongue e. Curved, small fingers R: Children with Down syndrome have close-set upturned eyes, simian creases in palms of hands, protruding tongues, and curved, small fingers. They also have a wide space between their first and second toe and a high incidence of heart defects.

What will the nurse take into consideration when educating parents regarding infant nutrition? (Select all that apply.) a. Cultural practices b. Sex of the infant c. Parental knowledge d. Infants developmental level e. Parent-child interaction

a. Cultural practice c. Parental knowledge d. Infants developmental level e. Parent-child interaction R: Parents have many concerns about feeding their infant during the first year of life. This is a period when readiness to receive nutrition education is usually high; therefore the nurse looks for opportunities to provide accurate information. Assessment of parental knowledge; infant development, behavior, and readiness; parent-child interaction; and cultural and ethnic practices is important. Sex of the infant does not enter into nutritional education.

The school nurse is discussing challenges of the adolescent years with a group of high school students in health class. What challenges toward adolescent development will the nurse include? a. Developing intimacy b. Maintaining dependence on parents c. Searching for identity d. Adjusting to body changes e. Establishing future goals

a. Developing intimacy c. Searching for identity d. Adjusting to body changes e. Establishing future goals R: Adolescents face the challenges of developing intimacy, searching for identity, adjusting to body changes and establishing goals for the future. Adolescents are striving for independence from parents.

The nurse emphasizes to a patient with a high-risk pregnancy that the impact of such a pregnancy might result in which problems? (Select all that apply.) a. Disruption of family roles b. Financial pressures c. Excessive attachment to infant d. Frustration with activity restriction e. Alteration in child care practices

a. Disruption of family roles b. Financial pressures d. Frustration with activity restriction e. Alteration in child care practices R: High-risk pregnancies may produce problems such as disruption of family roles, financial pressures, delayed attachment to the infant, alteration in child care practices, and frustration with activity restriction.

To what is the restlessness seen in the adolescent considered to be attributed? (Select all that apply.) a. Drive to be accepted by society as an individual b. Urge for independence c. Establishment of a personal identity d. Intense libido e. Slowing of body changes

a. Drive to be accepted by society as an individual b. Urge for independence c. Establishment of a personal identity d. Intense libido R: All the options listed are sources of stress to the adolescent and are stimulants to restlessness except option E: body changes are rapid.

A nurse is teaching a lesson on fetal development to a class of high school students and explains the primary germ layers. What are the germ layers? (Select all that apply.) a. Ectoderm b. Endoderm c. Mesoderm d. Plastoderm e. Blastoderm

a. Ectoderm b. Endoderm c. Mesoderm R: The zygote transforms its embryonic disc into three layers: the ectoderm, the mesoderm, and the endoderm.

How has synthetic recombinant antihemophilic factor improved the management of hemophilia? (Select all that apply.) a. Eliminates the need for frequent transfusions b. Can be administered by family at home c. Prevents hemorrhage d. Reduces cost of care of the hemophiliac e. Reduces risk of HIV and hepatitis A and B transmission

a. Eliminates the need for frequent transfusions b. Can be administered by family at home d. Reduces cost of care of the hemophiliac e. Reduces risk of HIV and hepatitis A and B transmission R: The drug can be given at home by the family. Because it supplies the missing factor, transfusions are not necessary and consequently the exposure to HIV and hepatitis A and B is reduced. Cost of care is greatly reduced because hospitalizations and transfusions are not as frequently required. The drug does not prevent hemorrhage; it makes hemorrhage manageable.

The nurse is educating parents on prevention of eyestrain in their 5-year-old child. What information will the nurse include? (Select all that apply.) a. Encourage books with large type. b. Words in books should be closely spaced. c. Provide adequate lighting without glare. d. Be sure desks and chairs are adequate height. e. Instruct child to squint when reading.

a. Encourage books with large type. c. Provide adequate lighting without glare. d. Be sure desks and chairs are adequate height. R: Children who are beginning to read need books with large type in which the letters are spaced far apart. The lighting must be adequate and without glare. Chairs and desks must be of the proper height.

Which interventions could a nurse apply to help stimulate contractions? (Select all that apply.) a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples d. Offering emotional support e. Allowing the patient to vent frustration

a. Encouraging the patient to sit upright b. Assisting the patient to ambulate c. Stimulating the nipples R: Sitting upright, ambulating, and stimulating the nipples may encourage progression of labor. Offering emotional support and allowing patient to vent frustration are supportive to the patient but do not stimulate more effective labor.

What does including play in the plan of care for a 5-year-old allow the child to do? (Select all that apply.) a. Exercise his imagination b. Assume a role and act it out c. Offers an emotional outlet d. Avoid magical thinking e. Interact with other children

a. Exercise his imagination b. Assume a role and act it out c. Offers an emotional outlet e. Interact with other children R: Benefits of play for the preschooler include exercising imagination, assuming a role and acting it out, offering an emotional outlet, and interaction with other children. Play employs the use of magical thinking.

How would the nurse caring for an infant with congestive heart failure (CHF) modify feeding techniques to adapt for the childs weakness and fatigue? (Select all that apply.) a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding d. Substituting glucose water for formula e. Offering high-caloric formula

a. Feeding more frequently with smaller feedings b. Using a soft nipple with enlarged holes c. Holding and cuddling the child during feeding e. Offering high-caloric formula R: Infants with CHF fatigue easily. Feeding can be given more frequently in smaller amounts through a soft, large-holed nipple. Formulas with a denser caloric content can be offered. The child may be encouraged to nurse if he or she is held.

The nurse is preparing to outline principles of discipline for parents of an infant. What information should the nurse include? (Select all that apply.) a. Firmly say No. b. Distract the child to another activity. c. Bribe the child with a sweet treat. d. Remain consistent. e. Ignore the child until behavior improves.

a. Firmly say No. b. Distract the child to another activity. d. Remain consistent. R: Parental approval is important to the infant, and setting limits early is important (Anderson, 2008). Principles of discipline for an infant include lowering the voice to say no firmly, removing the child from the situation, distraction, and consistency.

What breathing techniques would the nurse teach the prenatal patient to help her focus during labor in order to reduce pain? (Select all that apply.) a. First stage breathing b. Abdominal breathing c. Fourth stage breathing d. Modified pace breathing e. Patterned paced breathing

a. First stage breathing b. Abdominal breathing d. Modified pace breathing e. Patterned paced breathing R: First stage breathing includes the techniques of modified pace breathing and patterned paced breathing, which are types of abdominal breathing techniques. These patterns of breathing will help a woman in labor to focus and reduce pain perception. The fourth stage of labor is the womans recovery stage and does not require a breathing technique.

The nurse is obtaining history and physical information on a new patient attending her first prenatal visit. After recording current height, weight, and BMI, it is determined that the patient is obese. What complications related to obesity will the nurse assess this patient for during pregnancy? (Select all that apply.) a. Gestational diabetes b. RH Incompatibility c. Hypertension d. Pre-eclampsia e. Infection

a. Gestational diabetes c. Hypertension d. Pre-eclampsia R: The obese woman who is pregnant has a high risk for developing complications during pregnancy such as gestational diabetes, hypertension, cardiac problems, pre-eclampsia, and respiratory problems.

What are the classic symptoms of thalassemia major (Cooleys anemia)? (Select all that apply.) a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures e. Renal failure

a. Hepatomegaly b. Jaundice c. Protruding teeth d. Pathological fractures R: All of the options are classic signs of thalassemia major except renal failure.

A 16-year-old patient is diagnosed with primary hypertension. What risk factors does the nurse mention when providing education on this diagnosis to the patient and his family? (Select all that apply.) a. Heredity b. Stress c. Congenital defect d. Obesity e. Poor diet

a. Heredity b. Stress d. Obesity e. Poor diet R: Primary, or essential, hypertension implies that no known underlying disease is present. Nevertheless, heredity, obesity, stress, and a poor diet and exercise pattern can contribute to any type of hypertension.

What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply.) a. High-pitched cry b. Inequality of pupils c. Bulging fontanelles d. Diarrhea e. Hiccups

a. High-pitched cry b. Inequality of pupils c. Bulging fontanelles R: Increased ICP is manifested by high-pitched cry, inequality of pupils, and bulging fontanelles.

How do children differ from adults? (Select all that apply.) a. Higher metabolic rate b. Greater surface area in relation to their weight c. Less mature organ systems d.More fluid reserves e. Continuously changing growth and development pattern

a. Higher metabolic rate b. Greater surface area in relation to their weight c. Less mature organ systems e. Continuously changing growth and development pattern R: Children are in a continuous growth and development pattern. Children have a greater surface area and a higher metabolic rate. All of their organ systems are not mature.

What are the advantages of a freestanding birth center? (Select all that apply.) a. Home-like setting b. Designed for high-risk pregnancies c. Lower costs d. Attended by certified obstetricians e. Immediate emergency access

a. Home-like setting c. Lower costs R: Advantages of a freestanding birth center include a homelike setting and lower costs because the center does not require expensive departments such as emergency or critical care. Freestanding birth centers are not designed for high-risk patients, are not attended by certified obstetricians, and do not have immediate emergency access.

A mother confides in the school nurse that she witnessed her son kissing another boy. Which concepts should guide the nurse to base a reply? (Select all that apply.) a. Homosexual behavior in adolescents is not uncommon. b. Homosexuality is a mental disorder. c. Adolescents often desire to explore alternative lifestyles. d. Homosexual tendencies should be addressed with counseling. e. Parents should seek a support group for parents of gays.

a. Homosexual behavior in adolescents is not uncommon. c. Adolescents often desire to explore alternative lifestyles. R: Adolescents may experiment with an alternate sexual expression as part of their self-discovery. Homosexual activities are not uncommon in adolescence.

What are the four structural heart anomalies that make up the tetralogy of Fallot? (Select the four that apply.) a. Hypertrophied right ventricle b. Patent ductus arteriosus c. Ventral septal defect d. Narrowing of pulmonary artery e. Dextroposition of aorta

a. Hypertrophied right ventricle b. Patent ductus arteriosus d. Narrowing of pulmonary artery e. Dextroposition of aorta R: The four anomalies that comprise tetralogy of Fallot are hypertrophied right ventricle, patent ductus arteriosus, stenosis of pulmonary artery, and dextroposition of the aorta.

The nurse points out what advantage(s) of a nursery school or preschool experience? (Select all that apply.) a. Increasing self-confidence b. Fostering group cooperation c. Detecting adjustment problems d. Attainment of toilet training skills e. Playing experiences with other children

a. Increasing self-confidence b. Fostering group cooperation c. Detecting adjustment problems e. Playing experiences with other children R: Nursery school increases self-confidence, group cooperation, social skills, and cooperative play. Objective observations by a nursery school instructor can detect early adjustment problems. The child is usually toilet trained prior to the start of preschool.

What typical types of classes are available to help expectant parents prepare for parenthood? (Select all that apply.) a. Infant care b. Breastfeeding c. Gestational diabetes d. Sources of financial aid e. Yoga

a. Infant care b. Breastfeeding c. Gestational diabetes R: Prenatal classes include such topics as infant care, breastfeeding, gestational diabetes, exercising, and sibling and grandparent preparation. Yoga and financial information are not traditional content for prenatal instruction.

What would the nurse teaching an asthmatic child the technique of pursed-lip breathing include? (Select all that apply.) a. Inhale deeply through nose with mouth closed. b. Make exhalation twice as long as inhalation. c. Use medicated inhaler prior to performing breathing exercise. d. Exhale through mouth as if whistling. e. Exhale forcefully.

a. Inhale deeply through nose with mouth closed. b. Make exhalation twice as long as inhalation. d. Exhale through mouth as if whistling. R: The technique requires that breath be inhaled through the nose and exhaled through pursed lips in a nonforceful manner. The exhalation should be twice as long as the inhalation.

A woman is preparing for administration of a cervical ripening agent. What nursing actions will the nurse anticipate implementing? (Select all that apply.) a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. d. Instruct patient to ambulate immediately afterward. e. Ensure a tocolytic is available.

a. Insert IV. b. Record a baseline fetal heart rate. c. Explain procedure to patient. R: The cervical ripening procedure should be explained to the woman and her family. A fetal heart rate baseline is recorded. An intravenous (IV) line with saline or heparin sodium (Hep-Lock) may be placed in case uterine tachysystole (hyperstimulation) occurs and IV tocolytics (drugs that reduce uterine contractions) are needed. After insertion of the prostaglandin gel, the woman remains on bed rest for 1 to 2 hours and is monitored for uterine contractions. Vital signs and fetal heart rate are also recorded.

Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all that apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts e. Anticoagulants

a. Insulin b. Digoxin d. Calcium salts e. Anticoagulants R: Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a licensed nurse prior to administration.

The nurse cautions that children who have unmet hunger needs will likely display which characteristic(s)? (Select all that apply.) a. Irritability b. Ineffective feeding patterns c. No predictable sleep-wake cycle d. Distrust e. Effective parent bonding

a. Irritability b. Ineffective feeding patterns c. No predictable sleep-wake cycle d. Distrust R: Children who experience frequent hunger do not have effective parental bonding. All other options are probable outcomes for a child who has unmet hunger needs.

What intervention(s) would the nurse caring for a child with infectious meningitis include? (Select all that apply.) a. Isolation precautions b. Provision of brightly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions

a. Isolation precautions b. Provision of brightly lit room c. Observation for increasing intracranial pressure d. Preparation for spinal tap e. Seizure precautions R: All elements of nursing care listed in the options, except a brightly lit room, would be part of comprehensive care of a child with meningitis.

What would be included in the plan of care for a child just returned to the floor from surgery in which a clubfoot was repaired? (Select all that apply.) a. Keep cast uncovered to allow drying. b. Check toes for capillary refill. c. Circle with a pen any area of bleeding on the cast. d. Keep casted leg lowered. e. Observe for skin irritation.

a. Keep cast uncovered to allow drying. b. Check toes for capillary refill. c. Circle with a pen any area of bleeding on the cast. e. Observe for skin irritation. R: The casted leg should be kept elevated. All the other options are necessary nursing interventions for a child who is freshly casted.

What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage? (Select all that apply.) a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. c. Stimulate often to maintain level of consciousness. d. Hold and coddle frequently to stimulate. e. Observe for increased intracranial pressure.

a. Keep positioned with head elevated. b. Feed slowly to reduce possibility of vomiting. e. Observe for increased intracranial pressure. R: These children should be kept positioned with the head elevated, fed slowly, and monitored for increased intracranial pressure. Children with intracranial hemorrhages are not stimulated and are kept in a quiet environment.

The nurse instructs the postpartum patient that her nutritional intake should include which food(s) particularly supportive to healing? (Select all that apply.) a. Legumes b. Potatoes and pasta c. Citrus fruits. d Rice e. Cantaloupe

a. Legumes c. Citrus fruits. e. Cantaloupe R: Legumes and foods containing vitamin C are conducive to healing. Starches are not.

What might the nurse advise the woman with pelvic floor dysfunction to do for relief of the associated discomfort? (Select all that apply.) a. Lie down with feet elevated. b. Practice Kegel exercises. c. Assume knee-chest position periodically. d. Perform leg lift exercises. e. Prevent constipation.

a. Lie down with feet elevated. b. Practice Kegel exercises. c. Assume knee-chest position periodically. e. Prevent constipation. R: Elevating the feet, performing Kegel exercises, assuming the knee-chest position, and preventing constipation will reduce the pelvic discomfort of pelvic floor dysfunction.

The nurse suggests to parents that they use the outpatient surgical center for their childs upcoming surgery. What advantage(s) does this type of facility have to offer? (Select all that apply.) a. Lower cost b. Less incidence of health care associated infections c. Reduction of parent-child separation d. Ample time for recuperation at the facility e. Decreased emotional impact of illness

a. Lower cost b. Less incidence of health care associated infections c. Reduction of parent-child separation d. Ample time for recuperation at the facility e. Decreased emotional impact of illness R: All options listed are advantages of outpatient services with the exception of recuperating at the facility.

How does the pediatric skeletal system differ from that of the adult? (Select all that apply.) a. Lower mineral content b. More ossification c. Open epiphyses d. Less porosity e. Greater strength

a. Lower mineral content c. Open epiphyses e. Greater strength R: The childs skeletal system has less mineral content, greater porosity, open epiphyses, greater bone strength, and a thicker periosteum.

What basic feeling words should the nurse use in attempting to help a 7-year-old girl express her feelings about being in a new school? (Select all that apply.) a. Mad b. Glad c. Sad d. Scared e. Jealous

a. Mad b. Glad c. Sad d. Scared R: The words mad, glad, sad, and scared are basic feeling words that can prompt a young child to better express his or her feelings.

What are the functions of amniotic fluid? (Select all that apply.) a. Maintaining an even temperature b. Impeding excessive fetal movement c. Lubricating fetal skin d. Acting as a reservoir for nutrients e. Acting as a cushion for the fetus

a. Maintaining an even temperature e. Acting as a cushion for the fetus R: The amniotic fluid provides maintenance of even temperature; prevents amnion from adhering to fetal skin; allows buoyancy, symmetrical growth, and fetal movement; and acts as a cushion for the fetus. Although the fetus does swallow amniotic fluid, it has no nutritional value.

What information will the nurse include when taking a developmental history? (Select all that apply.) a. Previous experience with hospitalization b. Cultural needs c. History of illness d. Allergies e. Childs nickname

a. Previous experience with hospitalization b. Cultural needs e. Childs nickname R: The developmental history has information about the child and the childs developmental and cultural needs and personal preferences. The information relative to history of illness or allergies would be covered in the medical history.

The nurse cautions that women with a history of which disorders are not candidates for HRT? (Select all that apply.) a. Melanoma b. Estrogen-dependent breast cancer c. Hepatitis C d. Thromboembolic disease e. Hyperthyroidism

a. Melanoma b. Estrogen-dependent breast cancer c. Hepatitis C d. Thromboembolic disease R: Persons who are absolutely restricted from HRT are those with melanoma, estrogen-dependent breast cancers, chronic liver disorders, thromboembolic disease, and seizure disorders.

The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are appropriate for the nurse to implement? (Select all that apply.) a. Model desired behavior. b. Instruct patient not to yell. c. Use distractions. d. Explain the procedure in detail. e. Encourage the child to ask questions.

a. Model desired behavior. c. Use distractions. R: Whenever possible the parent should be involved in the preparation for and initiation of a treatment or procedure, and the child should be prepared according to his or her developmental level. For a toddler, model the behavior desired (i.e., opening the mouth), tell the child it is okay to yell if the treatment or procedure is uncomfortable, and use distractions. Explaining the procedure in detail and encouraging questions are appropriate interventions for an older child.

The nurse describes the allergic salute as a cluster of what signs related to chronic allergy? (Select all that apply.) a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes d. Productive cough e. Reddened conjunctiva

a. Mouth breathing b. Transverse nasal crease c. Dark circles under the eyes e. Reddened conjunctiva R: The allergic salute does not include a productive cough.

What nursing interventions are appropriate for the prenatal patient in terms of prenatal care? (Select all that apply.) a. Offer nutritional counseling. b. Reinforce responsibility of parenthood. c. Reduce risk factors. d. Improve health practices. e. Make financial arrangements for delivery.

a. Offer nutritional counseling. b. Reinforce responsibility of parenthood. c. Reduce risk factors. d. Improve health practices. R: Nutritional counseling, reinforcing and discussing the responsibility of parenthood, reducing risk factors for the pregnant woman and the fetus, and improving health practices are all goals of prenatal care.

The nurse assesses a preterm infant in the NICU. What signs should be reported to the physician? (Select all that apply.) a. Paleness b. Transparent skin c. Superficial scalp veins d. Vomiting e. Bulging fontanelles

a. Paleness d. Vomiting e. Bulging fontanelles R: Paleness, vomiting, and bulging fontanelles can indicate complications in the preterm newborn. Transparent skin and superficial scalp veins are expected findings.

The school nurse is preparing an educational program for new teachers regarding school-age children. What information is accurate for the nurse to include? (Select all that apply.) a. Participation in group activity increases b. Egocentricity prevails c. Thinking is logical d. Preference is toward family interaction e. Understand cause and effect

a. Participation in group activity increases c. Thinking is logical e. Understand cause and effect R: Piaget refers to the thought processes of the school age period as concrete operations.Concrete operations involve logical thinking and an understanding of cause and effect.The egocentric view of the preschool child is replaced by the ability to understand the point of view of another person. Between 6 and 12 years of age, children prefer friends of their own sex and usually prefer the company of their friends to that of their brothers and sisters.

The nurse is educating parents of a 2-month-old about immunizations. What immunizations against illness should their child receive? (Select all that apply.) a. Pertussis (whooping cough) b. Influenza c. Diptheria d. Tetanus e. Polio

a. Pertussis (whooping cough) b. Influenza c. Diptheria d. Tetanus e. Polio R: The first DPT, polio, and flu immunizations are given at the age of 2 months.

The nurse is caring for a child with a low platelet count. What skin assessments would alert the nurse to bleeding? (Select all that apply.) a. Petichiae b. Purpura c. Ecchymosis d. Hematoma e. Lymphadenopathy

a. Petichiae b. Purpura c. Ecchymosis d. Hematoma R: The reduction or destruction of platelets in the body interferes with the clotting mechanism. Skin lesions that are common to these disorders include petechiae, a bluish, nonblanching, pinpoint-sized lesion; purpura, groups of adjoining petechiae; ecchymosis, an isolated bluish lesion larger than a petechia; and hematoma, a raised ecchymosis. Lymphadenopathy is an enlargement of lymph nodes that is indicative of infection or disease.

The nurse is caring for a woman who gave birth to a preterm infant. The nurse is aware that what are possible causes of preterm delivery? (Select all that apply.) a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension d. Hyperemesis gravidarum e. Chloasma

a. Placenta previa b. Gestational diabetes c. Pregnancy-induced hypertension R: The predisposing causes of preterm birth are numerous; in many instances the cause is unknown. Prematurity may be caused by multiple births, illness of the mother (e.g., malnutrition, heart disease, diabetes mellitus, or infectious conditions), or the hazards of pregnancy itself, such as gestational hypertension, placental abnormalities that may result in premature rupture of the membranes, placenta previa (in which the placenta lies over the cervix instead of higher in the uterus), and premature separation of the placenta. Studies also indicate the relationships between prematurity and poverty, smoking, alcohol consumption, and abuse of cocaine and other drugs. Hyperemesis gravidarum and chloasma are not risk factors for preterm birth.

What will the nurse include then documenting a grand mal seizure? (Select all that apply.) a. Presence of incontinence b. Current dose of antispasmodic medication c. Activity level prior to and following seizure d. Level of consciousness following seizure e. Length of seizure

a. Presence of incontinence c. Activity level prior to and following seizure d. Level of consciousness following seizure e. Length of seizure R: Documentation on a seizure should include LOC following episode, activity prior to and following seizure, change in color, respiration, muscle tone, and length of seizure. Reporting of medication regimen is not necessary.

A patient who is 30 weeks pregnant delivers a stillborn child in the emergency department (ED). What should the ED nurse offer the patient? (Select all that apply.) a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) e. A warm beverage

a. Privacy b. An opportunity to hold the infant c. Materials about support groups d. A memento (footprint or lock of hair) R: The patient should be offered privacy, an opportunity to hold the infant, support group information, and a memento. A warm beverage is not a priority at this time.

Parents attending a well visit for their 11-year-old son verbalize concern over his computer use. When asked about it, the boy states, I play games on my computer for 1 hour a day. The nurse knows that computer games can provide what opportunities to childhood development? (Select all that apply.) a. Problem-solving skills b. Gross motor development c. Manipulative skills d. Learning opportunities e. Increased self-worth

a. Problem-solving skills c. Manipulative skills d. Learning opportunities R: Computer programs are popular with all age groups, providing problem-solving skills, manipulative skills, and opportunities for new learning.

While caring for an Arab woman in labor, the nurse should provide cultural sensitivity through which interventions? (Select all that apply.) a. Provide for extreme modesty. b. Assign a male caregiver. c. Arrange for the husband/partner to participate in labor. d. Provide adequate pain control. e. Respect protective amulets.

a. Provide for extreme modesty. d. Provide adequate pain control. e. Respect protective amulets. R: Arab women are extremely modest, usually have a low pain tolerance, and wear various protective and religious amulets. The husband is in attendance but not as a participant. Arabs prefer female caregivers. If a male is in attendance, then the husband will remain in the room as long as the male is there.

A postpartum patient is experiencing hypovolemic shock. What interventions can the nurse anticipate? (Select all that apply.) a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation d. Administration of anticoagulants e. Blood transfusion

a. Provision of IV fluids b. Placement of an indwelling Foley catheter c. Assessment of oxygen saturation e. Blood transfusion R: Medical management for the patient experiencing hypovolemic shock includes stopping blood loss, giving IV fluids to maintain circulating volume and replace fluids, giving blood transfusions to replenish erythrocytes, and assessment of oxygen saturation. Anticoagulants would not be given.

The nurse demonstrates which similarities among all traction devices? (Select all that apply.) a. Pull the limb into extension b. Decrease muscle spasm c. Reduce pain d. Align two bone fragments e. Immobilize the limb

a. Pull the limb into extension b. Decrease muscle spasm d. Align two bone fragments e. Immobilize the limb R: Tractions are designed to immobilize and pull limbs into extension. Traction can also align broken bones and decrease muscle spasm. Although some traction devices may relieve pain, many may actually cause pain.

The nurse is aware that the 7-month-old can signal feeding readiness by which action(s)? (Select all that apply.) a. Pulling spoon toward mouth b. Biting at spoon with upper and lower incisors c. Pointing to food bowl d. Bouncing up and down with excitement at sight of food e. Manipulating finger foods

a. Pulling spoon toward mouth e. Manipulating finger foods R: The 7-month-old pulls the spoon toward his or her mouth and can manipulate finger foods. The 7-month-old does not have upper incisors and has not developed adequately to recognize the food container or exhibit excitement related to the sight of food.

Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be brought for damages d. That the document must be signed and witnessed e. That information was given

a. Purpose of the procedure b. Risks associated with the procedure d. That the document must be signed and witnessed e. That information was given R: The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed.

While instructing a new mother on formula preparations, the nurse would include what types? (Select all that apply.) a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula d. Cows milk e. Canned evaporated milk

a. Ready-to-feed formula b. Concentrated liquid formula c. Powdered formula R: Formula choices are ready-to-use, concentrated liquid formula that will be diluted according to the infants needs and powdered formula that is mixed as needed. Cows milk and canned evaporated milk are unsuitable because they are nutritionally inadequate and stress the kidneys.

The nurse is assessing Apgar score on a newborn. What will be evaluated? (Select all that apply.) a. Reflexes b. Color c. Heart rate d. Respiration e. Weight

a. Reflexes b. Color c. Heart rate d. Respiration R: The Apgar score is a standardized method of evaluating the newborns condition immediately after delivery. Five objective signs are measured: heart rate, respiration, muscle tone, reflexes, and color. The score is obtained 1 minute after birth and again after 5 minutes.

What should the teaching plan include about infant fall precautions? (Select all that apply.) a. Remove all unsteady furniture. b. Keep crib rails up and in locked position. c. Steady infant with hand when on changing table. d. Use tray attachment on high chair as restraint. e. Keep infant seat on the floor.

a. Remove all unsteady furniture. b. Keep crib rails up and in locked position. c. Steady infant with hand when on changing table. e. Keep infant seat on the floor. R: The tray attachment to a high chair is an inadequate restraint. All other options are good precautions to prevent an infant from a fall.

The nurse knows that a postterm infant may experience which potential problems? (Select all that apply.) a. Seizures b. Asphyxia c. Paralysis d. Visual defects e. Polycythemia

a. Seizures b. Asphyxia e. Polycythemia R: The postterm infant should be assessed closely for indication of asphyxia, seizures, and polycythemia.

What are the basic fears of a young child being hospitalized? (Select all that apply.) a. Separation b. Permanent scarring c. Pain d. Cost e. Body intrusion

a. Separation c. Pain e. Body intrusion R: Small children all share the same basic fears relative to hospitalization, which are separation from family, pain, and body intrusion or mutilation.

What approaches should the nurse suggest for introducing a toddler to new foods? (Select all that apply.) a. Serve one food at a time. b. Avoid showing personal likes or dislikes. c. Offer foods in small amounts, less than a teaspoon. d. Entice the toddler to eat with sweets. e. Serve food warm.

a. Serve one food at a time. b. Avoid showing personal likes or dislikes. c. Offer foods in small amounts, less than a teaspoon. e. Serve food warm. R: Foods should be introduced in small, warm servings, one food at a time. Sweets and milk should not be offered until after solid food.

Why would the nurse urge the family of a dying 12-year-old boy to include his 8-year-old sister in care? (Select all that apply.) a. She will feel less neglected by the parents. b. She can make amends for past hostilities to her brother. c. She will feel increased helplessness. d. She can express her feelings through care. e. She can experience being supportive of her parents and brother.

a. She will feel less neglected by the parents. b. She can make amends for past hostilities to her brother. c. She will feel increased helplessness. d. She can express her feelings through care. e. She can experience being supportive of her parents and brother. R: All options are potential benefits to including the sibling in the care of a dying child except increased helplessness. She would feel less helpless.

The nurse recognizes which behavior characteristic(s) of women in their first trimester of pregnancy? (Select all that apply.) a. Showing off her sonogram photos b. Ambivalence about pregnancy c. Emotional and labile mood d. Focusing on her infant e. Fatigue

a. Showing off her sonogram photos b. Ambivalence about pregnancy c. Emotional and labile mood e. Fatigue R: Showing off photos, feeling ambivalence about the pregnancy, fragile emotions, and fatigue and sleepiness are all characteristic of behaviors seen in the first trimester. Women are not focused on their infant; they are focused on themselves and the physical changes they are experiencing.

Which are nonpharmacological forms of pain relief? (Select all that apply.) a. Skin stimulation b. Diversion and distraction c. Breathing techniques d. Exercise e. Yoga

a. Skin stimulation b. Diversion and distraction c. Breathing techniques R: Skin stimulation, diversion and distraction, and breathing techniques are the bases of nonpharmacological pain control. Although exercise and practices such as yoga and Pilates are beneficial, they are not means of pain control.

When selecting a potty chair, the parents are encouraged to select one that has which characteristic(s)? (Select all that apply.) a. Small enough for the childs feet to touch floor b. Sturdy and stable c. Supportive of childs back and arms d. Made of plastic or fiberglass e. Capable of being taken apart easily

a. Small enough for the childs feet to touch floor b. Sturdy and stable c. Supportive of childs back and arms R: Potty chairs should be small and sturdy and supportive of the childs back and arms. The composition is not important as long as it is stable.

The nurse takes into consideration that newborns are especially prone to dehydration because of which aspects of their physiology? (Select all that apply.) a. Small glomeruli b. Minimal renal blood flow c. Inactive gastrointestinal (GI) tract d. Excessive fluid loss from the sweat glands e. Immature renal tubules that do not concentrate urine

a. Small glomeruli b. Minimal renal blood flow e. Immature renal tubules that do not concentrate urine R: The newborns glomeruli are small and have only one third of the blood circulation of an adult, and they are unable to effectively concentrate urine. The GI tract is active. The infants sweat glands do not work effectively and allow very little fluid loss through sweat.

Which aspect(s) of a childs development does the nurse caution parents that hearing impairment can affect? (Select all that apply.) a. Speech clarity b. Language development c. Immunity to disease d. Personality development e. Academic achievement

a. Speech clarity b. Language development d. Personality development e. Academic achievement R: All the options, except immunity to disease, are areas in which a hearing impairment could interfere with normal development.

What assessment(s) in a child with tetralogy of Fallot would indicate the child is experiencing a paroxysmal hypercyanotic episode? (Select all that apply.) a. Spontaneous cyanosis b. Dyspnea c. Weakness d. Dry cough e. Syncope

a. Spontaneous cyanosis b. Dyspnea c. Weakness e. Syncope R: Indicators of a paroxysmal hypercyanotic episode or a tet episode are spontaneous cyanosis, dyspnea, weakness, and syncope.

Parents of a toddler are discussing the emotion of fear with the pediatric nurse. What information can the nurse offer regarding fear and the toddler? (Select all that apply.) a. Stress increases fear. b. Rituals help deal with fear. c. Teasing the child can decrease fear. d. Once fear is learned it is difficult to eliminate. e. Adults should openly share their fears.

a. Stress increases fear. b. Rituals help deal with fear. d. Once fear is learned it is difficult to eliminate. R: Once a fear has been learned, it is more difficult to eliminate. Clinging to favorite possessions and repetitive rituals are self-consoling behaviors for the toddler, particularly at bedtime and during separation from parents. Stress increases fear of separation. Adults should attempt to control their own fears in the presence of young children. Respect and understanding should always be accorded to children who are afraid. Making fun of the fear or shaming the child in front of others is detrimental to self-esteem.

What will the nurse discourage when providing education to parents of a child with asthma? (Select all that apply.) a. Stuffed toys b. Pet ownership c. Gymnastics d. Basketball e. Cotton blankets

a. Stuffed toys d. Basketball R: Use of stuffed toys is discouraged due to potential allergens. Basketball might not be well tolerated because of the constant physical exertion. Certain pets are encouraged, gymnasitics is usually well tolerated, and cotton blankets are recommended for children with asthma.

A woman who is 37 weeks pregnant reports feeling dizzy when lying on her back. What does the nurse explain as the most likely cause of this symptom?

a. Supine hypotension syndrome R: Supine hypotension syndrome, also called aortocaval compression or vena cava syndrome, may occur if the woman lies on her back. Symptoms of supine hypotension syndrome include faintness, lightheadedness, dizziness, and agitation.

What noninvasive forms of pain relief might a nurse implement with a newborn? (Select all that apply.) a. Swaddling b. Rocking c. Offering a pacifier d. Distraction e. Cuddling

a. Swaddling b. Rocking c. Offering a pacifier e. Cuddling R: Swaddling, rocking, nonnutritive sucking, quiet environment, and cuddling are all effective, noninvasive pain remedies. Distraction is not a dependable method of pain reduction with infants.

The nurse would suggest the parents of an asthmatic child to encourage participation in which sport(s)? (Select all that apply.) a. Swimming b. Gymnastics c. Baseball d. Cross-country skiing e. Distance running

a. Swimming b. Gymnastics c. Baseball R: Sports that require bursts of energy rather than long-term output of energy are suitable pursuits for asthmatics. Swimming, gymnastics, and baseball fit this criterion.

Which bedtime preparation rituals are the most appropriate for the nurse to suggest? (Select all that apply.) a. Telling a story b. Placing a favorite toy in bed c. Placing a glass of water at the bedside d. Turning on a night light e. Playing energetically

a. Telling a story b. Placing a favorite toy in bed c. Placing a glass of water at the bedside d. Turning on a night light R: All options are soothing bedtime rituals except energetic playing, which would be stimulating and counterproductive to sleep.

The nurse is providing a conference on nonpharmacological pain control methods. What major advantages of nonpharmacological pain control methods will the nurse include in the presentation? (Select all that apply.) a. They sedate the mother. b. They do not slow labor. c. They do not dull the excitement of the birth experience. d. They do not have the potential to cause allergic reactions. e. They do not have to be delayed until labor is well established.

a. They sedate the mother. b. They do not slow labor. c. They do not dull the excitement of the birth experience. d. They do not have the potential to cause allergic reactions. e. They do not have to be delayed until labor is well established. R: All the options mentioned are benefits of nonpharmacological pain control methods with the exception of sedating the mother.

Which assessments would lead the nurse to determine the gestational age of the infant as preterm? (Select all that apply.) a. Thin, transparent skin b. Vernix only in the body creases c. Folded ear springs back slowly d. Breast tissue under the nipple e. Creases over entire sole

a. Thin, transparent skin c. Folded ear springs back slowly R: The only signs of preterm are the thin skin and the slowly responding ear.

What will the nurse include when documenting the discharge of a pediatric patient? (Select all that apply.) a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation e. Instructions that were given to physician

a. Time of discharge b. Adult(s) accompanying the child and the relationship to the child c. Condition of the child d. Method of transportation R: Information that should be included in the discharge note include time of discharge, adults accompanying the child and relationship to child, condition of the child, and method of transportation. It should also be documented that instructions were given to parents.

The nurse points out which physiological change(s) in the toddler that serve(s)as protection against disease? (Select all that apply.) a. Toughening of the skin b. Increased capillary response for thermoregulation c. Stabilization of body temperature d. Elevation in white blood cell count e. Enlarged adenoids and tonsils

a. Toughening of the skin b. Increased capillary response for thermoregulation c. Stabilization of body temperature e. Enlarged adenoids and tonsils R: With the exception of an increased white blood cell (WBC) count, which is always pathological, the other options are all maturing changes that equip the toddler to better fight disease.

The nurse educates prenatal patients about the threat of TORCH infections. Which infections are included in this classification? (Select all that apply.) a. Toxoplasmosis b. Toxemia c. Cytomegalovirus d. Rubella e. Herpes simplex

a. Toxoplasmosis c. Cytomegalovirus d. Rubella e. Herpes simplex R: The TORCH infections are toxoplasmosis, rubella, cytomegalovirus, and herpes simplex.

The family of a child receiving chemotherapy for leukemia should be taught to focus on which aspect(s) of the childs care? (Select all that apply.) a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration d. Continuing with scheduled immunizations e. Reporting exposure to infectious diseases

a. Using a support group b. Stimulating appetite c. Maintaining adequate hydration e. Reporting exposure to infectious diseases R: Support groups are helpful for emotional support and realistic tips on care. The child on chemotherapy is anorexic and has no appetite. Maintenance of hydration is essential for the adequate therapeutic effect of the drugs. Because the drugs suppress the bone marrow, children are at risk for infection, and the suppression will not allow the antibody response needed for immunization.

. The nurse takes into consideration that the patient with placenta previa is at risk for postpartum infection for what reasons? (Select all that apply.) a. Vaginal organisms can invade the placenta. b. The undernourished placenta becomes necrotic. c. The amniotic fluid can become infected. d. The placenta is an excellent growth medium. e. The misplaced placenta weakens the uterine wall.

a. Vaginal organisms can invade the placenta. d. The placenta is an excellent growth medium. R: Vaginal organisms reach the placenta through the cervix. Once there, the organisms can multiply in the nutrient-rich environment of the placenta. The weak musculature of the lower segment of the uterus will cause postpartum hemorrhage rather than infection.

The nurse reminds new parents that newborns must be protected from environments that are too cold or too hot because of which aspects of the newborns physiology? (Select all that apply.) a. Very little subcutaneous fat b. Low metabolic rates c. Ineffective sweat glands d. Small fluid reserves e. Low red blood cell counts

a. Very little subcutaneous fat c. Ineffective sweat glands R: Newborns have very little subcutaneous fat, which offers little insulation against cold. Newborns have ineffective sweat glands and cannot cool themselves through evaporation.

The nurse explains that the COPP medical regimen for the treatment of Hodgkins disease uses a combination of which drugs? (Select all that apply.) a. Vincristine b. Cyclophosphamide c. Methotrexate d. Prednisone e. Procarbazine hydrochloride

a. Vincristine b. Cyclophosphamide d. Prednisone e. Procarbazine hydrochloride R: The COPP medical regimen includes the combination of cyclophosphamide, vincristine (Oncovin), prednisone, and procarbazine hydrochloride.

The nurse cautions the patient that, because of hormonal changes in late pregnancy, the pelvic joints relax. What does this result in? (Select all that apply.) a. Waddling gait b. Joint instability c. Urinary frequency d. Back pain e. Aching in cervical spine

a. Waddling gait b. Joint instability R: A waddling gait and joint instability are the only signs that relate to joint changes. The other discomforts are related to the enlarging uterus with its attendant weight.

Which interventions would be included in the nursing care of the newly circumcised infant? (Select all that apply.) a. Wash penis with warm water. b. Wipe with alcohol swab. c. Gently remove the yellow crust formation. d. Apply diaper loosely. e. Dress with simple bandage.

a. Wash penis with warm water. d. Apply diaper loosely. R: Postcircumcision care includes washing with warm water, avoiding alcohol wipes, leaving the yellow crust in place, and diapering loosely.

What complications of overstimulation of uterine contractions may occur? (Select all that apply.) a. Water intoxication b. Impaired placental exchange of oxygen and nutrients c. Increased blood pressure d. Convulsions e. Uterine rupture

a. Water intoxication b. Impaired placental exchange of oxygen and nutrients e. Uterine rupture R: The most common complications are impaired placental exchange and uterine rupture, but water intoxication can occur due to fluid retention.

When obtaining a urine specimen on an infant, the adhesive of the urine collector is placed between the _____________ and the _________________.

anus, perineum R: Begin by applying the urine collector to the tiny area of skin between the anus and the perineum. The narrow bridge on the adhesive patch keeps feces from contaminating the specimen and helps to position the collector correctly.

The toddler is in Eriksons stage of _______________versus_______________.

autonomy; shame and doubt R: The toddler is in Eriksons stage of autonomy versus shame and doubt, which is based on a continuum of trust established during infancy

The nurse assesses the perineal pad placed on a 3-hour postdelivery patient and finds that there is no lochia on it. What would the nurse expect to find on further assessment? (Select all that apply.) a. A firm fundus the size of a grapefruit b. A full bladder c. Retained placental fragments d. Vital signs indicative of shock e. A soft, boggy fundus

b. A full bladder e. A soft, boggy fundus R: Large clots that form in a flaccid uterus can obstruct the flow of lochia. A full bladder is a major cause of a uterus that is boggy.

Which major developmental tasks will the nurse expect a child to accomplish by the end of the preschool years? (Select all that apply.) a. Development of parallel play b. Acceptance of separation c. Increased communication skills d. Consistent appetite e. Control of bodily functions

b. Acceptance of separation c. Increased communication skills e. Control of bodily functions R: The major tasks of the preschool child include preparation to enter school, development of a cooperative type of play, control of body functions, acceptance of separation, and increase in communication skills, memory, and attention span. Appetite remains inconsistent.

A 3-year-old patient is admitted to the pediatric unit with a fever of 103 F. Which actions will the nurse implement? (Select all that apply.) a. Assess rectal temperature every 4 hours. b. Administer Acetaminophen as ordered. c. Assess skin turgor. d. Restrict fluids. e. Assess level of consciousness.

b. Administer Acetaminophen as ordered. c. Assess skin turgor. e. Assess level of consciousness. R: When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.

A nurse is discussing risk factors for postpartum shock with a childbirth preparation class. What will the nurse include in this education session? (Select all that apply.) a. Hypertension b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage

b. Blood clotting disorders c. Anemia d. Infection e. Postpartum hemorrhage R: Hypertension is not a cause for postpartum shock; all the other options can cause shock.

How might the nurse instruct the patient to stimulate her nipples in an attempt to increase the quality of uterine contractions? (Select all that apply.) a. Place a warm, moist washcloth over the breast. b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. e. Press the palms of her hands down on her breasts.

b. Brush the nipples with a dry washcloth. c. Gently pull on the nipples. d. Apply suction to the nipples with a breast pump. R: Brushing nipples with a dry washcloth, gently pulling nipples, and applying suction with a breast pump are all effective methods of nipple stimulation, which will increase the quality of uterine contractions.

A toddler must maintain bed rest for the diagnosis of pneumonia. What actions will the nurse implement? (Select all that apply.) a. Maintain strict bed rest. b. Consider age. c. Assess developmental level. d. Implement light play activities. e. Provide hypnotic medication as ordered.

b. Consider age. c. Assess developmental level. d. Implement light play activities. R: Confinement to bed for a child does not always result in physical rest. In pediatrics, bed rest means providing play therapy that promotes minimal activity. The nurse should consider the age and developmental level of the child and the activity level involved in the play when designing appropriate activities and guiding parents in the home care of their child.

The physician has ordered Fentanyl (Sublimaze) for a woman in labor and has asked the nurse to provide patient education. What will the nurse include in the educational plan? (Select all that apply.) a. Onset is slow. b. Duration is short. c. Administration is by mouth. d. No known side effects. e. It is not the same drug as sufentanil.

b. Duration is short. e. It is not the same drug as sufentanil. R: Fentanyl has a rapid onset and short duration of action. Fentanyl, sufentanil, and alfentanil are not the same drugs. Fentanyl can cause respiratory depression but less than meperidine. It is not administered by mouth.

The nurse is instructing a woman at 6 months postpartum on weaning her infant from breastfeeding. What interventions will the nurse suggest? (Select all that apply.) a. Omit newborns favorite feeding first. b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. e. Pump breasts in place of eliminated feeding.

b. Eliminate one feeding at a time. c. Expect the need for comfort feeding. d. Formula will need to be provided to substitute for feeding. R: When weaning a newborn from breastfeeding, the mother should eliminate the favorite feeding last. One feeding should be eliminated at a time, and the need for comfort feeding should be expected. In younger infants formula will need to be substituted. The mother should not be instructed to pump in place of eliminated feeding or the breasts will continue to produce milk.

What will the nurse teach a nursing mother to do to reduce the risk of mastitis? (Select all that apply.) a. Limit fluid intake to 1 liter per day. b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying.

b. Empty both breasts with each feeding. c. Take warm showers. d. Wear a supportive bra. e. Pump breasts to ensure emptying. R: Nursing mothers should take in about 3 liters of fluid a day. All the other options are interventions to reduce the risk of mastitis and milk accumulation in the breast.

The nurse suggests offering which food(s) to support the toddlers desire to self-feed? (Select all that apply.) a. Pureed foods b. Finger foods c. Foods served cold d. Foods in colorful dishes e. Foods that are varied and colorful

b. Finger foods d. Foods in colorful dishes e. Foods that are varied and colorful R: Finger foods that are varied and colorful and served in colorful dishes at a moderate temperature are all attractive. Foods can be chopped into small pieces but not pureed.

What are anonymous sperm donors screened for? (Select all that apply.) a. Particular physical features b. Genetic defects c. Infections d. High-risk behaviors e. Nationality

b. Genetic defects c. Infections d. High-risk behaviors R: Sperm donors are screened for genetic defects, infections, and high-risk behaviors. As an added precaution, the sperm are kept frozen for 6 months before the sample is used.

The nurse assesses the progress from the announcement stage of fatherhood to the acceptance stage when the patient reports which actions by the father? (Select all that apply.) a. Goes fishing every afternoon b. Has revised his financial plan c. Spends leisure time with his friends d. Traded his sports car for a sedan e. Helped select a crib

b. Has revised his financial plan d. Traded his sports car for a sedan e. Helped select a crib R: Active planning for an infant is an indication of the acceptance stage. Concentration on a hobby and spending time away from home are indicators of nonacceptance.

What sign(s) of infection should the nurse assess for after an amniotomy? (Select all that apply.) a. Oral temperature of 37 C (99.8 F) b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute c. Flecks of vernix in the amniotic fluid d. Low back pain e. Edematous labia

b. Increase of fetal heart rate (FHR) from 160 to 174 beats/minute R: Increase in the FHR above 160 beats/minute frequently precedes a womans temperature elevation. All the other options are normal findings for late pregnancy.

Which assessments would cause the pediatric nurse to suspect the probability of an ear infection in a 6-month-old child? (Select all that apply.) a. Hypersensitivity to noise b. Irritability c. Reddened ear canal d. Rolls head from side to side e. Temperature of 39.4 C (103 F)

b. Irritability d. Rolls head from side to side e. Temperature of 39.4 C (103 F) R: Infants signal ear infections by being irritable, rolling their heads from side to side, spiking a temperature, and pulling at or rubbing their ears.

The nurse is caring for a patient planning to undergo a uterine fibroid embolization. What information can the nurse provide? (Select all that apply.) a. It involves laser destruction of fibroids. b. It has fewer physiological effects than drug therapy. c. It is nonsurgical. d. It is associated with more psychological effects than surgery. e. It has a faster recovery time than surgery.

b. It has fewer physiological effects than drug therapy. c. It is nonsurgical. e. It has a faster recovery time than surgery. R: Uterine fibroid embolization is a nonsurgical technique of treating uterine fibroids that involves fewer physiological effects than drug therapy, fewer psychological effects than surgery, and a faster recovery time than surgery. Myolysis is the laser or electrosurgical destruction of fibroids, and it also preserves fertility.

A 10-year-old child with disabilities is begging her parents for a dog. When at the pediatric clinic, the parents inquire about possible benefits pet ownership may provide to their child. What benefits of pet ownership should the nurse indicate? (Select all that apply.) a. Decrease the need for physical therapy b. Lower blood pressure c. Improve communication d. Foster trust e. Ease path to socialization

b. Lower blood pressure c. Improve communication d. Foster trust e. Ease path to socialization R: Studies have documented the positive influence of pet ownership on improving the medical and psychological outcome after illness or surgery. Disabled children especially benefit from interacting with pets. The interaction with animals can lower blood pressure and heart rate, reduce loneliness and feelings of isolation, improve communication, foster trust, and motivate participation in physical therapy. Pets allow the ill child who feels separated from other people to feel companionship and acceptance. Shy children often find pet ownership eases the path to socialization with others who initiate contact because of the pet.

The pediatric nurse is presenting school-age children with information on safety issues to follow when going home alone. What guidelines should they be educated to follow? (Select all that apply.) a. Ask for identification before letting someone in the house. b. Never accept rides with strangers. c. Keep doors locked. d. Do not enter house if door is ajar. e. Walk to and from school with friends.

b. Never accept rides with strangers. c. Keep doors locked. d. Do not enter house if door is ajar. e. Walk to and from school with friends. R: Strangers should never be allowed in the house. Children should be instructed never to accept rides with strangers, to keep doors locked, not to enter the house if the door is ajar, and to walk to and from school with friends.

Which position(s) and exercise(s) will the nurse teach as beneficial in combating discomfort in the later stages of pregnancy? (Select all that apply.) a. Leg lifts b. Pelvic rock c. Tailor sitting d. Sit-ups e. Shoulder curling

b. Pelvic rock c. Tailor sitting e. Shoulder curling R: Pelvic rock, tailor sitting, and shoulder curling are beneficial to the muscles that will have to adapt to the extra weight and changed posture of later pregnancy. Leg lifts and sit-ups are not beneficial because they both increase intraabdominal pressure.

A woman is 37 weeks pregnant and questioning the nurse about possible induction of labor at term. What conditions would contraindicate labor induction? (Select all that apply.) a. Maternal gynecoid pelvis b. Placenta previa c. Horizontal cesarean incision d. Prolapsed cord e. Gestational diabetes

b. Placenta previa d. Prolapsed cord R: Labor induction is contraindicated with placenta previa or a prolapsed umbilical cord. Gynecoid pelvis is the most favorable shape for vaginal delivery. Induction can be attempted as a VBAC after a horizontal cesarean incision but is contraindicated with a classic (vertical) incision. Gestational diabetes is not a contraindication for labor induction.

The nurse is giving a shower to a patient who had a cesarean section 2 days previously. What interventions should be included before, during, and after the shower? (Select all that apply.) a. Leave abdominal dressing open to air. b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability.

b. Position patient with back to water stream. c. Cover infusion site with rubber glove. d. Provide a shower chair. e. Confirm ambulation ability. R: The patient should be evaluated for ambulatory ability, and the abdominal dressing and infusion site should be covered with a waterproof cover. The patient should be provided a shower chair and positioned with her back to the water stream.

A woman, gravida 3, para 2, is attending her fourth prenatal visit and confides in the nurse that she is battered by her husband. She is assessed to have multiple bruises at various stages of healing. What nursing actions are appropriate for the nurse to implement? (Select all that apply.) a. Tell the husband that authorities will be notified immediately. b. Provide privacy for the assessment. c. Determine if children are being hurt. d. Communicate in a non-judgmental way. e. Determine factors that increase the risk of injury.

b. Provide privacy for the assessment. c. Determine if children are being hurt. d. Communicate in a non-judgmental way. e. Determine factors that increase the risk of injury. R: The woman being assessed for abuse is taken to a private area. The nurse determines whether there are factors that increase the risk for severe injuries or homicide, such as drug use by the abuser, a gun in the house, prior use of a weapon, or violent behavior by the abuser outside the home. The nurse also determines whether children are being hurt. It is vital that the abuser not find out that the woman has reported the abuse or that she intends to leave.

Place the three stages of smoke inhalation injury in the correct order (first to last). Put a comma and space between each answer choice (a, b, c, d, etc.) a. Bronchopneumonia b. Pulmonary insufficiency c. Pulmonary edema

b. Pulmonary insufficiency c. Pulmonary edema a. Bronchopneumonia R: Smoke inhalation injury may cause carbon monoxide poisoning. Poisonous substances inhaled from burning material may also cause pathological disturbance. There are three stages of inhalation injury: 1. Pulmonary insufficiency in the first 6 hours 2. Pulmonary edema from 6 to 72 hours 3. Bronchopneumonia after 72 hours, which may cause atelectasis

An 8-year-old near-drowning victim is rushed into the ED. What priorities of care will be implemented? (Select all that apply.) a. Parental education regarding prevention b. Respiratory support c. Cardiovascular support d. Controlled rewarming e. Adequate cerebral oxygenation

b. Respiratory support c. Cardiovascular support d. Controlled rewarming e. Adequate cerebral oxygenation R: Respiratory and cardiovascular support, controlled rewarming, and maintenance of adequate cerebral oxygenation are priorities of care. The parents should be offered support, explanations of the therapy, and referral to social services, religious, or community agencies for follow-up.

The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.) a. Harsh cough b. Restlessness c. Edematous epiglottis d. Child insists on lying down e. Drooling

b. Restlessness c. Edematous epiglottis e. Drooling R: H. influenzae type B and most often occurs in children 3 to 6 years of age. It can occur in any season. The course is rapid and progressive. The onset of epiglottitis is abrupt, and the child presents with classic symptoms. The child insists on sitting up, leans forward with the mouth open, and drools saliva because of the difficulty in swallowing. The child appears wide-eyed, anxious, and restless, and he or she may emit a froglike croaking sound on inspiration. Cough is absent. Inspection of the throat shows an enlarged, reddened edematous epiglottis much like a beefy-red thumb. However, the examining tongue blade may trigger a laryngospasm and result in sudden respiratory arrest.

The nurse suggests to the parents of an obese 10-year-old that they use the Portion Plate for Kids placemat. How does this tool help with selection of portion sizes? (Select all that apply.) a. Cartoon characters eating healthy foods b. Tips on healthy food choices c. Portion measurement in tablespoons for common food d. Calorie values for cup-size portions of common foods e. Familiar objects such as a deck of cards to measure servings

b. Tips on healthy food choices e. Familiar objects such as a deck of cards to measure servings R: The Portion Plate for Kids is a placemat that uses common objects such as a deck of playing cards or a baseball to measure serving portions.

The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents? (Select all that apply) a. Cover the infants eyes when under the light. b. Use a three-prong plug. c. Keep a diaper in place. d. Place the light source on an absorbent surface. e. Expose as much skin as possible.

b. Use a three-prong plug. c. Keep a diaper in place. e. Expose as much skin as possible. R: Parents should be instructed to use a three-prong plug for safety, keep a diaper in place, and expose as much skin as possible. The light source should be placed on a nonabsorbent surface, not on carpet or in a crib. It is not necessary to cover the infants eyes when under the light.

The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth. What assessment findings can the nurse anticipate? (Select all that apply.) a. High blood glucose levels b. Weight of 9 pounds or more c. Decreased subcutaneous fat d. Hypocalcemia e. Hyperbilirubinemia

b. Weight of 9 pounds or more d. Hypocalcemia e. Hyperbilirubinemia R: Many newborn infants of diabetic mothers have serious complications. When the mother is hyperglycemic, large amounts of glucose are transferred to the fetus. After delivery the infant often has low blood glucose levels because of the abrupt loss of maternal glucose and hypertrophy of the pancreatic islet cells, which results in a temporary overproduction of insulin. Hyperinsulinism, along with excess production of protein and fatty acids, often results in a newborn infant who weighs more than 4082 g (9 lb). These infants suffer from hypoglycemia, hypocalcemia, and hyperbilirubinemia.

The nurse explains that with the completion of myelination, the toddler will have the neuromuscular maturity to attain _______________ or _______________ control.

bowel, bladder R: With the mature myelin, the toddler is able to translate neural impulses and respond in a significant manner. With myelination, the toddler can now translate the feeling of a full bladder or bowel and respond by defecating or urinating at willhopefully in the bathroom.

Parents are preparing their child for admission to the pediatric unit for minor surgery. What should they expect to see when visiting the pediatric unit? (Select all that apply.) a. Nurses wearing all white b. Formal atmosphere c. Availability of a playroom d. Dim lighting e. Colored bedding

c. Availability of a playroom e. Colored bedding R: The childrens hospital unit differs in many respects from adult divisions. The pediatric unit or hospital is designed to meet the needs of children and their parents. A cheerful, casual atmosphere helps to bridge the gap between home and hospital and is in keeping with the childs emotional, developmental, and physical needs. Nurses wear colorful uniforms, and colored bedspreads and wagons or strollers for transportation provide a more homelike atmosphere. The physical structure of the unit includes furniture of the proper height for the child, soundproof ceilings, and color schemes with eye appeal. Most pediatric departments include a playroom.

A patient at the obstetric office has just learned she is pregnant with dizygotic twins. What facts will the nurse include when educating this patient? (Select all that apply.) a. Dizygotic twins are the same sex. b. Dizygotic twins share a placenta. c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. e. Dizygotic twin incidence decreases with maternal age.

c. Dizygotic pregnancies tend to repeat in families. d. Dizygotic twins have separate chorions. R: Dizygotic twins tend to repeat in families and have separate chorions. They can be the same sex or different sexes and have their own placenta. Incidence increases with maternal age.

The nurse is caring for a macrosomic newborn of a diabetic patient. What complications will the nurse assess for in the newborn? (Select all that apply.) a. Meconium ileus b. Diarrhea c. Hypoglycemia d. Muscle tremors e. Urine retention

c. Hypoglycemia R: The fetus responds to the hyperglycemia from the mothers blood and produces increased insulin. This insulin may cause hypoglycemia in the infant after it is no longer exposed to the mothers blood.

A school-aged child is living with a chronic disease process. How would the nurse anticipate chronic illness will effect growth and development? (Select all that apply.) a. Delayed bonding with parents b. Delayed toilet training c. Impaired sense of belonging d. Decreased feelings of independence e. Impaired speech development

c. Impaired sense of belonging d. Decreased feelings of independence R: A school-age child is in the stage of industry versus inferiority. A chronic illness might experience loss of grade level in school because of illness and inability to participate or compete can lead to sense of inferiority. Sense of independence and accomplishment can be lost. Being different from peers may impede childs sense of belonging.

The nurse performing a neurovascular check on a limb in traction would report and document which finding(s) as indicative of altered circulation? (Select all that apply.) a. Pulse is equal to uncasted limb. b. Patient is aware of touch and warm and cold application. c. Limb is cool to the touch. d. Capillary refill is 5 seconds. e. Distal limb can flex and extend. ANS: C, D The limb should be warm, and capillary refill should be less than 3 seconds.

c. Limb is cool to the touch. d. Capillary refill is 5 seconds. R: The limb should be warm, and capillary refill should be less than 3 seconds.

Which healthy snack foods would the school nurse suggest to a group of adolescents? (Select all that apply.) a. Bubble gum b. Chocolate-covered peanuts c. Raw vegetables d. Cheese e. Dried fruits

c. Raw vegetables d. Cheese R: Cheese and raw vegetables are acceptable healthy snacks. Bubble gum, chocolate-covered peanuts, and dried fruits all contain high amounts of sugar.

A woman who is 36 weeks pregnant tells the nurse she plans to take a 12-hour flight to Hawaii. What would the nurse recommend that the patient do during the flight? (Select all that apply.) a. Wear tight-fitting clothing to promote venous return. b. Eat a large meal before boarding the flight. c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently.

c. Request a seat with greater leg room. d. Drink at least 4 ounces of water every hour. e. Get up and walk around the plane frequently. R: Because of the increase in clotting potential, the pregnant patient is prone to a thromboembolism. Adequate hydration, frequent position changes, and movement decrease the risk.

An educational program is being presented to pediatric nurses on the relationship of play to childhood development. What information should be included in this presentation? (Select all that apply.) a. Art play should be used sparingly. b. Use of computer/video games is detrimental. c. Understanding of child/parent relationships can be gained by observing play. d. Play encourages self-expression. e. Play provides a sense of accomplishment.

c. Understanding of child/parent relationships can be gained by observing play. d. Play encourages self-expression. e. Play provides a sense of accomplishment. R: Art is an appropriate play activity at almost any age and provides an avenue for experimentation as well as for creative expression and a feeling of accomplishment in the child. Observing the child at play can aid in assessing growth and development and understanding the childs relationships with family members. Any plan of care for a hospitalized child of any age should include a play activity that either encourages growth and development or encourages the expression of thoughts and feelings. Computer programs are popular with all age groups, providing problem-solving skills, manipulative skills, and opportunities for new learning.

To prevent ________________ ________________, the nurse warms the blood that is to be given as a transfusion through a central line.

cardiac arrhythmias R: Cold blood entering the heart via a central line can trigger an irregular heartbeat.

What are the rationales for labor induction? (Select all that apply.) a. Placenta previa b. Prolapse of cord c. High station of fetus d. Maternal diabetes e. Placental insufficiency

d. Maternal diabetes e. Placental insufficiency R: Maternal diabetes and placental insufficiency are rationales for induction. The other options are contraindications for labor induction.

A pregnant woman arrives at the emergency department (ED) and reports she is in labor. After a thorough examination and diagnostic testing, it is determined to be false (prodromal) labor. What signs and symptoms would lead the nurse to suspect false (prodromal) labor? (Select all that apply.) a. Leaking of vaginal fluid b. Contractions intensify with ambulation c. Pink spotting d. Painless tightening of abdominal muscles e. Cervix thick and not effaced

d. Painless tightening of abdominal muscles e. Cervix thick and not effaced R: Painless tightening of abdominal muscles (Braxton-Hicks contractions) and cervix thick and not effaced lend to the determination of false (prodromal) labor. Leaking of vaginal fluid may indicate rupture of membranes and is a sign of true labor. Contractions that intensify with ambulation and pink spotting (bloody show) are signs of true labor.

What are the best breakfast choices for the nurse to point out prior to a big exam, to provide high levels of alertness and increased memory? (Select all that apply.) a. Pancakes and syrup b. Coffee and chocolate-covered donuts c. Bacon and fried eggs d. Whole grain cereal and yogurt e. Oatmeal and sliced apples

d. Whole grain cereal and yogurt e. Oatmeal and sliced apples R: Meals high in protein will break down into norepinephrine and increase alertness. Meals with a high sugar content result in a soothing sleepy response. Meals high in fats digest slowly and draw blood from the brain during the lengthy digestive process.

The sign that suggests possible damage to the cortex of the brain is ____________ posturing.

decorticate R: Decorticate posturing is a flexor rigidity of the arms, wrists, fingers, and feet. This posture suggests injury to the brain cortex.

Systemic blood pressure increases with age and is correlated with _________ and _________throughout childhood and adolescence.

height; weight R: Systemic blood pressure increases with age and is correlated with height and weight throughout childhood and adolescence. Significant hypertension is considered when measurements are persistently at or above the 95th percentile for the patients age and sex.

The nurse explains that the three infections that are contraindications to breastfeeding are _______________, _______________, and ________________.

human immunodeficiency virus (HIV), hepatitis B, hepatitis C R: Mothers who are HIV positive should not breastfeed because the virus can be transmitted through breast milk, as can the viruses that cause hepatitis B and C.

The cranial nerve responsible for allowing an infant to suck and swallow formula from a bottle is the __________________ nerve.

hypoglossal R: The hypoglossal (XII) nerve allows the infant to be able to suck and swallow. It is also responsible for tongue movement.

The nurse is aware that because of the function of the mist tent that a child is at risk for ________________.

hypothermia R: Children in mist tents are at risk for hypothermia because of the high humidity and the cooled oxygen. These children should be dressed warmly and changed frequently. The bed linens should be changed frequently as they absorb moisture from the tent as well.

The nurse assesses an unmet need in a hospitalized child who clings to his mother as she is about to leave. As described by Maslow, the basic needs that may be unmet in this case are __________ and ___________.

love, belonging R: The hospitalized child displaying these symptoms may feel a loss of love and a lack of belonging to the family unit.

The nurse records the finding of ______________ _____________ when the child with meningitis cries out in pain when his head is flexed toward his chest.

nuchal rigidity R: Stiffness of the neck resulting from inflamed meninges is a sign of meningitis called nuchal rigidity.

The nurse cautions that children who are put to sleep with a bottle are at risk for a dental problem called ___________ _____________.

nursing caries R: The bactericidal effects of saliva decrease during sleep; therefore, when the saliva and the milk combine, they bathe the teeth in a mixture that encourages dental caries.

The nurse explains that the four Ps of the birth process are __________, __________, __________, and __________.

powers, passenger, passage, psyche R: The four interrelated components of the process of labor and birth, called the four Ps, are powers, passenger, passage, and psyche.

The nurse explains that the difference between the systolic blood pressure reading and the diastolic blood pressure reading is called the __________ ___________.

pulse pressure R: The pulse pressure is the difference between the diastolic pressure and the systolic pressure.

The nurse is searching through several blood pressure cuffs to find a cuff that is the appropriate size for her small patient. The nurse selects a cuff that covers ______ _______ of the patients upper arm.

two thirds R: No matter the age of the patient, for the blood pressure cuff to provide an accurate reading it should cover two thirds of the upper arm. A smaller cuff will give an inaccurately high reading and a larger cuff will give an inaccurately low reading.

The nurse takes into consideration that the most common congenital heart defect is the ____________ ____________ defect.

ventricular septal R: VSDs are the most common congenital heart defect.

The nurse reminds the parents who are trying to select a dog for their allergic child that the best selection would be a female dog that is ______________ and _______________.

young, spayed R: Young, neutered female dogs produce less allergens.