PEDS EAQ

Which suggestion would the nurse make to a client with morning sickness? "Eat dry crackers before you get out of bed." "Increase your fat intake before bedtime." "Drink high-carbohydrate fluids with meals." "Eat 2 small meals a day and a snack at noon."

"Eat dry crackers before you get out of bed." Nausea and vomiting in the morning occur in almost 50% of all pregnancies. Eating dry crackers before getting out of bed in the morning is a simple remedy that may provide relief. Increasing fat intake does not relieve the nausea. Drinking high-carbohydrate fluids with meals is not helpful; separating fluids from solids at mealtime is more advisable. Eating 2 small meals a day and a snack at noon does not meet the nutritional needs of a pregnant woman, nor will it relieve nausea. Some women find that eating 5 or 6 small meals daily instead of three large ones is helpful.

Which statement explains the primary purpose of the side-lying position during labor? "Lying on the side prevents fetal hyperactivity." "It makes it less likely that you'll have nausea and vomiting." "Lying on the side encourages the presenting part to descend." "It enhances blood flow to the uterus and makes contractions easier."

"It enhances blood flow to the uterus and makes contractions easier." In the side-lying position, the gravid uterus does not impede venous return; cardiac output increases, leading to improved uterine perfusion, uterine contractions, and fetal oxygenation. Lying on the side does not affect fetal activity. This position will not ease nausea and vomiting; nausea and vomiting may occur as labor progresses toward the second stage. Walking or squatting will best bring about descent of the presenting part.

Which descriptor would the nurse use when explaining to a client how to time the frequency of contractions? From the end of 1 contraction to the end of the next contraction From the end of 1 contraction to the beginning of the next contraction From the beginning of 1 contraction to the end of the next contraction From the beginning of 1 contraction to the beginning of the next contraction

From the beginning of 1 contraction to the beginning of the next contraction The frequency of contractions is timed from the beginning of 1 contraction to the beginning of the next; this is the definition of 1 contraction cycle. The beginning, not the end, of a contraction is the starting point for timing the frequency of contractions. The time between the end of 1 contraction and the beginning of the next contraction is the interval between contractions. Timing from the beginning of 1 contraction to the end of the next contraction is too long a time frame and will produce inaccurate information.

The nurse anticipates that a newborn has impaired vision. Which finding supports the nurse's conclusion? The newborns blinks in response to light The newborn has visual acuity of 20/100 The newborn does not produce tears while crying The newborn has no corneal reflex after a light touch

The newborn has no corneal reflex after a light touch

Which intervention will be delayed until the newborn is 36 to 48 hours old? Vitamin K injection Test for blood glucose level Screening for phenylketonuria Test for necrotizing enterocolitis

Screening for phenylketonuria In 36 to 48 hours the newborn will have ingested an ample amount of the amino acid phenylalanine, which, if not metabolized because of a lack of a specific liver enzyme, can result in excessive levels of phenylalanine in the bloodstream and brain, resulting in cognitive impairment; early detection is essential to prevent this. The infant will have a vitamin K injection soon after birth to prevent bleeding problems. Blood is withdrawn from the heel soon after birth to test for hypoglycemia. Necrotizing enterocolitis is a disorder that can affect preterm infants. It is not identified with the use of a test.

The nurse notices an infant has developed a color preference for red and yellow. Which should be the likely age of the infant? 4 weeks 8 weeks 15 weeks 20 weeks

20 weeks

Who would the nurse include when providing education to the parents of a 7-year-old client related to moral development? The school-age child The school-age child's peers Any higher power the child believes in Any adult with authority over the child

Any adult with authority over the child

A prenatal client's vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client's clinical record? Hegar Goodell Chadwick Braxton-Hicks

Chadwick A purplish coloration, called the Chadwick sign, results from the increased vascularity and blood vessel engorgement of the vagina. The Hegar sign is softening of the lower uterine segment. The Goodell sign is softening of the cervix. After the fourth month of pregnancy, irregular, painless uterine contractions, called Braxton-Hicks contractions, can be felt through the abdominal wall.

When can a primigravida fetal heartbeat be heard for the first time? A stethoscope at 4 weeks A fetoscope at 10 to 12 weeks Doppler ultrasound after 20 weeks Doppler ultrasound at 10 to 12 weeks

Doppler ultrasound at 10 to 12 weeks A fetal heartbeat can be obtained at 10 to 12 weeks with electronic Doppler ultrasound. The heartbeat cannot be obtained with a stethoscope, and 4 weeks is too early to hear a fetal heart. A fetoscope cannot pick up the heartbeat until the 17th week. The heart rate can be detected 8 to 10 weeks earlier than 20 weeks.

A pregnant client's last menstrual period was on February 11. A physical assessment on July 18 would reveal the top of the fundus to be where? Even with the umbilicus Just above the symphysis pubis Two fingerbreadths above the umbilicus Halfway between the symphysis and umbilicus

Even with the umbilicus Around the 22nd week of gestation the top of the fundus is at the level of the umbilicus. Just above the symphysis pubis is too low for a pregnancy between the 5th and 6th months of gestation. Two fingerbreadths above the umbilicus is too high for 20 to 22 weeks' gestation. Halfway between the symphysis pubis and umbilicus is too low for a pregnancy between the 5th and 6th months of gestation.

A nonstress test evaluates the condition of the fetus by comparing the fetal heart rate with which factor? Fetal lie Fetal movement Maternal blood pressure Maternal uterine contractions

Fetal movement In a healthy, well-oxygenated fetus the heart rate increases with fetal movement; there should be an acceleration of 15 beats with fetal movement. Fetal lie and maternal blood pressure are not a part of the evaluation of the fetus in the nonstress test. Maternal uterine contractions are used in the contraction stress test.

Because of the increased discomfort level during the transition phase of labor, nursing care would be directed toward what? Helping the client maintain control Decreasing the rate of intravenous fluid Administering the prescribed medication Having the client breathe in a uniform pattern

Helping the client maintain control The transition phase is the most difficult phase of labor, and the client needs encouragement and support to cope and maintain control. Fluids should be increased at this time because of the increase in metabolism. Medication is contraindicated at this point because it may depress the newborn at birth. The breathing pattern should be complex, not uniform, at this time because it requires a high level of concentration that helps distract the client.

Which would evidence of the Babinski reflex indicate during a newborn assessment? Hypoxia during labor Neurological injury during birth Hyperreflexia of the muscular system Immaturity of the central nervous system (CNS)

Neurological injury during birth Stimulation of the newborn's immature neuromuscular system causes dorsiflexion of the big toe and fanning of the remaining toes (Babinski sign). CNS damage resulting from hypoxia may manifest as a lack of Babinski sign. The newborn would not elicit the Babinski reflex if there were neurological injury during birth. Hyperreflexia is an abnormal increase in reflexes; it is not related to the Babinski reflex.

Which individual completes the developmental questionnaire for an infant using the Developmental (ASQ-3) screening? Child Parent Nurse Primary Health Care Provider

Parent

A newborn is admitted to the neonatal intensive care unit with a myelomeningocele. Which is the priority nursing intervention during the first 24 hours? Using only disposable diapers for perineal care Placing the infant in a prone or side lying position Washing the infants genital area with an anti-infective wipe Performing neurological checks above or at the site of lesion

Placing the infant in a prone or side lying position A prone or side-lying position will prevent pressure on the sac; if the sac ruptures, infection may occur. Diapers should not be applied, because they may irritate or contaminate the sac. Anti-infective wipes are too caustic. Assessment of the area below, not at or above, the defect is essential for determination of motor, urinary, and bowel function.

A toddler wearing a diaper is impatient with the wet diaper and shows a desire to have it changed. Which toilet training readiness does this behavior indicate? Mental readiness Physical readiness Parental readiness Psychological readiness

Psychological readiness

A toddler is raised in a controlled environment. The parents keep imposing restrictions on the child's desire for autonomy. Which is a possible consequence? Guilt Mistrust Isolation Sense of shame and doubt

Sense of shame and doubt

Which stage describes the Oedipus complex, according to Freud's theory? Stage 2 Stage 3 Stage 4 Stage 5

Stage 3

Which observations would indicate findings found in a child with Turner syndrome? Select all that apply. Webbed neck Impaired language Tall stature with long legs Low position of posterior hairline Shield-shaped chest with wide space between nipples

Webbed neck Low position of posterior hairline Shield-shaped chest with wide space between nipples

Which pain scale would the nurse use when assessing a 4-year-old child? CRIES FLACC Numerical Wong-Baker

Wong-Baker

A parent expresses concern that a 2-year-old child has become a "finicky eater" and is eating less. How would the nurse respond? "Your child has become manipulative." "Your child is probably experiencing the stress of a typical 2-year-old." "Your child may have an eating problem that requires a referral to a specialist." "Your child's behavior is expected in response to slower growth."

"Your child's behavior is expected in response to slower growth."

The nurse is performing physical assessments for children in a daycare center. Which children should require a head circumference measurement to monitor growth patterns? Select all that apply. A 6-month-old infant who is breast-fed A 15-month-old toddler who has asthma A 3-year-old child whose birthday was the day prior A 5-year-old who will attend kindergarten in the fall An 8-year-old child who will begin playing soccer next week

A 6-month-old infant who is breast-fed A 15-month-old toddler who has asthma A 3-year-old child whose birthday was the day prior

Which would the nurse encourage for a school-age client diagnosed with a chronic illness to enhance a sense of accomplishment? Wearing make-up Making up missed work Participating in sports Participating in creative activities

Making up missed work

The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? Develop a basic teaching plan. Ask the mother if she understands. Observe the mother feeding the infant. Determine the mother's readiness to learn

Observe the mother feeding the infant. A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother's readiness to learn is part of planning in the nursing process, not evaluating.

Which instruction would the nurse include when teaching episiotomy care? Rest with legs elevated at least 2 times a day. Avoid stair climbing for several days after discharge. Perform perineal care after toileting until healing occurs. Continue sitz baths 3 times a day if they provide comfort.

Perform perineal care after toileting until healing occurs. Performing perineal care after toileting until the episiotomy is healed is critical to the prevention of infection, which is at the core of episiotomy care. Resting is encouraged to promote involution and general recovery from childbirth. Stair climbing may cause some discomfort but is not detrimental to healing. There is no limit to the number of sitz baths per day that the client may take if they provide comfort.

Which potential complication is associated with ketonuria that can occur when clients severely restrict their calorie intake during pregnancy? Preterm labor Placenta previa Gestational diabetes Hyperemesis gravidarum

Preterm labor Dietary restriction during pregnancy results in catabolism of fat stores that in turn augments the production of ketones, and ketonuria is associated with preterm labor. Ketonuria is not associated with placenta previa, gestational diabetes, or hyperemesis gravidarum.

Which assessment question would the nurse ask the parents of a 1-year-old client to assess language development? "Does your child form sentences?" "Does your child say 3 to 5 words?" "Does your child understand 10 words?" "Does your child respond when you say her or his name?"

"Does your child say 3 to 5 words?"

Which lecithin/sphingomyelin (L/S) ratio is indicative of fetal lung maturity? 1:1 1:4:1 1:8:1 2:1

2:1 The detection of the presence of pulmonary surfactants, surface-active phospholipids, in amniotic fluid has been used to determine the degree of fetal lung maturity, or the ability of the lungs to function after birth. Lecithin (L) is the most critical alveolar surfactant required for postnatal lung expansion. It is detectable at approximately 21 weeks and increases after week 24. Another pulmonary phospholipid, sphingomyelin (S), remains constant in amount. The measure of lecithin in relation to sphingomyelin, or the L/S ratio, is used to determine fetal lung maturity. When the L/S ratio reaches 2:1, the fetus' lungs are considered mature. The ratios of 1:1, 1.4:1, and 1.8:1 are incorrect.

At which point during a human pregnancy does the embryo become a fetus? During the 8th week of the pregnancy At the end of the 2nd week of pregnancy When the fertilized egg becomes implanted When the products of conception are seen on the ultrasound

During the 8th week of the pregnancy During the 8th week of pregnancy the organ systems and other structures are developed to the extent that they take the human form; at this time the embryo becomes a fetus and remains so until birth. At the end of the 2nd week of pregnancy, the developing cells are called an embryo. At the time of implantation, the group of developing cells is called a blastocyst. The embryo can be visualized on ultrasound before it becomes a fetus.

Which intervention would the nurse implement to enhance sensorimotor development for an infant who is diagnosed with a chronic illness? Encouraging consistent caregivers for the infant. Encouraging the infant to hold his or her own bottle. Encouraging periodic respite for the infant's parents. Emphasizing the healthy attributes of the infant to the parents.

Encouraging the infant to hold his or her own bottle.

Although the newborn was just cleaned and examined, the mother notes a red rash consisting of small papules on the face, chest, and back of the newborn. Which condition would the nurse recognize? Harlequin sign Vernix caseosa Nevus flammeus Erythema toxicum

Erythema toxicum Erythema toxicum is a benign, generalized, transient rash that is a reaction to the new environment in which a neonate finds itself. It disappears a short time after birth. It is not the harlequin sign, which is dilation of blood vessels on one side of the body resulting in red skin on one side and white skin on the other. It is not vernix caseosa, which is a thick, white, greasy substance that protects the skin in utero. It is not nevus flammeus, or port wine stain, which is a reddish-purple capillary angioma below the dermis.

An 8-year-old child is being prepared for surgery the next day. How would the nurse present preoperative instructions to this child? Be sure to repeat instructions often Provide time for needle play Use several abstract examples Focus on simple anatomical diagrams

Focus on simple anatomical diagrams

Which stage of development would the nurse anticipate for an adolescent client when using Piaget's theory to assess cognitive development? Sensorimotor Preoperational Formal operational Concrete operational

Formal operational

The nurse is teaching hygiene practices to a 16-year-old client who has recently had her first menstrual flow. Which phase of development would the nurse classify the client? Prepubescent Post Pubescent Late adolescence Middle adolescence

Middle adolescence

Which high-risk nutritional practice must be assessed for when a pregnant client is found to be anemic? Pica Caffeine intake Alcohol abuse Artificial sweetener use

Pica The practice of pica, especially the ingestion of heavy metals, must be considered when pregnant women are found to be anemic. Caffeine, alcohol, and artificial sweeteners are not directly linked to anemia in pregnant women.

Which effect does the nurse expect after an amniotomy is performed on a client in active labor? Diminished vaginal bleeding Less discomfort with contractions Progressive dilation and effacement Increased maternal and fetal heart rates

Progressive dilation and effacement Amniotomy permits more effective pressure of the fetal head on the cervix, enhancing dilation and effacement. Vaginal bleeding may increase because of the progression of labor. Discomfort may increase because contractions usually become more intense after amniotomy. Amniotomy should not affect maternal and fetal heart rates.

The nurse is assessing a newborn with exstrophy of the bladder. Which other defect is often associated with exstrophy of the bladder and may be of concern to the nurse? Absence of one kidney Congenital heart disease Pubic bone malformation Tracheoesophageal fistula

Pubic bone malformation Incomplete formation of the pubic bone is often associated with exstrophy of the bladder. Absence of one kidney, congenital heart disease, and tracheoesophageal fistula are not associated with exstrophy of the bladder.

Which task is appropriate for the postpartum nurse to delegate to an unlicensed assistive personnel? Evaluation of a postpartum client's lochia Vital signs on a client 4 hours after delivery Assessment of a postpartum client's episiotomy Assisting the postpartum client to breast-feed for the first time

Vital signs on a client 4 hours after delivery Evaluating the client's lochia, assessing the client's episiotomy, and assisting the client breast-feed for the first time would involve assessment, teaching, or evaluation and should not be delegated. The only task that does not require any of these is taking vital signs 4 hours after delivery.

Which would the nurse recommend to overwhelmed new parents to prevent shaken baby syndrome? "Just ignore the baby's crying." "You can place your baby in daycare." "Call your pediatrician for an appointment." "Plan periods of rest so you can have a break."

"Plan periods of rest so you can have a break."

The nurse is teaching growth and development activities to the parents of a 3-month-old infant. Which statements would the nurse include in the teaching plan? Select all that apply. "Your child should be able to show the grasp reflex." "Your child should be able to coo, babble, and chuckle." "Your child should be able to pull at blankets or clothes." "Your child should be able to put the feet into the mouth when supine." "Your child's head can come up to a 45- to 90-degree angle from the table."

"Your child should be able to coo, babble, and chuckle." "Your child should be able to pull at blankets or clothes." "Your child's head can come up to a 45- to 90-degree angle from the table."

For which reason would the nurse encourage a client to void during the first stage of labor? A full bladder is often injured during labor. A full bladder may inhibit the progress of labor. A full bladder jeopardizes the status of the fetus. A full bladder predisposes the client to urinary infection.

A full bladder may inhibit the progress of labor. A full bladder inhibits the progress of labor by encroaching on the uterine space and impeding the descent of the fetal head. The bladder may become atonic, but is not physically damaged during the course of labor. A full bladder may lead to prolonged labor but generally does not jeopardize fetal status as long as adequate placental perfusion continues. A full bladder during labor does not predispose the client to infection.

Which is the initial approach the nurse would use when teaching a pregnant woman about the foods she should be eating to promote healthy growth and development of her fetus? Asking the client what she usually eats at each meal Explaining to the client why spicy foods should be avoided Instructing the client to add calories while continuing to eat a healthy diet Providing the client with a list of foods for reference when planning meals

Asking the client what she usually eats at each meal Successful dietary teaching should incorporate the client's food preferences and dietary patterns. Spicy foods are permissible if the client does not experience discomfort after eating them. Instructing the client to add calories while continuing to eat a healthy diet presupposes that the client has been eating a healthy diet. It does not provide for the additional protein requirements of pregnancy. Providing the client with a list of foods for reference when planning meals does not take into consideration the client's likes and dislikes or cultural preferences.

During which stage of development would the nurse anticipate sibling relationships that fluctuate between open bickering and supportive relationships? Preschool Early school-age Late adolescence Middle school-age

Middle school-age

Which complication would the nurse anticipate when a client who is 36 weeks' pregnant presents with swelling of the face, blurred vision, and epigastric discomfort? Preeclampsia Placenta previa Gestational diabetes Hyperemesis gravidarum

Preeclampsia Swelling of the face, blurred vision, and epigastric discomfort are classic signs of preeclampsia. Placenta previa, gestational diabetes, and hyperemesis gravidarum do not present with swelling of the face, blurred vision, and epigastric discomfort.

When low back pain is a problem, which position would the nurse advise a client in labor to avoid? Sitting Supine Knee-Chest Left Side-Lying

Supine Low back pain is aggravated when the client is in the supine position because of increased pressure from the fetus as the head rotates. A sitting position relieves back pain. The knee-chest position is an alternative position that a client may choose to use when laboring. The left side-lying position relieves back pain.

The nurse is providing care to an infant who is diagnosed with cystic fibrosis (CF). Which parental statement indicates the need for further education related to the potential for poor growth? "My child's diagnosis is associated delayed bone growth." "My child will have a poor appetite, which will lead to poor growth." "My child will have increased oxygen demands, which will lead to poor growth." "My child will have a decreased ability to absorb nutrients, which will cause poor growth."

"My child will have a poor appetite, which will lead to poor growth."

A neonate weighing 5 lb 6 oz (2438 g) is born in a cesarean birth and admitted to the newborn nursery. Which range of resting respiratory rate would the nurse anticipate? 20 to 40 breaths/min 30 to 60 breaths/min 60 to 80 breaths/min 70 to 90 breaths/min

30 to 60 breaths/min After respiration is established, the normal neonate respiratory rate ranges from 30 to 60 breaths/min with short periods of apnea. Twenty breaths per minute is bradypnea. A respiratory rate faster than 60 breaths/min is tachypnea.

Which statement made by a pregnant client after a prenatal class on fetal growth and development indicates the need for additional teaching? "The baby is smaller if the mother smokes." "The baby gets food from the amniotic fluid." "The baby's oxygen is provided by the mother." "The baby's umbilical cord has 2 arteries and 1 vein."

"The baby gets food from the amniotic fluid." The amniotic fluid serves as a protective environment; the fetus depends on the placenta, along with the umbilical blood vessels, to supply blood containing nutrients and oxygen. "The baby is smaller if the mother smokes," "The baby's oxygen is provided by the mother," and "The baby's umbilical cord has 2 arteries and 1 vein" are all true statements, and further teaching would not be required.

Which recommendation would the nurse make to a pregnant client who sits almost continuously during her working hours? "Try to walk around every few hours during the workday." "Ask for time in the morning and afternoon to elevate your legs." "Tell your boss that you won't be able to work beyond the second trimester." "Ask for time in the morning and afternoon so you can go get something to eat."

"Try to walk around every few hours during the workday." Maintaining the sitting position for prolonged periods may constrict the vessels of the legs, particularly those in the popliteal spaces, and may diminish venous return. Walking causes the leg muscles to contract and applies gentle pressure to the veins, thereby promoting venous return. Walking around several times each morning and afternoon will improve circulation; the legs may be elevated while the client is sitting at her desk. If the client is feeling well, there are no contraindications to working throughout her pregnancy. Adequate nourishment can be obtained during mealtimes; the client does not require extra nutrition breaks.

Which direction would the nurse give a client in preparation for ultrasonography at the end of her first trimester? Empty her bladder. Avoid eating for 8 hours. Take a laxative the night before the test. Increase fluid intake for 1 hour before the procedure.

Increase fluid intake for 1 hour before the procedure. In the first trimester when fluid fills the bladder, the uterus is pushed up toward the abdominal cavity for optimum ultrasound viewing. The bladder must be full, not empty, for better visualization of the uterus. The gastrointestinal tract is not involved in ultrasound preparation, so directing the client to not eat for 8 hours before the test or to take a laxative would not be appropriate.

How is the magnet reflex elicited in a full-term newborn? Striking the surface of the newborn's crib suddenly Stroking the outer sole of the newborn's foot from the heel to the little toe Maintaining the supine position and applying pressure to the soles of the newborn's feet Holding the newborn's body upright and allowing the feet to touch the surface of the crib

Maintaining the supine position and applying pressure to the soles of the newborn's feet Applying pressure to the sole of the foot produces the magnet reflex, in which the legs extend in response to the pressure on the soles of the feet. Jarring the crib produces a startle response (Moro reflex). Stroking the outer sole of the foot from the heel to the little toe produces the Babinski or plantar reflex; all of the toes hyperextend. Allowing the feet to touch the surface of the crib produces the stepping reflex, in which one foot is placed before the other in a simulated walk, with the weight on the toes.

Which factor explains why a breast-feeding mother who is 3 days postpartum complains that her breasts are tight and swollen? There is an overabundance of milk Breast-feeding is probably ineffective The breasts have been inadequately supported The lymphatic system in the breasts is congested

The lymphatic system in the breasts is congested An exaggeration of venous and lymphatic circulation caused by prolactin occurs before lactation. Effective breast-feeding does not prevent engorgement; a lag between the production of milk and the efficiency of the ejection reflex often causes engorgement. Engorgement occurs before lactation or milk production. Inadequate support of the breasts does not cause engorgement, but support may relieve some of the discomfort.

Morning sickness generally disappears by the end of which month? Fifth month Third month Fourth month Second month

Third month Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin but has usually diminished by the fifth month.

During a nonstress test, the baseline fetal heart rate of 130 to 140 beats per minute rises to 160 twice and 157 once during a 20-minute period. Each of these episodes lasts 20 seconds. Which action would the nurse take? Discontinue the test because the pattern is within the normal range. Encourage the client to drink more fluids to decrease fetal heart rate. Notify the primary health care provider and prepare for an emergency birth. Record this nonreassuring pattern and continue the test for further evaluation.

Discontinue the test because the pattern is within the normal range. The baseline heart rate is within the expected range. The accelerations meet the criteria for an increase of 15 beats that lasts at least 15 seconds during a 20-minute period. This is a reassuring pattern that is indicative of fetal well-being. Drinking more fluids is unnecessary because the fetal heart rate is within the expected range. Preparing for an emergency birth is unnecessary because the test results indicate fetal well-being. The test results meet the standards for a reassuring pattern; further evaluation is unnecessary.

The nurse is teaching safe transportation techniques to new parents who have a low economic background. Which advice given by the nurse is appropriate? "You should borrow or buy a second-hand car seat." "You should place padding in the car seat behind the baby." "You should buy an infant-only model and an infant-toddler convertible car seat." "You should place the baby's car seat in the rear-facing position in the backseat."

"You should place the baby's car seat in the rear-facing position in the backseat."

The nurse explains to a client that she will need additional calcium during pregnancy and that the ideal source is milk. The client states, "I never drink milk or eat milk products. They turn my stomach." Which is an appropriate reply? "Your practitioner can prescribe calcium supplements." "Just make sure that the rest of your diet is nutritionally sound." "Eliminating milk from your diet may cause your teeth to loosen." "Drinking milk is so important for your baby to develop strong bones."

"Your practitioner can prescribe calcium supplements." Calcium is essential to a pregnant woman's diet for the development of the fetal skeleton; it must be supplemented if the client dislikes or is allergic to milk and milk products. A nutritionally sound diet without dairy products does not meet the needs of the pregnant woman or her fetus. Dental care and oral hygiene will be more beneficial for maintaining healthy teeth than adding more calcium to the diet will. If milk makes the client ill, the statement "Drinking milk is so important for your baby to develop strong bones" is ineffective advice, and the dietary regimen probably will not be followed.

The nurse knows that jaundice first becomes visible in a newborn when serum bilirubin reaches which level? 1 to 3 mg/dL (17.1-51.3 µmol/L) 2 to 4 mg/dL (34.2-68.4 µmol/L) 5 to 7 mg/dL (85.5-119.7 µmol/L) 8 to 10 mg/dL (136.8-171 µmol/L)

5 to 7 mg/dL (85.5-119.7 µmol/L) Jaundice in a newborn first becomes visible when the serum bilirubin level reaches 5 to 7 mg/dL (85.5-119.7 µmol/L). Jaundice will not be visible at a serum bilirubin level of less than 5 mg/dL (85.5 µmol/L).

The nurse is assessing a newborn in the well-baby nursery. Which type of respirations would the nurse expect to identify in a healthy newborn? Deep and retracting Shallow and thoracic Stertorous and regular Abdominal and irregular

Abdominal and irregular A newborn's respirations are abdominal, diaphragmatic, and irregular; the rate varies from 30 to 60 breaths/min. Retractions are a sign of respiratory distress. A newborn's respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress.

Which is a similarity between Havighurst's stage-crisis and Erikson's psychosocial development theories? Both theories are based on developmental tasks Both theories incorporate eight stages of development Both theories are based on psychosexual development Both theories emphasize that a child's grown is directed by gene activity

Both theories are based on developmental tasks

The nurse is caring for a preterm neonate with physiological jaundice who requires phototherapy. Which is the physiological mechanism of this therapy? Stimulates the liver to dispose of the bilirubin Breaks down the bilirubin into a conjugated form Facilitates the excretion of bilirubin by activating vitamin K Dissolves the bilirubin, allowing it to be excreted by the skin

Breaks down the bilirubin into a conjugated form Phototherapy changes unconjugated bilirubin in the skin to conjugated bilirubin bound to protein, permitting excretion in the urine and feces.Phototherapy does not affect liver function; the liver does not dispose of bilirubin. Vitamin K is necessary for prothrombin formation, not bilirubin excretion. The bilirubin is not excreted by way of the skin.

Which is a description of contractions that indicate true labor in a nullipara? Decrease when the client walks Are irregular and vary in intensity Come every 5 minutes for an hour Come every 10 minutes for an hour

Come every 5 minutes for an hour Contractions every 5 minutes apart for 1 hour are an indication of true labor. Because the woman is a nullipara, this is an appropriate response. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for a multiparous woman, whose labor is likely to be shorter and more intense.

The nurse in the newborn nursery is monitoring an infant for jaundice related to ABO incompatibility. Which blood type does the mother usually have to cause this incompatibility? A B O AB

O Mothers with type O blood have anti-A and anti-B antibodies that are transferred across the placenta. This is the most common incompatibility, because the mother is type O in 20% of all pregnancies. Blood types A, B, and AB usually do not present this problem.

The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. Crackles Cyanosis Wheezing Tachypnea Retractions

Cyanosis Tachypnea Retractions Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism necessary to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in the healthy newborn. Wheezing in the newborn is benign.

Which feelings are enhanced in the school-age child through the use of positive reinforcement of success by adults? Select all that apply. Happiness Likeability Feeling worthwhile to others Feeling disrespected by others Capability of valuable contributions

Happiness Likeability Capability of valuable contributions

A neonate at 34 weeks' gestation is admitted to the neonatal intensive care unit. The nurse reviews the medical record and obtains the neonate's vital signs. Which objective would the nurse designate as the priority? Oxygenation will remain adequate. Weight will increase by 30 g per day. Heart rate will recover to an acceptable range. Body temperature will increase to 98.6°F (37°C).

Oxygenation will remain adequate. At 34 weeks' gestation the respiratory system is not fully developed; adequate oxygenation is the priority. Newborn respiration ranges from 30 to 60 breaths/min. A weight gain of 30 g per day is too rapid; 20 to 25 g/day is expected at this gestational age. A temperature of 98°F (36.7°C) is adequate for a newborn; increasing it to 98.6°F (37°C) is not necessary at this time. The heart rate of a newborn is 110 to 160 beats/min; a heart rate of 130 is within the expected range.

While showing a new mother how to care for her infant's umbilical cord stump, the nurse explains that the stump is a potential source of infection for which reason? Wharton jelly is no longer present It contains exposed tissue and blood It is touched by diapers, blankets, and clothing Newborns do not have immunity to cord infections

It contains exposed tissue and blood Exposed tissue and blood in an area that is moist, warm, and dark make an excellent culture medium, so it is important to keep the umbilical area clean and dry. Wharton jelly is present and provides a protective barrier. The diaper is kept below the level of the umbilicus. Although the site may be touched by clothing, this usually is not a source of bacterial infection. Newborns do have resistance to infections because they carry antibodies from the mother.

Which action would the nurse take to prevent the loss of heat through convection in a newborn? Dry the infant immediately after birth Keep the infant's crib away from the window Cover the scale before weighing the infant Wrap the infant in blankets and place a cap on the head

Keep the infant's crib away from the window The crib should be kept away from the window to prevent heat loss through convection. The scale should be covered before weighing the infant to prevent heat loss through conduction. The infant should be thoroughly dried after birth and wrapped in blankets with a cap placed on the head to prevent heat loss through evaporation.

Which suggestion would the nurse make regarding what a client would wear to prevent back pain as pregnancy progresses? Maternity girdle Support stockings Low-heeled shoes Loose-fitting clothing

Low-heeled shoes Low-heeled supportive shoes help maintain the body's center of gravity over the hips, limiting arching of the back that compensates for the increased weight in the abdominal area. Maternity girdles are no longer recommended. Support stockings may be helpful for a woman with varicose veins or ankle edema; however, wearing them does not prevent back pain. Loose-fitting clothing is more comfortable but has no effect on back pain.

Which assessments and interventions are needed once an epidural catheter has been inserted? Select all that apply. Maintain intravenous fluid administration Have oxygen available in case of hypotension Check the bladder for distention every 2 hours Position the client supine for ease of monitoring Monitor fetal heart rate and labor progress per hospital protocol Administer an oxytocin infusion to maintain the labor pattern

Maintain intravenous fluid administration Have oxygen available in case of hypotension Check the bladder for distention every 2 hours Monitor fetal heart rate and labor progress per hospital protocol Hypotension is a common problem in the client receiving epidural analgesia. Intravenous fluids can help counter this problem and provide a vehicle for emergency medication administration. Oxygen should be available in case of hypotension as a result of the epidural block or as emergency care should the anesthetic agent migrate upward. Because sensation below the waist will be compromised, the client may be unaware of bladder distention, a situation that can occur with labor, possibly resulting in trauma to the bladder. Fetal heart rate and the progress of labor should be monitored. The client should be positioned on her side to prevent vena cava syndrome. Labor may be slowed by the epidural, but it is not essential that a woman receiving an epidural have oxytocin to maintain the labor pattern.

An adolescent who gave birth 12 hours ago continually talks on the phone to her friends and does not respond when her new baby cries. Which is the priority intervention at this time? Initiating a social services consult Calling the psychiatric team for an intervention Arranging for the client's parent to speak with her Modeling appropriate behaviors that encourage infant bonding

Modeling appropriate behaviors that encourage infant bonding All women go through several phases of adapting to the role of mother. An adolescent may still need time to adjust to her new role, especially if she has just given birth in the past 24 hours. By modeling appropriate behavior, the nurse demonstrates appropriate maternal skills to the adolescent. This will assist her as she makes the transition into her new role as a mother. If this behavior continues and does not improve before discharge, social services may need to get involved, but a consult is not needed in this early phase. A psychiatric consult is not necessary because this is not a psychiatric illness. The adolescent's parent is an important part of the plan, especially if the adolescent is going home to her or his house, but the relationship between the two needs to be assessed to see what role he or she will play in this new parent-child relationship.

Between contractions that are 2 to 3 minutes apart and last about 45 seconds the internal fetal monitor shows a fetal heart rate (FHR) of 100 beats/min. Which is the priority nursing action? Notify the health care provider. Resume continuous fetal heart monitoring. Continue to monitor the maternal vital signs. Document the fetal heart rate as an expected response to contractions.

Notify the health care provider. The expected FHR is 110 to 160 beats/min between contractions. An FHR of 100 beats/min is bradycardia (baseline FHR slower than 110 beats/min) and indicates that the fetus may be compromised, requiring notifying the health care provider and medical intervention. Resuming continuous fetal heart monitoring may be dangerous. The fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. Although a fetal heart rate slower than 110 beats/minute should be documented, it is not an expected response.

After an uneventful pregnancy a client gives birth to an infant with a meningocele. The neonate has 1-minute and 5-minute Apgar scores of 9 and 10, respectively. Which is the priority nursing care for this newborn? Protecting the sac with moist sterile gauze Removing buccal mucus and administering oxygen Placing name bracelets on both the mother and infant Transferring the newborn to the neonatal intensive care unit

Protecting the sac with moist sterile gauze Preventing infection and trauma is the priority; rupture of the sac may lead to meningitis. The Apgar scores are 9 and 10 at 1 and 5 minutes, respectively; oxygen is not needed. Removing buccal mucus is not the priority. Placement of name bracelets on both mother and infant may be done before the infant leaves the birthing room; the priority is care of the infant's sac. The infant's sac must be protected before the infant is transferred to the neonatal intensive care unit.