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3-year-old child is admitted to the pediatric unit with a diagnosis of acute asthma. The child is short of breath, with a respiratory rate of 56 breaths/min; the pulse is 102, and the child has a nonproductive cough. What blood gas value does the nurse expect to see? 1 pH of 7.32 2 Po2 of 95 mm Hg 3 HCO3- of 20 mEq/L 4 Pco2 of 30 mm Hg

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A 6-year-old child undergoes supratentorial craniotomy for evacuation of a subdural hematoma. In what position should the nurse place the child during the first 24 hours after surgery? 1 At a 45-degree angle 2 At a 90-degree angle 3 In the supine position 4 In the side-lying position

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A dehydrated infant with a several-day history of vomiting is admitted to the pediatric unit with the diagnosis of gastroenteritis. The nurse plans to monitor the infant's response to parenteral therapy. What is the best indicator of rehydration? 1 Increased weight 2 The number of wet diapers 3 Decreased central venous pressure 4 The record of higher intake than output

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A nurse is caring for an infant with hydrocephalus after the insertion of a shunt. How should the nurse evaluate the effectiveness of the shunt? 1 By palpating the anterior fontanel 2 By determining the frequency of voiding 3 By assessing the child for periorbital edema 4 By assessing the symmetry of the Moro reflex

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A nurse is reviewing the admission laboratory report of an infant with severe gastroenteritis. The serum potassium is 3 mEq/L. Potassium chloride 20 mEq/L is prescribed to be added to the infant's IV. What should the nurse do next? 1 Find out when the infant last had a wet diaper. 2 Question the prescription and withhold the medication. 3 Ask the mother whether the infant is allergic to potassium. 4 Administer the potassium and then monitor the infant's response

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A nurse is teaching skin and basic care to the mother of a 6-month-old infant with eczema. Which statement indicates that the mother needs further teaching? 1 "I'll have to be careful not to cut my baby's nails short." 2 "I gave all of my baby's woolen blankets to my nephew." 3 "The baby can't have foods made with whole milk anymore." 4 "I'll need to buy a whole new wardrobe of cotton clothing for the baby."

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A pregnant client tells the nurse in the prenatal clinic that although she and her husband do not have the disease, she has a 1-year-old daughter with sickle cell anemia. She asks the nurse, "Will this baby also have sickle cell anemia?" How should the nurse respond? 1 "The chance that another child will have sickle cell anemia is 25%." 2 "Only one child in a family is affected, so the others probably will be all right." 3 "The most likely conclusion is that your children will have sickle cell anemia." 4 "If your partner has the sickle cell gene, 50% of your children will have sickle cell anemia."

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After an infant who was born with talipes equinovarus (clubfoot) has the cast removed, the nurse teaches the mother how and when to exercise the baby's foot. The nurse concludes that the mother understands the instructions when she says that she will exercise the foot: 1 With each diaper change 2 Once a day in the morning 3 Twice a day after each nap 4 Every 4 hours during the day

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After surgery a 2-month-old infant is returned to the pediatric unit with an intravenous infusion running and a nasogastric tube in place. What is the initial nursing action? 1 Assessing the infant's status 2 Giving the infant a mild sedative 3 Connecting the nasogastric tube to wall suction 4 Placing the intravenous tubing through an infusion pum

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An adolescent is admitted to the unit with a tentative diagnosis of a bone tumor of the left femur. During the admission procedure the adolescent casually asks, "Do they ever have to cut off a leg if someone has bone cancer?" How should the nurse respond? 1 "Sometimes it's necessary. What do you think about that treatment?" 2 "Most times the leg can be saved, but sometimes it may be necessary." 3 "I don't understand why you're asking. Do you think that this will happen to you?" 4 "The decision can't be made now, because the kind of bone cancer must be determined first."

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An adolescent with acute lymphocytic leukemia (ALL) completes parenteral chemotherapy, and the practitioner prescribes mercaptopurine (6-MP). The nurse teaches the adolescent about this medication. What statement indicates that the adolescent has understood the information? 1 "This will help prevent a relapse." 2 "I guess I'll need an IV for this drug." 3 "I guess this drug is a substitute for brain radiation." 4 "This will stop the cancer from spreading to my stomach

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An infant is admitted to the pediatric unit with bronchiolitis caused by the respiratory syncytial virus (RSV). What medication does the nurse anticipate that the practitioner will prescribe? 1 Ribavirin 2 RespiGam 3 Prednisone 4 Gentamycin

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An infant with a diagnosis of failure to thrive has been receiving enteral feedings for 3 days. All feedings have been retained, but the skin and mucous membranes are dry and the infant has lost weight. What should the nurse do first in light of these findings? 1 Notify the practitioner. 2 Document the assessment findings. 3 Increase the fluid component in the feeding. 4 Increase the calorie component of the feeding

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At her first prenatal clinic visit a primigravida has blood drawn for a rubella antibody screening test, and the results are positive. What intervention is important when the nurse discusses this finding with the client? 1 Asking her whether she has had German measles and when she had the disease 2 Arranging for her to receive the rubella booster vaccine after the birth 3 Planning for her to receive the rubella booster vaccine at her next visit 4 Informing her that the result was expected and that treatment will not be needed

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During a routine examination at the prenatal clinic the nurse notes significant increases in the client's blood pressure and edema of the face and hands. The diagnostic criterion for preeclampsia is a blood pressure of 140/90 mm Hg, but what is the lowest blood pressure that should prompt the nurse to monitor the client for other signs and symptoms of preeclampsia? 1 130/85 mm Hg 2 125/80 mm Hg 3 115/75 mm Hg 4 110/70 mm Hg

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The nurse is teaching the parents of an 8-month-old infant about oral hygiene in infants. Which action by the parents indicates the need for further teaching? 1 Giving honey-coated pacifiers to the child 2 Avoiding rubbing the infant's teeth with salicylates 3 Giving the infant fruit juice from a cup 4 Avoiding bottle-feeding at night

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The site of choice for administration of an intramuscular (IM) medication to an infant is: 1 Vastus lateralis 2 Ventrogluteal 3 Dorsogluteal 4 Deltoid

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n 18-year-old high school student arrives at the local blood drive center to donate blood for the first time. As the site is being prepared for needle insertion, the student becomes agitated, starts to hyperventilate, and complains of dizziness and tingling of the hands. What should the nurse instruct the student to do? 1 Breathe into cupped hands. 2 Pant, using rapid, shallow breaths. 3 Use a rapid deep-breathing pattern. 4 Hold the breath for as long as possible.

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The nurse is teaching an adolescent about the different methods of contraception. Which statement made by the adolescent indicates a need for further teaching? 1 A diaphragm is a soft rubber dome with a firm but pliable rim. 2 Condoms require consistent use and may cause decreased spontaneity. 3 Lea's shield is less effective in women who have had previous deliveries. 4 A cervical cap is contraindicated in women with a history of toxic shock syndrome.

1 A diaphragm is a contraceptive device used along with spermicidal jelly to cover the cervical opening. A cervical cap is a soft rubber dome with a firm, pliable rim. A condom covers the penis and traps the sperm. Condoms need to be used consistently and may cause decreased spontaneity. Lea's shield is a reusable vaginal contraceptive that is elliptical in shape. However, it is not effective in women who have already delivered a baby, as the vagina does not remain elliptical. The cervical cap should not be used by women who have a history of toxic shock syndrome.

A nurse is caring for a toddler who has undergone bone marrow transplantation. What clinical finding(s) should the nurse anticipate if an infection develops? 1 Fever and lethargy 2 Positive blood antibody titers 3 A delay in the growth of bone 4 Neutropenia and lymphocytopenia

1 A fever occurs with an infection because pyrogens affect the temperature-regulating center in the hypothalamus; lethargy occurs with an infection because of the related increased basal metabolic rate. Antibody titers indicate exposure to microorganisms, not the presence of an actual infection. Delayed bone growth is not an indication of infection. After a bone marrow transplant, neutropenia and lymphocytopenia are present until the bone marrow is fully repopulated. An altered white blood cell count is not a reliable indicator of infection.

At 22 weeks' gestation a client visits the prenatal clinic for the first time. As part of the prenatal workup, the client has blood work performed. The nurse concludes that further assessment is indicated when the laboratory findings show a: 1 Hemoglobin of 10 g/dL 2 Sedimentation rate of 15 mm/hr 3 Blood glucose level of 115 mg/dL 4 White blood cell (WBC) count of 9000/mm3

1 A hemoglobin reading below 11 g/dL suggests true anemia rather than physiologic anemia; this occurs because the plasma volume increases more than the red blood cell count during pregnancy, especially during the second trimester. The sedimentation rate in women is up to 20 mm/hr; no further assessment is necessary, because this is an expected value. The normal blood glucose level ranges from 70 to 105 mg/dL; a slightly increased level is common during pregnancy. A WBC count of 5000 to 10,000/mm3 is within expected limits; no further assessment is necessary.

Which between-meal snack should a nurse tell the parents of a preschooler with a urinary tract infection to offer their child? 1 Skim milk 2 Fresh fruit 3 Hard candy 4 Cream soup

1 A high-protein, high-carbohydrate snack provides additional nutrients to combat an infection and a fever. Also, fluid helps flush the urinary tract. Fruit does not provide the protein needed for the healing process. Candy provides empty calories. A cream soup is too heavy for a between-meal snack and does not provide the needed protein.

A nurse teaches the warning signs that should be reported throughout pregnancy. Which statement by the client indicates an understanding of the prenatal instructions? 1 "I'll call the clinic if I have abdominal pain." 2 "Mild, irregular contractions mean that my labor is starting." 3 "I need to call the clinic if my ankles start to swell at night." 4 "A whitish vaginal discharge means that I'm getting an infection."

1 Abdominal pain should be reported immediately because it may indicate abruptio placentae or the epigastric discomfort of severe preeclampsia. Mild, irregular contractions are preparatory (Braxton Hicks) contractions, which are common and are believed to help prepare the uterus for labor. Swelling of the ankles at night is physiologic edema of pregnancy, caused by pressure of the gravid uterus that impedes venous return; it disappears with elevation of the legs. Leukorrhea occurs during pregnancy as a result of increases in the estrogen and progesterone levels, which cause the vaginal discharge to become more alkaline.

The nurse is applying skin ointment to acne lesions on a patient who has recently reached puberty. What does the nurse anticipate as the cause for the extensive acne? 1 Highly active sebaceous glands in "flush areas" of the body 2 Increased subcutaneous fat prior to a skeletal growth spurt 3 Thelarche as the first indication of puberty 4 Influence of gonadal and adrenal androgen

1 Acne is a common skin problem seen in patients of pubertal age. The pathogenesis of pubertal acne is linked with the hormonal influences on the skin and its appendages. The "flush areas" of the body include the face and neck, shoulders, back and chest. The sebaceous glands in these "flush areas" become very active and secrete excessive sebum under the influence of hormones at the time of puberty. This hyperactivity of the sebaceous glands results in the development of puberty-related acne. In boys, just before the skeletal growth spurt, there is a transient increase in subcutaneous fat. Girls in whom thelarche is the first indication of puberty exhibit an early onset of menstruation and higher body fat. The hair at sites related to secondary sex characteristics becomes coarser, darker, and longer because of the influence of gonadal and adrenal androgens.

A nurse is obtaining the health history of a 5-year-old child who has been admitted to the child health unit with acute glomerulonephritis. The nurse expects the child's mother to report that the: 1 Child had a sore throat a few weeks ago 2 Child has just recovered from the measles 3 Child's father has a family history of urinary tract infections 4 Child's immunizations were administered at the start of schoo

1 Acute poststreptococcal glomerulonephritis (APSGN) is associated with a history of streptococcal infection of the throat. The measles virus is not associated with the development of APSGN. APSGN is not an inherited disease. No immunizations can cause glomerulonephritis.

A nurse is caring for a toddler with the diagnosis of nephrotic syndrome. What is the best indicator of kidney function in this toddler? 1 Urine output 2 Daily weights 3 Abdominal girth 4 Improved appetite

1 Although it is difficult to obtain an accurate recording of output in a child who is not toilet trained, urine output is a good indicator of kidney function and adequate kidney perfusion. In nephrotic syndrome a large proportion of the child's body weight is composed of retained fluid; the loss of fluid is reflected by a loss of weight. Daily weights are good indicators of fluid balance. Measurements of abdominal circumference are not a good indicator of kidney function. Although increased appetite is a sign of improvement, it is not an indicator of kidney function.

The mother of a 2-year-old girl expresses concern that her daughter's growth rate has slowed. What should the nurse explain to the mother about the growth of toddlers? 1 "This growth pattern is typical at this age." 2 "Toddlers are too busy exploring their world to eat." 3 "This growth pattern can't be interpreted for another year." 4 "Toddlers usually lose their taste for foods they liked when younger."

1 As the child gets older, growth slows. Toddlers develop physiologic anorexia because their appetite decreases along with their growth rate. Although the toddler may be too busy to eat, this is not why the growth rate slows. This growth pattern may be interpreted now. Although a toddler may lose his or her taste for a particular food, it is not common in this age group

male adolescent with cystic fibrosis, whose parents are both carriers of the disease, asks the nurse, "When I have children, could they have cystic fibrosis like me?" What information should the nurse consider before responding? 1 Men with cystic fibrosis usually are sterile, although sexual function is not affected. 2 Men with cystic fibrosis generally have a 50% chance of having children with the disease. 3 Women will pass this disease to their children because it is carried on the sex chromosome. 4 Women have a 25% chance of passing the disease to their children if their parents are carriers.

1 Because of inadequate development of the vas deferens, epididymis, and seminal vesicles, as well as blockage of the vas deferens with thickened secretions, the production of sperm is diminished or absent in males with cystic fibrosis, and most men with the disease are sterile. Cystic fibrosis is inherited as an autosomal recessive trait; it is not sex linked.

A nurse is teaching a 12-year-old child about a bone marrow aspiration. What statement indicates that the preadolescent needs further explanation of the procedure? 1 "I'll have to rest after the procedure." 2 "My hip will be sore after the procedure." 3 "You'll put a tight bandage on me where the needle goes in." 4 "The doctor is going to stick a needle into the middle of one of my hip bones."

1 Bone marrow aspiration generally involves the use of conscious sedation; activity is usually not restricted after a child recovers from the sedation. In addition to conscious sedation, the health care provider will probably use a local anesthetic. The child should not feel discomfort, pain, or pressure while the bone marrow is being withdrawn, but there may be some discomfort after the procedure once the sedation/anesthetic wears off. A tight dressing prevents bleeding from the puncture site. The anterior or posterior iliac crest is the site most often used for bone marrow aspiration in children.

The nurse notes that a 6-month-old infant is startled by a loud noise but does not turn in the direction of the sound. How should the nurse interpret this response? 1 As evidence of hearing loss 2 As an effect of vision deficits 3 As developmentally appropriate 4 As evidence of a low-normal hearing range

1 By 3 to 4 months of age an infant should localize sound by looking in the direction of the sound. The nurse's observation does not provide information about the infant's ability to see. Low-normal hearing range is not within the norm for this age group. This response indicates that that the infant's hearing is not developmentally appropriate.

An infant who had been receiving humidified oxygen because of dyspnea caused by acute spasmodic laryngitis is being discharged. The parents ask the nurse about caring for their baby at home. What is the best response by the nurse? 1 "There are no restrictions after your baby goes home." 2 "Keep visitors away from your home for several days." 3 "Give the baby 2 oz of water after each formula feeding." 4 "You'll need to avoid allergen producers such as animals."

1 Care for an infant after spasmodic croup should be directed toward personal care, optimal nutrition, and stimulation. Infants need environmental stimuli; friends and family who do not have a communicable infection should be encouraged to visit. The infant does not require additional fluids if all feedings are consumed. Croup is not directly related to antigen-antibody responses.

The hypertonicity of the muscles in an infant with cerebral palsy causes scissoring of the legs. The nurse teaches the mother that the preferred way to carry the infant is in a sitting position: 1 Astride one of her hips 2 Strapped in an infant seat 3 Wrapped tightly in a blanket 4 Under the arm in a football hold

1 Carrying the infant astride the parent's hip prevents scissoring by keeping the infant's legs abducted. An infant seat will not prevent scissoring. Tight wrapping maintains the infant's legs in a scissored position. When the football hold is used, the infant is carried in a supine position with the legs adducted, which promotes scissoring.

new father tells a nurse that his sister and her family plan to visit the new baby and that his niece and nephew have just recovered from chickenpox (varicella). Their lesions are completely healed or have scabs and are no longer draining. He asks the nurse whether it is safe for them to be near the baby. What is the best response by the nurse? 1 "The most contagious time is before the spots appear. It'll be safe to visit." 2 "People are contagious as long as they still have lesions. Tell them to stay home." 3 "People with open noncontagious lesions shouldn't visit. Tell them to stay home." 4 "The baby received immunity from the mother at birth. It will be safe for them to visit

1 Chickenpox (varicella) is an infectious respiratory disease spread by droplets; the chief contagious period occurs 1 day before the lesions appear and for 6 days after the first crop of vesicles have crusts. Chickenpox is spread primarily in respiratory droplets, not discharge from the lesions. Not all open lesions are contagious; if prospective visitors know that the lesions are not contagious, they may visit. Passive immunity at birth does not provide complete protection; infants need to be protected against those with active infection.

Which of the following combinations of foods should the nurse encourage a child with glomerulonephritis to choose for a meal? 1 Corn, roast chicken, peach 2 Tuna salad, cheese melt, milk 3 Hamburger, baked potato, banana 4 Bologna sandwich, salad, vanilla malte

1 Children with glomerulonephritis have a decreased filtration rate of plasma, which results in sodium and water retention; therefore, a low-sodium diet is ordered. With sodium and water retention stemming from a renal problem there is decreased urine output. If the child has oliguria a low-potassium diet is ordered because the child will not be able to excrete the potassium ingested and may develop hyperkalemia, possibly life threatening. All these foods are permitted on a low-sodium, low-potassium diet. Tuna, cheese, and milk are high in sodium. Potatoes and bananas are high in potassium. Bologna and milk are high in sodium; green leafy vegetables and tomatoes are high in potassium.

How should the nurse expect the urine of a child with acute glomerulonephritis with hematuria to appear? 1 Cola-colored 2 Orange 3 Bright red 4 Straw-colored

1 Cola-colored urine indicates the presence of large numbers of red blood cells. Orange-colored urine usually is associated with certain foods or medications. Red indicates frank bleeding that is associated with urinary tract trauma, not glomerulonephritis. Straw-colored urine is the color of dilute urine; it is an expected finding in a healthy child.

n adolescent who has been prescribed prednisone (Meticorten) and vincristine (Oncovin) for leukemia tells the nurse that he is very constipated. What should the nurse cite as the probable cause of the constipation? 1 It is a side effect of the vincristine. 2 The spleen is compressing the bowel. 3 It is a toxic effect from the prednisone. 4 The leukemic mass is obstructing the bowe

1 Constipation is a side effect of vincristine (Oncovin) because it slows gastrointestinal motility. An enlarged spleen will put pressure on the stomach and diaphragm, not on the large bowel. Constipation is not a toxic effect of prednisone (Meticorten). It is unlikely that leukemia is causing an obstruction.

An 18-month-old toddler who stepped on a rusty nail 4 days ago shows signs of generalized tetanus, including neck and jaw stiffness and facial muscle spasms. The toddler is receiving intravenous diazepam (Valium) as a muscle relaxant every 4 hours. What response to the medication does the nurse anticipate? 1 Control of hypertonicity and prevention of seizures 2 Control of laryngospasms and neck and jaw rigidity 3 Prevention of excess oxygen and caloric expenditure 4 Prevention of restlessness and resistance to assisted ventilatio

1 Diazepam is commonly used to manage generalized muscular spasms. Laryngospasm and nuchal rigidity are responses to the exotoxin and are treated with tetanus immune globulin. Diazepam is not administered to decrease the metabolic rate. Pancuronium bromide (Pavulon), an acetylcholine antagonist, is given to children who do not respond to sedatives and muscle relaxants and therefore resist ventilatory assistance.

1 5-year-old child is brought into the clinic with lethargy, abdominal ascites, and peripheral and periorbital edema. The history indicates ongoing diarrhea and decreased urine output. The child is found to have nephrotic syndrome and started on corticosteroid therapy. The nurse informs the parents that after a week or two of medication therapy, they can expect the child to exhibit: 1 Diuresis 2 Formed stools 3 No signs of infection 4 Enhanced physical growth

1 Diuresis begins 1 to 3 weeks after the start of corticosteroid therapy in nephrotic syndrome. Other symptoms, such as diarrhea, begin to resolve after the diuresis stage. Risk of infection is one of the nursing concerns with nephrotic syndrome. Enhanced physical growth is not a sign of resolving nephrotic syndrome; growth retardation is seen in long-term corticosteroid therapy.

Which behavior does the nurse expect when observing a 5-month-old infant? 1 Picking up a toy and putting it in the mouth 2 Waving the fists and dropping toys placed in the hands 3 Exploratory searching when an object is hidden from view 4 Simultaneously kicking the legs and batting the hands in the air

1 During the oral stage, infants tend to complete the exploration of an object by putting it into the mouth. Waving the fists and dropping toys placed in the hands is the momentary grasp reflex, seen in neonates before the development of eye-hand-mouth coordination. Infants 9 to 10 months old play search for an object that is hidden from view as they learn that objects continue to exist even though they are not visible. Kicking and batting the hands are the random reflexive movements of 1- to 2-month-old infants, whose voluntary control of distal extremities is not developed.

5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant? 1 Tachycardia 2 Hypotension 3 Respiratory arrest 4 Central nervous system depressio

1 Epinephrine stimulates β- and α-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.

ter assessing a neonate who was delivered using forceps immediately after birth, the nurse confirms facial paralysis. Which information does the nurse provide to the mother? 1 Don't panic; it will resolve within a few days. 2 The neonate requires phototherapy for a few minutes. 3 Take the newborn to a neurologist immediately. 4 Refrain from breastfeeding the neonate for a few days

1 Facial paralysis may occur in a neonate as a result of forceps delivery. This facial paralysis generally disappears within a few hours or days, so no medical intervention is required. Phototherapy does not affect facial paralysis in a neonate. Facial paralysis in a neonate generally does not reflect brain damage, so there is no immediate need to consult a neurologist. Breastfeeding is not contraindicated in neonates with facial paralysis.

While caring for a pregnant patient with body mass index of 32 during labor, the nurse observes that the second stage of labor lasts for about 11 minutes. The nurse also finds that the expected birth weight of the fetus is around 4200 g. Which complication does the nurse anticipate in the neonate after birth? 1 Erb palsy 2 Klumpke palsy 3 Strawberry hemangioma 4 Erythema toxicum neonatorum

1 Maternal body mass index of greater than 30, a second stage of labor lasting less than 15 minutes, and an infant birth weight higher than 4000 g indicates a risk of Erb palsy or Erb-Duchenne paralysis in the neonate. Klumpke palsy can result due to severe stretching of the upper extremities, while the trunk is relatively less mobile during labor. A maternal body mass index greater than 30, a second stage of labor lasting less than 15 minutes, and infant birth weight higher than 4000 g are not indicators of strawberry hemangioma or erythema toxicum neonatorum.

A 26-year-old G1 P0 is seen in the clinic for her routine prenatal visit at 29 weeks' gestation. On examination the nurse notes that she has gained 8 lb since her last visit, 2 weeks ago; that her blood pressure is 150/90 mm Hg, and that she has 1+ proteinuria on urine dipstick. What is the likely diagnosis for this client? 1 Mild preeclampsia 2 Severe preeclampsia 3 hypertension Incorrect4 Gestational hypertensio

1 Preeclampsia is hypertension that develops after 20 weeks' gestation in a previously normotensive woman. With mild preeclampsia the systolic blood pressure is below 160 mm Hg and diastolic BP is below 110 mm Hg. Proteinuria is present, but there is no evidence of organ dysfunction. Severe preeclampsia is a systolic blood pressure of greater than 160 mm Hg or diastolic blood pressure of at least 110 mm Hg and proteinuria of 5 g or more per 24-hour specimen. Chronic hypertension is hypertension that is present before the pregnancy or diagnosed before 20 weeks' gestation. Gestational hypertension is the onset of hypertension during pregnancy without other signs or symptoms of preeclampsia and without preexisting hypertension.

A nurse is planning to teach the parents of a preterm infant about the infant's nutritional needs. Some nutrients are required in greater quantities in a preterm infant than a full-term one. Which nutrients should the nurse include in the plan? 1 Proteins 2 Carbohydrates 3 Vitamins A, D, E, and K 4 Calcium and phosphorus

1 Proteins are needed for tissue building; therefore the preterm infant's need for protein is greater than the full-term infant's. Carbohydrates are not needed in greater quantities by the preterm infant than by the full-term infant. Vitamins A, D, E, and K are fat-soluble vitamins; all of these vitamins are needed, but the B vitamins, found in proteins, are most important for the preterm infant. Although minerals are needed for electrolyte balance, they are not the priority nutrient for a preterm newborn.

The nurse is teaching the mother of a 2-year-old child teeth brushing techniques to ensure proper oral hygiene. Which action made by the mother indicates the need for further teaching? 1 Rinsing the mouth after brushing with a fluorinated gel 2 Asking the child to say "cheese" to clean the front teeth 3 Asking the child to "roar like a lion" to clean the back teeth 4 Placing the tooth brush vertical to the teeth while brushing

1 Rinsing the child's mouth after the use of fluorinated gels or pastes can diminish the activity of the fluorinated gels. Therefore, the mother should refrain from rinsing the child's mouth to maximize the beneficial effects of the fluorinated gels while brushing the child's teeth. The word "cheese" helps to expose the front teeth; therefore, the mother should ask the child to say "cheese" while cleaning the front teeth. Asking the child to "roar like a lion" encourages the child to open the mouth and expose the back teeth, which helps the parent clean the teeth. While brushing, the mother should place the toothbrush vertical to the teeth and move up and down to maintain proper oral hygiene.

A 4-month-old infant had a spica cast applied. What should the nurse include in the discharge instructions to the parents? 1 Obtain a specially designed car seat. 2 Keep diapers on to prevent soiling of the cast. 3 Be sure to change the infant's position every 8 hours. 4 Use the bar between the infant's legs to change positions.

1 Standard seat belts and car seats are not easily adapted for use by children in spica casts; specially designed devices are available to meet safety requirements. Other strategies in addition to diapers will be necessary to keep the cast clean. Changing the infant's position every 8 hours is inadequate; the position should be changed at least every 2 hours. Using the abduction bar to lift or turn the child can weaken the cast; the bar is designed to keep the hips in alignment.

2-month-old infant is to have a nasogastric tube inserted. The nurse expects that: 1 A pacifier will be offered to lessen gagging and allow easier insertion of the tube. 2 Gastric contents will not appear in the tube if the infant is receiving nothing by mouth. 3 The tube will be passed a distance equal to the length from the chin to the tip of the sternum. 4 Coughing, irregular breathing, and slight cyanosis will occur during introduction of the tube.

1 Sucking and swallowing (the infant's response to a pacifier) reduce gagging and facilitate the insertion of the nasogastric tube. A small amount of gastric fluid is always present and will appear in the tube. The tube is passed the distance from the ear to the tip of the nose to the distal end of the sternum. Coughing, gagging, and cyanosis are indications that the tube has passed into the larynx, not the stomach.

A pregnant woman who was admitted to the high-risk maternity unit for severe hyperemesis gravidarum is receiving total parenteral nutrition (TPN). Intralipids are not being administered. For what potential complication should the nurse monitor the client? 1 Dehydration 2 Hypoglycemia 3 Allergic reaction 4 Diabetes insipidus

1 TPN is a hypertonic solution that pulls fluid from the interstitial compartment into the intravascular compartment, resulting in diuresis and dehydration. Because of its high glucose content, TPN may cause hyperglycemia, not hypoglycemia. Allergic reaction is unlikely; the administration of lipids is associated more commonly with allergic reactions. TPN may precipitate hyperglycemia (pseudo diabetes mellitus), not diabetes insipidus.

A nurse is caring for an infant with meningitis. When the nurse extends the baby's leg, the hamstring muscles go into spasm and the infant begins to cry. What sign or reflex is the infant exhibiting? 1 Kernig sign 2 Babinski reflex 3 Chvostek sign 4 Cremasteric reflex

1 The Kernig sign is indicative of meningitis; it is demonstrated by a spasm of the hamstring muscles when the legs are extended. The Babinski reflex is dorsiflexion and fanning of the toes when the sole is stroked; adults with neuromuscular impairment and healthy infants exhibit this sign. The Chvostek sign is elicited by tapping on the facial nerve in the region of the parotid gland; spasm indicates tetany. In a male, the cremasteric reflex is elicited by stroking the inner thigh; this should cause the testes to retract into the scrotal sac.

The nurse assesses a patient and determines that she has achieved thelarche. What clinical finding prompted the nurse's report? 1 Appearance of breast buds 2 Growth of hair on mons pubis 3 Occurrence of menstrual cycle 4 Occurrence of gynecomastia

1 The appearance of breast buds is considered to be an initial indication of puberty, known as thelarche. A few months after thelarche, growth of pubic hair on the mons pubis occurs. This is known as adrenarche. The occurrence of the first menstrual cycle is known as

During a routine prenatal office visit at 26 weeks' gestation, a client states that she is getting fat all over and that she even needed to buy bigger shoes. What is the next nursing action? 1 Obtaining the client's weight and blood pressure 2 Reassuring the client that weight gain is expected 3 Supporting the client's decision to buy comfortable shoes 4 Teaching the client about the importance of limiting fatty foods and sweets

1 The client's weight and blood pressure helps the nurse determine whether an unusual weight gain or an increase in blood pressure has occurred; both of these findings are early signs of preeclampsia. The data suggests a greater-than-expected weight gain. Supporting the client's decision to buy comfortable shoes ignores the possibility that the edema and weight gain are related to preeclampsia. The weight gain may not be caused by inappropriate dietary intake but rather by an underlying pathologic condition.

The parents of a toddler who has been admitted to the pediatric unit for surgery to correct hypospadias ask the nurse when this defect happened. The nurse responds that it usually occurs during fetal development, in the: 1 First 12 weeks 2 Third trimester 3 Second 16 weeks 4 Implantation phase

1 The critical period of organogenesis occurs during the first trimester, when fetal development is most likely to be adversely affected. The fetus is less vulnerable after the first trimester because organ development is complete. The fetus is less vulnerable to major anomalies during the second 16 weeks because all major organ systems already are formed. At the time of implantation cellular differentiation has not occurred; the genital bud appears in the seventh week.

A school-age child with a fracture of the femur near the epiphyseal plate is admitted to the hospital. The parents ask if there will be any after effects when the bone heals. Before responding, what should the nurse consider? 1 Growth of that leg may be affected. 2 Risk for infection at this location is increased. 3 Fracture repair will necessitate prolonged traction. 4 Long bones contain marrow, which increases the risk for anemia

1 The epiphyseal plate is the area in which new bone is formed, increasing limb length. If this area is damaged, the child may experience decreased growth in this leg. There is not a greater risk for infection in this fracture than in fractures at other locations. The healing time will be the same as that for other areas of the femur. The bone marrow is not involved in this type of fracture; the epiphysis is at the end of the bone, and the medullary cavity in the diaphysis contains the marrow.

A child is born to a mother whose hepatitis B status is negative. While assessing the newborn, the nurse finds that the birth weight is 1.8 kg. Which action by the nurse is appropriate in this situation? 1 Administer HepB vaccine to the newborn 1 month after birth. 2 Administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth. 3 Administer monovalent HepB vaccine to the newborn during discharge. 4 Administer HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth.

1 The immune response to the HepB vaccine is not optimum in newborns weighing less than 2 kg. As the mother's hepatitis B status is negative, the first dose of HepB vaccine should be administered 1 month after birth. There is no need to administer 0.5 mL of hepatitis B immune globulin (HBIG) within 12 hours of birth, as the mother's hepatitis B status is negative. Monovalent HepB vaccine is administered during discharge to newborns whose birth weight is more than 2 kg. If the infant were born to a hepatitis-positive mother, HepB vaccine and 0.5 mL of hepatitis B immune globulin (HBIG) would be administered within 12 hours of birth.

The nurse is assessing a newborn immediately after birth. Which finding indicates normal development in a newborn? 1 A body weight of 3500 g 2 A core body temperature of 96° F 3 Blood pressure of 70/60 mm Hg 4 Head circumference is 3 cm less than chest circumference

1 The newborn has a body weight of 3500 g, which is within the normal range of 2700 to 4000 g. Therefore, this indicates normal development. The core body temperature of the newborn is 96° F, which is lower than the normal range of 97.7° F to 99.7° F. Therefore, the core body temperature of 96°F indicates hypothermia. The normal blood pressure of a newborn on the first day of birth is 65/45 mm Hg. A blood pressure finding of 70/60 mm Hg indicates very high blood pressure. The head circumference of the newborn is less than the chest circumference, which indicates that the newborn may have microcephaly.

What characteristic that may be a potential nutrition problem should the nurse identify in a preterm neonate? 1 Inadequate sucking reflex 2 Diminished metabolic rate 3 Rapid digestion of formula 4 Increased absorption of nutrient

1 The reflexes and muscles of sucking and swallowing are immature; this may result in oral feedings that are ineffectual and exhausting. The metabolic rate is increased because of fatigue and growth needs. The digestive process is slow, especially in regard to the ability to digest lipids. Absorption of nutrients is decreased because the gastrointestinal tract is immature.

When assessing a child's reflexes, the nurse places the child in the prone position and presses a thumb along the child's spine from sacrum to neck. The nurse finds that the child starts crying and urinates while flexing the extremities. Which reflex is the nurse assessing in the child? 1 Perez reflex 2 Babinski reflex 3 Trunk incurvation 4 Ankle clonus reflex

1 To assess the Perez reflex, the nurse places the child in a prone position and presses a thumb along the child's spine from sacrum to neck, and the child starts crying. This indicates that the child has the Perez reflex. To assess the Babinski reflex, the nurse strokes the child's foot upward from the heel; in response, the child hyperextends the toes. To assess trunk incurvation, the nurse strokes the infant's spine; in response, the child's hips move to the stimulated side. To assess the ankle clonus reflex, the nurse performs dorsiflexion of the child's foot while ensuring that the knee is flexed. The child's foot will make an oscillating movement in response.

hat is the most appropriate nursing intervention for an adolescent child with sickle cell anemia? 1 Teaching the family how to limit sickling episodes 2 Preparing the child for occasional blood transfusions 3 Educating the family about prophylactic medications 4 Explaining to the child how excess oxygen causes sicklin

1 To help prevent a crisis, the child and family must be taught to try to prevent sickling by maintaining hydration, promoting adequate oxygenation, and avoiding strenuous exercise. Blood transfusions are a common treatment rather than a rare occurrence. There are no prophylactic medications to prevent sickle cell crisis. It is a lack, not an excess, of oxygen that contributes to sickling.

n adolescent experiencing a vaso-occlusive crisis reports right knee pain. What is the most appropriate nursing intervention? 1 Applying a warm soak to the knee 2 Applying a compression wrap to the right leg 3 Administering acetaminophen (Tylenol) 4 Decreasing the amount of intravenous fluid

1 Warmth causes vasodilation, which will lessen the pain of the vaso-occlusive crisis. Applying a compression wrap is not helpful because the problem is sickling of the red blood cells, not a lack of venous return. Tylenol is inadequate for pain relief during a vaso-occlusive crisis. Intravenous fluids should be increased to dilute the blood and prevent further sickling.

Which fine motor skill will be seen in a 10-month-old infant? 1 Picking up finger foods 2 Releasing a cube in a cup 3 Building towers of two blocks 4 Turning many pages in a book

1 When an infant is 10 months old, the pincer grasp is well established, which helps the infant pick up finger foods. When an infant is 11 months, the infant has a neat pincer grasp and is able to release a cube in a cup. One-year-old infants can build a tower of two blocks and turn many pages in a book.

A client at 30 weeks' gestation visits the clinic for a routine examination. At her last visit she told the nurse that she wanted to diet to avoid losing her figure after the baby's birth and as a result the nurse provided nutrition counseling. At this visit the client weighs 10 lb less than on her previous visit. The nurse suspects that the client is not complying with the pregnancy diet. For what complication should the client be monitored? 1 Ketonemia 2 Hyperglycemia 3 Anorexia nervosa 4 Hyperemesis gravidarum

1 When protein and carbohydrate intake is inadequate, the body catabolizes fat stores for energy, leading to the production of excess fatty acids. Excess fatty acids produce excess ketones in the blood (ketonemia). Hypoglycemia is more likely to occur because carbohydrate intake probably is low. Anorexia nervosa is a prepregnancy disorder. The data do not indicate a history of this problem. The data do not indicate that the client has a history of hyperemesis gravidarum, which begins during the first trimester.

n adolescent girl is concerned about her body image after amputation of a leg for bone cancer. After the nurse has obtained the girl's consent, what nursing action is most therapeutic? 1 Encouraging her peers to visit 2 Keeping her lower body covered 3 Placing her in a room by herself 4 Limiting her visitors to the family

1 Peer acceptance is crucial during this period; friends must have the opportunity to accept the client with one leg. Concealment does not help the adolescent or others accept the loss. Isolating the adolescent will increase feelings of alienation and being different. An adolescent needs to relate to and be accepted by peers as well as family.

A cast is applied to the involved extremity of an infant with talipes equinovarus (clubfoot). The nurse tells the parents that they will have to bring their baby back to the clinic for a cast change: 1 Each week 2 Once a month 3 When the cast edges fray 4 If the cast becomes soiled

1...

12-year-old boy with nephrotic syndrome is in remission for several months. One day the mother calls the clinic to report that for the past week her child's skin has a pale, muddy appearance; his appetite is poor; and he has been unusually tired after school. In light of the mother's description, what does the nurse suspect? 1 Impending renal failure 2 Excessive activity at school 3 Development of a viral infection 4 Nonadherence to the medication protoco

11 The anemia associated with renal failure accounts for the pallor and decreased energy; the decreased appetite and decreased energy are related to the accumulation of toxic wastes. Excessive activity should not cause the signs and symptoms identified by the mother if the child is in remission. An increased temperature will probably be present with an infection; an infection does not cause a muddy pallor. Discontinuing the corticosteroids and diuretics, if prescribed, might result in a recurrence of edema in the steroid-dependent child; it is not a sign of renal failure.

The urinary output of a 9-year-old child with acute glomerulonephritis decreases to 250 mL/24 hr. A diet low in sodium and potassium is prescribed. What should the nurse encourage the child to have for lunch? 1 Baked chicken, green beans, and lemonade 2 Cream of tomato soup, salami sandwich, and cola 3 Grilled cheese sandwich, sliced tomatoes, and milk 4 Peanut butter and jelly sandwich, celery, and orangeade

11 The foods in this grouping have the least sodium and potassium. Cream of tomato soup, a salami sandwich, and cola are high in sodium; some colas also have a high potassium content. A grilled cheese sandwich, sliced tomatoes, and milk are high in sodium. Celery is high in sodium; the sodium content is moderately high in bread and peanut butter.

The parents of an infant who has undergone surgical repair of a myelomeningocele express concern about skin care and ask what they can do to prevent problems. The nurse should teach the parents that their infant: 1 Will require long-term multidisciplinary follow-up care 2 Should take prophylactic antibiotic therapy indefinitely 3 Must be kept dry by applying powder after each diaper change 4 Does not need anything more than routine cleansing and diaper changes

11 These infants need follow-up care with a variety of health care providers (e.g., neurologist, physical therapist) to manage the child's condition during growth and development. Taking prophylactic antibiotic therapy indefinitely is unnecessary. Powder should be avoided; it will create a pastelike substance when mixed with urine, and when aerosolized it is a respiratory irritant. These children require more frequent perineal care than just routine cleansing and diaper changes.

What are the indicators of nutritional risk in pregnancy in a client who is of normal weight? Select all that apply. 1 Smoker 2 Twin gestation 3 Hemoglobin of 12 g/dL 4 Term delivery 2 years ago 5 Caffeine intake of 180 mg/day 6 Fasting blood sugar of 80 mg/dL

12 Smokers generally have a nutrient-poor diet and are at risk for continuing the same diet through pregnancy. Multifetal pregnancies require nutrition above the normal requirements for pregnancy. A hemoglobin reading of 12 g/dL and fasting blood sugar of 80 mg/dL are normal values. Caffeine intake of 180 mg/day is less than the daily recommended intake.

A client with a history of three spontaneous abortions is now at 16 weeks' gestation and attending the high-risk prenatal clinic. She expresses concerns about remaining at home during this pregnancy. Which questions will elicit responses most helpful to the nurse developing the client's plan of care? Select all that apply. 1 "Do you have a support system available to help you?" 2 "Have you been told about the status of your pregnancy?" 3 "Do you know the causes related to spontaneous abortions?" 4 "Are you aware of how a healthy lifestyle affects a pregnancy?" 5 "What are the characteristics of an impending spontaneous abortion?"

12 The availability of support persons is important when the client is deciding how to try to maintain the pregnancy. Knowing the status of her pregnancy is helpful to the nurse planning her care. If the status is not known, the nurse can correct any misconceptions and assist the client in focusing on reality while helping ease her anxiety. The causes of spontaneous abortion are not always known; theoretic knowledge of the causes will not help the client maintain her pregnancy. Questions about the interrelationship of lifestyle and a healthy pregnancy may add to the client's anxiety; they are not relevant at this time. Questioning the client's knowledge of an impending spontaneous abortion may add to the client's anxiety; after three abortions the client probably knows what to expect before there is a spontaneous abortion.

A nurse is teaching a prenatal class about the changes that occur during the second trimester of pregnancy. What cardiovascular changes should the nurse include? Select all that apply. 1 Cardiac output increases. 2 Blood pressure decreases. 3 The heart is displaced upward. 4 The blood plasma volume peaks. 5 The hematocrit level is lowered.

123 Cardiac output increases during the second trimester because of an increasing plasma volume. The blood pressure decreases because of the enlarged intravascular compartment and hormonal effects on peripheral resistance. As the fetus grows and the enlarging uterus outgrows the pelvic cavity, it displaces the heart upward and to the left. The blood volume starts to increase earlier but does not peak until the third trimester. The reduction in hematocrit occurs in the first trimester; the erythrocyte increase may not be in direct proportion to the blood volume, lowering hematocrit and hemoglobin levels, which remain lower throughout pregnancy.

A neonate is returned to the pediatric surgical unit after repair of a myelomeningocele. What priority assessments should be performed in the immediate postoperative period for this infant? Select all that apply. 1 Incision, for signs of CSF leak 2 Urinary bladder, for distention 3 Vital signs, for signs of infection 4 Head circumference, for increase 5 Sensation assessment of lower extremities 6 Lower extremities, for return of movement

1234

Considerations in caring for an infant who is failing to thrive (FTT) should include: select all that apply 1 Dietary history 2 Signs of malnutrition 3 Familial stress factors 4 Parent and infant interaction 5 Sustained growth under 5th percentile 6 75th percentile for weight

12345 Dietary history should include type of feedings, as failure to thrive may be a result of an inadequate milk supply in a breast feeding mother. Signs of malnutrition can affect hair and skin. The infant also may be listless and slow to achieve milestones. Familial stress factors, such as depression and substance abuse, impact the ability of the caregiver to meet the infant needs. Lack of parent and infant interactions contributes to failure to thrive, as infancy is the time to develop trust or mistrust. Sustained growth under the 5th percentile indicates FTT. It is expected that an infant will double birth weight by 6 months of age. Weight in the 75th percentile indicates thriving.

A woman visits the prenatal clinic because an over-the-counter pregnancy test has rendered a positive result. After the initial examination verifies the pregnancy, the nurse explains some of the metabolic changes that occur during the first trimester of pregnancy. Select all that apply. 1 Sleep needs increase. 2 Fluid retention increases. 3 Body temperature decreases. 4 Calcium requirements increase. 5 The need for carbohydrates decreases.

124 Estrogen increases the secretion of corticosteroids, which decrease the basal metabolic rate, resulting in fatigue. Sodium is retained, and fluid retention increases to meet total needs. During the first trimester approximately 1.2 g of calcium is needed each day; this need continues throughout pregnancy as the fetal skeleton is being formed. Body temperature increases because of the increased metabolism related to the growth of the fetus. Carbohydrate needs increase because the secretion of insulin by the pancreas is increased

A 25-day-old infant is admitted to the hospital after 3 days of vomiting, and pyloric stenosis is diagnosed. What are the most important nursing assessments at the time of admission? Select all that apply. 1 Tissue turgor 2 Neurologic status 3 Time of last feeding 4 Amount of last voiding 5 Character of the vomitus

124 It is likely that dehydration and metabolic alkalosis are present when an infant vomits for 3 days. Hydrochloric acid is lost in the vomitus. The infant will exhibit inelastic tissue turgor. It is likely that metabolic alkalosis is present when an infant vomits for 3 days. Alkalosis causes hyperreflexia, tetany, and seizures. It is likely that dehydration is present when an infant vomits for 3 days. The infant will void scanty, dark urine, indicating dehydration. The time of the last feeding and character of the vomitus are not priority assessments.

Which of the following are congenital anomalies or birth defects seen in children? Select all that apply. 1 Dysplasias 2 Disruptions 3 Teratogens 4 Deformations 5 Malformations

1245Dysplasias occur due to abnormal organization of cells into a particular tissue type. Disruptions are sometimes seen in a child due to the breakdown of previously normal tissue. Deformations may be seen in a child at birth due to extrinsic mechanical forces on normally developing tissue. Malformations are abnormal body parts caused by an abnormal developmental process. Teratogens are agents, such as drugs, warfarin, alcohol, or bacteria that cause birth defects in a child.

pregnant woman at 6 weeks' gestation tells the nurse at her first prenatal visit that she uses an over-the-counter herbal product as a health supplement that has been approved by the Food and Drug Administration. What should the nurse recommend to the client? Select all that apply. 1 Stop taking the supplement immediately. 2 Discuss the use of the supplement with the practitioner. 3 Increase the dosage of the supplement as pregnancy progresses. 4 Ask the pharmacist whether the supplement is safe for use during pregnancy. 5 Discuss the use of any over-the-counter products with the practitioner.

125

n adolescent who is undergoing chemotherapy for the treatment of bone cancer has stomatitis as a result of chemotherapy. What should the nurse include when teaching the child about self-care? Select all that apply. 1 Clean the teeth with a swab. 2 Drink fluids through a straw. 3 Brush the teeth three times a day. 4 Rinse frequently with a mouthwash. 5 Avoid foods served at extremes of temperature

125 A soft-tipped applicator should be used to help prevent trauma to the oral mucosa. Drinking fluids through a straw allows the fluid to bypass the sores in the mouth and may be less irritating to the mucosa; it provides comfort. Extremes in temperature may injure the oral mucosa and cause discomfort. Brushing the teeth three times a day will injure the oral mucosa and should be avoided. Rinsing frequently with a mouthwash may irritate the oral mucosa and should be avoided; if mouthwash is prescribed, it should be diluted.

On her first visit to the prenatal clinic a client with rheumatic heart disease asks the nurse whether she has special nutritional needs. What supplements in addition to the regular pregnancy diet and prenatal vitamin and minerals will she need? Select all that apply. 1 Iron 2 Calcium 3 Folic acid 4 Vitamin C 5 Vitamin B12

13 Because pregnant women with heart disease are more likely to have anemia, there may be an additional need for iron and also for folic acid. If the pregnant client with heart disease is eating the recommended pregnancy diet and taking prenatal vitamin and mineral supplements, there is no additional need for calcium, vitamin C, and vitamin B12.

What dietary information should the nurse include in the teaching plan for parents of an infant with galactosemia? Select all that apply. 1 Eliminate milk. 2 Substitute meat for eggs. 3 Provide soybean-based formulas. 4 Avoid baby cereals containing wheat flour. 5 Give prescribed pancreatic enzyme capsules with meals.

13 Milk and dairy products are high in lactose content and should be eliminated from the diet. Soybean-based formulas are permissible because they do not contain lactose. Both meat and eggs are permitted because neither contains lactose. Cereals containing wheat products are eliminated from the diet of children with celiac disease. Pancreatic enzymes are prescribed for children with cystic fibrosis, not galactosemia.

3-year-old child with nephrotic syndrome has been receiving prednisone (Meticorten) for 1 week. The nurse reviews the child's progress record and determines that the medication has been effective. What information supports this conclusion? Select all that apply. 1 Weight loss 2 Lower blood pH 3 Shorter rest periods 4 Increased urine output 5 Decreased blood pressur

134 Children with nephrotic syndrome are grossly edematous. Those who have the steroid-sensitive form of nephrotic syndrome respond to corticosteroids with diuresis within 7 to 21 days after therapy is started, and the edematous weight is lost. Once the child feels better, lethargy decreases and the activity level increases. Steroid therapy does not affect the blood pH. There is no increase in the blood pressure of a child with nephrotic syndrome and therefore no change in blood pressure when the child improves.

A 6-year-old child is hospitalized with nephrotic syndrome. The mother asks the nurse what she may bring for her child to play with during the hospitalization. In light of the child's age, what should the nurse suggest? Select all that apply. 1 Checkers 2 Wooden puzzles 3 Paper and crayons 4 Simple card games 5 CDs and a CD playe

134 Six-year-old children enjoy competition and challenges to their intellectual ability. They are also creative, and coloring is a quiet activity that is age appropriate and enjoyable. Six-year-olds enjoy competition. Wooden puzzles are more appropriate for toddlers. Listening to CDs is more appropriate for an older child.

A nurse teaches a mother about appropriate play for an 8-month-old infant. Which of the mother's suggestions indicate that the teaching has been understood? Select all that apply. 1 Textured book 2 Modeling clay 3 Stuffed animal 4 Play telephone 5 Hanging mobile

135

The nurse teaches a client about the increased need for vitamin A to meet the demands imposed by rapid fetal tissue growth during pregnancy. Which foods should the nurse encourage the client to ingest to meet this increased need? Select all that apply. 1 Carrots 2 Citrus fruits 3 Fat-free milk 4 Sweet potatoes 5 Extra egg white

14 Carrots provide the precursor pigment carotene, which the body converts to vitamin A. Sweet potatoes baked in the skin contain large amounts of carotene, which the body converts to vitamin A. Citrus fruits contain only a very small amount of vitamin A precursor. Fat-free milk contains only about half the needed vitamin A precursor. Egg whites contain no vitamin A precursor.

When reviewing the results of a toddler's complete blood count, a nurse concludes on the basis of decreased hemoglobin and hematocrit levels that the child has iron-deficiency anemia. Which other laboratory findings are indicative of iron-deficiency anemia? Select all that apply. 1 Microcytic red blood cells 2 Hyperchromic red blood cells 3 Low total iron-binding capacity 4 Slightly reduced reticulocyte count 5 Increased erythrocyte sedimentation rate

14 In iron-deficiency anemia the red blood cells are microcytic, with a decreased mean corpuscular volume. The reticulocyte count is within the expected range or slightly reduced. The red blood cells are hypochromic, not hyperchromic. The total iron-binding capacity is increased in children with iron-deficiency anemia as the body attempts to absorb more iron. An increased erythrocyte sedimentation rate (ESR) indicates an inflammatory process. The ESR is not related to iron-deficiency anemia.

The laboratory blood tests of a client at 10 weeks' gestation reveal that she has anemia. The client refuses iron supplements. The nurse teaches her that the best source of iron is liver. What other foods does the nurse encourage the client to eat? Select all that apply. 1 Tofu 2 Chicken 3 Canned ham 4 Broiled halibut 5 Ground beef patt

15

A client at 7 weeks' gestation tells the nurse in the prenatal clinic that she has been bothered by episodes of nausea, but no vomiting, throughout the day. What should the nurse recommend? Select all that apply. 1 Focus on and repeat a rhythmic chant. 2 Sit upright for 30 minutes after meals. 3 Take low-sodium antacids after meals. 4 Drink carbonated beverages with meals. 5 Eat small, frequent meals and eat dry crackers in between.

15 Focusing helps mitigate odors, tastes, and thoughts that may cause nausea. Avoiding an empty stomach decreases the occurrence of nausea associated with pregnancy. Sitting upright after meals will help ease heartburn but not nausea. Prescribed low-sodium antacids may be taken between meals later in pregnancy to promote relief from heartburn. Carbonated beverages may or may not help, but women should be advised to take fluids between, not with meals.

During a follow-up visit, the nurse finds that the adolescent uses artificial tanning methods and has phototoxic reactions on the skin. What is the nurse's best response? 1 "You should wear goggles if you insist on using the tanning booth." 2 "You should perform sunbathing for 1 hour just before getting tanned." 3 "You should refrain from using broad spectrum sunscreens just before tanning." 4 "You should use sunscreen with sun protective factor of 10 after getting tanned."

1Serious corneal burning can occur in adolescents while they are in the tanning booth. Therefore, adolescents should wear goggles while they are in tanning booths. Sunbathing for extended periods should not be done. Adolescents should use a broad spectrum sunscreen to prevent exposure to harmful ultraviolet rays. Sunscreens with sun protective factor of 15 should be used to ensure safety.

9-year-old child is found to have acute glomerulonephritis after a recent infection. What microorganism should the nurse suspect as the cause of the child's current health problem? 1 Haemophilus 2 Streptococcus 3 Pseudomonas 4 Staphylococcu

2

A 10-year-old child is undergoing radiation therapy for a brain tumor. What should the nurse include in the skin care for this child? 1 Applying baby oil to the head 2 Cleansing the head with water 3 Washing the head with mild soap 4 Rinsing soap from the head under a shower

2

A 3-month-old infant hospitalized with severe diarrhea has excoriated skin in the diaper area. The mother becomes concerned when she discovers that the nurse has left her infant without a diaper. What is the nurse's explanation for this action? 1 Exposing the excoriated areas helps reduce the fever 2 Cleansing of the skin followed by air-drying reduces excoriation 3 Air-drying the perineal area prevents the diaper from sticking to the skin 4 Leaving the area exposed allows observation of when the infant passes stool

2

A boy in kindergarten has experienced urinary incontinence during the first few weeks of school. What should the school nurse do? 1 Suggest that his mother send him to school in training pants. 2 Keep a change of clothes available for him in the health office. 3 Ask his teachers to remind him several times a day to go to the bathroom. 4 Explain to him why it is important to stay dry now that he is old enough to attend school.

2

A nurse evaluating a 1-year-old infant's hematocrit reading compares it with the expected hematocrit range for this age group. What is the hematocrit of a healthy 12-month-old infant? 1 19% to 32% 2 29% to 41% 3 37% to 47% 4 42% to 69%

2

A nurse in the family planning clinic reviews the health history of a sexually active 16-year-old girl whose chief concern is a thick, burning discharge accompanied by a burning sensation and lower abdominal pain. After an examination the girl is informed that she may have a sexually transmitted infection (STI) that requires treatment. The adolescent is concerned that her parents will discover that she has been sexually active and asks the nurse whether her parents will be contacted. The nurse explains that her parents will: 1 Need to know to sign a consent form for testing and treatment 2 Not be contacted, because treatment at the clinic is confidential 3 Be notified when the insurance company is billed for testing and treatment 4 Remain uninformed if the adolescent ensures that her sexual contacts will come for testing

2

A nurse is discussing immunizations needed to confer active immunity with a pregnant client during her first visit to the prenatal clinic. What information should the nurse consider including that the client will understand with regard to active immunity? 1 Protein antigens are formed in the blood to fight invading antibodies. 2 Protein substances are formed by the body to destroy or neutralize antigens. 3 Blood antigens are aided by phagocytes in defending the body against pathogens. 4 Sensitized lymphocytes from an immune donor act as antibodies against invading pathogens.

2

A nurse is teaching a class of expectant parents about nutritional needs during pregnancy. What information should the nurse include? 1 Carbohydrate needs decrease during pregnancy. 2 Protein needs increase to at least 70 g/day during pregnancy. 3 Phosphorus and calcium needs decrease gradually throughout pregnancy. 4 Caloric needs increase gradually up to 100 more kcal/day throughout pregnancy.

2

A nurse on the pediatric unit is planning recreational activities for a 4-year-old with an exacerbation of nephrotic syndrome. What are the most appropriate activities, in light of the child's developmental level and physical status? 1 Riding a tricycle and playing with large blocks 2 Watching cartoon videos and listening to stories 3 Reading animal stories and playing video games 4 Leading a pull toy and playing with a map puzzl

2

A preschool-aged child is admitted to the pediatric unit for urinary diversion surgery. The ureters are transplanted to a section of the colon, with one end attached to the abdominal wall as an ileostomy. The parents ask the nurse for the name of the procedure. What is the nurse's response? 1 Cystostomy 2 Ileal conduit 3 Ureterosigmoidostomy 4 Cutaneous ureterostomy

2

A primigravida in her 10th week of gestation is concerned because she has read that nutrition during pregnancy is important for the growth and development of the fetus. She wants to know something about the foods she should eat. How should the nurse respond initially? 1 By instructing her to continue eating her regular diet 2 By asking her what she has eaten over the last 3 days 3 By giving her a list of foods to help her plan her meals more efficiently 4 By emphasizing to her the importance of limiting highly seasoned foods

2

A teenage boy with a diagnosis of osteosarcoma is to have the affected leg amputated. What should the nurse do to promote psychological adjustment and early function immediately after surgery? 1 Allow him to change the first dressing. 2 Help him adjust to the temporary prosthesis. 3 Assign him to a room with another adolescent. 4 Have him meet with a member of a cancer survivor organization

2

A teenager is being discharged with a cast. What should the nurse recommend if the client experiences pruritus around the cast edges? 1 "Scratch the itchy area gently." 2 "Put an ice pack on the affected area." 3 "Sprinkle a layer of powder around the itchy spots." 4 "Ask your doctor for a prescription for an antihistamine

2

Before surgery to relieve an intestinal obstruction, a 3-month-old infant is kept on nothing-by-mouth status and has a nasogastric tube in place. Which nursing intervention will help calm the infant and meet developmental needs? 1 Offering the infant a toy to hold 2 Providing a pacifier for the infant to suck 3 Hanging a brightly colored mobile in the infant's crib 4 Placing the infant on the abdomen to permit crawling

2

During a follow-up visit, the mother of a 10-month-old infant says, "My child lifts one foot to take a step, stands by holding the furniture, but does not attempt to stand alone without support, and walks while holding onto a hand." What is the accurate nursing response in this situation? 1 "Your child may be in need of minor leg surgery." 2 "Your child should be able to stand alone in another 2 months." 3 "You should consult an orthopedic specialist immediately." 4 "You should encourage physiotherapy for your child's legs.

2

Genetic testing is being discussed with a couple at the fertility clinic. What is the nurse's best response when they express concerns? 1 "You should be tested, because it will be to your benefit." 2 "Environmental factors can have an impact on genetic factors." 3 "This type of testing will determine whether you'll need in vitro fertilization." 4 "If you have a gene for a disease there is a probability that your children will inherit it."

2

On her first visit to the prenatal clinic, a client tells the nurse she is ambivalent about continuing the pregnancy. Why does the nurse conclude that the client is experiencing a crisis? 1 Mood changes occur during pregnancy. 2 Pregnancy is a period of change and adjustment to change. 3 Hormonal and physiologic changes occur during pregnancy. 4 Pregnancy changes the future parents' relationship with each other

2

The nurse is caring for a first-time mother at her first prenatal visit. The client confides, "I'm not sure about all this." Which research-based knowledge guides a nurse regarding the emotional factors of pregnancy? 1 A rejected pregnancy will result in a rejected infant. 2 Ambivalence and anxiety about mothering are common. 3 A mother's love usually develops in the first week after birth. 4 An effective mother does not experience ambivalence and anxiety about mothering.

2

The nurse is counseling the parents of an adolescent child on the benefits of social development in the child's maturation process. Which statement by the nurse needs correction to convey an appropriate message to the parents? 1 The family should encourage the child to make relationships outside the family. 2 Feelings of immortality in the child are undesirable and should be condemned. 3 Feelings of intense sociability and equally intense loneliness are normal in the child. 4 The family should encourage the child to develop an identity independent of parental authority

2

The nurse knows that additional discharge instructions are needed for parents whose infant has just undergone corrective surgery for cleft palate when the mother says: 1 "We need to schedule regular hearing tests, even at this young age." 2 "Lying on the abdomen is prohibited, so we'll keep him in an infant seat." 3 "We know that some difficulty breathing is expected, so we'll position him upright." 4 "We'll use the elbow restraints you provided to keep him from putting his hands in his mouth."

2

The parent of a school-age child tells the nurse, "Sometimes my child is fatigued in the morning." Upon assessment, the nurse finds that the blood and urine reports of the child are normal. What could be the possible cause of the child's fatigue? 1 The child has a brain tumor. 2 The child often stays up late. 3 The child watches too much TV. 4 The child consumes starchy food.

2

To confirm a tentative diagnosis of leukemia a bone marrow aspiration and biopsy are to be performed on a 4-year-old boy. The nurse gives an age-appropriate explanation of the procedure to the child. What else is involved in caring for this child? 1 Telling the child that there will be pressure without pain 2 Explaining to the child that he will sleep during the procedure 3 Placing the child in the semi-Fowler position supported by pillows 4 Asking the child to hold some nonsterile equipment during the tes

2

Which medication is prescribed to an infant with congenital syphilis? 1 Vidarabine (Vira-A) 2 IV penicillin (Pfizerpen) 3 Pyrimethamine (Daraprim) 4 Trimethoprim-sulfamethoxazole (Bactrim

2

n unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube? 1 Once a day 2 Before each feeding 3 At every shift change 4 During the night shift

2

pregnant client who is Rh negative visits the prenatal clinic during the first trimester of pregnancy. She is informed by the health care provider that Rh sensitization is suspected and that Rho(D) immune globulin (RhoGAM) eventually will be given. At what week of gestation should the nurse explain that the medication will be administered? 1 12 weeks 2 28 weeks 3 36 weeks 4 40 weeks

2

A nurse is discussing diet with a pregnant client who is 5 feet 4 inches tall and whose prepregnancy weight was 120 lb. What should the nurse include about the changes in calories and nutrients, compared with the prepregnancy diet, during the second trimester? 1 Decreasing daily fat consumption by 220 calories 2 Increasing total daily caloric intake by 340 calories 3 Increasing total daily caloric intake by 460 calories 4 Decreasing daily carbohydrate consumption by 130 calorie

2 A daily increase of 340 calories is recommended for adult women during the second trimester of pregnancy. Decreasing fat or carbohydrates in the diet will result in weight reduction, which is not recommended during pregnancy. A daily increase of 462 calories is recommended for adult women during the third trimester of pregnancy.

hat is the first action a nurse should take before administering a tube feeding to an infant? 1 Irrigating the tube with water 2 Offering a pacifier to the infant 3 Slowly instilling 10 mL of formula 4 Placing the infant in the Trendelenburg position

2 A pacifier should be given during the feeding to help the infant associate sucking with feeding and to meet oral needs. Irrigating the tube with water will cause complications if the tube is not in the stomach. Ten milliliters of formula should be instilled slowly after placement of the tube and verification of residual return. Upright positioning is essential to prevent regurgitation or reflux and subsequent aspiration.

According to Freud, which aspect of one's life helps in the development of our personality? 1 The need for self-knowledge 2 The need for sensual pleasure 3 The need for trust and identity 4 The need for moral development

2 According to Freud, sexual instincts or sensual pleasure is significant in the development of our personalities. From childhood to later stages of development, a child obtains pleasure from different parts of the body. Self-knowledge is not a theory, but an aspect of the personality that develops gradually as an infant learns about one's independent existence. Erikson proposed the psychosocial development of personality, wherein he states that a child tries to master key conflicts, like trust versus mistrust and identity versus role confusion, at different stages in life. Kohlberg, who explains that children develop moral reasoning in two stages, describes moral development.

The nurse is assessing head growth in a 7-month-old infant. The nurse observes that the rate of the growth has been 0.5 cm since the 6-month check-up. What does the nurse tell the parents about the child's development? 1 "The child needs to be screened." 2 "The child's head growth is normal." 3 "There may be some developmental issues." 4 "The child's posterior fontanel is not fused

2 After the sixth month, the infant's head grows at 0.5 cm every month. Therefore, the nurse informs the parents that the head growth rate is normal for the child. There is no need for screening, as the child has not received any head injuries. There may be developmental issues if the head growth is not normal. The posterior fontanel is fused at 6-8 weeks of age, so this is not a plausible finding at the 8-month mark.

An infant born with exstrophy of the bladder is admitted to the pediatric unit for urinary diversion surgery in which the ureters are to be transplanted to a resected section of the small intestines, with one end attached to the abdominal wall. What does the nurse call the procedure when explaining the surgery to the parents? 1 Cystostomy 2 Ileal conduit 3 Ureterosigmoidostomy 4 Cutaneous ureterostomy

2 An ileal conduit is the transplantation of the ureters into a resected portion of the ileum, which is then used to create a stoma on the abdominal wall for drainage of urine. Cystostomy is an opening into the bladder through the abdominal wall that allows urine to flow out. In ureterosigmoidostomy the ureter is transplanted into the colon and urine is excreted through the rectum. In cutaneous ureterostomy the ureter is transplanted through the abdomen and attached to the skin.

A 5-year-old child is returned to the pediatric intensive care unit after cardiac surgery. The child has a left chest tube attached to water-seal drainage, an intravenous line running of D5½NS at 4 mL/hr, and a double-lumen nasogastric tube connected to continuous suction. A cardiac monitor is in place, as is a dressing on the left side of the chest dressing. What is the priority nursing intervention? 1 Auscultating breath sounds 2 Testing the level of consciousness 3 Measuring drainage from both tubes 4 Determining the suction pressure of the nasogastric tube

2 Assessing the level of consciousness provides the nurse with information about how awake the client is and therefore able to clear the throat and protect the airway. The airway takes priority over listening to the lungs (checking for breathing: ABCs—airway, breathing, circulation), measuring drainage, or determining the suction pressure of the nasogastric tube.

he nurse is assessing an 8-month-old child's gross motor development. Which action by the child indicates late development? 1 The child cannot change from a prone to a sitting position. 2 The child is unable to stand by holding onto furniture. 3 The child cannot sit down from a standing position without help. 4 The child cannot sit steadily on the floor for a prolonged period of time.

2 At 8 months of age the child should be able to stand by holding onto furniture, as the child readily bears weight on its legs when supported. When a child is 10 months old, the child can change from a prone to a sitting position. When a child is 12 months old, the child is able to sit down from a standing position without any help. When a child is at least 9 months old, the child can sit steadily on the floor for a prolonged period of time.

An adolescent child who has sustained full-thickness burns is to undergo skin grafting. The nurse explains to the child's parents that for permanent grafts the child must have: 1 Steroids 2 Autografts 3 Homografts 4 Immunosuppressants

2 Autografts consist of tissue from the individual's own body, meaning that the chance of rejection is minimal. Steroids are not part of the therapy for skin grafts. Homografts consist of tissue from genetically different members of the same species, usually a cadaver; they are used as temporary grafts. Immunosuppressive drugs are not part of the therapy for skin grafts.

A couple seeking genetic counseling are heterozygous carriers of Tay-Sachs disease. They ask the nurse what the chances are that each of their children will inherit the disease. The nurse responds that the probability is: 1 0% 2 25% 3 50% 4 100%

2 Because Tay-Sachs disease is an autosomal recessive disorder

A hospitalized 3-year-old child with leukemia is undergoing chemotherapy. The mother tells the nurse that her child is asking for fried chicken. How should the nurse respond? 1 Fried foods might cause nausea and vomiting during chemotherapy. 2 Any food that is requested should be given, because the child needs calories. 3 Coatings on foods to be fried may irritate the child's mouth and cause bleeding. 4 Foods from outside should not be brought to the unit because of the potential for infection.

2 Because chemotherapy can cause nausea, vomiting, and anorexia, the child should be offered any food that is requested. Even if the nutritional quality is minimal, the child will be receiving needed calories. Fried foods can usually be eaten because generally they do not cause nausea and vomiting or irritate the mouth. Food prepared adequately should not be contaminated and therefore should not cause problems for a child undergoing chemotherapy.

Which nursing action should be included in the plan of care for a child with acute poststreptococcal glomerulonephritis? 1 Encouraging fluids 2 Monitoring for seizures 3 Measuring abdominal girth 4 Checking for pupillary reactions

2 Cerebral edema from hypertension or cerebral ischemia may occur, which may result in seizures. Increasing fluid intake may lead to an increase in blood pressure and edema. Measuring abdominal girth is appropriate for children with nephrotic syndrome, in which the child has hypoalbuminemia that causes fluid to shift from plasma to the abdominal cavity. Glomerulonephritis will not alter pupillary reactions.

An adolescent has been admitted with symptoms of fatigue, intermittent fever, weight loss, and arthralgia, and the diagnosis is systemic lupus erythematosus. The nurse knows that the best intervention at this time is: 1 Implementation of corticosteroids 2 Education about diet, rest, and exercise 3 Sun avoidance and calcium supplements 4 Avoidance of destructive coping mechanisms

2 Client education about the integrative interventions of diet, rest, and exercise will be of the most help to the adolescent client with newly diagnosed lupus. These are interventions that the client has some control over, and this is important to the adolescent. Corticosteroids may not be used until other therapies are unsuccessful. Although sun avoidance and calcium supplements may be helpful, they are not most important. Avoidance of negative coping strategies may be helpful if they are noted, but control over diet, rest, and exercise is a positive coping strategy.

During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? 1 Recent history of drug abuse 2 Family history of genetic abnormalities 3 More than three prior spontaneous abortions 4 Maternal age greater than 30 years at the time of the first pregnancy

2 During their first visit to the prenatal clinic a couple asks the nurse whether the woman should have an amniocentesis for genetic studies. Which factor indicates that an amniocentesis should be performed? 1 Recent history of drug abuse 2 Family history of genetic abnormalities 3 More than three prior spontaneous abortions 4 Maternal age greater than 30 years at the time of the first pregnancy

The nurse is teaching health promotion techniques to the parents of a 5-year-old child. During the follow-up visit, the nurse anticipates that the child has a risk of muscle injury due to overuse. Which statement by the parent supports the nurse's opinion? 1 "I advise my child to walk with his back straight." 2 "I make my child exercise 3 hours per day." 3 "I give my child a glass of whole cow's milk every day." 4 "I encourage my child to sleep 10 to 12 hours per night.

2 Excessive exercise can cause tissue injury and impair muscular development in a child. Cow's milk is a rich source of calcium and helps in bone and teeth formation. The parent should encourage the child to walk with his or her back straight as it helps prevent spine problems in the child. Sleeping 10 to 12 hours per night provides proper rest, which is beneficial for overall growth and development.

A 3-year-old child has been experiencing chronic diarrhea, abdominal distention, and muscle wasting, and a tentative diagnosis of celiac disease has been proposed. The nurse determines that the teaching of the parents will need to include: 1 How to give daily injections 2 The necessity of reading food labels carefully 3 How to pace the child's activities to allow plenty of rest 4 The need for respiratory therapy to keep airways clear of mucus

2 Food labels must be read carefully for hidden sources of gluten. Daily injections are not part of the treatment for celiac disease. Fatigue is not a symptom of celiac disease. Respiratory therapy is not a treatment for celiac disease.

A 6-week-old infant has just been found to have gastroesophageal reflux. What teaching is most important to discuss with the parents at this time? 1 Feeding cereal with a spoon 2 Providing formula thickened with cereal 3 Placing the infant on the back immediately after feedings 4 Explaining changes in care after surgical repair of the esophageal defect

2 For some infants the thickened formula decreases the number of vomiting episodes while increasing caloric intake to support adequate growth. Breast milk can be placed in a bottle and cereal can be added to thicken it. A 6-week-old infant cannot take food from a spoon and swallow it. Placing the infant on the back after feedings increases the risk for aspiration. These infants should not be left alone after feeding. Surgery may be indicated only after more conservative treatments have been tried or if complications, such as respiratory distress, esophagitis, or esophageal stricture, occur.

A client starting her second trimester asks a nurse in the prenatal clinic whether she can safely take an over-the-counter (OTC) medicine now that she is past the first 3 months of pregnancy. The nurse explains why she should consult with her health care provider before taking any oral medications. What physiologic alteration associated with pregnancy may change the client's response to medication? 1 Decreased glomerular filtration rate 2 Longer gastrointestinal emptying time 3 Increased secretion of hydrochloric acid 4 Development of fetal-placental circulation

2 Gastrointestinal motility is reduced during pregnancy because of the high level of placental progesterone and displacement of the stomach superiorly and the intestines laterally and posteriorly; absorption of some drugs, vitamins, and minerals may be increased because of their slow passage through the gastrointestinal tract.

A 16-year-old adolescent sustains an ankle injury while playing soccer. Crutches and no weight-bearing are prescribed by the practitioner. What must the nurse ensure when adjusting the crutches? 1 That they reach to 1 inch below the axillae 2 That they extend to 6 inches from the side of each foot 3 That the elbows are extended when the crutches are held by the crossbars 4 That the shoulders are slightly stooped when the crutches are bearing body weight

2 Having the crutches extend to 6 inches from the sides of the feet ensures the maximal base of support when the adolescent ambulates. Having the crutches reach to 1 inch below the axillae may cause trauma to the brachial plexus; the crutches should be 2 inches below the axillae. The elbows should be flexed, not extended, when the client holds the crossbars. Hunched shoulders indicate that the crutches are too short, which could result in trauma to the brachial plexus.

An unconscious school-aged child is admitted to the pediatric intensive care unit with a closed head injury. Arterial and central venous pressure lines, an indwelling urinary catheter, and a nasogastric tube are inserted. What is the nurse's primary goal for this child? 1 Prevention of unnecessary trauma to the vital organs 2 Limitation of stimuli that increase intracranial pressure 3 Establishment of access routes for infusion of medications 4 Enhancement of the health team's management of the illness

2 Increased intracranial pressure is associated with a high risk for mortality; stimuli must be minimized. Although prevention of trauma to the vital organs, establishment of routes for the delivery of medications, and fulfilling the health team's needs are all important, none is the priority.

What birth weight of a neonate indicates a very low birth weight (VLBW) infant? 1 900 g 2 1300 g 3 1700 g 4 2000 g

2 Infants whose birth weight is less than 1500 g are known as very low birth weight infants. Infants whose birth weight is less than 1000 g are known as extremely low birth weight infants. Infants whose birth weight is less than 2500 g are known as low birth weight infants

During discharge planning the parents of an infant with spina bifida express concern about skin care and ask the nurse what can be done to avoid problems. What is the best response by the nurse? 1 Diapers should be changed at least every 4 hours. 2 Frequent diaper changes with cleansing are needed. 3 Medicated ointment should be applied six times a day. 4 Powder may be used in the perineal area when it becomes wet

2 Infants with spina bifida often exhibit dribbling of urine; they need meticulous skin care and frequent diaper changes to prevent skin breakdown. Changing diapers every 4 hours is insufficient and may result in skin breakdown. Medicated ointments are unnecessary; if a skin irritation develops and an ointment becomes necessary, it should be prescribed by the health care provider. Powder will not keep the skin dry; when powder mixes with urine, it forms a pastelike substance that promotes skin breakdown. Also, powder is toxic if inhaled and should be avoided.

A client has been taking methadone 40 mg/day for treatment of an opioid addiction. During a methadone clinic visit she tells the counselor that she is 3 months pregnant and receiving prenatal care. The counselor notifies the nurse in the prenatal clinic about the client's addiction history. What should the nurse in the prenatal clinic recommend that the client do? 1 Withdraw the methadone slowly over the next several weeks. 2 Continue the prescribed methadone to prevent withdrawal symptoms. 3 Temporarily discontinue the methadone to improve maternal and neonatal outcome. 4 Leave the methadone maintenance program during the pregnancy and reenter it after the birth.

2 Methadone is the only medication approved for the treatment of pregnant women with opioid addiction. Although methadone crosses the placenta, it is considered safer for the newborn than the acute opioid detoxification that would result if the methadone was not administered. Withdrawing the methadone slowly over the next several weeks is not recommended. Detoxification from methadone, a long-acting opioid, takes longer than several weeks. Discontinuing methadone treatment can lead to withdrawal problems and put the client at risk for a return to opioid abuse. If methadone is discontinued during the pregnancy, both client and fetus will be at risk.

What major cause of iron-deficiency anemia should the nurse include when planning a discussion with an infant's parents? 1 Blood disorders 2 Overfeeding of milk 3 Lack of adequate iron reserves from the mother 4 Introduction of solid foods too early for adequate absorption

2 Milk is an inadequate source of iron. Milk ingested in large amounts to the exclusion of solid foods after 4 to 6 months of age results in iron-deficiency anemia. Anemia is a blood disorder. Iron stores received from the mother in the last trimester usually are adequate for the infant's first 4 to 5 months. Lack of absorption of solid foods that are introduced too early is not the cause of anemia in infants.

An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL. What finding does the nurse expect during the initial assessment? 1 Pyrexia 2 Hyperpnea 3 Bradycardia 4 Hypertension

2 Rapid breathing is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.

During her first prenatal visit a client tells the nurse that she needed an exchange transfusion when she was born because of Rh incompatibility. She asks the nurse whether her baby will need one also. How should the nurse respond? 1 "Your baby has a 50% chance of being affected." 2 "You should have no problem, because you're Rh positive." 3 "You'll be given RhoGAM, which will prevent the development of antibodies." 4 "Your baby's cord blood will be tested to determine whether there's going to be a problem."12

2 Rh incompatibility occurs if the mother is Rh negative and becomes sensitized and the infant is Rh positive. Because the client had Rh incompatibility, she is Rh positive, and her infant will not be affected.

Which stage of Freud's psychosexual development theory does the nurse observe in a 3-year-old child? 1 Oral stage 2 Anal stage 3 Phallic stage 4 Latency stage

2 The anal stage of development is seen in a child at 1 to 3 years of age, during the time the child is being toilet trained. The period from birth to 1 year of age, when the child likes sucking, biting, and chewing, is said to be the oral stage. A child is in the phallic stage of development from 3 to 6 years of age. During the phallic stage, the child develops interest in sensitive areas of the body like the genitals. The latency stage of development is seen from 6 to 12 years of age, when the child channels all energy to gain knowledge and play.

A toddler with a history of enlarged lymph nodes, prolonged fever that is unresponsive to antibiotics, erythema of the extremities, and a rash is admitted to the pediatric unit with a diagnosis of Kawasaki disease. What does the nurse suspect was essential in confirming this diagnosis? 1 An increased ASO titer 2 A combination of signs 3 A low-grade temperature 4 An increased sedimentation rate

2 The diagnosis is based on the presence of five of six specific signs: fever, trunk rash, enlarged cervical lymph nodes, bilateral congestion of the conjunctiva, edema, and redness of the extremities. Increased ASO titer is associated with streptococcal infection. Pronounced fever is a sign of Kawasaki disease. Increased sedimentation rate is not specific to Kawasaki disease; the sedimentation rate increases in the presence of inflammation.

A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag? 1 Auscultating for breath sounds 2 Removing the tube, then reinserting it 3 Administering the tube feeding slowly 4 Observing the infant for circumoral cyanosi

2 The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.

A nurse is caring for a newborn with a diaphragmatic hernia and impaired gas exchange. What does the nurse identify as the cause of the infant's decreased gas exchange? 1 Incarcerated hernia 2 Decreased oxygen intake 3 Increased basal metabolic rate 4 Excessive respiratory secretion

2 The presence of abdominal viscera in the thoracic cavity impinges on the lungs and affects their ability to expand, thus limiting the amount of air that can enter the lungs and alveoli. In addition, these newborns tend to have underdeveloped lungs. An incarcerated hernia, although a medical emergency, does not impair gas exchange on a long-term basis. The basal metabolic rate is not increased with a diaphragmatic hernia. Excessive secretions do not occur with a diaphragmatic hernia.

An infant is receiving intermittent nasogastric tube feedings. In what position should the nurse place the infant? 1 Prone 2 Semi-Fowler 3 Left side-lying 4 Supine with the head turned

2 The semi-Fowler position limits the potential for aspiration; because the infant will be partially upright, fluid is held within the stomach by gravity. The prone position permits gastric reflux and may lead to aspiration. The left side-lying position allows gastric reflux and may lead to aspiration. The supine position with the head turned allows gastric reflux and may lead to aspiration.

A nurse has just finished feeding a 4-year-old child through a nasogastric tube. In what position should the child be placed to help ensure retention of the feeding and prevent aspiration? 1 Supine 2 Semi-Fowler 3 Trendelenburg 4 Left side-lying

2 The semi-Fowler position limits the potential for aspiration; the child will be partially upright and fluid will remain in the stomach by means of gravity. The supine, Trendelenburg, and side-lying positions all allow gastric reflux and may lead to aspiration.

The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse? 1 "Touch the tick with a lit cigarette." 2 "Remove the tick carefully with tweezers." 3 "Pour ammonia over the tick, and it will shrivel up." 4 "Spray the tick with insect repellent, and it will fall off."

2 The tick must be carefully removed with tweezers or forceps so the body and head are both removed; this technique prevents further inoculation of the individual. Using a lit cigarette, ammonia, or insect repellent is unsafe; the tick may further inoculate the child, and the method may hurt the child.

A nurse in the prenatal clinic is caring for a pregnant client with well-controlled type 1 diabetes. What does the nurse anticipate for this client? 1 Cesarean birth 2 Intensive prenatal care 3 High perinatal mortality 4 Decreased insulin requirements

2 There is a constant need for evaluation of diabetic status, fetal maturity, and placental function; if the pregnancy is well managed, the outcome should be the same as for a healthy pregnancy. A client with well-controlled diabetes should be able to have a vaginal birth. If the diabetes is well controlled, the risk of perinatal mortality is the same as in the rest of the pregnant population. Insulin requirements vary and usually are increased during the second and third trimesters of pregnancy.

A nurse notes that an infant with a diagnosis of failure to thrive, who has been receiving tube feedings for 3 days, has very dry skin and mucous membranes. The nurse verifies that all feedings have been retained, but the daily urine output is consistently 250 mL and the infant has lost weight. What does the nurse conclude? 1 This is an expected finding in an infant with failure to thrive. 2 The infant is dehydrated and the fluid intake needs to be increased. 3 This finding is a reflection of the infant's inability to absorb nutrients. 4 The infant is undernourished and a higher caloric intake will be required.

2 These are classic signs of dehydration; the health care provider should be notified, because a prescription to increase fluids is needed. It is not common for the condition of an infant with failure to thrive to continue to deteriorate once therapy has been implemented. Although the infant may have a gastrointestinal problem, the classic signs of dehydration must be addressed before this conclusion is reached. These signs indicate dehydration, not undernutrition.

Trimethoprim/sulfamethoxazole (Bactrim) is prescribed for a child with a urinary tract infection. Which statement by the parent about the drug indicates that the nurse's instructions about administration have been understood? 1 "Mealtime is a good time to give the medication." 2 "I'll make sure to give each pill with 6 to 8 oz of fluid." 3 "It must be taken with orange juice to ensure acidity of urine." 4 "The drug has to be taken every 4 hours to maintain a blood level.

2 This drug does not have to be given with meals; it is administered every 12 hours. This is a sulfa drug; water must be encouraged to prevent crystallization in the kidneys. Orange juice causes an alkaline urine; water is the best fluid to be administered with this drug. This drug maintains the blood level for 8 to 12 hours; it is an intermediate-acting drug.

A 7-year-old child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. The nurse concludes that the presence of the oculocephalic reflex in an unconscious child is: 1 Unusual 2 Expected 3 Suppressed 4 Hyperactive

2 This reflex indicates the functional integrity of the brainstem in unconscious individuals. Failure of the eyes to lag adequately or to revert to midline on rapid side-to-side movement of the head suggests brainstem damage. It is not unusual in the unconscious child; it is absent in conscious individuals, whose extraocular movements are controlled voluntarily. Extraocular movements are not suppressed in unconscious individuals. This reflex is not hyperactive in the unconscious individual.

The mother of a 17-year-old adolescent who is going to be a foreign exchange student asks the nurse why her child must have a tetanus toxoid immunization instead of tetanus immunoglobulin. The nurse responds that the tetanus toxoid immunization provides: 1 Lifelong passive immunity 2 Longer-lasting active immunity 3 Temporary active natural immunity 4 Temporary passive natural immunity

2 Toxoids are modified toxins that stimulate the body to form antibodies that can last up to 10 years against the specific disease. Because the adolescent will be in a foreign country, the tetanus toxoid is given prophylactically. The tetanus toxoid provides active, not passive, immunity; all passive immunity is short acting. Only by having the disease can a person gain natural immunity.

A nurse in the emergency department is assessing a 10-month-old infant who was injured in an automobile collision. The infant, who is quiet but does not appear lethargic, has a large hematoma on the left temporal area. What sign of neurological involvement is the most critical to identify? 1 Babinski reflex 2 Persistent vomiting 3 Heart rate of 110 beats/min 4 Temperature of 99.6° F (37.6° C)

2 Vomiting frequently accompanies a head injury because of increased intracranial pressure and stimulation of the vomiting reflex. A temperature of 99.6° F (37.6° C), presence of the Babinski reflex, and a heart rate of 110 beats/min are all expected in a 10-month-old infant.

28-year-old woman comes into the clinic and tells the nurse that she fears that she is infertile because she has been trying to become pregnant for 2 years. While collecting the health history the nurse learns that the client experiences irregular and infrequent menstrual periods. The client is overweight and has severe acne and alopecia. The health care provider diagnoses polycystic ovarian syndrome (PCOS). Which of the following interventions is the most important? 1 Consoling the client over her inability to have children 2 Discussing weight loss, exercise, and a balanced low-fat diet 3 Providing information to the client on how to prepare for surgery 4 Informing client that there are no long-term complications of PCOS

2 Weight loss, exercise, and a balanced low-fat diet can reduce insulin and androgen levels related to PCOS. Meeting with a dietitian may be helpful. Surgery is not necessary at this time. The health care provider would most likely prescribe hormones, other medications, or both. If pregnancy does not occur, surgery is an option. Pregnancy may be possible with hormones, other medications, or both. Early detection of PCOS is important because the condition can lead to type 2 diabetes, hypertension, cardiovascular disease, and ovarian, breast, and endometrial cancers. Encourage treatment compliance, and encourage positive lifestyle changes.

Which characteristics does the nurse observe in a patient who has secondary amenorrhea? 1 No uterine bleeding for 4 years after breast development 2 Absence of menstrual bleeding for three cycles after menarche 3 Absence of uterine bleeding and secondary sex characteristics at the age of 16 4 No uterine bleeding for 1 year after attaining a sexual maturity rating of 5 on the Tanner scale

2 When the patient's menstrual cycle is absent three successive times after menarche, it indicates secondary amenorrhea. The absence of uterine bleeding 4 years after breast development indicates primary amenorrhea. The absence of uterine bleeding and secondary sex characteristics at the age of 16 years indicates primary amenorrhea. No uterine bleeding for 1 year after attaining a sexual maturity rating of 5 on the Tanner scale is indicative of primary amenorrhea.

A severely dehydrated infant with gastroenteritis is admitted to the pediatric unit. Nothing-by-mouth (NPO) status is prescribed. The parents ask why their baby cannot be fed. The nurse explains that this is necessary to: 1 Correct electrolyte imbalances. 2 Allow the intestinal tract to rest. 3 Determine the cause of the diarrhea. 4 Prevent perianal irritation from the diarrhea.

2 Withholding food reduces the need for intestinal activity, which rests the intestines and minimizes diarrhea and the loss of fluid. Although intravenous therapy will be started for rehydration and to correct electrolyte imbalances, this is not the reason for the NPO status. Stool cultures are used to determine the cause of the diarrhea. Perianal irritation is prevented with meticulous skin care, not by withholding food and fluids.

A nurse in the prenatal clinic reviews second-trimester physiological changes in the hematological system before explaining them to a client. What change should the nurse identify? 1 Increased hematocrit 2 Increased blood volume 3 Decreased white blood cells 4 Decreased sedimentation rate

2 he blood volume increases by approximately 50% during pregnancy; peak blood volume occurs between 30 and 34 weeks' gestation. The hematocrit decreases as a result of hemodilution. The white blood cell count remains stable during the prenatal period. The sedimentation rate increases because of a decrease in plasma proteins.

A nurse in the pediatric clinic receives a call from the mother of a 12-month-old infant who has had a fever, runny nose, cough, and white spots in the mouth for 3 days. A rash started on the face and has now spread to the entire body. Which communicable infection does the nurse suspect? 1 Rubella 2 Rubeola 3 Pertussis 4 Varicella

2 white spots-Koplik spots and coryza-mucous discharge

Which screening report will help the nurse determine skeletal growth in a child? 1 Electroencephalogram reports 2 Radiographs of the hand and wrist 3 Magnetic resonance imaging (MRI) 4 Denver Developmental Screening Test

22 Skeletal growth in a child can be determined from the ossification centers. At 5-6 months, the capitate and hamate bones in the wrist are the earliest centers. Therefore, radiographs of the hand and wrist will help determine skeletal growth in the child. Electroencephalogram reports will help assess a child's brain activity.MRI is used to scan the internal structures of a patient. The Denver Developmental Screening Test is used to understand developmental issues of a child.

What are the different patterns of physical development and maturation of neuromuscular functions in a child? Select all that apply. 1 Sensorimotor 2 Proximodistal 3 Cephalocaudal 4 Differentiation 5 Undifferentiated

234 Proximodistal development refers to near-to-far development in the infant. The infant first gains motor control of the shoulder and then the hands. Additionally, the infant's central nervous system (CNS) develops more rapidly than the peripheral nervous system (PNS). Cephalocaudal is the head-to-tail growth seen in a child. The infant achieves control of the head first, followed by the trunks and extremities. Infants gain control of their hands before they are able to control their feet. Differentiation refers to the development from simple operations to more complex activities and functions. For instance, early embryonal cells develop into an immensely complex organism made up of highly specialized and diversified cells, tissues, and organs. Sensorimotor development is not a pattern of development, but a part of the theory of cognitive development as proposed by Piaget. Fowler proposed the undifferentiated stage of spiritual development, in which the child has no concept of right and wrong to guide the child's behavior.

Which aspects of the "self" do children assess while forming an evaluation of their self-esteem? Select all that apply. 1 Body image 2 Moral worth 3 Competence 4 Sense of control 5 Worthiness of love

2345 A child's self-esteem is based on certain aspects of the personality. Moral worth helps develop self-esteem when children question if their actions and behaviors meet the established moral standards. Children assess their competence to understand the adequacy of their cognitive, physical, and social skills. One's sense of control is assessed by understanding if one can complete tasks needed to produce desired actions. Worthiness of love is important in developing self-esteem, as the child questions if he or she is worthy of the parent's love and acceptance from peers. Body image is an important element in shaping personality during adolescence, but not during childhood.

A nurse teaches a pregnant woman about the need to increase her intake of complete proteins. Which foods identified by the client indicate that the teaching is effective? Select all that apply. 1 Nuts 2 Milk 3 Eggs 4 Bread 5 Beans 6 Cheese

236 Milk contains animal proteins, which are complete proteins that contain all of the essential amino acids. Eggs contain animal proteins, which are complete proteins that contain all the essential amino acids. Cheese contains milk, which is a complete protein that contains of all the essential amino acids. Nuts are incomplete proteins. Bread is not a complete protein. Beans are not complete proteins unless eaten in a specific combination with soy products.

he nurse, teaching a client in early pregnancy about the need to increase her intake of complete proteins, asks the client to identify foods that contain these proteins. Which response indicates that client understands the teaching? Select all that apply. 1 Spinach and broccoli 2 Milk, eggs, and cheese 3 Beans, peas, and lentils 4 Fish, hamburger, and chicken 5 Whole-grain cereals and breads

24 Milk, eggs, and cheese are complete proteins containing all nine indispensable (essential) amino acids. Likewise, fish, hamburger, and chicken are complete proteins containing all nine indispensable (essential) amino acids. Plant proteins are incomplete proteins. Whole-grain cereals and breads are incomplete proteins, and they contain comparatively small amounts of protein.

An adolescent child is in the terminal stage of cancer. The parents ask how they will know when death is imminent. The nurse discusses the physical manifestations with the parents. What are the signs and symptoms of approaching death? Select all that apply. 1 Thirst 2 Weak pulse 3 Increased pulse rate 4 Difficulty swallowing 5 Loss of bladder contro

245 As the flow of blood through the body decreases, the vital centers in the brain, including the centers for thirst and appetite, become dulled; as a result, the child loses the desire for fluid and food. As nerve impulses become weaker, the entire digestive tract is slowed and the child has difficulty controlling the act of swallowing (deglutition), resulting in dysphagia; also, the gag reflex is lost. The loss of sensation and control starts in the lower extremities and progresses upward; control of the bladder and bowel is lost as loss of control reaches the trunk. As circulation slows, oxygenation and muscle tone decrease; the heart loses its contractile force, and the pulse becomes weaker and slower. Bradycardia, not tachycardia, occurs as the heart fails.

What are the different stages of cognitive development in an infant as described by Piaget? Select all that apply. 1 Narcissism 2 Separation 3 Attachment 4 Using symbols 5 Object permanenc

245 The first stage of cognitive development is separation, in which infants learn that they are separate from the objects in their environment. Using symbols or mental representation to think of an object without actually experiencing it is the last stage of intellectual development and occurs at 12 months of age. In the object permanence stage the infant understands that the objects exist even after they are outside the visual field. Narcissism refers to total control for oneself, which is seen in infants at the first stage of psychosocial development. Attachment is a development of the social aspects in a child, and is not a stage of cognitive development.

During a follow-up visit, the nurse observes that a toddler still has improper bone development, even after proper nutritional counseling to the mother. Which foods, when omitted, are responsible for this condition in the infant? Select all that apply. 1 Fish 2 Waffles 3 Dried fruits 4 Red meats 5 Orange juice

25 Calcium plays an important role in bone development in the body. Foods such as waffles and orange juice are rich in calcium sources. Therefore, the mother should feed the child these foods to help the development of the skeletal system. Fish, dried fruits, and red meats are not rich sources of calcium; therefore, these foods do not aid in bone development. Instead, they aid in preventing iron-deficiency anemia in the body.

uring a follow-up visit, the nurse observes that a toddler still has improper bone development, even after proper nutritional counseling to the mother. Which foods, when omitted, are responsible for this condition in the infant? Select all that apply. 1 Fish 2 Waffles 3 Dried fruits 4 Red meats 5 Orange juice

25 Calcium plays an important role in bone development in the body. Foods such as waffles and orange juice are rich in calcium sources. Therefore, the mother should feed the child these foods to help the development of the skeletal system. Fish, dried fruits, and red meats are not rich sources of calcium; therefore, these foods do not aid in bone development. Instead, they aid in preventing iron-deficiency anemia in the body.

6-year-old child is in the acute phase of nephrotic syndrome. The mother asks the nurse about play activities for her child. What should the nurse suggest? Select all that apply. 1 Hula hoop 2 Video games 3 Large puzzles 4 Stuffed animal 5 Children's books

26 Age-appropriate video games do not require excessive energy to play and will help a 6-year-old child avoid boredom. Children's books are appropriate for 6-year-old children because at this age they are beginning to read. Also, the parents may read to the child. This activity does not require energy. Playing with a hula hoop requires energy that a child in the acute phase of nephritic syndrome does not have. Large puzzles are more appropriate for toddlers who are developing fine motor skills. A stuffed animal is more appropriate for an infant or toddler. It is a passive toy that will not be stimulating for a 6-year-old child.

2-month-old infant is to receive the second hepatitis B vaccination. What muscle should the nurse select for the injection? 1 Deltoid 2 Ventrogluteal 3 Vastus lateralis 4 Dorsal quadriceps

3

6-year-old boy is hospitalized with an exacerbation of nephrotic syndrome. The mother asks the nurse what she should bring for her son to play with during the hospitalization. What should the nurse suggest? 1 Plastic bat, cloth ball, and a hula hoop 2 Stuffed animals, large puzzles, and blocks 3 Checkers, simple card games, and crayons 4 Children's magazines, a model plane kit, and laptop computer

3

99. A 9-year-old child with a tentative diagnosis of leukemia is to undergo bone marrow aspiration. What information should the nurse give the child before the procedure? 1 "There'll be a few stitches at the site after the test, but you'll be able to walk after the test." 2 "You'll be given a local anesthetic before the test, and you may feel some pressure during the test." 3 "You'll be given medication to relax you before the test, and you'll remember nothing afterward." 4 "There will be a prescription for you to stay in bed for several hours after the test, but you may still turn from side to side."

3

A 14-year-old adolescent is severely injured in a motor vehicle collision. There are multiple fractures, contusions, and muscle spasms, causing the teenager to refuse to move. How can the nurse best support the adolescent and encourage movement? 1 Allowing friends to visit daily 2 Explaining that some pain is inevitable 3 Permitting decision-making regarding care 4 Setting specific limits regarding this behavio

3

A 38-year-old client attends the prenatal clinic for the first time. A nurse explains that several tests will be performed, one of which is the serum alpha-fetoprotein test. The client asks what the test will reveal. What should the nurse include in the reply? 1 Trisomy 21 2 Turner syndrome 3 Open neural tube defects 4 chromosomal aberrations

3

A Girl Scout leader arrives at the hospital's emergency department with a 7-year-old child who may have a broken ankle. The history reveals that the child fell about 1 mile from the camp while on a hike with the scout leader and four other 7-year-olds. The nurse asks whether all of the other children are safely back in camp. Assuming that the scout leader acted appropriately, the nurse expects the scout leader to respond: 1 "I left the girls and brought the injured child to the hospital." 2 "I sent two of the girls back to camp and had them ask for help." 3 "I carried the injured girl and led the rest of the girls back to camp." 4 "I stayed with the injured girl and sent the four other girls back to camp for help."

3

A couple in their late 30s who wish to have a child are referred for genetic counseling. They tell the nurse that they have a family history of an inheritable problem but have reservations about genetic counseling because they believe that genetic clinics favor abortion when the studies reveal a defective fetus. How should the nurse respond regarding genetic counseling? 1 Abortion is suggested only when the fetus is found to have a severe defect that is not compatible with life. 2 Recommendations are made to consider adoption when defects are predicted. 3 Families are helped to understand the diagnosis, the probable cause of the disorder, and how the condition can be managed. 4 After the probability of a defect is determined, the couple's own practitioner helps the couple decide on the appropriate action.

3

A nurse is caring for several pregnant clients in the prenatal clinic. Which client causes the most concern because of her predisposition to placenta previa? 1 19 year old, gravida 1, para 0 2 25 year old, gravida 2, para 1 3 30 year old, gravida 6, para 5 4 40 year old, gravida 2, para 1

3

A nurse is providing nutritional counseling to a low-income pregnant client who has iron-deficiency anemia. What food should the nurse encourage the client to include in her diet each day to best address this problem? 1 Two hard-boiled eggs 2 ⅓ cup of red grapes 3 ½ cup of red kidney beans 4 3 oz of skinless chicken breas

3

During a routine second-trimester visit to the prenatal clinic a client expresses concern about gaining weight and losing her figure. She says to the nurse, "I'm going on a diet." What is the nurse's best response? 1 "That's fine as long as you include a variety of foods daily." 2 "It's a good idea for you to keep your weight down during your pregnancy." 3 "If you add 340 calories a day to your regular diet, you won't become overweight." 4 "Gain no more than 25 lb so that it'll be easier to lose the weight after the baby's born."

3

Using the five-digit system, determine the obstetric history in this situation: The client is 38 weeks into her fourth pregnancy. Her third pregnancy, a twin gestation, ended at 32 weeks with a live birth, her second pregnancy ended at 38 weeks with a live birth, and her first pregnancy ended at 18 weeks. 1 G4, T2, P1, A1, L2 2 G4, T1, P2, A1, L1 3 G4, T1, P1, A1, L3 4 G4, T2, P1, A1, L1

3

hat question should a nurse in the prenatal clinic ask during the first few minutes of taking a client's health history? 1 "Did you do a home pregnancy test?" 2 "What brings you to the clinic today?" 3 "When did you have your last period?" 4 "How do you feel about being pregnant?"

3

he mother of an 8-year-old child with the diagnosis of acute poststreptococcal glomerulonephritis (APSGN) is concerned that a 4-year-old sibling may also have the disorder. When preparing to explain the disease process the nurse recalls that it is caused by: 1 A systemic infection causing clots in the small renal tubules 2 A factor that is unknown and therefore is difficult to prevent 3 An immune complex disorder occurring after a group A β-hemolytic Steptococcus infection 4 An autosomal recessive trait, meaning that there is an increased probability that a sibling will also have the disease

3

hich instruction does the nurse give to the parents to help their child get accustomed to a new babysitter? 1 "Ask the babysitter to stand very close to the child." 2 "Ask the babysitter to hold out arms and smile broadly." 3 "Stay close and allow the child to observe the babysitter." 4 "Discourage the child from clinging in front of the babysitter."

3

The nurse finds that a 2-year-old child has impaired fine motor skills. The nurse recommends toys that will be beneficial for the child. Which statement by the child's parents needs correction? 1 "I should provide musical toys." 2 "I should provide straddle trucks." 3 "I should provide battery-operated cars." 4 "I should provide thick crayons and finger paints."

3 Passive toys such as battery-operated cars should not be provided as they do not stimulate musculoskeletal development. Musical toys can improve coordination. Straddle trucks improve locomotive skills. Thick crayons and finger paints improve fine motor skills.

While teaching parents about the developmental milestones of a 15-month-old child, the nurse informs the parents about various activities that their child should be able to do. Which statement of the parent indicates effective learning? 1 "My child can jump with both feet." 2 "My child can walk up stairs with one hand held." 3 "My child can creep up stairs and kneel without support." 4 "My child goes up and down stairs alone with two feet on each step."

3 A 15-month-old child has the ability to creep up stairs and kneel without support due to the development of gross motor skills. The child starts jumping with both feet at the age of 30 months. The child will start walking up stairs with one hand held at the age of 18 months. The calf muscles develop sufficiently for the child to walk up and down stairs alone at the age of 24 months.

While interacting with a 4-year-old child, the nurse observes that the child exhibits which behavior congruent with Piaget's cognitive development theory? 1 The child is beginning to use language to communicate. 2 The child uses abstract symbols and draws conclusions. 3 The child is unable to see things from others' perspectives. 4 The child is able to classify and sort facts to solve problems

3 A 4-year-old child has his or her own perspective and expects that others also think the same way. This behavior is seen in the preoperational stage of Piaget's development theory. A 1- to 2-year-old child who is in the sensorimotor stage, according to Piaget's theory, will begin to use language. An adolescent who is in the formal operations stage of Piaget's developmental theory will use abstract symbols and draw conclusions. The ability to draw conclusions from abstract symbols is not a finding in a 4-year-old. The ability to classify and sort problems is developed between the ages of 7 and 11 years. A child who is in the concrete operations stage of Piaget's development theory will exhibit the ability to classify and sort facts to solve problems.

The nurse is assessing a newborn and anticipates that the newborn has renal impairment. Which finding supports the nurse's conclusion? 1 The newborn has colorless urine. 2 The newborn has odorless urine. 3 The newborn first voids after 76 hours. 4 The newborn's urine has specific gravity of 1.020.

3 A newborn should void within 24 hours. However, in this case, the newborn first voids after 76 hours, indicating renal impairment. The urine should be colorless and odorless. This indicates that the urine is normal and the child has normal renal function. Normally the specific gravity of urine is 1.020.

After an above-the-knee amputation for bone cancer, an adolescent boy is returned to his room. He is monitored closely because of the potential for hemorrhage from the residual limb. What should the nurse plan to keep at the bedside? 1 Hemostat 2 Vitamin K 3 Pressure dressing 4 Protamine sulfate

3 A pressure dressing will control hemorrhage until surgical intervention can be instituted. A hemostat is not practical because bleeding may be internal. Vitamin K is the antidote for warfarin (Coumadin). There is no indication that the client is taking Coumadin. Protamine sulfate is the antidote for an excessive amount of heparin; the client is not receiving heparin.

nurse on the pediatric unit is admitting an adolescent child with acute glomerulonephritis (AGN). What is the priority nursing intervention? 1 Assessing the child for dysuria 2 Inspecting the child for jaundice 3 Monitoring the child for hypertension 4 Testing the child's vomitus for occult blood

3 Acute hypertension, which may occur in children with AGN, must be anticipated and identified early to prevent complications. If the child has dysuria, it should be documented, but it is not the priority problem. The child with AGN does not exhibit jaundice. Vomiting is not a characteristic of AGN.

client at 38 weeks' gestation is admitted to the prenatal unit with preeclampsia. A loading dose of magnesium sulfate is administered, and the dosage is subsequently lowered to a maintenance dosage. What is the most important parameter for the nurse to assess while monitoring the client for magnesium sulfate toxicity? 1 Pulse rate 2 Daily weight 3 Patellar reflex 4 Blood pressure

3 An absence of deep tendon reflexes is one of the first signs of magnesium sulfate toxicity. Magnesium sulfate interferes with the release of acetylcholine at the synapses, thereby decreasing neuromuscular irritability. Magnesium sulfate toxicity cannot be determined by alterations in the maternal heart rate or blood pressure. Diuresis and its related weight loss are signs of the therapeutic effect of magnesium sulfate.

What should a nurse include in nutritional planning for a newly pregnant woman of average height who weighs145 lb? 1 A decrease of 100 calories per day 2 A decrease of 200 calories per day 3 An increase of 300 calories per day 4 An increase of 500 calories per day

3 An increase of 300 calories per day is the recommended caloric increase for adult women to meet the increased metabolic demands of pregnancy. A decrease of 100 to 200 calories per day will not meet the metabolic demands of pregnancy and may harm the fetus. An increase of 500 calories per day is the recommended caloric increase for breastfeeding mothers.

Parents are considering a bone marrow transplant for their child who has recurrent leukemia. The parents ask the nurse for clarification about the procedure. What is the best response by the nurse? 1 "Bone marrow transplantation is rarely performed in children these days." 2 "The hematopoietic stem cells are surgically implanted in the bone marrow." 3 "Your child's immune system must be destroyed before the transplantation can take place." 4 "It is a simple procedure with little preparation needed, and the stem cells are infused as in a blood transfusion."

3 An intensive preparatory regimen is needed to destroy the child's immune system. Once the process is started, no rescue therapy except for the transplant is provided. The procedure is performed in children for recurrent malignancies. The child's bone marrow must be clear of all cells before transfusion of the stem cells is performed.

A client at 32 weeks' gestation visits the prenatal clinic because she is having uterine contractions. She is to be treated at home with restricted activity and long periods of bedrest. What instructions should the teaching plan include when the client is advised to remain in bed? 1 Raise the foot of the bed on blocks. 2 Sit with several large pillows supporting the back. 3 Assume a side position, with the head raised on a small pillow. 4 Assume the knee-chest position several times a day for a few minutes.

3 Bedrest keeps the pressure of the fetus off the cervix, minimizing cervical dilation; the side-lying position enhances uterine perfusion. Raising the foot of the bed on blocks will impede respiration and is not advised. Sitting will increase pressure on the cervix. Assuming the knee-chest position several times a day for a few minutes may help relieve the pressure of the fetus on the cervix, but it will not enhance uterine perfusion and is not recommended.

What does the nurse inform the parent of an infant who is at risk for infections? 1 "You must avoid placing the infant in bright sunlight." 2 "Use soy-based infant formulas to help prevent infection." 3 "Breastfeeding will provide protection against bacteria." 4 "The infant will be less susceptible to infections later in life

3 Breast milk contains immunoglobulin G (IgG) that protects the infant against many bacteria, such as Escherichia coli. The nurse instructs the parent to avoid placing the infant in bright sunlight for a long period of time to avoid burns, but not to prevent infections. Soy-based infant formulas are used only if the infant is allergic to lactose in the breast milk, and is not used to prevent the risk for infections. Later, susceptibility would be dependent on multiple factors, including nutrition and exposure to infections.

A nurse is helping an adolescent with type 1 diabetes establish a consistent meal pattern. What feedback from the adolescent indicates that further teaching is needed? 1 Weighs portion sizes for several months 2 Reads nutrition labels on prepared foods 3 Avoids complex carbohydrate substitutes 4 Limits sugar alternatives containing sorbito

3 Complex carbohydrates may be substituted, depending on caloric content and amount eaten per serving. Flexibility is needed to promote adherence to any dietary regimen. Using consistent portion sizes is a key to maintaining diabetic control. By weighing and measuring portion sizes for several months the adolescent learns to recognize the acceptable amount to be eaten at a glance. The adolescent should read nutrition labels carefully, especially for their carbohydrate and caloric content. Most dietetic foods contain sorbitol. Sorbitol metabolizes to fructose and then glucose, so its use should be restricted when possible.

0-year-old child with acute glomerulonephritis (AGN) is selecting foods for dinner from a menu. Which foods should the nurse encourage? 1 Baked potato, meatloaf, banana, and pretzels 2 Baked ham, bread and butter, peaches, and milk 3 Corn on the cob, baked chicken, rice, apple, and milk 4 Hot dog on a bun, potato chips, dill pickle slices, and brow

3 Corn, chicken, rice, apples, and milk are permitted on the low-sodium, low-potassium diet that the child should be following. Bananas and potatoes are high in potassium, and pretzels are high in sodium. Only the peaches are low in sodium, and all but the butter are fairly high in potassium. Processed foods are high in sodium and fairly high in potassium.

The alkylating agent cyclophosphamide (Cytoxan) is prescribed for a school-aged child with cancer. What is the most important sign or symptom for the nurse to be alert for while the child is receiving this medication? 1 Irritability 2 Unexpected nausea 3 Pain with urination 4 Hyperplasia of the gum

3 Cystitis is a potentially serious adverse reaction to cyclophosphamide (Cytoxan); it sometimes can be prevented by increasing hydration, because the fluid flushes the bladder. Irritability may be present but is not a result of cyclophosphamide administration. Unexpected nausea is an expected but manageable side effect of cyclophosphamide. Hyperplasia of the gums is unrelated to cyclophosphamide administration; it may occur with prolonged phenytoin (Dilantin) therapy.

An infant has been vomiting after each feeding. Physical assessment reveals poor skin turgor, a sunken anterior fontanel, and tremors. The infant's acid-base balance is outside the expected range. What does the nurse suspect as the cause of this imbalance? 1 Retention of potassium in the cells 2 Loss of fluid by way of the kidneys 3 Loss of chloride ions through vomiting 4 Reduction of blood supply to body cells

3 Electrolyte deficits, rather than urinary excretion, precipitate an acid-base imbalance. Loss of gastric secretions, which contain sodium, chloride, and potassium, usually results in metabolic alkalosis. With vomiting, a depletion of cellular potassium occurs. Electrolyte deficits, rather than inadequate blood supply, can precipitate an acid-base imbalance.

The primary health care provider instructs the nurse to apply an emollient to an infant. During assessment, the nurse finds that the neonate is preterm and has a body weight of 900 g. Which is the appropriate nursing intervention in this situation? 1 Administer intravenous fluids before applying emollient. 2 Avoid applying emollient to dry, flaking, and fissured areas of the skin. 3 Monitor for coagulase-negative staphylococcus infection. 4 Do not apply emollient and recheck with the primary health care provider.

3 Emollients can cause coagulase-negative staphylococcus infection in a preterm infant who weighs less than or equal to 900 g. Intravenous fluids do not increase the effectiveness of emollients, so there is no need to administer intravenous fluids before applying the emollient. Emollients effectively reduce dry, flaking, and fissured areas on the infant's skin. Emollients are not contraindicated in preterm infants, so there is no need to avoid application or to recheck with the primary health care provider.

What is the priority nursing action for an infant recently admitted with a diagnosis of diarrhea caused by a Salmonella infection? 1 Monitoring oral fluid intake 2 Establishing a play schedule 3 Establishing a skin care routine 4 Obtaining a recent food history

3 Enzymes in the stool may irritate the skin; maintaining skin integrity is the priority. Oral fluid intake usually is not instituted for 24 to 48 hours to avoid stimulating the intestinal tract. Establishing a play schedule is not the priority of care. Physiological problems, such as altered skin integrity, should be addressed first. Although obtaining a food history is important, it is not the priority.

A 1-month-old infant is fed breast milk exclusively. The parent asks the nurse if fluoride supplementation is required. What is the best response from the nurse? 1 "Fluoride supplementation is needed in hot climates." 2 "There is no need to give fluoride if the child appears fine." 3 "Fluoride supplementation may result in dental fluorosis." 4 "The child may need fluoride supplementation after 3 months of age."

3 Fluoride supplementation before 6 months of age may result in dental fluorosis. Fluoride supplementation is not associated with hot climates. The appearance of the child does not determine the need for fluoride. Fluoride supplementation is necessary only if the breastfeeding mother's water supply does not contain the required amount of fluoridation, and not after 3 months of ag

he nurse is giving nutritional counseling to the parents of an 8-month-old infant. Which statement does the nurse include in the counseling? 1 "You can give low-fat cow's milk to your baby." 2 "Avoid giving puréed vegetables to your baby." 3 "Avoid peanuts and eggs in your baby's diet." 4 "You can give pasteurized whole cow's milk to your baby.

3 Foods such as peanuts, eggs, fish, and seafood can result in food allergy in infants. Therefore, these foods should not be given until 12 months of age. An 8-month-old infant can digest puréed vegetables; therefore, they can be given to the infant. Low-fat cow's milk can result in brain impairment in infants due to inadequate fat supplementation. Pasteurized whole cow's milk is low in iron, zinc, and vitamin C and may result in iron deficiency anemia in the infant.

A mother brings her 6-month-old infant to the emergency department with a 3-day history of gastroenteritis. What priority intervention does the nurse anticipate? 1 Placement in a heated crib 2 Withdrawal of blood for testing 3 Insertion of an intravenous catheter 4 Institution of intestinal decompression

3 Gastroenteritis causes a disturbance in intestinal motility and absorption, accelerating excretion and fluid loss, which quickly leads to severe dehydration and fluid and electrolyte imbalance. Intravenous fluids are necessary. A 6-month-old infant does not need the protection of a heated crib; heated cribs are used for newborns and preterm infants. Withdrawal of blood may be done later; it is not the priority in this life-threatening situation. Intestinal intubation with suction is not necessary. Intestinal decompression is used to remove intestinal contents when there is an obstruction or when it is necessary to have the gastrointestinal tract clear of contents.

A practitioner recommends that an adolescent with the diagnosis of osteogenic sarcoma have the affected leg amputated and then be treated with chemotherapy. The parents are concerned about what to tell their child and ask the nurse for advice. The nurse suggests that they discuss the: 1 Causes of cancer and details about the treatment 2 Chemotherapy and the possibility of an amputation 3 Amputation and provide information about chemotherapy 4 Treatment choices and explain that it is too soon for a final decision

3 Honesty is essential in helping the adolescent accept the loss of the leg; only a brief discussion of chemotherapy is needed because otherwise the adolescent may be overwhelmed. A theoretical discussion and detailed information will not be heard or understood during a crisis situation. The amputation is necessary; lying avoids the issue and may destroy the adolescent's trust in parents and staff.

A client at the prenatal clinic has mild preeclampsia. What should the nurse teach her to do in regard to her fluid and nutritional intake? 1 Restrict fluid intake. 2 Stay on a low-salt diet. 3 Continue the pregnancy diet. 4 Increase carbohydrate consumption

3 If the client with mild preeclampsia is following the recommended pregnancy diet, she should continue it. Fluids should not be restricted during pregnancy. Salt restriction may activate an angiotensin response, which could cause an increase in blood pressure; moderate salt intake is recommended. There is no reason for the client with mild preeclampsia to increase her intake of carbohydrates.

A child watches an older sibling playing with a ball, but makes no effort to participate in the play. What social character of play is the child exhibiting? 1 Parallel play 2 Pretend play 3 Onlooker play 4 Associative play

3 In onlooker play a child actively observes other children playing and does not attempt to enter into the activity; the child is interested only in observation and not in participation. In parallel play children play independently among other children. In pretend play children act out any event of daily life and practice the roles and identities as established in their surroundings. In associative play children play together and are engaged in a similar or identical activity.

A nurse in the prenatal clinic assesses clients for signs of preeclampsia. What sign, other than increased blood pressure, may indicate preeclampsia? 1 Positive nonstress test 2 Negative contraction stress test 3 Weight gain of 6 lb in 1 month 4 Fetal heart rate below 120 beats/min

3 In preeclampsia, renal blood flow and the glomerular filtration rate are decreased, resulting in fluid retention and rapid weight gain. A positive nonstress test and negative contraction stress test each indicate fetal well-being. The fetal heart rate in a healthy fetus ranges from 110 to 160 beats/min.

The nurse is caring for an infant undergoing laser therapy for port-wine stain. Which instruction does the nurse give to the infant's parents? 1 Avoid trimming the fingernails during the laser therapy. 2 Use salicylate pain medications for the infant during the laser therapy. 3 Avoid any trauma to the lesion by picking at the scab during the therapy. 4 Apply sunscreen to the infant while going in sunlight during the therapy.

3 Laser therapy can effectively reduce port-wine stain in an infant. Picking at the scab during therapy increases the risk of infection. Therefore, the parents should avoid any trauma to the lesion. Salicylates can reduce the effectiveness of the therapy; therefore, they should not be used during therapy. The infant may have access to the lesions with the fingernails. Therefore the fingernails should be trimmed frequently during the therapy. During therapy, the child should not be exposed to sunlight as it aggravates the condition.

A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. What should the nurse teach the parents? 1 An ileal bladder will be necessary once the child is of school age. 2 An indwelling catheter offers the best hope for bladder management. 3 The child will probably require a program of intermittent straight catheterization. 4 The child will have to wear diapers for many years because bladder training is a slow process.

3 Most children with spinal cord damage resulting from spina bifida can be managed successfully with a program of intermittent straight catheterization. An ileal bladder is not necessary because most of these children can be managed successfully with intermittent straight catheterization. An indwelling catheter is the least desirable approach because of the risk for recurrent urinary tract infection. Stating that the child will have to wear diapers for many years is inaccurate and may be devastating to the parents.

A 5-year-old child is being given dactinomycin (Cosmegen) and doxorubicin (Adriamycin) therapy after nephrectomy for Wilms tumor. What should the nursing care include? 1 Administering aspirin for pain 2 Offering citrus juices with meals 3 Ensuring meticulous oral hygiene 4 Eliminating spicy foods from the diet

3 Oral hygiene is essential, especially during the administration of medications that have a negative effect on the oral mucosa. Although pain may be present, aspirin is avoided because doxorubicin (Adriamycin) is also being used, and a side effect of this medication is thrombocytopenia. Aspirin is contraindicated for children because it is associated with Reye syndrome. Citrus juice will aggravate stomatitis, which is a common side effect of dactinomycin (Cosmegen). Spicy foods may aggravate the stomatitis that occurs with chemotherapy. However, usually any food that the child requests is permitted.

A 4-year-old boy with acute lymphocytic leukemia (ALL) is to undergo bone marrow aspiration. While involving the child in therapeutic play before the procedure, the nurse should help him understand that: 1 He needs to have a positive attitude. 2 His parents are concerned about him. 3 He did nothing to cause his current illness. 4 His problem was caused by an environmental factor

3 Preschoolers (ages 3 to 5 years) are in the preoperational stage of cognitive development; it consists of a preconceptual phase that involves egocentric thought and the phase of intuitive thought, which transitions to the more logical thought of school-age children. Four-year-old children often believe that they cause their own illnesses. Emphasizing that the child did not cause the illness will help elicit and eliminate any fantasy he might have; it helps the child understand that treatment is not a punishment. Telling a 4-year-old to have a positive attitude is inappropriate and does not elicit feelings. Although parental concern is important, it does not address the developmental concerns of a 4-year-old child. Environmental factors are not currently supported as a cause of ALL; it is an inappropriate discussion for a 4-year-old child.

A pregnant woman with a history of heart disease visits the prenatal clinic at the end of her second trimester. What does the nurse anticipate about the care she will need? 1 Preparation for a cesarean birth 2 Bedrest during the last trimester 3 Prophylactic antibiotics at the time of birth 4 Increasing dosages of cardiac medications as pregnancy progresses

3 Prophylactic antibiotics are given to clients with heart disease to reduce their risk for bacterial endocarditis. A vaginal birth, with a shortened second stage and an assisted birth involving forceps or vacuum extraction, is preferred. The data do not indicate which class of heart disease the client has; if it is class I and there is no cardiac decompensation, activities may be restricted but bedrest is not necessary. Increasing the dosages of the client's cardiac medications may or may not be necessary; dosages are based on each individual's response to the stress imposed by pregnancy.

The nurse should assess an infant with gastroesophageal reflux for what complication? 1 Bowel obstruction 2 Increased hematocrit 3 Respiratory problems 4 Abdominal distention

3 Reflux of gastric contents to the pharynx predisposes the infant to aspiration and the development of respiratory problems. There is no risk for a bowel obstruction; the problem is an incompetent esophageal sphincter. An increased hematocrit is not expected unless there is severe dehydration. Abdominal distention does not occur, because gastric contents are forcefully vomited.

A 15-year-old high school student with hay fever has been taking a prescribed long-acting antihistamine/decongestant every 8 hours for the past 2 days. The adolescent tells the nurse, "This medicine is making me sleepy. Can you change it to something else?" How should the nurse respond? 1 "Take half a tablet before school." 2 "Try omitting the early-morning dose." 3 "The drowsiness usually goes away after several days." 4 "I'll ask the doctor for a prescription for another medicine.

3 Telling the adolescent that the drowsiness will likely disappear after a few days addresses the adolescent's concern; central nervous system depressant effects may diminish or spontaneously disappear after several days of therapy. Nurses do not have the legal authority to instruct a client to alter the dosage of a prescribed medication. Requesting a prescription for another medicine is unnecessary because the side effect of drowsiness should diminish within several days.

pregnant client is making her first antepartum visit. She has a 2-year-old son born at 40 weeks, a 5-year-old daughter born at 38 weeks, and 7-year-old twin daughters born at 35 weeks. She had a spontaneous abortion 3 years ago at 10 weeks. How does the nurse, using the GTPAL format, document the client's obstetric history? 1 G4 T3 P2 A1 L4 2 G5 T2 P2 A1 L4 3 G5 T2 P1 A1 L4 4 G4 T3 P1 A1 L4

3 The acronym GTPAL stands for gravidity, term births, preterm births, abortions, and living children; G5 T2 P1 A1 L4 indicates that there the client has had five pregnancies (twins count as one pregnancy and the current pregnancy counts as one); two term births; one preterm birth (the twins); one abortion; and four living children. G4 T3 P2 A1 L4 indicates that there were four, not five, pregnancies; three, not two, term births; twins counted as one, not two, preterm birth; one abortion; and four living children. G5 T2 P2 A1 L4 indicates that there were five pregnancies; two term births; twins counted as one, not two, preterm births; one abortion; and four living children. G4 T3 P1 A1 L4 indicates that there were four, not five, pregnancies; three, not two, term births; twins counted as one preterm birth; one abortion; and four living children.

An adolescent who has sickle cell anemia is recovering from a painful episode. What does the nurse see as the priority issue for this adolescent? 1 Restriction of movement during periods of arthralgia 2 Separation from family during periods of hospitalization 3 Alteration in body image resulting from skeletal deformities 4 Interruption of education as a result of multiple hospitalization

3 The adolescent is concerned with body image and fears change or mutilation of body parts. The occlusions in the microvasculature associated with sickle cell anemia can cause bone deformities. Restriction of movement is not a major problem because when the pain is relieved and the crisis is over, activity is resumed. Teenagers can tolerate extended periods of separation from the family. Although learning interruptions may be a concern for a teenager, altered body image is a more feared threat.

efore administering a nasogastric feeding to a preterm infant the nurse aspirates a small amount of residual fluid from the stomach. What is the nurse's next action? 1 Returning the aspirate and withholding the feeding 2 Discarding the aspirate and administering the full feeding 3 Returning the aspirate and subtracting the amount of the aspirate from the feeding 4 Discarding the aspirate and adding an equal amount of normal saline solution to the feeding

3 The aspirate should be returned to ensure that the gastric enzymes and acid-base balance are maintained. The amount of the aspirate returned should be subtracted from the volume to be administered in the next feeding. Withholding the feeding will compromise the infant's fluid and electrolyte balance, as will discarding the aspirate from the full feeding. Discarding the aspirate and adding an equal amount of normal saline solution to the feeding will compromise the infant's fluid and electrolyte balance.

2-year-old child is admitted with gastroenteritis and dehydration. Peripheral intravenous fluids are prescribed. What is the most appropriate site for the first intravenous insertion? 1 Scalp vein near the fontanel 2 Venous arch on top of the foot 3 Dorsal metacarpals of the hand 4 Basilic vein at the antecubital fossa

3 The choice of first insertion site should be distal (low) on the periphery of an extremity and progress proximally (upward) toward the trunk; the upper extremities are the most appropriate sites for intravenous insertions for adults and children older than 1 year. Scalp veins are used for infants only if peripheral veins are inaccessible. Foot veins should not be used once a child is walking. The antecubital fossa should be avoided because the arm will have to be immobilized to stabilize the intravenous insertion site to prevent an infiltration.

A school-age child is admitted to the pediatric oncology unit with end-stage cancer. Although the child's pain is being managed with a continuous infusion of morphine, breakthrough pain occurs, and a fentanyl (Actiq) "lollipop" is prescribed. How should the nurse instruct the child to use the lollipop when pain occurs? 1 Chew it and then swallow every 4 hours. 2 Suck on it for a half an hour every 6 hours. 3 Hold it in the cheek only until the pain is relieved. 4 Place it in the mouth and suck on it until it dissolves.

3 The fentanyl lozenge is absorbed through the buccal mucosa; once the pain is relieved the lozenge should be removed and kept until it is needed again. The lozenge should be sucked, not chewed. There is no specific length of time to suck on the lozenge. The lozenge should not remain in the mouth once the pain is relieved.

After returning from surgery an infant suddenly becomes cyanotic. What is the nurse's priority intervention? 1 Checking vital signs 2 Administering oxygen 3 Suctioning the nasopharynx 4 Placing the infant in the side-lying position

3 The most likely cause of cyanosis is secretions in the airway. The airway must be cleared of secretions for effective air exchange. Taking vital signs is unsafe because valuable time is lost while the infant's brain is deprived of oxygen. Oxygenation is ineffective if secretions are not first cleared from the airway. The side-lying position helps promote drainage of secretions, but this intervention should be undertaken only after the airway is cleared.

A nurse is teaching a prenatal class about the types of pain blocks that provide perineal anesthesia during labor. Which type of pain block should the nurse include in the discussion that will provide perineal anesthesia but allow the client to feel contractions and push during the second stage of labor? 1 Saddle 2 Epidural 3 Pudendal 4 Paracervical

3 The pudendal block relieves vaginal and perineal pain but does not impair the ability to push during the second stage of labor. The saddle block relieves pain from the umbilicus to the lower perineum and inner thigh; the client may have difficulty pushing during the second stage of labor. The epidural block relieves pain from the umbilicus to the midthigh; the client may have difficulty pushing during the second stage of labor. The paracervical block relieves uterine pain; it does not relieve perineal pain.

A 9-year-old child is admitted to the pediatric unit with a diagnosis of acute glomerulonephritis. What does the nurse expect the admission urinalysis to reveal? 1 Polyuria 2 Ketonuria 3 Hematuria 4 Bacteriuria

3 The urine is cloudy, smoky, or the color of tea because of the presence of erythrocytes and casts from the affected kidney tissue. Oliguria and increased blood pressure occur as a result of kidney impairment. Excessive metabolism of fats does not occur in glomerulonephritis. At this time there is no infection in the urinary tract.

An infant has been admitted for dehydration as a result of acute gastroenteritis and vomiting, and the nurse administers lactated Ringer's solution intravenously. The nurse concludes that the treatment has been effective after noting: 1 Tenting turgor 2 Pink mucous membranes 3 Three wet diapers in 24 hours 4 Capillary refill greater than 2 second

3 Three or more wet diapers in 24 hours indicates that fluid balance is improving and that the kidneys are functioning. Capillary refill of more than 2 seconds, fewer than three wet diapers in a day, and tenting turgor are all signs of dehydration, not of improvement.

While mopping the kitchen floor, a client at 37 weeks' gestation experiences a sudden sharp pain in her abdomen with a period of fetal hyperactivity. When the client arrives at the prenatal clinic, the nurse examines her and detects fundal tenderness and a small amount of dark-red bleeding. What does the nurse conclude is the probable cause of these clinical manifestations? 1 True labor 2 Placenta previa 3 Partial abruptio placentae 4 Abdominal muscular injury

3 Typical manifestations of abruptio placentae are sudden sharp localized pain and small amounts of dark-red bleeding caused by some degree of placental separation. True labor begins with regular contractions, not sharp localized pain. There is no pain with placenta previa, just the presence of bright-red bleeding. There are no data to indicate that the client sustained an injury.

A 16-year-old girl with sickle cell anemia is experiencing a painful episode (vaso-occlusive crisis) and has a patient-controlled analgesia (PCA) pump. She complains of pain (5 on a scale of 1 to 10) in her right elbow. The nurse observes that the pump is "locked out" for another 10 minutes. What action should the nurse implement? 1 Turning on the television for diversion 2 Calling the health care provider for another analgesic prescription 3 Placing the prescribed as-needed warm, wet compress on the elbow 4 Informing her gently that she must wait until the pump reactivates to get more medication

3 Vasodilation should help reduce pain from cellular clumping; applying a warm, wet compress will address the pain until the pump can be activated. Television may be an adequate distractor for mild pain, not moderate or severe pain. Nursing measures should be attempted first to relieve the pain before the health care provider is called. Telling the adolescent to wait provides no comfort.

While assessing an infant, the nurse finds the presence of white, adherent patches on the tongue, palate, and inner aspects of the cheeks. The mother also states that the infant is refusing to suck the milk. Which medication does the nurse expect to be prescribed? 1 Acyclovir (Zovirax) 2 Vidarabine (Vira-A) 3 Nystatin (Mycostatin) 4 Fluconazole (Diflucan

3 White, adherent patches on the tongue, palate, and inner aspects of the infant's cheeks indicate oral candidiasis or thrush. Oral candidiasis is caused by a fungus called candida albicans. Nystatin (Mycostatin) is an antifungal agent prescribed to treat oral thrush in an infant. Acyclovir (Zovirax) and vidarabine (Vira-A) are antiviral agents and are not used to treat oral candidiasis in the infant. Fluconazole (Diflucan) can effectively treat oral thrush but its use in infants is not approved by the Food and Drug Administration.

A 9-month-old infant has been prescribed iron supplements. The nurse teaches the infant's parents the measures to follow. During follow-up visits, the nurse observes that the iron deficiency anemia in the infant has not improved despite the treatment regimen. Which action of the parents does the nurse expect to be the reason for the lack of improvement? 1 Administering iron supplements through a straw 2 Administering iron supplements along with orange juice 3 Administering iron supplements with whole cow's milk 4 Administering iron supplements at the back of the mouth

3 Whole cow's milk binds with free iron and reduces drug absorption. Therefore, the infant has developed drug insufficiency for maximum therapeutic action. Administering iron supplements through a straw does not reduce drug absorption; it prevents the iron from staining the infant's teeth. Orange juice increases the absorption of iron supplements. Administering iron supplements at the back of the mouth does not reduce drug absorption; it prevents the iron from staining the infant's teeth.

nurse is planning play activities for a 6-year-old child whose energy level has improved after an acute episode of gastroenteritis. What activity should the nurse encourage? 1 Using a set of building blocks 2 Finger-painting on a large paper surface 3 Drawing and writing with a pencil or marker 4 Taking apart and putting together a wooden truc

3 Writing and drawing pictures provides a 6-year-old, who is of school age, with an appropriate way to express feelings. Playing with blocks is appropriate for preschoolers, who have active imaginations. Finger-painting is appropriate for preschoolers, who enjoy experimenting with different textures. Manipulating pieces of a toy is appropriate for preschoolers, who like repetition.

A nurse at the well-child clinic determines a 1-year-old infant's length to be below what is expected. The current height is 28 inches, and the birth length was 20 inches. What should this infant's current length be? Record your answer using a whole number. ___ inches

30 This infant is 2 inches shorter than expected. At 1 year of age an infant should have increased the birth length by 50%; 50% of 20 inches is 10 inches; 10 inches added to the birth length of 20 inches equals 30 inches.

A 2-month-old infant is admitted to the pediatric unit with gastroenteritis and dehydration. Which assessment finding should the nurse anticipate? 1 Bulging fontanels 2 Marked restlessness 3 Resilient tissue turgor 4 Tachycardi

34 Tachycardia is expected with dehydration because of a decrease in circulating fluid volume. Bulging fontanels are associated with increased intracranial pressure, not dehydration; the fontanels are depressed with dehydration. Because of loss of fluid and electrolytes, the infant is lethargic, not restless. Resilient tissue turgor is associated with an adequate fluid balance.

A newly arrived Russian immigrant attends the prenatal clinic for the first time. Although she states that she has had immunizations, she does not know which ones. Which immunizations should the nurse recommend? Select all that apply. 1 Mumps 2 Measles 3 Diphtheria 4 Hepatitis B 5 Chickenpo

34 The diphtheria vaccine and hepatitis B vaccine contain dead viruses and can be administered safely. The mumps, measles, and chickenpox vaccines are all contraindicated because they contains live virus, which is teratogenic.

After surgical repair of a urinary tract malformation, a school-aged child is to be discharged with an indwelling catheter. The nurse teaches the parents the necessary interventions if urine does not appear in the drainage bag for 1 hour or more. Place the interventions in the order that they should be performed. 1. Offering more fluids 2. Calling the practitioner 3. Checking for blocked drainage tubing 4. Pressing on the abdominal wall just above the bladder

3412 Kinking or twisting of the tubing can result in obstruction of urine flow; the parents can solve this problem by unkinking the tube. If the tubing is not kinked, the bladder should be checked for distention. Slight pressure on the abdominal wall just above the bladder may increase intraabdominal pressure, promoting urine flow. Fluids should be offered because the child should be kept hydrated to produce urine. If no urine is produced within 1 hour, the practitioner should be called because the parents have been unable to solve the problem.

The nurse is examining a teenage patient who has a gawky, long-legged appearance. What is the sequence of growth changes that lead to this characteristic early adolescent appearance? 1. Increase in the depth of the chest 2. Increase in the width of the shoulders 3. Growth of the neck, hands, and legs in length 4. Increase in the breadth of the hips and chest 5. Increase in the length of the trunk

34251 There is a characteristic sequence in the growth changes that occur during adolescence. The lengthwise growth of the neck and extremities occurs before growth in other areas of the body. This is followed by an increase in the breadth of the hips and chest. Months later there is an increase in shoulder width. Then the trunk increases in length. Finally there is an increase in the depth of the chest. This sequential growth pattern results in the characteristic gawky, long-legged appearance of early adolescence.

A 24-year-old client who has been told that she is pregnant is at her first prenatal visit. She is 5 feet 6 inches tall and weighs 130 lb. What should the nutrition plan regarding her daily caloric intake include? 1 100 more calories during the first trimester 2 540 more calories during the third trimester 3 300 more calories during the three trimesters 4 340 more calories during the second trimester

4

A client at 32 weeks' gestation is admitted to the prenatal unit in preterm labor. An infusion of magnesium sulfate is started. What physiologic response indicates to the nurse that the magnesium sulfate is having a therapeutic effect? 1 Dilation of the cervix by 1 cm every hour 2 Tightening and pain in the perineal area 3 A decrease in blood pressure to 120/80 mm Hg 4 A decrease in frequency and duration of contractions

4

A father expresses concern that his 2-year-old daughter has become a "finicky eater" and is eating less. How should the nurse respond? 1 "Your daughter has become manipulative." 2 "She's probably experiencing the stress of a typical 2-year-old." 3 "She may have an eating problem that requires a referral to a specialist." 4 "Your daughter's behavior is expected in response to her slower growth."

4

A pregnant client with diabetes is referred to the dietitian in the prenatal clinic for nutritional assessment and counseling. What should the nurse emphasize when reinforcing the client's dietary program? 1 The need to increase high-quality protein and decreasing fats 2 The need to increase carbohydrates to meet energy demands and prevent ketosis 3 The need to eat a low-calorie diet that maintains the current insulin coverage and helps prevent hyperglycemia 4 The need to eat a pregnancy diet that meets increased dietary needs and to adjust the insulin dosage as necessary

4

A primigravida at 12 weeks' gestation complains of nausea and vomiting during a visit to the prenatal clinic. Which pregnancy hormone should the nurse explain is thought to be responsible for nausea and vomiting during the first trimester? 1 Estrogen 2 Progesterone 3 Human placental lactogen (hPL) 4 Human chorionic gonadotropin (hCG)

4

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? 1 Mental readiness 2 Physical readiness 3 Parental readiness 4 Psychological readiness

4

A worried mother reports that her teenage child wears unusual clothes and makeup and refuses to wear the clothes the mother buys. What does the nurse suspect as the cause for this behavior? 1 The child is establishing self-image in relation to others. 2 The child is establishing gender role identification. 3 The child is identifying him- or herself as a separate entity from the mother. 4 The child is displaying group identity in order to develop a personal identity.

4

The nurse instructs parents to avoid placing their infant in a prone position while sleeping. Which risk does the nurse seek to prevent with this instruction? 1 Otitis media of the ear 2 Conjunctivitis of the eye 3 Infantile colic or baby colic 4 Sudden infant death syndrome

4

The nurse is explaining to the mother of two teenage children why her daughter's height is comparatively less than her son's height. What is the reason for lower overall height in girls compared to boys? 1 Increase in muscle mass 2 Hypertrophy of the laryngeal mucosa 3 Maturation of structural appendages of the skin 4 Closure of epiphyses due to estrogen secretion

4

The nurse is teaching a prenatal class to expectant mothers in their first trimester of pregnancy. In addition to discussing the need for 0.6 mg/day of folic acid replacement, which dietary choice that is high in folic acid should the nurse recommend? 1 One egg 2 Slice of bread 3 Half cup of corn 4 Half cup of cooked spinach

4

The parents inform the nurse that their child is often seen daydreaming. What does the nurse inform the parents? 1 "The child is engaged in onlooker play." 2 "The child needs to play with other children." 3 "The child may have some neurological issues." 4 "The child is exhibiting normal behavior seen in children."

4

The parents inform the nurse that their child often engages in 'doctor play' with other kids, with an aim to learn more about the sexual organs. The parents have often expressed their disapproval to the child, but it has no effect on the child's behavior. What does the nurse suggest to the parents? 1 "Offer a reward for not engaging in such activities." 2 "Tell the child it is dangerous to engage in such activities." 3 "Encourage the child to engage in some other sports activity." 4 "Tell the child to talk about any questions related to sexuality

4

The parents of a school-age child tell the nurse that their child is tall, broad, and very active in sports, and so they are planning to enroll the child for strenuous competitive athletics. What is the best response from the nurse? 1 "The child may not be interested." 2 "The child requires more rest periods." 3 "The child has a brilliant sports career." 4 "The child is not ready for strenuous activities.

4

When assessing the development of a school-age child, the nurse concludes that the child has normal development according to Fowler's spiritual development theory. Which behavior helped the nurse reach this conclusion? 1 The child imitates the religious gestures of elders. 2 The child does not differentiate between right and wrong actions. 3 The child has spiritual disappointment and modifies religious practices. 4 The child believes God will punish bad behavior and reward good behavior.

4

nurse in the clinic is taking the health history of a 16-year-old girl. When the nurse asks questions concerning sexual activity, the adolescent begins to perspire and hyperventilate. As her anxiety increases, she indicates that she feels dizzy and short of breath and that her heart is racing. What condition does the nurse identify? 1 Metabolic alkalosis 2 Respiratory acidosis 3 Pulmonary hypertension 4 Hyperventilation syndrom

4

A nurse at the fertility clinic is counseling a couple about the tests that will be needed to determine the cause of their infertility. Which test should the nurse describe that will be used to evaluate the woman's organs of reproduction? 1 Biopsy 2 Cystogram 3 Culdoscopy 4 Hysterosalpingogram

4 A hysterosalpingogram enables the examiner to visualize the uterus and fallopian tubes and the pelvic organs of reproduction. A biopsy is the surgical excision of tissue for diagnostic purposes. A cystogram is used to visualize the urinary bladder. Culdoscopy is the direct examination of female pelvic viscera with the use of an endoscope introduced through a perforation in the vagina.

A client who is pregnant for the first time attends the prenatal clinic. She tells the nurse, "I'm worried about gaining too much weight, because I've heard that it's bad for me." How should the nurse respond? 1 "Yes, too much weight gain causes complications during pregnancy." 2 "You'll have to follow a low-calorie diet if you gain more than 15 lb." 3 "We're more concerned that you won't gain enough weight to ensure adequate growth of your baby." 4 "A 25-lb weight gain is recommended, but the pattern of weight gain is more important than the total amount."

4 A sudden sharp increase in weight may indicate fluid retention related to preeclampsia. Weight gain is necessary to ensure adequate nutrition for the fetus.

While assessing the development of a child, the nurse finds that the child is imitating the actions of her elders. Which stage, according to Erickson's developmental theory, does the nurse expect the child is in? 1 Initiative versus guilt 2 Industry versus inferiority 3 Identity versus role confusion 4 Autonomy versus shame and doubt

4 According to Erickson's developmental theory, a child who is 1 to 3 years old is in the autonomy versus shame and doubt stage. The child will have control over his or her body and environment. Therefore, the child starts imitating elders in an attempt to learn and do things for him- or herself. A 3- to 6-year-old child is in the initiative versus guilt stage according to Erickson's theory of development. The child who is in the initiative versus guilt stage will try to explore things with all of the senses. A 6- to 12-year-old child is in the industry versus inferiority stage according to Erickson's theory of development. Industry versus inferiority is a higher stage of development where the child will perform tasks to attain real achievements, not mere imitation. A child who is 12 to 18 years old is in the identity versus role confusion stage of Erickson's developmental theory. In this stage, the child becomes preoccupied with personal appearance.

An 8-year-old child who has been undergoing chemotherapy will soon return to school after a prolonged absence. Classmates are aware that the child is being treated for cancer. How should the school nurse prepare the class for the child's return to school? 1 Encourage the students to think about how they feel toward their classmate. 2 Explain to the students why it is important to tolerate those who are different. 3 Ask the students not to make fun of their classmate because of lost weight and having no hair. 4 Initiate a discussion with the students about cancer treatments and the side effects of chemotherapy.

4 According to Piaget's cognitive development theory, school-age children use concrete operational thinking; a general discussion in concrete terms will be understood and transferred to the actual situation. These children are capable of understanding a concrete explanation; this request belittles them. The other options require conceptual thinking, which is just beginning to develop during the school-age years; 8-year-old children are not ready for this thought process.

An 8-year-old child is being prepared for surgery the next day. How should the nurse present preoperative instructions to this child? 1 By repeating instructions often 2 By providing time for needle play 3 By using several abstract examples 4 By focusing on simple anatomical diagrams

4 According to Piaget, an 8-year-old child's level of development is in the stage of concrete operations; the child will benefit from simple, concrete examples. The preschooler and younger child, not the school-age child, require repetition. Therapeutic needle play is more appropriate if and when the child is to receive an injection. The child who is in the period of concrete operations cannot think in the abstract; the ability to do this develops during adolescence.

A nurse is obtaining a health history from a primigravida on her first visit to the prenatal clinic. Before discussing the client's health habits with her, what does the nurse consider the most important factor in the survival of the client's newborn? 1 Reproductive history 2 Adequacy of prenatal care 3 Health habits and social class 4 Gestational age and birthweight

4 Adaptation to the extrauterine environment is dependent on the functional capacity of vital organ systems, which is established during intrauterine development; this is measurable in terms of the newborn's gestational age and weight. Although reproductive history, adequacy of prenatal care, and health habits and social class may all influence health, none is the most critical to neonatal survival.

A child with acute poststreptococcal glomerulonephritis requests a snack. Which is the most therapeutic selection of food the nurse can provide? 1 Peanuts 2 Pretzels 3 Bananas 4 Applesauce

4 Applesauce provides nutrition without large additional amounts of potassium and sodium. Peanuts and pretzels are high in sodium, which increases fluid retention. Bananas are high in potassium, which is contraindicated.

The parents of a preschooler tell the nurse that they try to inculcate good eating habits by asking the child to be at the table until the "plate is clean." What condition is the child at risk for? 1 Anorexia 2 Depression 3 Aggression 4 Poor eating habits

4 Asking the child to be at the table until the "plate is clean" results in overeating and develops poor eating habits later in life. Anorexia is seen if the child does not consume the required amount of food. Depression is seen in a child if there are any psychological issues. Aggression is seen due to sociocultural and familial influences on the child.

4-year-old child with Wilms tumor undergoes nephrectomy. What essential information should the nurse plan to teach the parents? 1 Prepare for a kidney transplant. 2 Restrict the child's intake of sodium. 3 Maintain the child's fluid restrictions. 4 Recognize the signs of urinary tract infection

4 Because the child now has one kidney, the parents must watch carefully for signs and symptoms of urinary tract infection (UTI) on an ongoing basis. A UTI can compromise kidney function; therefore, it should be identified in the early stage and treated immediately. A kidney transplant is not necessary because the child has a functioning kidney. Sodium is usually not restricted. Fluids are not restricted; adequate fluid intake is encouraged to prevent UTI.

A nurse suspects that a 7-month-old infant who is brought to the well-baby clinic for the first time has a hearing deficit. What behavior leads the nurse to come to this conclusion? 1 The infant does not always turn the head when called by name. 2 The mother says that the infant is unable to learn the word "mama." 3 The infant fails to demonstrate the Moro reflex in response to hand clapping. 4 The mother says the infant stopped making verbal sounds about a month ago.

4 Deaf infants commonly babble until they are about 6 months old but then stop because their vocalizations are not reinforced with hearing. Learning to say one word starts at about 11 to 12 months of age. Infants with no hearing impairment do not respond to their names all the time. The Moro reflex is not expected at 7 months; it usually disappears when the infant is 3 to 4 months old.

The registered nurse is teaching a student nurse about adhesives to be used for preterm infants. Which statement by the student nurse indicates effective learning? 1 "I should remove the adhesive with solvents or bonding agents." 2 "I should remove the adhesive within 24 hours after application." 3 "I should avoid semipermeable dressings to secure intravenous lines." 4 "I should secure pulse oximeter probes with elasticized dressing material."

4 Elasticized dressing material can effectively secure pulse oximeter probes or electrodes with minimum skin irritation in preterm infants. Adhesive removers, solvents, or bonding agents may result in skin damage in a preterm neonate. Therefore, the adhesives are removed using water, mineral oil, or petrolatum. The adhesive should not be removed for at least 24 hours after application. Semipermeable dressings can be used to secure intravenous lines and silicone catheters in a preterm neonate.

A nurse teaches an adolescent undergoing chemotherapy for cancer about the need for special mouth care because of the potential for oral lesions. What statement indicates to the nurse that the instructions have been understood? 1 "I'll use a toothbrush to brush my teeth and tongue." 2 "I need to rinse my mouth out with a mild mouthwash." 3 "I need to rinse my mouth out with hydrogen peroxide." 4 "I can use foam-tipped applicators to wipe my teeth and gums.

4 Foam is soft, so it will not damage the oral mucosa. A toothbrush will injure the oral mucosa. Mouthwash may irritate the oral mucosa and should be avoided. Hydrogen peroxide will irritate the mucosa, has an offensive taste, and should be avoided.

A 7-year-old child contracts a urinary tract infection. A sulfonamide preparation is prescribed. What is the priority nursing responsibility when the nurse is administering this drug? 1 Weighing the child daily 2 Giving the medication with milk 3 Taking the child's temperature frequently 4 Administering the drug at the prescribed time

4 For the desired blood level to be maintained, the medication must be administered in the exact amount at the times directed. If the blood level of the drug falls, the microorganisms have an opportunity to build resistance to the drug. Weighing is important with drugs that affect fluid balance, such as diuretics. Sulfa medications should be given on an empty stomach to promote absorption. Monitoring the temperature is important with antipyretic drugs.

chool nurse teaches a 13-year-old child with hay fever that the prescribed phenylephrine (Neo-Synephrine) nasal spray must be used exactly as directed. What complication may occur if the nasal spray is used incorrectly? 1 Tinnitus 2 Nasal polyps 3 Bleeding tendencies 4 Increased nasal congestion

4 Frequent and continued use of phenylephrine (Neo-Synephrine) can cause rebound congestion of mucous membranes. Tinnitus is not a side effect of phenylephrine nasal spray; however, hypotension, tachycardia, and tingling of the extremities may occur. Nasal polyps may be associated with allergies but are unrelated to phenylephrine nasal spray. Bleeding tendencies are unrelated to the use of phenylephrine nasal spray.

The alkylating chemotherapeutic agent cyclophosphamide (Cytoxan) is prescribed for a school-aged child with cancer. What is the most important nursing assessment while the child is receiving this medication? 1 Extent of alopecia 2 Changes in appetite 3 Hyperplasia of gums 4 Daily intake and outpu

4 Hemorrhagic cystitis is a potentially serious adverse reaction to cyclophosphamide (Cytoxan) that can sometimes be prevented with increased fluid intake because the fluid flushes the bladder. The extent of hydration can be measured with hourly documentation of intake and output. Alopecia is expected; however, it is a benign side effect and the hair will regrow when therapy is completed. A change in appetite is expected but is not a serious side effect of cyclophosphamide administration. Hyperplasia of the gums is unrelated to cyclophosphamide administration; it occurs with phenytoin (Dilantin) therapy.

Which is an inborn error of metabolism that affects growth and development? 1 Cystic fibrosis 2 Achondroplasia 3 Turner syndrome 4 Hunter syndrome

4 Hunter syndrome is an inborn error of metabolism that hinders development and results in altered physical appearance and impaired mental development. Cystic fibrosis is a genetic disorder that results in accumulation of mucus in the lungs and pancreas. Achondroplasia is a congenital disorder that is a common cause for the structural defect called dwarfism. Turner syndrome is a chromosomal abnormality associated with webbed neck and low-set ears.

pregnant client with type 1 diabetes is visiting the prenatal clinic for the first time. What is the primary long-term goal for this client? 1 Insulin dosages will decrease. 2 Dietary fluctuations will be minimized. 3 The blood glucose level will remain stable. 4 Pregnancy will end with the birth of a healthy infant.

4 In any prenatal situation, the goal is an optimally healthy mother and newborn, no matter what other factors are involved.

1-year-old infant with a distended abdomen is admitted to the pediatric unit with the diagnosis of Hirschsprung disease. In which position should the nurse place the infant? 1 Prone 2 Sitting 3 Supine 4 Latera

4 In the lateral position the distended abdomen does not press against the diaphragm, facilitating lung expansion. The prone position is difficult to assume with a distended abdomen; also, the weight of the body will limit lung expansion. The sitting position is not conducive to easy breathing and is difficult to assume with abdominal distention. The distended abdomen will press against the thighs and then the diaphragm, which will hinder full lung expansion. The supine position will interfere with respiration because the abdominal distention will exert pressure against the diaphragm.

nurse is completing the discharge protocol for a 14-year-old adolescent with osteomyelitis. The nurse teaches the parents how and when to administer the intravenous antibiotic at home. The schedule for administration is four times a day. At what times should the parents administer the antibiotic? 1 8 am, 12 pm, 4 pm, 8 pm 2 8 am, 4 pm, 12 am, 4 am 3 10 am, 2 pm, 10 pm, 2 am 4 6 am, 12 pm, 6 pm, 12 am

4 Intravenous antibiotics should be administered with doses equally spaced over 24 hours so a constant blood level of the drug is maintained. The 12 hours between the 8 pm and 8 am doses in the 8 am, 12 pm, 4 pm, and 8 pm dosing schedule is too long; the blood level of the antibiotic will drop and the therapy will not be as effective. Administering doses at 8 am, 4 pm, 12 am, and 4 am or at 10 am, 2 pm, 10 pm, and 2 am will not work because the doses are not equally spaced over 24 hours and the blood level of the antibiotic will not remain constant.

A 28-year-old woman who has phenylketonuria (PKU) visits the fertility clinic for genetic counseling. After deciding that she wants to become pregnant, she tells the nurse that she ate a low-phenylalanine diet until she was 18 years old. What is the nurse's best response? 1 Eat a regular pregnancy diet after becoming pregnant. 2 Start the low-phenylalanine diet during the third trimester. 3 Maintain a low-protein diet starting in the second trimester. 4 Return to the low-phenylalanine diet before becoming pregnant.

4 It is essential that a woman with PKU return to a low-phenylalanine diet before becoming pregnant; phenylalanine crosses the placenta, and a high blood level can damage the fetus, especially during organogenesis. Eating a regular pregnancy diet can endanger the fetus. Starting the low-phenylalanine diet in the third trimester is too late to protect the fetus. Advising a client to eat a low-protein diet is too vague, and starting the diet in the third trimester is too late to protect the fetus.

A nurse is caring for an infant with gastroenteritis and diarrhea. What should the nurse evaluate to determine the magnitude of the infant's fluid loss? 1 Tissue turgor 2 Hematocrit value 3 Moistness of mucous membranes 4 Weight compared with prior weigh

4 Loss of weight is the most accurate measurement of the magnitude of fluid loss; 1 L of fluid weighs 2.2 lb. Tissue turgor is subjective measure of dehydration and not as accurate as a comparison with the preillness weight. Although an increased hematocrit and dry mucous membranes each indicate dehydration, neither is an effective tool for assessing the amount of fluid loss.

A client visits the prenatal clinic for the first time. The client tells the nurse that her last menstrual period began June 10. The nurse uses Nägele's rule to calculate the EDB. What is the EDB? 1 April 7 2 March 7 3 April 10 4 March 17

4 Month-3 day+7

A nurse provides a list of foods for a breastfeeding client with phenylketonuria (PKU) to avoid. Which nutrient is included on the list? 1 Lactose 2 Glucose 3 Fatty acids 4 Amino acid

4 PKU is an inborn error of metabolism involving an inability to metabolize phenylalanine, an essential amino acid. Lactose, glucose, and fatty acids are all metabolized by people with PKU.

An infant who has undergone surgical correction of a myelomeningocele is to be discharged. What information should the nurse include when preparing the parents to care for their infant at home? 1 The need to limit the infant's fluid intake to formula 2 The need to provide a quiet environment to limit external stimuli 3 The positions to be avoided to help prevent the infant from turning 4 How to perform range-of-motion exercises for the lower extremities

4 Passive range of motion, positioning, and stretching may help decrease the risk of muscle contractures in the lower extremities. Fluid intake should be unrestricted to provide adequate kidney function and prevent constipation. The infant needs stimulation to develop mentally and socially. Development of mobility should be encouraged; the infant's movements should not be restricted.

The parents of a toddler ask the nurse about the importance of play for a child. What is the best answer by the nurse? 1 "The child will develop creative skills later in life." 2 "The children will learn and adopt their friends' cultures." 3 "There is little evidence that play influences intelligence." 4 "Play activities will help release the child's surplus of energy."

4 Play activities develop the sensorimotor functions and help to release the child's surplus of energy. Children develop creative skills while engaging in play, as they can experiment and try out their ideas through playful actions. Children learn about different cultural values through play, but are not mature enough to adopt them. Play stimulates intellectual development, as children learn about colors, shapes, sizes, textures, and the meaning of objects.

A toddler receives a gastrostomy tube feeding every 4 hours. What is the priority nursing intervention for this child? 1 Opening the tube 1 hour before feeding 2 Keeping the child lying flat during the feeding 3 Flushing the tube with normal saline after the feeding 4 Positioning the child on the right side after the feeding

4 Positioning the child on the right side after feeding facilitates digestion because the pyloric sphincter is on this side and gravity aids emptying of the stomach. The feeding may be started immediately after the tube is opened. Keeping the child lying flat during the feeding may result in aspiration; the child's head and torso should be elevated. If the gastrostomy tube is flushed before or after a feeding, water, not normal saline, is used.

An adolescent is admitted with an acute hemophilia episode. Rest, ice, compression, and elevation will be most helpful in: 1 Encouraging immobilization 2 Decreasing swelling and inflammation 3 Providing pain relief and reduce anxiety 4 Controlling bleeding and retaining joint functio

4 Rest, ice, compression, and elevation (RICE) therapy is implemented to support joints and prevent bleeding into joints. Total immobilization is not required. Pain may be relieved to some degree but is not assured. Reducing inflammation is not the goal of treatment for the hemophiliac process.

A mother complains to the nurse that her 4-year-old child partially awakens from sleep, sweats profusely, and screams in the night. What is the best nursing action in this situation? 1 Recommend that the mother take her child into her own bed. 2 Ask the child to describe the dream that he or she saw last night. 3 Advise the mother to accept the child's dream as a real fear of the child. 4 Advise the mother to observe her child for a few minutes until the child is calm.

4 Sleep terrors are characterized by partially awakening from sleep accompanied by screaming, perspiration, and increased heart rate. During the terror, the child screams but calms down later. The nurse advises the mother to avoid disturbing the child and to watch carefully until the child calms down. A child will generally not have trouble returning to sleep after a night terror and will not remember the details, so it is not necessary to bring the child into the parent's bed, and it would be of no benefit to ask the child to describe the dream or accept it as real.

Allopurinol (Zyloprim) is prescribed for a 6-year-old child undergoing chemotherapy regimen for cancer of the bone. When given the medication, the child asks, "Why do I have to take this pill?" What is the best response by the nurse? 1 "It protects your body from getting new problems after your treatment is over." 2 "It stops your sick white cells from going to other parts of your body." 3 "You know the doctor wouldn't order anything for you unless it was very important." 4 "With the other medicines it helps you get rid of the things that are making you sick."

4 Telling the child it helps get rid of the things making the child sick is the most accurate and age-appropriate response to the child's question. Telling the child that the medicine protects the body from new problems is inaccurate, and not being truthful will interfere with the development of the child's trust in the nurse. Telling the child that it stops sick white cells from spreading is inaccurate and may instill more fear. Telling the child that it is needed because the health care provider says so is insensitive to the question and does not provide an explanation.

A nurse is teaching a young primigravida about body changes during pregnancy. The nurse explains that most prenatal clients experience urinary frequency in the first trimester because of an increase in: 1 Estrogen level 2 Extracellular fluid volume 3 Kidney glomerular filtration 4 Bladder pressure from the enlarged uterus

4 The anatomic position of the uterus in the pelvis is directly above the urinary bladder; as the uterus enlarges, it exerts pressure on the bladder. After the first trimester the uterus rises into the abdominal cavity and urinary frequency lessens. Estrogen causes fluid retention, not frequency. An increase in extracellular volume does not occur until the second trimester. An increased glomerular filtration rate does not cause urinary frequency.

Six weeks after birth an infant is found to have developmental dysplasia of the hip. The nurse explains to the parents the benefits of early treatment. What is the rationale for the immediate institution of corrective measures? 1 Mobility will be delayed if correction is postponed. 2 Traction is effective if it is used before toddlerhood. 3 Infants are easier to manage in spica casts than are toddlers. 4 Infants' cartilaginous hip joints promote molding of the acetabulum.

4 The cartilaginous hip joints are the basis for the use of abduction devices (e.g., Pavlik harness) and spica casts when the infant is very young. Congenital hip dysplasia does not limit ambulation for the young child, although the gait will be affected. Traction is not used to correct developmental dysplasia of the hip. Although casted infants are easier to manage than casted toddlers, this is not the reason for early treatment.

A nurse is teaching an adolescent with a sprained ankle how to use one crutch when walking. What statement indicates that no further teaching is necessary? 1 "I shouldn't use my crutch on stairs." 2 "After a month I can stop using the crutch." 3 "I should place the crutch in front of my bad ankle." 4 "I should use the crutch on the side of my good ankle.

4 The crutch is positioned on the unaffected side and advanced with the affected leg; the crutch supports the body's weight while the client is walking on the affected leg. The crutch should be used on the stairs to provide a wide base and extra support when the client goes up or down the stairs. A sprained ankle should heal in less than 1 week, after which the crutch should no longer be needed. Positioning the crutch in front of the affected foot will place that foot in a weight-bearing position without support, defeating the purpose of the crutch.

The nurse teaches a mother about the dietary measures to be followed for her 5-month-old infant. During the follow-up visit, the nurse finds that the child has indigestion. Which action by the mother is responsible for this situation? 1 Feeding almond milk to the child 2 Feeding bottle milk at night to the child 3 Feeding vegetable juice to the child 4 Feeding mashed sweet potatoes to the child

4 The enzyme amylase is needed for the digestion of complex carbohydrates. A 4- to 6-month-old infant is deficient in amylase. Sweet potatoes are rich in complex carbohydrates; therefore the 5-month-old infant can have indigestion due to eating sweet potatoes. Almond milk, vegetable juice, and bottle milk do not contain complex carbohydrates; therefore, they do not result in indigestion.

To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the nurse position the infant? 1 On either side and flat 2 Supine and Trendelenburg 3 Prone, with the legs elevated about 30 degrees 4 Supine, with the head elevated about 45 degrees

4 The head should be elevated, allowing gravity to minimize intracranial pressure. The Trendelenburg position is contraindicated because it can increase intracranial pressure. The infant may be positioned on the back or side to allow routine changes in head position.

The nurse administers a second dose of inactivated polio vaccine (IPV) to a 4-month-old child. When does the child receive the third dose of IPV? 1 8 to 9 months of age 2 4 to 6 years of age 3 12 to 14 years of age 4 14 to 18 months of age

4 The inactivated polio vaccine (IPV) vaccine is given to children in four doses at 2 months, 4 months, 14 to 18 months, and 4 to 6 years of age, respectively. The child has received a second dose at 4 months of age, so he or she should receive the third dose at 14 to 18 months of age

The nurse is assessing the development of a male child and finds that the child is tall, with deficient secondary sex characteristics and hypogenitalism. Which chromosomal notation is associated with the child's condition? 1 45,XO 2 47,XXX 3 47,XYY 4 48,XXXY

4 The male child is tall, with deficient secondary sex characteristics and hypogenitalism, indicating Kleinfelter syndrome. The chromosomal abnormality present in the child is denoted as 48,XXXY. The chromosomal complement 45,XO is seen in children with Turner syndrome. A child with Turner syndrome will have short stature and a webbed neck. The 47,XXX chromosomal complement indicates that the child has triple X, or superfemale, chromosomal abnormality. This condition is associated with impaired language and mental capacity. A child with the chromosomal complement 47,XYY has Jacobs XYY chromosomal abnormality, which is associated with normal sexual development and aggressive sexual tendencies.

An infant is born with exstrophy of the bladder. The parents are concerned and confused when they are told that their infant will need surgery. What nursing intervention will best help the infant's parents? 1 Teaching them about their infant's postoperative care 2 Decreasing the odor of leaking urine by keeping the infant clean 3 Reassuring them that their infant will be healthy after the surgery 4 Demonstrating the same manner of care for the infant as for other infants on the unit

4 The nurse's acceptance of the infant, even with an altered appearance, helps the parents adjust. It is premature to discuss postoperative care; teaching will not be heard during a crisis. The parents' current major adjustment problem is the infant's altered appearance; odor is secondary. Reassuring the parents that the child will be healthy after surgery is false reassurance; there are no guarantees that this is true.

A nurse is obtaining the health history of a woman who is visiting the prenatal clinic for the first time. She states that she is 5 months pregnant. For what positive sign of pregnancy should the nurse look in this patient? 1 Quickening 2 Enlarged abdomen 3 Cervical color change 4 Audible fetal heartbea

4 The presence of the fetal heartbeat is a positive sign of pregnancy. The feeling of movement is a presumptive sign of pregnancy. An enlarged abdomen is a probable sign of pregnancy. The bluish color of the cervix (Chadwick's sign) is caused by pelvic congestion and edema; it is a probable sign of pregnancy.

A nurse is caring for an infant who has undergone surgery to repair a diaphragmatic hernia. What is the best position for the nurse to place the infant in? 1 Semi-Fowler in an infant seat 2 Side-lying on the unaffected side 3 Prone with the head turned to the side 4 Supine with the head of the bed elevated

4 The supine position keeps pressure off the surgical site. Elevating the head of the bed allows the abdominal organs to move downward, away from the diaphragm, which will promote respiratory expansion. Using an infant seat will not promote maximal aeration of the lungs, because hip flexion adds tension to the abdominal muscles. Placing the infant on the unaffected side limits gas exchange in the lung on the unoperated side. The prone position increases the effort of breathing because respiratory excursion is impeded by the weight of the body.

client who has had recurrent infections before and during pregnancy should be instructed to eat a nutrient-rich diet as a means of supporting the body's natural defense mechanisms. What should the nurse encourage the client to include in her diet? 1 Fat-soluble vitamins 2 Dietary fiber and oat bran 3 Low-fat foods with essential fatty acids 4 Vitamins A, C, and E and selenium

4 Vitamins A, C, and E and selenium are immune-stimulating nutrients. Too much emphasis on fat-soluble vitamins may result in an inadequate intake of important water-soluble vitamins and minerals. Dietary fiber and oat bran and low-fat foods with essential fatty acids have no known effect on natural defenses.

A nurse in the clinic is obtaining a health history of a 16-year-old boy with a complaint of a thick urethral discharge. What is the most appropriate nursing action to help confirm a tentative diagnosis of gonorrhea? 1 Assessing the temperature for fever 2 Collecting a urine sample for a urinalysis 3 Drawing blood for a complete blood count 4 Obtaining a urethral specimen for a culture

4 When the Gonococcus organism is present in the genitourinary tract of a male client, a culture of the urethral exudate provides a definitive diagnosis. Fever is not a specific diagnostic tool because it occurs with other infections. Although urine may contain Gonococcus organisms, the urine dilutes the concentration; the organisms are more concentrated in the urethral discharge. The Gonococcus organism is in the genitourinary tract, not the blood; a complete blood count will not provide information with which to diagnose gonorrhea.

The mother of a 4-week-old boy reports, "He cries all the time and always acts hungry, but he throws up everything. He looks like a skinny old man." In light of this information, what is the focus of the nurse's assessment? 1 Inspecting the anus to confirm rectal prolapse 2 Obtaining the elimination history to confirm celiac disease 3 Noting the color of vomitus to confirm a bile duct obstruction 4 Palpating the abdomen to confirm hypertrophic pyloric stenosis

4 With a history that strongly suggests hypertrophic pyloric stenosis (HPS), the nurse should assess the abdomen for an olive-shaped mass and visible peristalsis. The data presented are not consistent with rectal prolapse. The data are not consistent with celiac disease, which involves diarrhea resulting from a reaction to gluten; the infant is too young to have ingested grains. Although the color of vomitus is important for a diagnosis of HPS, bile duct obstruction is not indicated by the history.

nurse in the prenatal clinic is obtaining the health history of a 39-year-old primigravida. What question should the nurse ask to elicit information about exposure to diethylstilbestrol (DES)? 1 "Have you ever taken oral contraceptives?" 2 "Did you ever have an unusual vaginal discharge?" 3 "Have you noticed any lesions in your perineal area?" 4 "Do you know if your mother took hormones during her pregnancy?"

4 problems of the reproductive system may occur in the daughters of women who took the synthetic hormone DES during pregnancy. Use of oral contraceptives is not associated with DES exposure. Although clients exposed to DES may exhibit abnormal bleeding or a heavy mucoid vaginal discharge, there are other causes for these problems, such as chlamydial infection. Lesions on the perineum are not related to exposure to DES exposure.

he mother of an infant with Down syndrome asks the nurse what causes the disorder. Before responding, the nurse recalls that the genetic factor of Down syndrome results from: 1 An intrauterine infection 2 An X-linked genetic disorder 3 An Autosomal recessive gene 4 Extra chromosomal materia

4 trisomy 21

A nurse is preparing an infant for insertion of a nasogastric tube. List the steps of the procedure in the order that they should be performed. 1. Insert the tube. 2. Use the tube to measure from ear to nose to stomach. 3. Aspirate stomach contents. 4. Wash hands before opening the package

4213 Before the nurse performs any care, the hands must be washed to prevent contamination; after this has been done, the package may be opened. The distance that the tube must be passed is determined before insertion. After tube insertion, stomach contents should be aspirated to confirm placement of the tube in the stomach.

The mother of a 5-year-old child recovering from varicella (chickenpox) calls the nurse in the pediatric clinic, asking how the child's itching can be relieved. What is the best response by the nurse? 1 Have the child wear mittens. 2 Rub an antibiotic ointment on the lesions. 3 Use wet-to-dry saline dressings over the oozing vesicles. 4 Pat the lesions while applying the prescribed calamine lotion

44 Drying the lesions relieves the itching (pruritus). Patting the lesions will not disturb them, and calamine lotion is an effective drying agent. Mittens may minimize injury caused by scratching but will not relieve pruritus. An antibiotic ointment prevents secondary infection but does not relieve the itching because it does not have a drying effect. An antibiotic requires a practitioner's order. Dressings may disrupt the vesicles and lead to scar formation.

A toddler undergoes the implantation of a low-profile (skin-level) device (button) for a gastrostomy. The gastrostomy is now healed, and the parents are being taught to care for the stoma. What parental behavior indicates to the nurse that additional teaching is needed? 1 A parent is cleaning the stoma with soapy water. 2 Gastric contents are aspirated before the start of a feeding. 3 A parent inserts an adapter into the button to initiate a feeding. 4 The button is being maintained in the same position within the stoma.

44 Further teaching is necessary because the button should be rotated to prevent adherence to the skin. The stoma and the skin around the button should be kept clean and free of drainage. As with other gastrostomy tube feedings, use of a gastrostomy button requires patency to be determined; residual gastric fluid should be present. Extension tubing should be inserted into the device for feedings.

After assessing a 1-year-old child, the nurse concludes that the child has normal development. Which finding supports the nurse's conclusion? 1 The child's head bends toward the side that the nurse strokes. 2 The child's hips move toward the side that the nurse stimulates. 3 The child abducts his or her arms while flexing the elbows when the nurse makes a loud noise. 4 The child's toes hyperextend when the nurse strokes the heel upward across the foot.4

444 A normal 1-year-old child will exhibit the Babinski reflex. To assess the Babinski reflex, the nurse strokes the heel of the child upward across the foot, which results in hyperextension of the infant's toes. To assess the rooting reflex, the nurse strokes the child's cheek; the child's head bends toward the side being stroked, and the child begins to suck. This reflex disappears at the age of 4 months. To assess trunk incurvation, the nurse strokes the child's spine. In response the child's hips move to the side of stimulation or toward the stroke. This reflex disappears at the age of 6 months. When assessing the child's startle reflex, the nurse makes a sudden loud noise. In response to the noise the child abducts his or her arms while flexing the elbows. The reflex disappears at the age of 3-4 months. Therefore, the appearance of the rooting reflex, trunk incurvation, or startle reflex in a 1-year-old child would indicate abnormal development.

A nurse is assessing a 6-month-old infant's motor skills. Which skills does the nurse expect this infant to exhibit? Select all that apply. 1 Sits unsupported 2 Uses a pincer grasp 3 Releases objects at will 4 Bears weight on hands when prone 5 Turns from prone to supine position at will

45 Around 6 months of age the infant can lift the head and chest and can bear upper body weight on the hands. Around 5 months of age the infant can turn willfully from the prone to the supine position, although it can happen accidentally before this; around 6 months of age the infant can turn willfully from the supine to the prone position. The tripod sitting position occurs around 7 months of age, and sitting unsupported occurs around 8 months of age. A crude pincer grasp starts to develop at 8 months of age. The ability to deliberately let go of an object develops between 8 and 10 months of age.

nurse is providing dietary counseling to a client at 14 weeks' gestation. The client is a recent immigrant from Asia, and the nurse explores the foods that the client usually eats. Which foods should the nurse counsel the client to avoid during pregnancy? Select all that apply. 1 Yogurt 2 Oily fish 3 Apricots 4 Raw shellfish 5 Herbal supplements 6 Soft-scrambled egg

456 The March of Dimes has included raw shellfish, which may be contaminated with hepatitis or typhoid, on its list of foods to avoid during pregnancy. Herbal supplements and teas often contain ingredients that are medicinal and should not be taken during pregnancy unless a health care provider has been consulted regarding their safety. The March of Dimes has included soft-scrambled eggs on its list of foods to avoid during pregnancy because they may be contaminated with Salmonella. Yogurt is an excellent source of calcium and is safe to eat during pregnancy. Oily fish has a high level of omega-3 oils and is safe to eat in limited amounts during pregnancy. Apricots are a source of potassium and are safe to eat during pregnancy.

The factor that is most significant for the nurse working with the family of an infant born with a genetic disorder is their: 1 Willingness to give physical care to their infant 2 Understanding of the factors causing the infant's disorder 3 Response to the reactions of significant others to their infant 4 Readiness to talk about problems their infant may have in the future

4`

After assessing a newborn infant, the nurse finds that the infant has a heart rate of 90 beats/minute, irregular respirations with a weak cry, limp extremities, sneezing reflex, and a completely pink body. What would be the Apgar score of the child? Record your answer using a whole number. ______

6 The infant has a heart rate of 90 beats/minute, which is given a score of 1. The infant also has irregular respiration with a weak cry, which is scored as 1. The infant has limp extremities, which receives a score of 0. The infant has the sneezing reflex, which is given a score of 2. The infant has a completely pink body, which is also given a score of 2. Therefore, the total Apgar score of the infant is 1 + 1 + 0 + 2 + 2 = 6.

How many teeth does a 10-month-old infant usually have?

According to a quick guide to assessment of deciduous teeth, the number of teeth in a child during the first 2 years is calculated using the formula [Age of the child in months] − 6 = [Number of teeth]. The age of child is 10 months; therefore, the number of teeth in the child is 10 − 6 = 4.

The nurse is conducting a physical examination of a 2-year-old child and records the child's height as 90 cm. What would be the estimated height of the child as an adult? Record your answer using a whole number. ______ cm

Doubling the height of a 2-year-old child gives an estimate of the person's height as an adult. The height of the child is 90 cm. Therefore, the estimated height of the child as an adult would be 90 x 2 = 180 cm.

During a clinical assessment, what secondary sex characteristics does the nurse observe in a teenage patient? Select all that apply. A Change in voice B Enlargement of breasts C Development of facial hair D Beginning of menstruation E Completion of skeletal growth

ac Secondary sex characteristics are the changes observed in various parts of the body due to hormonal alterations. Voice change occurs as a result of changes in the larynx, while facial hair develops on the face and neck regions. Primary sex characteristics are the changes that occur in the internal and external organs involved in reproductive functions. Enlargement of breasts and beginning of menstruation are regarded as primary sex characteristics. The completion of skeletal growth is seen in postpubescence and is not a secondary sex characteristic.

The nurse is teaching a mother about the developmental behaviors of a 7-month-old infant. Which statement by the mother indicates effective learning? Select all that apply. A "I should start oral hygiene in my child." B "I should not change my child's diet." C "I should call my child by her name." D "I should not leave the child with an unfamiliar relative." E "I should encourage my child to produce n, k, g, p, and b sounds.

acd The upper central teeth begin to erupt in a 7-month-old infant; therefore, the mother can buy a toothbrush with soft bristles to maintain oral hygiene. A 7-month-old infant can remember and respond to his or her own name. A 7-month-old infant often has a fear of the strangers, so the mother should not leave the infant with new people. A 7-month-old infant has taste preferences, so the mother can expose the child to different foods. A 7-month-old infant is able to say words such as dada, baba, kaka, etc. Therefore, the parents should encourage the infant to produce these words, not specific sounds like n, k, g, p, and b.

The nurse is assessing a female preterm neonate after delivery. Which assessment findings does the nurse document in the hospital reports of the infant? Select all that apply. A The infant has a prominent clitoris. B The sole of the infant is deeply creased. C The hair of the infant is fine and feathery. D The infant rests in a more flexed attitude. E The infant shows no resistance to the heel-to-ear maneuver

ace A female preterm neonate lacks proper growth of the labia majora; therefore, the neonate will have a prominent clitoris. A preterm neonate lacks proper nourishment to the hair, resulting in fine and feathery hair. The knee of a preterm infant does not offer resistance to the heel-to-ear maneuver. The soles of a preterm infant's feet appear more turgid and may have only fine wrinkles. The preterm infant has less subcutaneous tissue, and therefore rests in a relaxed attitude

Which physiologic functions decrease in response to certain pubertal changes? Select all that apply. A Pulse rate B Blood volume C Strength of the heart D Basal heat production E Systolic blood pressure

ad Pubertal changes induce physiologic changes. The physiologic functions that decrease in response to pubertal changes include pulse rate and basal heat production. Blood volume, strength of the heart, and systolic blood pressure increase along with changes occurring during puberty. Pubertal changes herald adulthood and therefore the heart increases in size and strength and the systolic blood pressure increases to reach the adult level.

The nurse is assessing an 8-year-old child who suffers from encopresis. Which advice given by the nurse provides effective treatment for the child? Select all that apply. A "You should include cereals in your diet." B "You should include milk in your diet." C "You should delay the urge to defecate." D "You should drink lots of fluids." E "You should eat fresh fruit for breakfast.

ade Encopresis is the voluntary or involuntary passage of feces of varying consistency at inappropriate settings. The child with encopresis usually has constipation. Therefore, cereals should be included in the child's diet as they contain high amounts of fiber, which helps in the formation and passage of regular stools. Sufficient water is necessary to prevent constipation or pain during defecation. Therefore, the nurse instructs the child to drink sufficient fluids. Fruits are also rich fiber sources and ease the process of defecation. Milk increases the risk of uncontrolled defecation. Therefore, the nurse instructs the child to avoid milk. Avoiding defecation results in water absorption from the stool, which may cause constipation and increased pain.

The nurse is preparing to bathe a neonate born at 30 weeks gestation. Which practices by the nurse ensure the infant's safety? Select all that apply. A Gives the neonate a daily warm-water bath B Immerses the neonate fully (except the head) in the tub C Measures the body temperature within 2 to 4 hours before giving the bath D Uses cleansing agents with neutral pH and minimal dyes while giving the bath E Removes the vernix completely from the neonate's skin while giving the bath

bcd A neonate born before 32 weeks of gestational age is known as a preterm infant. Immersing the neonate's head in water during a bath can increase the risk of respiratory depression. The neonate's body temperature should be stable 2 to 4 hours before giving the initial bath. Therefore, the nurse monitors body temperature before giving a bath. Cleansing agents with neutral pH and minimal dyes reduce skin irritation, so these are used when bathing the neonate. The nurse should give a warm-water bath every second or third day, not daily, to prevent hypothermia. Removing vernix completely during the initial bath can alter thermoregulation in a neonate.

The nurse is teaching the mother of 24-month-old child effective ways of cleaning the toddler's teeth. Which actions facilitate access to the child's mouth and help stabilize the child's head for comfort? Select all that apply. A Holding the child's mouth open widely B Sitting on a couch or bed with the child's head resting in the mother's lap C Using one hand to hold the child's chin and the other to brush the teeth D Sitting on the floor or a stool with the child's head resting between her thighs E Making the child stand facing towards her while brushing the teeth in the bathroom

bcd The mother sits on a couch or bed with the child's head resting in her lap to provide comfort while brushing the child's teeth. The mother uses one hand to cup the chin and the other to brush the child's teeth to help with easy and effective cleaning. The mother sits on the floor or a stool with the child's head resting between her thighs to stabilize the child's head and provide comfort. The mother should not open the child's mouth wide, as this causes discomfort. The mother should make the child stand with his or her back towards the mother so that both the child and mother can see what is being done in the mirror.

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

bce Cooing, babbling, and chuckling in a 3-month-old infant indicate normal development. A 3-month-old infant can pull at blankets or clothes and can raise his or her head to a 45- to 90-degree angle from the table. The grasp reflex generally disappears by the age of 3 months. A 3-month-old infant may not able to put his or her feet in the mouth when lying in the supine position. Generally a 5-month-old infant can put his or her feet in the mouth when lying in the supine position.

During follow-up visits, the nurse informs the mother of a 3-month-old infant how to feed the infant expressed milk. Which statements by the mother indicate effective learning? Select all that apply. A "I can add water to dilute the expressed milk." B "I can express milk by hand or with a breast pump." C "I can store expressed milk at room temperature." D "I can store expressed milk in the refrigerator for 5 days." E "I can add honey to expressed milk to enhance the taste."

bd

During physical examination of a 3-year-old child, the nurse finds that the child has only 15 teeth. Which foods should be included in the child's diet to promote tooth formation? Select all that apply. A Soy B Milk C Legumes D Boiled egg E Fruits and vegetables

bd A 3-year-old child normally has approximately 20 teeth. The presence of only 15 teeth indicates calcium deficiency. Milk is rich in calcium. Eggs are also a good source of calcium. Soy and legumes are rich in protein and help build muscle mass. Fruits and vegetables are good sources of vitamins and minerals and increase immunity.

The nurse observes bleeding into the subgaleal compartment upon reviewing a child's magnetic resonance imaging (MRI) results. What other conditions should the nurse evaluate in the child? Select all that apply. A Decreased heart rate B Decreased platelet levels C Decreased bilirubin levels D Decreased hematocrit levels E Decreased head circumference

bd Bleeding into the subgaleal compartment indicates subgaleal hemorrhage in an infant. Subgaleal hemorrhage is also associated with disseminated intravascular coagulation, which results in thrombocytopenia or decreased blood platelets in the body. A neonate with subgaleal hemorrhage shows destruction of red blood cells within the hematoma; therefore, the neonate will have decreased hematocrit. Subgaleal hemorrhage is characterized by tachycardia, not decreased heart rate or bradycardia. A neonate with subgaleal hemorrhage is characterized by hyperbilirubinemia due to degradation of red blood cells. A neonate with subgaleal hemorrhage shows megacephaly, not decreased head circumference.

A worried parent informs the nurse, "My 6-year-old is otherwise healthy but still wets the bed at night." The nurse is teaching the parent necessary steps to manage the child's nocturnal enuresis. Which statement made by the parent indicates effective learning? Select all that apply. A "I should make my child wear diapers during day hours while at school." B "I should give my child diet soda instead of regular soda in the evening." C "I should avoid giving my child fruit juice after 4:00 pm." D "I should encourage my child to drink lots of water during the day." E "I should wake my child at the same time every night to use the bathroom."

cde

What growth changes are observed in a male patient during adolescence? Select all that apply. A Development of broader hips B Development of deep and fuller voice C Increase in length of vocal cords by 0.4 inch D Increase in length of vocal cords by 0.17 inch E Uncontrollable shifting of the voice from deep to high tone

ce There are marked differences in growth patterns in males and females during adolescence. On average, the length of the vocal cords in males increases by approximately 0.4 inch. The increased length of the vocal cords, accompanied with hypertrophy of the laryngeal mucosa, results in changes in the voice. Males generally have voices that shift uncontrollably between deep to high tones during a conversation. A characteristic feature of skeletal growth in females is the development of broader hips. The female voice during adolescence becomes deeper and fuller due to an average increase in vocal cord length of 0.17 inch, enlargement of the larynx, and hypertrophy of the laryngeal mucosa.

A mother of a 7-year-old child complains to the nurse that her child wets the bed at night. Upon interaction with the child, the nurse learns that the child is afraid of the dark. What does the nurse recommend to the mother? Select all that apply. A "Take your child for a walk before going to bed." B "Provide nutritious food to your child at dinner." C "Give your child a glass of milk before going to bed." D "Allow your child to keep a light on in the bedroom at night" E "Encourage your child to copy his siblings who sleep alone in their room."

de