Ch 18 Conception through young adult

The pregnant young adult asks the nurse when she will be able to hear the fetal heart beat. Which is the nurse's best response?

"At your 12-week appointment, you will be able to hear the heart beat by Doppler."

A newborn is scheduled for a circumcision and the parent is concerned with the baby feeling pain. What is the best response by the nurse?

"Baby's feel the sensation of touch and pain."

A nurse is assessing neonates in a hospital nursery. Which neonates are exhibiting expected developmental characteristics? Select all that apply.

Neonate who displays the Moro and stepping reflex Neonate who eliminates urine and stool Neonate who exhibits both an active crying state and a quiet alert state Neonate who inherits a transient immunity from infections from the mother

A nurse is teaching a "Preschool Childcare" class and Tiffany, one of the parents, asks when her toddler will have all of her baby teeth. Which of the following responses would be appropriate?

3 years Explanation: By 3 years of age most children have a full set of deciduous teeth. They begin to fall out at about age 6, with permanent teeth replacing them.

A baby has just been delivered. Her heart rate at one minute of age in 130 beats per minute and she is crying vigorously. Her extremities are flexed and she withdraws her feet when the soles are touched. Her trunk is pink and hands and feet are bluish. Based on the findings, which of the following should the nurse record as the baby's Apgar score?

9 Explanation: Heart rate of 130 bpm = 2 points, vigorous cry = 2 points, muscle tone = 2 points, flexed position = 2 points, acrocyanosis = 1 point, Apgar score = 9 points.

A nurse is assessing toddlers in a community health care clinic. Which toddlers would the nurse refer for follow-up care? Select all that apply.

A 2-year-old who cannot kick a ball An 18-month-old whose arms and legs are not increasing in length A 1-year-old who does not pick up small objects with fingers

A nurse is caring for children in a children's hospital. Which child would the nurse expect to develop separation anxiety?

A newly hospitalized toddler

The parents of a 4 month old cannot visit at the hospital except on weekends. Which of the following actions by the nurse indicates an understanding of the emotional needs of a young infant?

Assign the same nurse as much as possible

A 9-year-old child has been admitted to the orthopedic unit for treatment of a fractured leg due to an all-terrain vehicle accident. What would be a priority concern experienced by the child during hospitalization?

Absence from school and activities

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about the advantages of breastfeeding. An accurate statement from you about breastfeeding would be which of the following?

Acid environment prevents bacterial growth Explanation: Breastfeeding provides further protection against bacterial and viral infections through antibodies, immunoglobulins, and leukocytes in breast milk. The high lactose content in breast milk, combined with limited protein, promotes an acid environment that is unsuitable for bacterial growth.

Which of the following statements explains how pregnancy affects the growth and development of the adolescent?

Affects the normal physical and maturation processes

A nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks how the baby develops soon after conception. Which is an accurate statement from the nurse about the embryonic stage?

All basic organs are established here

A school nurse is assessing school-age children for developmental milestones. Which students would be a concern for the nurse? Select all that apply.

An 8-year-old student who is not writing with a pencil A 12-year-old student who still has baby teeth An 8-year-old student whose height hasn't changed since preschool An 11-year-old student who is not developing skills for physical games

When an infant is first fed solid foods, Which of the following advice does the nurse give the parent as to how to feed the infant?

Begin one type of food at a time Explanation: Begin solid foods one at a time to monitor for food allergies. Do not add honey, salt, or sugar to the feedings.

A school nurse is teaching a sexuality class to 5th- and 6th-grade girls. The nurse talks about secondary sexual characteristics and explains that these are which of the following? Choose all that apply.

Breast development Presence of body hair Facial hair growth in boys Voice changes in boys Explanation: Primary and secondary sexual development occurs with maturation of the genitalia; presence of body hair; breast development and menstruation in girls; and facial hair growth, voice changes, and spermatogenesis in boys. Presence of internal genitalia is a primary sexual characteristic.

The nurse is educating a new parent about what type of physical activities the infant will be able to achieve in the first year. What activities will the nurse discuss with the parent? Select all that apply

Crawl on all fours Stack building blocks Ambulation may start

The nurse is educating parents of a newborn about expected changes in the first year of life. Whcih milestones will the nurse discuss with the parents? Select all that apply.

Deciduous teeth begin to erupt Heart doubles in weight Body temperature stabilizes Birth weight usually triples by 1 year

A nurse is teaching a "Young Childcare" class and Bill, one of the parents, asks what kinds of new physical skills his 13-month-old son will be learning during the next 2 years. Which of the following responses would be appropriate? Choose all that apply.

Drinks from a cup Walks forward and backward Runs, kicks, climbs stairs Uses a spoon

A nurse is implementing a health/sex education program in a public school. With which grade level should the nurse begin the program?

Elementary

A nurse is counseling pregnant women about the detrimental effects of smoking and drinking on a fetus. During what stage of development is the fetus most susceptible to these teratogens?

Embryonic stage

The nurse is caring for a female client 15 years of age who is hospitalized with a fractured ankle. Her father tells the nurse that this happened during a gymnastics lesson. He goes on to explain that every six or eight months it seems his daughter is trying something different; right now it is gymnastics. The nurse knows that this behavior fits with which of the following theorist's developmental tasks for adolescents?

Erikson ("identity versus role confusion.")

A nurse is instructing a group of adolescents and young adults about safety. Which of the following topics should be included

Explaining that sports injuries are major causes of fatalities Instructing them about the dangers of bullying and gang involvement Reviewing the use of protection during sexual activity

The nurse is administering scheduled immunizations for a boy 18 months of age. The nurse would recognize that this child is most likely engaged in which of the following developmental tasks?

Expressing his autonomy Explanation: The toddler (ages 1 to 3) enters Erikson's stage of autonomy versus shame and doubt, a developmental task that manifests as developing early independence in activities such as feeding, walking, and expressing wishes verbally. Bonding with his father and taking initiative are likely manifestations of this larger developmental task. The development of trust is primary during the first year of a child's life.

Which of the following nursing activities is the most significant in assisting with transitioning from the adolescent to the young adult age group?

Facilitating healthy family relationships

Which of the following behaviors demonstrated by a 6-year-old child would help the school nurse assess characteristics of attention deficit hyperactivity disorder (ADHD)?

Gets into fights in cafeteria Is easily distracted in class Does not sit still in class Explanation: Characteristics of ADHD are impulsive behaviors, inattention, and hyperactivity, including getting into fights, being easily distracted, and not sitting still. Reversing letters and words are characteristics of dyslexia, and a speech impediment is a form of speech disorder with many causes, requiring further evaluation.

Which would be an expected reaction from a 5 year old when his 3-month-old infant sibling dies from Sudden Infant Death Syndrome (SIDS)?

Guilt he may have caused the death

You are the nurse providing prenatal education to a group of pregnant teenagers. One of the group members asks you to talk about how the baby develops soon after conception. An accurate statement from you about the zygote and preembryonic stage would be which of the following?

Has a total of three distinct cell layers Explanation: The preembryonic stage lasts for about 3 weeks. The zygote, which implants in the uterine wall, has three distinct cell layers. The endoderm (inner layer) becomes the respiratory system, the digestive system, the liver, and the pancreas. The mesoderm (middle layer) becomes the skeleton, connective tissue, cartilage, muscles, and the circulatory, lymphoid, reproductive, and urinary systems. The ectoderm (outer layer) becomes the brain, spinal cord, nervous system, and outer body parts (skin, hair, and nails). The basic organs are not established until the embryonic stage. Reflexes are not present until fetal development is occurring.

Sleep habits have been implicated in cases of sudden infant death syndrome (SIDS). What instructions will the nurse provide to new parents related to positioning their infant for sleeping?

Healthy infants up to age 6 months should be positioned on their backs on a firm surface.

The nurse is teaching child safety and nutrition to a group of young parents at a public health clinic. In answer to a question about childhood obesity, the nurse talks about the incidence of childhood obesity related to ethnic background. The nurse informs the group that although the incidence of obesity has risen by 50% in white children. It has risen more significantly in which ethnic groups? Choose all that apply.

Hispanic American Indian/First Nations Black

A nurse is teaching a parenting class for parents with infants. What is an example of an appropriate teaching point for this developmental age?

If choking occurs, give back blows and chest thrusts or CPR.

The nurse is caring for Amy, a 10-year-old, who is admitted for a fractured wrist (suffered during a soccer game) repair. She talks a lot about how well she is doing in school this year and her mother agrees. The nurse is assessing her developmental health and knows that Amy is well on the way to achieving which of the following according to Erik Erikson?

Industry Explanation: The school-aged child is in the industry-versus-inferiority stage of Erikson's theory, with the child focused on learning useful skills and thereby developing positive selfesteem. Trust is achieved as an infant, initiative is achieved as a preschooler, and identity is achieved as an adolescent.

A 9-year-old who is in the 3rd grade has great difficulty with reading. The child is becoming very withdrawn and depressed. According to Erik Erikson's developmental theory, the child is at risk for developing which self-concept?

Inferiority Explanation: The school-aged child is in the industry-versus-inferiority stage of Erikson's theory, with the child focused on learning useful skills and thereby developing positive self esteem. The client is withdrawn so thereby exhibiting inferiority to the other children in the class. Autonomy versus shame and doubt is the developmental task of the toddler, according to Erikson's theory.

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks to talk about how the baby develops soon after conception. What is the best response by the nurse about the zygote and preembryonic stage?

Inner layer becomes the respiratory system Explanation: The endoderm (inner layer) becomes the respiratory system, the digestive system, the liver, and the pancreas.

A more thorough medical examination of a 30-month-old is indicated when the nurse observes that the child has difficulty

Kicking a ball

The nurse is providing an educational program for a group of adolescents at the high school regarding suicide prevention. What should the nurse include with some of the identifying factors related to suicide? Select all that apply

More prevalent in teenagers than other age groups Males succeed at suicide more often Third leading cause of death in ages 15 to 24 Females attempt suicide more often

The mother of a girl 6 years of age is exasperated at her daughter's persistent enuresis. How can the nurse best respond to this mother's concern?

Most children outgrow their bedwetting at around your daughter's age or shortly after

Accurate instruction regarding the typical growth and development patterns for adolescents would include which of the following guidelines?

Peer relationships characterize the adolescent years.

The school nurse is teaching parents of adolescents about the development of self-concept in their children. What would the nurse state is most influential in stabilizing self-concept in this age group?

Peers

The nurse is caring for an infant with fetal alcohol syndrome. What nursing actions should the nurse perform when caringfor this infant? Select all that apply.

Provide adequate nutrition Participation in developmental program Promote bonding with parents Monitor weight and head circumfere

A nurse records an Apgar score of 3 for a newborn taken one minute after birth. What would be a priority intervention for this newborn?

Provide immediate life-saving support. Explanation: The neonate is assessed immediately after birth. Of several existing measurement scales, the Apgar rating scale is the most commonly used. This scale is used to assess neonates 1 minute and 5 minutes after birth. The scale has of a maximum of 10 points, ranking five categories on a scale from 0 to 2. The five categories are heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 7 to 10 would be considered normal. A score from 4 to 6 would require a newborn to have special medical assistance. A score of less than four would require a newborn to have immediate life-saving support. Since the Apgar is taken one minute after birth, the primary care provider is present at this time.

After assessing a female adolescent, a nurse collects the following data: development of breast tissue, growth spurt in height and weight, appearance of axillary hair, and initiation of menarche. Which stage of sexual development does this data confirm?

Pubescence

The nurse observes a hospitalized preschooler who clings excessively to his mother, sucks the thumb, and uses infantile speech patterns. This child is exhibiting what type of behavior?

Regression

A preschool child is hospitalized with an infection. The child refuses to eat anything but macaroni and cheese and ice cream. What is the nurse's best way of getting the child to eat more?

Rewarding the child with ice cream for eating more nutritious foods.

A nurse is assessing and diagnosing children in a pediatrician's office. Which diagnosis would be most appropriate for a school-age child?

Risk for infection

A toddler's mother exits the room to talk to the physician in the hallway. The nurse caring for the toddler notes that the child starts to cry when he no longer sees his mother in the room. He soon stops crying and appears saddened and depressed. The nurse recognizes this behavior as which of the following?

Separation anxiety

Which of the following points should the nurse prioritize when educating school-aged children about nutrition?

Sources of calcium and vitamin D

An 18 year old with a chronic illness tells the school nurse that he has recently started using marijuana with his friends on weekends. Which of the following should be the nurse's next action?

Teach him about effects of marijuana on his illness and potential complications with marijuana

A nurse is counseling adolescents in a group home setting. Which statements accurately describe the cognitive and psychosocial development of this age group? Select all that apply.

The concept of time and its passage enables the adolescent to set long-term goals. According to Piaget, adolescence is the stage when the cognitive development of formal operations is developed. According to Havighurst, more mature relationships with boys and girls are achieved by the adolescent.

The nurse is assessing a preschooler who has just turned 6 years of age. The nurse expects which of the following as typical development for a child in this developmental phase.

The head is close to adult size by age 6 years.

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks how the baby develops after the first trimester. An accurate statement from the nurse about the fetal stage would be which of the following?

The heartbeat can be heard

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks about how the baby develops soon after birth. An accurate statement from the nurse about neonatal development would be which of the following?

The neonate is able to hear and turn toward sound

A nurse is working with a nursing student today, whose focus and goal for the day is to assess the developmental stages of his patients. Both are caring for a group of pediatric patients that includes a 2-year-old, a 7-year-old, and a 16-year-old. The nurse and the student discuss Erik Erikson's development theory and the nurse asks the student to put the following tasks and stages in chronological order.

Trust versus mistrust(infant) Autonomy versus shame and doubt(toddler hood) Initiative versus guilt(preschooler) Industry versus inferiority(school -age) Identity versus role confusion(adolescence) Intimacy versus isolation(young adult)

While teaching a sex education class to a group of preadolescents, the school nurse explains that human growth and development begins at which of the following events?

When ovum is fertilized by sperm

The nurse is teaching a class to pregnant adolescents and young adults. What does the nurse explain is the most important reason for breastfeeding instead of bottle feeding?

breastfeeding provides protection against infections

A 6-month-old infant visits the pediatric clinic for a well-baby checkup. The infant's parent asks what the common health problems are for this age. What is the best response by the nurse?

food allergies. Explanation: Gastroenteritis and food allergies are common health concerns during infancy. Dental problems, communical diseases, and falls are common health problems seen more often in toddlers and preschoolers.

At which stage of pregnancy is the developing fetus most at risk for developing congenital anomalies?

embryonic stage Because the embryonic stage is a period of such rapid growth and change, the embryo is especially vulnerable to any factor that might cause congenital anomalies. The preembryonic stage is the stage of cell division. The fetal stage is growth of the organs formed in the embryonic stage. The ovum is the egg to be fertilized.

The school nurse is concerned about nutrition for school-age children. Which meal plan should be selected for a nutritious lunch?

grilled chicken with celery and carrot sticks and apple slices

The pregnant young adult states, "I heard all babies develop colic. What causes infant colic?" How does the health care provider explain the causes of infant colic to the client? Select all that apply.

swallowing too much air with feeding laying infant down with propped up bottle allergies to the formula causes abdominal pain

When assessing the health of a neonate, the nurse should be aware that

the neonate hears and turns toward sound and can smell and taste. Explanation: The neonate's senses are used to respond to the environment; see color and form; hear and turn toward sound, smell, and taste; and feel touch and pain. The neonate's reflexes include the Moro reflex, the stepping reflex, grasp reflex, hand-to-mouth activity, sucking, swallowing, blinking, sneezing, and yawning. The neonate's body temperature responds quickly to the environmental temperature.