Fundamentals- Ch. 22

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." The fetal heart beat is audible by Doppler by 12-weeks-gestation. The client will be able to hear the heart beat at an appointment around 12 weeks of pregnancy.

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." Neonates use senses to respond to the environment, they see color and form, hear and turn toward sound, smell and taste, and feel touch and pain. Anesthesia is usually given with circumcisions. It is not known how long a newborn will remember felt pain. It is not empathetic to tell the client's family that the baby cannot feel the pain or it only last one to two minutes.

A nurse is providing care to a new mother who yesterday gave birth to a healthy neonate. The new mother asks, "I was reading that it's important to bond and attach with my baby. But is there a difference in the two?" Which response by the nurse demonstrates understanding of these two concepts?

"Bonding is the immediate connection you have with your baby while attachment occurs over the long term." Bonding and attachment are different. Attachment is an active, affectionate, reciprocal relationship between two people. Bonding, described by Klaus and Kennell (1982), occurs during a sensitive period in the first few hours after birth (although bonding also may occur later in the first few months) and is necessary for later attachment. Bonding may be considered the emotional linkage of two people, and attachment the long-term maintenance and strengthening of the linked state. Bonding and attachment are not associated with satisfaction or development of trust.

A father is concerned because his 3-year-old daughter has been using the bathroom independently for the past 6 months, but has had a few "accidents" since her hospitalization. Which of the following is the nurse's best response?

"Her regressive behaviors are a reaction to being hospitalized."

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."

An 8-year-old girl is brought to the health care provider's office for a well-child visit. During the visit, the child's mother asks the nurse, "When should she get the human papillomavirus (HPV) vaccine? Which response by the nurse would be best?

"The first dose should be given at about 9 or 10 years of age." The CDC recommends vaccination with two doses of human papillomavirus (HPV) vaccine before age 15, with the first dose given at 9 or 10 years of age, to prevent the types of HPV that can cause cervical cancer and genital warts.

A parent brings the 18-month-old to the clinic for treatment of a head cold. The child has been coughing for the last two days and nights. The parent says, "When my older kids were this age, the only thing that would stop their cough was a cough syrup containing codeine." How should the nurse respond?

"We have discovered that codeine does not work well with young children."

A parent brings the 18-month-old to the clinic for treatment of a head cold. The child has been coughing for the last two days and nights. The parent says, "When my older kids were this age, the only thing that would stop their cough was a cough syrup containing codeine." How should the nurse respond?

"We have discovered that codeine does not work well with young children." The US Food and Drug Administration has changed labeling to indicate that medications containing codeine or hydrocodone should not be used in children. In addition, data indicate that these drugs have minimal therapeutic value for this age group.

A nurse is providing education to a group of new parents about ways to minimize the risk for sudden infant death syndrome (SIDS). The nurse determines that the teaching was successful based on which statement by the group? Select all that apply.

"We should put our baby on the back to sleep." "The sleeping surface should be firm." "The crib should be free of any soft objects or toys." The American Academy of Pediatrics recommends safe sleep guidelines for infants that include placing the infant on the back to sleep for every sleep; using a firm sleep surface; keeping soft objects (including toys) and loose bedding away from the infant's sleep area; and considering the use of a pacifier at naptime and bedtime.

A nurse is providing care to a preschooler who is hospitalized. The preschooler is about to have an intravenous line inserted for fluid replacement. The child asks the nurse, "Will this hurt?" Which response by the nurse would be best?

"You might feel a short pinch but it won't be for very long."

A nurse at the health center is reviewing the health records of several of the clients who are scheduled for appointments today. The nurse identifies which client as being an adolescent? Select all that apply.

14-year-old with asthma 12-year-old who had an appendectomy

A nurse is assessing a 12-month-old infant who is brought to the clinic by the parents for well-child visit. The nurse reviews the infant's health history and notes that the infant weighed 8 lb at birth. When assessing the infant's weight at this visit, the nurse would anticipate that the infant would weight approximately how much at this time?

24 lb Although weight gain during the first year varies and is highly individualized, birth weight usually triples by 1 year. Using this guideline, the nurse would anticipate that the infant who weighed 8 lb at birth would weigh approximately 24 lb.

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

When a nurse is working on a pediatric unit, which of the following clients would the nurse know has the greatest need for good nutrition?

5 month old

A neonate has a heartbeat of 92 beats/minute, good respiratory effort, active motion, a vigorous cry, a pink body, and blue extremities. Based upon these findings, what Apgar score will this neonate receive?

8 Rationale: The neonate will receive a score of 8. The score calculation is as follows: 1 = slow heart rate (less than 100 beats/minute), 2 = good respiratory effort and crying (respiratory effort), 2 = active motion (muscle tone), 2 = vigorous cry (reflex/irritability), 1 = pink body and blue extremities (color), for a total score of 8.

During a well-child visit, a mother says, "My child received a meningococcal vaccine at age 11." Which information should the nurse provide to this mother?

A booster shot at age 16 is recommended. Meningococcal immunizations should be given at age 11 to 12 with a booster at age 16.

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

The school nurse is teaching a class of 12-year-old children about nutrition for their age group. Which information should the nurse include? Select all that apply.

Be sure you are getting enough vitamin D through milk and enriched grains. Try to reduce the amount of salt you are adding to your food. Calcium is an important part of your diet.

Of the following components of psychosocial development in the neonate and infant, which one facilitates emotional linkage between a baby and caregiver?

Bonding

A nurse is participating in a local community health fair. The nurse is providing information about sexually transmitted infections. Which infection would the nurse describe as being the most common?

Chlamydia

The nurse is educating parents of a newborn about expected changes in the first year of life. Which 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 The physical characteristics of the infant that parents should expect include the brain to grow to about half the adult size, body temperature to stabilize, the heart to double in weight, the heart rate to slow, blood pressure to rise, deciduous teeth to begin to erupt at 4 to 6 months, and the birth weight to triple by 1 year.

The nurse is providing care for an 11-year-old child who has been diagnosed with central auditory processing disorder. Which strategy should the nurse use when teaching this child how to apply a wrist brace?

Demonstration-return demonstration The child with central auditory processing disorder has problems with processing and remembering language-based tasks. The nurse should demonstrate the application of the brace and ask the child to return demonstrate the skill so that additional teaching can occur if necessary. Showing a video without return demonstration does not allow the nurse to determine if learning has occurred. Explaining the process in detail will be confusing to this child. Written instructions do not allow the nurse to assess learning.

The nurse is teaching child safety and nutrition to a group of parents at a public health clinic. In answer to a question about childhood obesity, the nurse talks about the causes of school-age children being overweight. The nurse should include which of the following? Choose all that apply.

Diets that are high in saturated fats Lack of adequate, appropriate exercise Genetic and health factors Consuming more calories than expended

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 fetus is most susceptible to teratogens during the embryonic stage.

A nurse is provding care to a 2 1/2-year-old girl recently admitted to the hospital for an exacerbation of asthma. When developing this child's care plan, which intervention would the nurse likely include?

Encouraging the parents to provide care to the child

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 Based on Erikson's theory, the adolescent tries out different roles, personal choices, and beliefs in the stage called "identity versus role confusion." Through a series of stages, Piaget proposed four stages of cognitive development: the sensorimotor, preoperational, concrete operational and formal operational period. Freud's theory of personality is that it is formed through conflicts among three fundamental structures of the human mind: the id, ego, and superego. Havighurst emphasized that learning is basic and that it continues throughout life span. Growth and Development occurs in six stages.

In which developmental stage are genetic malformations most likely to occur?

First trimester

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

A school nurse is aware of the importance of creating and carrying out interventions that resonate with the developmental tasks of the adolescent population. Such interventions should appeal to adolescents' prioritization of their what?

Identity One of the key developmental tasks in adolescence is the creation and maintenance of an independent identity. This consideration frequently trumps goal orientation. While adolescents may often be skeptical and vulnerable, the role of identity is central to this population.

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 most appropriate teaching point for a class for parents with infants would be what to do if choking would occur. The other responses are incorrect. An infant should be placed in the supine position, on the back. The infant crib should not be lined with bumpers as the bumpers could lead to a child choking or suffocating. Weaning from the breast would not be encouraged as early as 9 months.

Adolescent sexual development occurs in three stages: prepubescence, pubescence, and postpubescence. Characteristics common to the phase of pubescence include which of the following?

Increase in the amount, pigmentation, and curling of pubic hair, and growth spurt in height and weight Characteristics common to the pubescence phase include an increase in the amount, pigmentation, and curling of pubic hair, and a growth spurt in height and weight. Axillary hair appears and no longer has a downy appearance. Sex organs continue to enlarge, and ovulation and spermatogenesis begins. Completion of sexual growth and development, as well as fertility, occur during the postpubescence phase. Appearance of breast buds in females, increase in length and circumference of penis, progressive enlargement of sex organs, and appearance of downy pubic hair occur during the prepubescence phase.

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 clinic nurse is seeing a female client 18 years of age who needs to renew her asthma prescription. The client tells the nurse that she is going to another province in a few weeks to attend college and will be living in a dorm. The nurse recommends which of the following while the client is being seen in the clinic?

Meningococcal vaccine

A school-aged child is attentive to following the rules at school, respects his teachers, and views justice as a means of fair play. These are characteristics of which type of development typical of this age group?

Moral development Following the rules at school, respecting teachers, and viewing justice as a means of fair play are important moral development characteristics. Spiritual development involves religious faith and spiritual beliefs. Psychosocial development includes theories by Freud, Erikson, and Havighurst. Physiologic development during the school-aged period focuses on growth and motor development.

A nurse is conducting a program for a group of parents who have preschoolers. The focus of the program is safety in this age group. The nurse would emphasize measures to address which potential source of injury? Select all that apply.

Motor vehicle crashes Drowning Burns Poisoning Accidents are the leading cause of injury and death in preschoolers, most often from motor vehicles, drowning, burns, and poisoning. Aspiration is more of a concern for infants and toddlers.

A nurse is providing care to a female adolescent diagnosed with binge eating disorder. The nurse understands that which situation is most often associated as the underlying issue with this disorder?

Negative self-concept Binge eating disorder refers to excessive eating that is not followed by purging, excessive exercise, or fasting. Although depression and anxiety may be associated with this eating disorder, it almost always involves a negative self-concept. Egocentrism is not associated with any eating disorder.

Which of the following topics for the client education of a pregnant woman should the nurse prioritize in an effort to promote healthy fetal development?

Nutrition

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

A nurse is conducting a class for the parents of toddlers at the local preschool. The nurse is teaching the parents about safety measures to prevent accidents in this age group. The nurse focuses the teaching on preventing which type of accident for this age group? Select all that apply.

Poisonings Drownings Choking Falls

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.

Presence of body hair Breast development Facial hair growth in boys Voice changes in boys 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.

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. 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.

A school nurse is preparing a presentation for the parent-teacher association at the local elementary school. The nurse is focusing on the topic of nutrition in this age group. Which suggestion would be appropriate for the nurse to include? Select all that apply.

Providing foods that are high in calcium Encouraging foods high in vitamin D Avoiding foods that contain empty calories

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 Adolescent sexual development is divided into three categories: prepubescence, pubescence, and postpubescence. Prepubescence would be defined by rounding of the hips, appearance of breast buds, and appearance of downy pubic hair. Pubescence would be defined by development of breast tissue, growth spurt in height and weight, appearance of axillary hair, and initiation of menarche. Postpubescence would be defined by completion of sexual growth and development and fertility. Precocious puberty is puberty that begins prior to age 8 in girls, and age 9 in boys. Certain conditions such as infections, brain abnormalities, tumors, or hormone disorders may cause precocious puberty.

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.

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

Sources of calcium and vitamin D

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.

Stack building blocks Ambulation may start Crawl on all fours The infant, 1 month to 1 year, will develop motor abilities that may include use of building blocks, attempting to feed self, crawling, and walking. Toilet training and speaking in complete sentences does not usually occur until toddlerhood or preschool age.

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 use

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

The nurse is providing prenatal education to a group of pregnant teenagers. One of the group members asks what the baby can do physically right after birth. Which is an accurate statement about neonatal ability following birth?

The newborn can suck, swallow, sneeze, and yawn

A nurse is preparing a presentation for a group of students who are entering high school in the fall. During the presentation, one of the students asks, "I've heard all sorts of things about puberty. But what exactly is it?" Which information would the nurse incorporate into the response?

The time when a person's ability to reproduce begins Puberty refers to the time when the ability to reproduce begins. It starts at 9 to 13 years of age in girls (with menstruation usually beginning between 10 and 14 years of age) and at 11 to 14 years of age in boys. It does not refer to the time when a person first engages in sexual activity. Prepubescence is the term that refers to the time when secondary sex characteristics begin to develop, but the reproductive organs do not yet function. Postpubescence refers to the time when reproductive functioning and the development of secondary sex characteristics reach adult maturity.

A school nurse is reviewing the medical record of a child who was just diagnosed with a learning disability. The record reveals that the child has problems with letters and activities that require hand-eye coordination. The nurse interprets this as which type of learning disability?

Visual perceptual/visual motor deficit A visual perceptual/visual motor deficit involves problems with letters and activities that require hand-eye coordination. Aphasia involves a language disability, including understanding, reading, writing, and verbal expression. Dyslexia involves difficulty in language skills, reading, and spelling. Nonverbal learning disorders involve difficulty with nonverbal cues and coordination.

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 Breastfeeding provides immunity to bacterial and viral infections which is the most important reason for the infant to feed on breast milk. Breastfeeding being cheaper, promoting closeness, and easier at night, are benefits, but these are not the most important reasons for breastfeeding.

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 pre-embryonic 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.

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

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.