NUR 1411C Exam 1 Summer
The earliest age at which a satisfactory radial pulse can be taken in children is: a. 1 year. b. 2 years. c. 3 years. d. 6 years.
b. 2 years. Satisfactory radial pulses can be used in children older than 2 years. In infants and young children the apical pulse is more reliable. The radial pulse can be used for assessment at ages 3 and 6 years.
By what age does the posterior fontanel usually close? a. 6 to 8 weeks b. 10 to 12 weeks c. 4 to 6 months d. 8 to 10 months
a. 6 to 8 weeks The bones surrounding the posterior fontanel fuse and close by age 6 to 8 weeks. Ten weeks or longer is too late and indicates a problem.
Preschoolers' fears can best be dealt with by which intervention? a. Actively involving them in finding practical methods to deal with the frightening experience. b. Forcing them to confront the frightening object or experience in the presence of their parents. c. Using logical persuasion to explain away their fears and help them recognize how unrealistic the fears are. d. Ridiculing their fears so they understand that there is no need to be afraid.
a. Actively involving them in finding practical methods to deal with the frightening experience. Actively involving the child in finding practical methods to deal with the frightening experience is the best way to deal with fears. Forcing a child to confront fears may make the child more afraid. Preconceptual thought prevents logical understanding. Ridiculing fears does not make them go away.
With the goal of preventing plagiocephaly, the nurse should teach new parents to consider which intervention? a. Place the infant prone for 30 to 60 minutes per day. b. Buy a soft mattress. c. Allow the infant to nap in the car safety seat. d. Have the infant sleep with the parents.
a. Place the infant prone for 30 to 60 minutes per day. Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or "tummy time" for approximately 30 to 60 minutes per day when the infant is awake. Soft mattresses or sleeping with parents (co-sleeping) are not recommended because they put the infant at a higher risk for a sudden infant death incident. To prevent plagiocephaly, prolonged placement in car safety seats should be avoided.
Which interventions should the nurse implement when caring for a family of a sudden infant death syndrome (SIDS) infant? (Select all that apply.) a. Allow parents to say goodbye to their infant. b. Once parents leave the hospital, no further follow-up is required. c. Arrange for someone to take the parents home from the hospital. d. Avoid requesting an autopsy of the deceased infant. e. Conduct a debriefing session with the parents before they leave the hospital.
a. Allow parents to say goodbye to their infant. c. Arrange for someone to take the parents home from the hospital. e. Conduct a debriefing session with the parents before they leave the hospital. An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say good-bye to their infant. These are the parents' last moments with their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as possible. Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional should visit them after the death as soon as possible.
Which clinical manifestations should cause the nurse to suspect that a child, diagnosed with a digestive disorder, may be demonstrating signs of failure to thrive? a. Avoidance of eye contact. b. An associated malabsorption defect. c. Weight that falls below the 15th percentile. d. Normal achievement of developmental landmarks.
a. Avoidance of eye contact. One of the clinical manifestations of nonorganic failure to thrive is the child's avoidance of eye contact with the health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is indicative of failure to thrive. Developmental delays, including social, motor, adaptive, and language, exist.
The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading? a. Birth history b. Present illness c. Chief complaint d. Review of systems
a. Birth history The birth history refers to information that relates to previous aspects of the child's health, not to the current problem. The mother's difficult delivery and prematurity are important parts of the past history of an infant. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It would not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth. Sequelae such as pulmonary dysfunction would be included.
A nurse is performing an assessment on a school-age child. Which findings suggest the child is receiving an excess of vitamin A? (Select all that apply.) a. Delayed sexual development b. Edema c. Pruritus d. Jaundice e. Paresthesia
a. Delayed sexual development c. Pruritus d. Jaundice Excess vitamin A can cause delayed sexual development, pruritus, and jaundice. Edema is seen with excess sodium. Paresthesia occurs with excess riboflavin.
In teaching parents about appropriate pacifier selection, the nurse should explain that a pacifier should have which characteristics? (Select all that apply.) a. Easily grasped handle b. One-piece construction c. Ribbon or string to secure to clothing d. Soft, pliable material e. Sturdy, flexible material
a. Easily grasped handle b. One-piece construction e. Sturdy, flexible material A good pacifier should be easily grasped by the infant. One-piece construction is necessary to avoid having the nipple and guard separate. The material should be sturdy and flexible. An attached ribbon or string and soft, pliable material are not characteristics of a good pacifier.
A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply.) a. Elicit one answer at a time. b. Interrupt the interpreter if the response from the family is lengthy. c. Comments to the interpreter about the family should be made in English. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family.
a. Elicit one answer at a time. d. Arrange for the family to speak with the same interpreter, if possible. e. Introduce the interpreter to the family. When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English.
Which consideration should be considered when planning care for an infant diagnosed with failure to thrive? a. Establishing a structured routine and follow it consistently. b. Maintaining a nondistracting environment by not speaking to the infant during feeding. c. Placing the infant in an infant seat during feedings to prevent overstimulation. d. Limiting sensory stimulation and play activities to alleviate fatigue.
a. Establishing a structured routine and follow it consistently. The infant with failure to thrive should have a structured routine that is followed consistently. Disruptions in other activities of daily living can have a great impact on feeding behaviors. Bathing, sleeping, dressing, playing, and feeding are structured. The nurse should talk to the infant by giving directions about eating. This will help the infant maintain focus. Young children should be held while being fed, and older children can sit at a feeding table. The infant should be fed in the same manner at each meal. The infant can engage in sensory and play activities at times other than mealtime.
Which information could be given to the parents of a 12-month-old child regarding appropriate play activities for this age? a. Give large push-pull toys for kinesthetic stimulation. b. Place cradle gym across crib to facilitate fine motor skills. c. Provide child with finger paints to enhance fine motor skills. d. Provide stick horse to develop gross motor coordination.
a. Give large push-pull toys for kinesthetic stimulation. The 12-month-old child is able to pull to a stand and walk holding on or independently. Appropriate toys for a child of this age include large push-pull toys for kinesthetic stimulation. A cradle gym should not be placed across the crib. Finger paints are appropriate for older children. A 12-month-old child does not have the stability to use a stick horse.
The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? a. Introduce himself or herself. b. Make the family comfortable. c. Explain the purpose of the interview. d. Give an assurance of privacy.
a. Introduce himself or herself. The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview the nurse should include general conversation to help make the family feel at ease. Next, the purpose of the interview and the nurse's role should be clarified. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.
The parents of a 4-month-old infant tell the nurse that they are getting a microwave oven and will be able to heat the baby's formula faster. What recommendations should the nurse provide the parents? a. Never heat a bottle in a microwave oven. b. Heat only 10 ounces or more. c. Always leave the bottle top uncovered to allow heat to escape. d. Shake the bottle vigorously for at least 30 seconds after heating.
a. Never heat a bottle in a microwave oven. Neither infant formula nor breast milk should be warmed in a microwave oven as this may cause oral burns as a result of uneven heating in the container. The bottle may remain cool while hot spots develop in the milk. Warming expressed milk in a microwave decreases the availability of antiinfective properties and causes separation of the fat content. Milk should be warmed in a lukewarm water bath. None of the other options adequately deals with the issue of overheating.
A 3-month-old infant, born at 38 weeks of gestation, will hold a rattle if it is put in her hands; however, she will not voluntarily grasp it. How should the nurse interpret this behavior? a. Normal development b. Significant developmental lag c. Slightly delayed development caused by prematurity d. Suggestive of a neurologic disorder such as cerebral palsy
a. Normal development This indicates normal development. Reflexive grasping occurs during the first 2 to 3 months and then gradually becomes voluntary. No evidence of developmental lag, delayed development, or neurologic dysfunction is present by this behavior.
During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is: a. a normal finding. b. an abnormal finding; the child needs referral to an ophthalmologist. c. a sign of a possible visual defect; the child needs vision screening. d. a sign of small hemorrhages, which usually resolve spontaneously.
a. a normal finding. A brilliant, uniform red reflex is an important normal and expected finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.
Which is an appropriate play activity for a 7-month-old infant to encourage visual stimulation? a. Playing peek-a-boo. b. Playing pat-a-cake. c. Imitating animal sounds. d. Showing how to clap hands.
a. Playing peek-a-boo. Because object permanence is a new achievement, peek-a-boo is an excellent activity to practice this new skill for visual stimulation. Playing pat-a-cake and showing how to clap hands will help with kinesthetic stimulation. Imitating animal sounds will help with auditory stimulation.
Which data would be included in a health history? (Select all that apply.) a. Review of systems b. Physical assessment c. Sexual history d. Growth measurements e. Nutritional assessment f. Family medical history
a. Review of systems c. Sexual history e. Nutritional assessment f. Family medical history The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history. Physical assessment and growth measurements are components of the physical examination.
In terms of gross motor development, what hallmark action should the nurse identify for the parents of a 5-month-old infant to anticipate? a. Roll from abdomen to back. b. Roll from back to abdomen. c. Sit erect without support. d. Move from prone to sitting position.
a. Roll from abdomen to back. Rolling from abdomen to back is developmentally appropriate for a 5-month-old infant. The ability to roll from back to abdomen usually occurs at 6 months old. Sitting erect without support is a developmental milestone usually achieved by 8 months. The 10-month-old infant can usually move from a prone to a sitting position.
In terms of gross motor development, what would the nurse educate the parents to expect a 5-month-old infant to do? (Select all that apply.) a. Roll from abdomen to back. b. Put feet in mouth when supine. c. Roll from back to abdomen. d. Sit erect without support. e. Move from prone to sitting position.
a. Roll from abdomen to back. b. Put feet in mouth when supine. Rolling from abdomen to back and placing the feet in the mouth when supine are developmentally appropriate for a 5-month-old infant. Rolling from back to abdomen is developmentally appropriate for a 6-month-old infant. An 8-month-old infant should be able to sit erect without support. A 10-month-old infant can usually move from a prone to a sitting position.
The nurse is doing a routine assessment on a 14-month-old infant and notes that the anterior fontanel is closed. This should be interpreted as: a. a normal finding. b. a questionable finding—the infant should be rechecked in 1 month. c. an abnormal finding—indicates the need for immediate referral to a practitioner. d. an abnormal finding—indicates the need for developmental assessment.
a. a normal finding. Because the anterior fontanel normally closes between ages 12 and 18 months, this is a normal finding, and no further intervention is required.
What skill that the nurse should expect a 5-year-old child to be able to master? a. Tie shoelaces. b. Use a knife to cut meat. c. Hammer a nail. d. Make change from a quarter.
a. Tie shoelaces. Tying shoelaces is a fine motor task typical of 5 year olds. Using a knife to cut meat is a fine motor task of a 7 year old. Hammering a nail and making change from a quarter are fine motor tasks of an 8 to 9 year old.
The nurse determines an infant of 7 months is demonstrating appropriate fine motor development when performing which action? a. Transferring a rattler from one hand to the other. b. Using thumb and index finger to grasp a piece of food. c. Holding a crayon and make a mark on paper. d. Releasing cubes into a cup.
a. Transferring a rattler from one hand to the other. By age 7 months, infants can transfer objects from one hand to the other, crossing the midline. The crude pincer grasp is apparent at about age 9 months. The infant can scribble spontaneously at age 15 months. At age 12 months, the infant can release cubes into a cup.
The nurse is interviewing the father of 10-month-old. When the child, playing on the floor and notices an electrical outlet and reaches up to touch it, the father says "No" firmly and removes the child away from the outlet. The nurse should use this opportunity to teach the father that the child is capable of understanding what association? a. Understand the word "No." b. Father always means "No." c. Electrical outlets are dangerous. d. Spanking as a deterrent.
a. Understand the word "No." By age 10 months, children are able to associate meaning with words. The child should be old enough to understand the word "No." The 10-month-old is too young to understand the purpose of an electrical outlet and is not likely to always associate her father with the word "No." The father is using both verbal and physical cues to teach safety measures and alert the child to dangerous situations. Physical discipline should be avoided.
In terms of cognitive development, the preschooler would be expected to engage in what behavior? a. Use magical thinking b. Think abstractly c. Understand conservation of matter d. Be able to comprehend another person's perspective
a. Use magical thinking Preschoolers' thinking is often described as magical thinking. Because of their egocentrism and transductive reasoning, they believe that thoughts are all-powerful. Abstract thought does not develop until school-age years. The concept of conservation is the cognitive task of school-age children ages 5 to 7 years. Five year olds cannot understand another's perspective.
What type of breath sound is normally heard over the entire surface of the lungs, except for the upper intrascapular area and the area beneath the manubrium? a. Vesicular b. Bronchial c. Adventitious d. Bronchovesicular
a. Vesicular Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate.
Sara, age 4 months, was born at 35 weeks' gestation. She seems to be developing normally, but her parents are concerned because she is a "more difficult" baby than their other child, who was term. The nurse should explain that: a. infants' temperaments are part of their unique characteristics. b. infants become less difficult if they are not kept on scheduled feedings and structured routines. c. Sara's behavior is suggestive of failure to bond completely with her parents. d. Sara's difficult temperament is the result of painful experiences in the neonatal period.
a. infants' temperaments are part of their unique characteristics. Infant temperament has a strong biologic component. Together with interactions with the environment, primarily the family, the biologic component contributes to the infant's unique temperament. Children perceived as difficult may respond better to scheduled feedings and structured caregiving routines than to demand feedings and frequent changes in routines. Sara's temperament has been created by both biologic and environmental factors. The nurse should provide guidance in parenting techniques that are best suited to Sara's temperament.
The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. The rationale for this position is that: a. it prevents cremasteric reflex. b. undescended testes can be palpated. c. this tests the child for an inguinal hernia. d. the child does not yet have a need for privacy.
a. it prevents cremasteric reflex. The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its contraction, which pulls the testes into the pelvic cavity. Undescended testes cannot be predictably palpated. Inguinal hernias are not detected by this method. This position is used for inhibiting the cremasteric reflex. Privacy should always be provided for children.
The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. The most appropriate action is to: a. refer for immediate medical evaluation. b. continue the assessment to determine the cause of neck pain. c. ask the parent when the child's neck was injured. d. record "head lag" on the assessment record and continue the assessment of the child.
a. refer for immediate medical evaluation. These symptoms indicate meningeal irritation and need immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag.
The nurse is caring for a hospitalized 4 year old. The parents tell the nurse that they will be back to visit at 6 PM. When the child asks the nurse, "when my parents are coming", what is the nurse's best response? a. "They will be here soon." b. "They will come after dinner." c. "Let me show you on the clock when 6 PM is." d. "I will tell you every time I see you how much longer it will be."
b. "They will come after dinner." A 4 year old understands time in relation to events such as meals. Children perceive "soon" as a very short time. The nurse may lose the child's trust if his parents do not return in the time he perceives as "soon." Children cannot read or use a clock for practical purposes until age 7 years. This answer assumes that the child understands the concept of hours and minutes, which is not developed until age 5 or 6 years.
The nurse assessing a 6-month-old healthy infant who weighed 7 lbs at birth, shares with the parents that the infant should weigh approximately how many pounds? a. 10 lbs. b. 15 lbs. c. 20 lbs. d. 25 lbs.
b. 15 lbs. Birth weight doubles at about age 5 to 6 months. At 6 months, an infant who weighed 7 lbs at birth would weigh approximately 15 lbs. Ten pounds is too little; the infant would have gone from the 50th percentile at birth to below the 5th percentile. Twenty pounds or more is too much; the infant would have tripled the birth weight at 6 months.
At what age should the nurse expect an infant to begin smiling in response to pleasurable stimuli? a. 1 month b. 2 months c. 3 months d. 4 months
b. 2 months At age 2 months, the infant has a social, responsive smile. A reflex smile is usually present at age 1 month. The 3-month-old can recognize familiar faces. At age 4 months, the infant can enjoy social interactions.
Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? a. 1 month b. 3 to 4 months c. 6 to 8 months d. 12 months
b. 3 to 4 months Binocularity is usually achieved by ages 3 to 4 months. Age 1 month is too young for binocularity. If binocularity is not achieved by 6 months, the child must be observed for strabismus.
When is the best age for solid food to be introduced into the infant's diet? a. 2 to 3 months b. 4 to 6 months c. When birth weight has tripled d. When tooth eruption has started
b. 4 to 6 months Physiologically and developmentally, the 4 to 6 months old is in a transition period. The extrusion reflex has disappeared, and swallowing is a more coordinated process. In addition, the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic food. Infants of this age will try to help during feeding. Two to three months is too young. The extrusion reflex is strong, and the infant will push food out with the tongue. No research base indicates that the addition of solid food to bottle-feeding has any benefit. Tooth eruption can facilitate biting and chewing; most infant foods do not require this ability.
The nurse is taking a health history on an adolescent. Which best describes how the chief complaint should be determined? a. Ask for a detailed listing of symptoms. b. Ask the adolescent, "Why did you come here today?" c. Use what the adolescent says to determine, in correct medical terminology, what the problem is. d. Interview the parent away from the adolescent to determine the chief complaint.
b. Ask the adolescent, "Why did you come here today?" The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A listing of symptoms will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him or her to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time.
What is descriptive of the preschooler's understanding of time? a. Has no understanding of time b. Associates time with events c. Can tell time on a clock d. Uses terms like "yesterday" appropriately
b. Associates time with events In a preschooler's understanding, time has a relation with events such as, "We'll go outside after lunch." Preschoolers develop an abstract sense of time at age 3 years. Children can tell time on a clock at age 7 years. Children do not fully understand use of time-oriented words until age 6 years.
A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply.) a. Complaints of a sore back b. Asymmetry of the shoulders c. An uneven hemline d. Inability to bend at the waist e. Unequal waist angles
b. Asymmetry of the shoulders c. An uneven hemline e. Unequal waist angles The assessment findings associated with scoliosis include asymmetry of the shoulder and hips, trouser pant leg length appearing shorter on one side, or an uneven hemline on a skirt, indicating unequal leg length. The child may also complain of a sore back. The child is able to bend at the waist adequately.
Which tool measures body fat most accurately? a. Stadiometer b. Calipers c. Cloth tape measure d. Paper or metal tape measure
b. Calipers Calipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.
Acyclovir is given to children with chickenpox for what purpose? a. Minimize scarring b. Decrease the number of lesions c. Prevent aplastic anemia d. Prevent spread of the disease
b. Decrease the number of lesions Acyclovir decreases the number of lesions, shortens duration of fever, and decreases itching, lethargy, and anorexia; however, it does not prevent scarring. Preventing aplastic anemia is not a function of acyclovir. Only quarantine of the infected child can prevent the spread of disease.
A nurse is teaching parents about prevention and treatment of colic. Which should the nurse include in the teaching plan? a. Avoid use of pacifiers. b. Eliminate all secondhand smoke contact. c. Lay infant flat after feeding. d. Avoid swaddling the infant.
b. Eliminate all secondhand smoke contact. To prevent and treat colic, teach parents that if household members smoke, they should avoid smoking near the infant; smoking activity should preferably be confined to outside of the home. A pacifier can be introduced for added sucking. The infant should be swaddled tightly with a soft, stretchy blanket, and placed in an upright seat after feedings.
In terms of language and cognitive development, which behavior is expected of a 4-year-old child? a. Thinking in abstract terms. b. Following simple commands. c. Understanding conservation of matter. d. Comprehending another person's perspective.
b. Following simple commands. Children ages 3 to 4 years can give and follow simple commands. Children cannot think abstractly at age 4 years. Conservation of matter is a developmental task of the school-age child. A 4-year-old child cannot comprehend another's perspective.
A 4 year old is hospitalized with a serious bacterial infection. The child tells the nurse that, "I am sick because I was bad." What is the nurse's best interpretation of this comment? a. It is a sign of stress. b. It is common at this age. c. It is suggestive of maladaptation. d. It is suggestive of excessive discipline at home.
b. It is common at this age. Preschoolers cannot understand the cause and effect of illness. Their egocentrism makes them think that they are directly responsible for events, making them feel guilt for things outside of their control. Children of this age show stress by regressing developmentally or acting out. Maladaptation is unlikely. This comment does not imply excessive discipline at home.
A nurse is conducting education classes for parents of infants. The nurse plans to discuss sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant's risk of a SIDS incident? (Select all that apply.) a. Breastfeeding b. Low Apgar scores c. Male sex d. Birth weight in the 50th or higher percentile e. Recent viral illness
b. Low Apgar scores c. Male sex e. Recent viral illness Certain groups of infants are at increased risk for SIDS: those with low birth weight, low Apgar scores, or recent viral illness, and those of male sex. Breastfed infants and infants of average or above-average weight are not at higher risk for SIDS.
The clinic is lending a federally approved car seat to an infant's family. Where in the car should the nurse explain is the safest place to put the car seat? a. Front facing in back seat. b. Rear facing in back seat. c. Front facing in front seat if an air bag is on the passenger side. d. Rear facing in front seat if an air bag is on the passenger side.
b. Rear facing in back seat. The rear-facing car seat provides the best protection for an infant's disproportionately heavy head and weak neck. Infants should face the rear from birth to 20 lbs and as close to 1 year of age as possible. The middle of the back seat provides the safest position. Severe injuries and deaths in children have occurred from air bags deploying on impact in the front passenger seat.
What is a normal characteristic of the language development of a preschool-age child? a. Lisp b. Stammering c. Echolalia d. Repetition without meaning
b. Stammering Stammering and stuttering are normal dysfluencies in preschool-age children. Lisps are not a normal characteristic of language development. Echolalia and repetition are traits of toddlers' language.
The parent of a 4 year old tells the nurse that the child believes "monsters and the boogeyman" are in the bedroom at night. What is the nurse's best suggestion for coping with this problem? a. Insist that the child sleep with his parents until the fearful phase passes. b. Suggest involving the child to find a practical solution such as a night-light. c. Help the child understand that these fears are illogical. d. Tell the child frequently that monsters and the boogeyman do not exist.
b. Suggest involving the child to find a practical solution such as a night-light. A night-light shows a child that imaginary creatures do not lurk in the darkness. Letting the child sleep with parents or telling the child that these creatures do not exist will not get rid of the fears. A 4 year old is in the preconceptual age and cannot understand logical thought.
The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply) a. The cuff is labeled "toddler." b. The cuff bladder width is approximately 40% of the circumference of the upper arm. c. The cuff bladder length covers 80% to 100% of the circumference of the upper arm. d. The cuff bladder covers 50% to 66% of the length of the upper arm.
b. The cuff bladder width is approximately 40% of the circumference of the upper arm. c. The cuff bladder length covers 80% to 100% of the circumference of the upper arm. Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. This size cuff will most accurately reflect measured radial artery pressure. The name of the cuff is a representative size that may not be suitable for any individual child. Choosing a cuff by limb circumference more accurately reflects arterial pressure than choosing a cuff by length.
What is an important consideration for the nurse who is communicating with a very young child? a. Speak loudly, clearly, and directly. b. Use transition objects such as a doll. c. Disguise own feelings, attitudes, and anxiety. d. Initiate contact with the child when the parent is not present.
b. Use transition objects such as a doll. Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This facilitates communication with this age child. Speaking loudly, clearly, and directly tends to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children.
The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as: a. inappropriate, because of child's age. b. a way to establish rapport. c. too distracting, when cooperation is important. d. acceptable, if there is adequate time.
b. a way to establish rapport. A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic.
When the nurse interviews an adolescent, it is especially important to: a. focus the discussion on the peer group. b. allow an opportunity to express feelings. c. emphasize that confidentiality will always be maintained. d. use the same type of language as the adolescent.
b. allow an opportunity to express feelings. Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age-group, the focus of the interview should be on the adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently.
The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: a. ask her, "Are you sexually active?" b. ask her, "Are you having sex with anyone?" c. ask her, "Are you having sex with a boyfriend?" d. ask both the girl and her parent if she is sexually active.
b. ask her, "Are you having sex with anyone?" Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase sexually active is broadly defined and may not provide specific information to the nurse to provide necessary care. The word anyone is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone.
Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for: a. deep tendon reflexes. b. cerebellar function. c. sensory discrimination. d. ability to follow directions.
b. cerebellar function. The finger-to-nose-test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Each sense is tested separately. Although this test enables the nurse to evaluate the child's ability to follow directions, it is used primarily for cerebellar function.
The appropriate placement of a tongue blade for assessment of the mouth and throat is the: a. the center back area of the tongue. b. the side of the tongue. c. against the soft palate. d. on the lower jaw.
b. the side of the tongue. The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement on the center back area of the tongue elicits the gag reflex. Against the soft palate and on the lower jaw are not appropriate places for the tongue blade.
The parent of a 2 week old asks the nurse if the infant needs fluoride supplements because they plan to exclusively breastfed. What is the nurse's best response? a. "Your infant needs to begin taking them now." b. "They are not needed if you drink fluoridated water." c. "Your infant may need to begin taking them at age 6 months." d. "Your infant can have infant cereal mixed with fluoridated water instead of supplements."
c. "Your infant may need to begin taking them at age 6 months." Fluoride supplementation is recommended by the American Academy of Pediatrics beginning at age 6 months if the child is not drinking adequate amounts of fluoridated water. The recommendation is to begin supplementation at 6 months, not at 2 weeks. The amount of water that is ingested and the amount of fluoride in the water are evaluated when supplementation is being considered.
By what age do the head and chest circumferences generally become equal? a. 1 month b. 6 to 9 months c. 1 to 2 years d. 2.5 to 3 years
c. 1 to 2 years Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference at ages 1 month and 6 to 9 months. Chest circumference is larger than head circumference at age 2.5 to 3 years.
The nurse should teach parents that at what age it is safe to give infants whole milk instead of commercial infant formula? a. 6 months b. 9 months c. 12 months d. 18 months
c. 12 months The American Academy of Pediatrics does not recommend the use of cow's milk for children younger than 12 months. At 6 and 9 months, the infant should be receiving commercial infant formula or breast milk. At age 18 months, milk and formula are supplemented with solid foods, water, and some fruit juices.
The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target? a. 1 month b. 1 to 2 months c. 3 to 4 months d. 6 months
c. 3 to 4 months Visual fixation and following a target should be present by ages 3 to 4 months. Ages 1 to 2 months are too young for this developmental milestone. If the infant is not able to fix and follow by 6 months of age, further ophthalmologic evaluation is needed.
A parent asks the nurse "At what age do most babies begin to fear strangers?" The nurse responds that most infants begin to fear strangers at what age? a. 2 months b. 4 months c. 6 months d. 12 months
c. 6 months Between ages 6 and 8 months, fear of strangers and stranger anxiety become prominent and are related to the infant's ability to discriminate between familiar and nonfamiliar people. At age 2 months, the infant is just beginning to respond differentially to the mother. At age 4 months, the infant is beginning the process of separation individuation when the infant begins to recognize self and mother as separate beings. Twelve months is too late and requires referral for evaluation if the infant does not fear strangers at this age.
At which age can most infants sit steadily unsupported? a. 4 months b. 6 months c. 8 months d. 10 months
c. 8 months Sitting erect without support is a developmental milestone usually achieved by 8 months. At age 4 months, an infant can sit with support. At age 6 months, the infant will maintain a sitting position if propped. By 10 months, the infant can maneuver from a prone to a sitting position.
With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight? a. 10th percentile b. 9th percentile c. 85th percentile d. 95th percentile
c. 85th percentile Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight.
By what age should the nurse expect that an infant will be able to pull to a standing position? a. 6 months b. 8 months c. 9 months d. 11 to 12 months
c. 9 months Most infants can pull themselves to a standing position at age 9 months. Any infant who cannot pull to a standing position by age 11 to 12 months should be referred for further evaluation for developmental dysplasia of the hips (DDH). At 6 months, the infant has just obtained coordination of arms and legs. By age 8 months, infants can bear full weight on their legs.
Which behavior indicates that an infant has developed object permanence? a. Recognizes familiar face such as the mother b. Recognizes familiar object such as a bottle c. Actively searches for a hidden object d. Secures objects by pulling on a string
c. Actively searches for a hidden object During the first 6 months of life, infants believe that objects exist only as long as they can see them. When infants search for an object that is out of sight, this signals the attainment of object permanence, whereby an infant knows that an object exists even when it is not visible. Between ages 8 and 12 weeks, infants begin to respond differentially to their mothers. They cry, smile, vocalize, and show distinct preference for their mothers. This preference is one of the stages that influence the attachment process, but it is too early for object permanence. Recognizing familiar objects is an important transition for the infant, but it does not signal object permanence. The ability to understand cause and effect, such as pulling on a string to secure an object, is part of secondary schema development.
Which type of play is most typical of the preschool period? a. Solitary b. Parallel c. Associative d. Team
c. Associative Associative play is group play in similar or identical activities but without rigid organization or rules. Solitary play is that of infants. Parallel play is that of toddlers. School-age children play in teams.
Why are imaginary playmates beneficial to the preschool child? a. Take the place of social interactions. b. Take the place of pets and other toys. c. Become friends in times of loneliness. d. Accomplish what the child has already successfully accomplished.
c. Become friends in times of loneliness. One purpose of an imaginary friend is to be a friend in time of loneliness. Imaginary friends do not take the place of social interactions but may encourage conversation. Imaginary friends do not take the place of pets or toys. They accomplish what the child is still attempting, not what has already been accomplished.
Which statement accurately describes an event associated with an infant's physical development? a. Anterior fontanel closes by age 6 to 10 months. b. Binocularity is well established by age 8 months. c. Birth weight doubles by age 5 months and triples by age 1 year. d. Maternal iron stores persist during the first 12 months of life.
c. Birth weight doubles by age 5 months and triples by age 1 year. Growth is very rapid during the first year of life. The birth weight approximately doubles by age 5 to 6 months and triples by age 1 year. The anterior fontanel closes at age 12 to 18 months. Binocularity is not established until age 15 months. Maternal iron stores are usually depleted by age 6 months.
A mother tells the nurse that she is discontinuing breastfeeding her 5-month-old infant. What should the nurse recommend to be used as substitute for the breastmilk? a. Skim milk b. Whole cow's milk c. Commercial iron-fortified formula d. Commercial formula without iron
c. Commercial iron-fortified formula For children younger than 1 year, the American Academy of Pediatrics recommends the use of breast milk. If breastfeeding has been discontinued, iron-fortified commercial formula should be used. Cow's milk should not be used in children younger than 12 months. Maternal iron stores are almost depleted by this age; the iron-fortified formula will help prevent the development of iron deficiency anemia.
During the preschool period, what should the emphasis of injury prevention be placed on? a. Constant vigilance and protection b. Punishment for unsafe behaviors c. Education for safety and potential hazards d. Limitation of physical activities
c. Education for safety and potential hazards Education for safety and potential hazards is appropriate for preschoolers because they can begin to understand dangers. Constant vigilance and protection is not practical at this age since preschoolers are becoming more independent. Punishment may make children scared of trying new things. Limitation of physical activities is not appropriate.
What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? a. S1, S2 b. S3, S4 c. Murmur d. Physiologic splitting
c. Murmur Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves, and both are considered normal heart sounds. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.
Where is the best place to observe for the presence of petechiae in dark-skinned individuals? a. Face b. Buttocks c. Oral mucosa d. Palms and soles
c. Oral mucosa Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.
Where in the health history should the nurse describe all details related to the chief complaint? a. Past history b. Chief complaint c. Present illness d. Review of systems
c. Present illness The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present. Past history refers to information that relates to previous aspects of the child's health, not to the current problem. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.
The mother of a breastfed infant being seen in the clinic for the sixth month checkup is concerned that the infant has begun thumb sucking. How should the nurse respond to the mother's concern? a. Recommend that the mother substitute a pacifier for the infant's thumb. b. Assess the infant for other signs of sensory deprivation. c. Reassure the mother that this behavior is very normal at this age. d. Suggest that the mother breastfeed more often to satisfy sucking needs.
c. Reassure the mother that this behavior is very normal at this age. Sucking is an infant's chief pleasure, and she may not be satisfied by bottle-feeding or breastfeeding alone. During infancy and early childhood, there is no need to restrict nonnutritive sucking. Dental damage does not appear to occur unless the use of the pacifier or finger persists after age 4 to 6 years. The nurse should explore with the mother her feelings about pacifier versus thumb. This is a normal behavior to meet nonnutritive sucking needs. No data support that Latasha has sensory deprivation.
During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? a. Teach the parents appropriate exercises. b. Recheck head control at the next visit. c. Refer the child for further evaluation. d. Refer the child for further evaluation if the anterior fontanel is still open.
c. Refer the child for further evaluation. Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.
Which age-group is most concerned with body integrity? a. Toddler b. Preschooler c. School-age child d. Adolescent
c. School-age child School-age children have a heightened concern about body integrity. They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggestion of injury. Body integrity is not as important a concern to children in the toddler, preschooler, and adolescent age-groups.
According to Piaget, the 6-month-old infant would be in what stage of the sensorimotor phase? a. Use of reflexes b. Primary circular reactions c. Secondary circular reactions d. Coordination of secondary schemata
c. Secondary circular reactions Infants are usually in the secondary circular reaction stage from age 4 months to 8 months. This stage is characterized by a continuation of the primary circular reaction for the response that results. For example, shaking of a rattle is performed to hear the noise of the rattle, not just for shaking. The use of reflexes is primarily during the first month of life. The primary circular reaction stage marks the replacement of reflexes with voluntary acts. The infant is in this stage from age 1 month to 4 months. The fourth sensorimotor stage is coordination of secondary schemata. This is a transitional stage in which increasing motor skills enable greater exploration of the environment.
What is the single most important factor to consider when communicating with children? a. The child's physical condition b. The presence or absence of the child's parent c. The child's developmental level d. The child's nonverbal behaviors
c. The child's developmental level The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child's physical condition is a consideration, developmental level is much more important. The parents' presence is important when communicating with young children, but it may be detrimental when speaking with adolescents. Nonverbal behaviors vary in importance based on the child's developmental level.
Which action is most likely to encourage parents to talk about their feelings related to their child's illness? a. Be sympathetic. b. Use direct questions. c. Use open-ended questions. d. Avoid periods of silence.
c. Use open-ended questions. Closed-ended questions should be avoided when attempting to elicit parents' feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.
Which term is used to describe breath sounds that are produced as air passes through narrowed passageways? a. Rubs b. Rattles c. Wheezes d. Crackles
c. Wheezes Wheezes are produced as air passes through narrowed passageways. The sound is similar when the narrowing is caused by exudates, inflammation, spasm, or tumor. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture.
When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are: a. unnecessary information because the child is age 3 years. b. an important part of the family history. c. an important part of the child's past growth and development. d. an important part of the child's review of systems.
c. an important part of the child's past growth and development. Information about the attainment of developmental milestones is important to obtain. It provides data about the child's growth and development that should be included in the history. Developmental milestones provide important information about the child's physical, social, and neurologic health. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones.
Parent guidelines for relieving colic in an infant include: a. avoiding touching the abdomen. b. avoiding using a pacifier. c. changing the infant's position frequently. d. placing the infant where the family cannot hear the crying.
c. changing the infant's position frequently. Changing the infant's position frequently may be beneficial. The parent can walk holding the infant face down and with the infant's chest across the parent's arm. The parent's hand can support the infant's abdomen, applying gentle pressure. Gently massaging the abdomen is effective in some infants. Pacifiers can be used for meeting additional sucking needs. The infant should not be placed where monitoring cannot be done. The infant can be placed in the crib and allowed to cry. Periodically, the infant should be picked up and comforted.
An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: a. ask her why she wants to know. b. determine why she is so anxious. c. explain in simple terms how it works. d. tell her she will see how it works as it is used.
c. explain in simple terms how it works. School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. A nurse should respond positively to requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification of what will be occurring. The nurse must explain how the blood pressure cuff works so the child can then observe during the procedure.
When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: a. indicates that they live in poverty. b. is lacking in protein. c. may provide sufficient amino acids. d. should be enriched with meat and milk.
c. may provide sufficient amino acids. The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that contain this combination of foods. It does not indicate poverty. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.
An appropriate approach to performing a physical assessment on a toddler is to: a. always proceed in a head-to-toe direction. b. perform traumatic procedures first. c. use minimal physical contact initially. d. demonstrate use of equipment.
c. use minimal physical contact initially. Parents can remove the child's clothing, and the child can remain on the parent's lap. The nurse should use minimal physical contact initially to gain the child's cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age-group.
The nurse should expect the anterior fontanel to close at age: a. 2 months. b. 2 to 4 months. c. 6 to 8 months. d. 12 to 18 months.
d. 12 to 18 months. Ages 2 through 8 months are too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes at these earlier ages, the child should be referred for further evaluation.
By what age would the nurse expect that most children could understand prepositional phrases such as "under," "on top of," "beside," and "in back of"? a. 18 months b. 24 months c. 3 years d. 4 years
d. 4 years At 4 years, children can understand directional phrases. Children 18 to 24 months and 3 years of age are too young.
The parents of a 3-month-old infant report that their infant sleeps supine (face up) but is often prone (face down) while awake. The nurse's response should be based on what knowledge? a. Unacceptable because of the risk of sudden infant death syndrome (SIDS). b. Unacceptable because it does not encourage achievement of developmental milestones. c. Unacceptable to encourage fine motor development. d. Acceptable to encourage head control and turning over.
d. Acceptable to encourage head control and turning over. These parents are implementing the guidelines to reduce the risk of SIDS. Infants should sleep on their backs and then be placed on their abdomens when awake to enhance development of milestones such as head control. The face-down position while awake and positioning on the back for sleep are acceptable because they reduce risk of SIDS and allow achievement of developmental milestones. These position changes encourage gross motor, not fine motor development.
Which accomplishment would the nurse expect of a healthy 3-year-old child? a. Jump rope b. Ride a two-wheel bicycle c. Skip on alternate feet d. Balance on one foot for a few seconds
d. Balance on one foot for a few seconds Three year olds are able to accomplish the gross motor skill of balancing on one foot. Jumping rope, riding a two-wheel bike, and skipping on alternate feet are gross motor skills of 5-year-old children.
In terms of fine motor development, what could the 3-year-old child be expected to do? a. Tie shoelaces b. Use scissors or a pencil very well c. Draw a person with 7 to 9 parts d. Copy (draw) a circle.
d. Copy (draw) a circle. Three-year-olds are able to accomplish the fine motor skill of drawing a circle. Tying shoelaces, using scissors or a pencil very well, and drawing a person with multiple parts are fine motor skills of 5-year-old children.
How should the nurse describe the fact that a 6 month old has 6 teeth? a. Normal tooth eruption. b. Delayed tooth eruption. c. Unusual and dangerous. d. Earlier-than-normal tooth eruption.
d. Earlier-than-normal tooth eruption. This is earlier than expected. Most infants at age 6 months have two teeth, the lower central incisors. Six teeth at 6 months is not delayed; it is early tooth eruption. Although unusual, it is not dangerous.
The parents of a 12-month-old child ask the nurse if the child can eat hot dogs. The nurse's reply should be based on what understanding? a. The child is too young to digest hot dogs. b. The child is too young to eat hot dogs safely. c. Hot dogs must be sliced into sections to prevent aspiration. d. Hot dogs must be cut into small, irregular pieces to prevent aspiration.
d. Hot dogs must be cut into small, irregular pieces to prevent aspiration. Hot dogs are of a consistency, diameter, and round shape that may cause complete obstruction of the child's airway. If given to young children, the hot dog should be cut into small irregular pieces rather than served whole or in slices. The child's digestive system is mature enough to digest hot dogs. To eat the hot dog safely, the child should be sitting down, and the hot dog should be appropriately cut into irregularly shaped pieces.
What is an important nursing responsibility when dealing with a family experiencing the loss of an infant from sudden infant death syndrome (SIDS)? a. Explain how SIDS could have been predicted and prevented. b. Interview parents in depth concerning the circumstances surrounding the infant's death. c. Discourage parents from making a last visit with the infant. d. Make a follow-up home visit to parents as soon as possible after the infant's death.
d. Make a follow-up home visit to parents as soon as possible after the infant's death. A competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS. An explanation of how SIDS could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. Parents should be allowed and encouraged to make a last visit with their infant.
A parent asks the nurse whether her infant is susceptible to pertussis. The nurse's response should be based on which statement concerning susceptibility to pertussis? a. Neonates will be immune the first few months. b. If the mother has had the disease, the infant will receive passive immunity. c. Children younger than 1 year seldom contract this disease. d. Most children are highly susceptible from birth.
d. Most children are highly susceptible from birth. The acellular pertussis vaccine is recommended by the American Academy of Pediatrics beginning at age 6 weeks. Infants are at greater risk for complications of pertussis. The vaccine is not given after age 7 years, when the risks of the vaccine become greater than those of pertussis. The infant is highly susceptible to pertussis, which can be a life-threatening illness in this age-group.
The most frequently used test for measuring visual acuity is the: a. Denver Eye Screening test. b. Allen picture card test. c. Ishihara vision test. d. Snellen letter chart.
d. Snellen letter chart. The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. Single cards (Denver—letter E; Allen—pictures) are used for children age 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for color vision.
Which characteristics best describes the language of a 3-year-old child? a. Asks meanings of words b. Follows directional commands c. Can describe an object according to its composition d. Talks incessantly, regardless of whether anyone is listening
d. Talks incessantly, regardless of whether anyone is listening Because of the dramatic vocabulary increase at this age, 3 year olds are known to talk incessantly, regardless of whether anyone is listening. A 4 to 5 year old asks lots of questions and can follow simple directional commands. A 6 year old can describe an object according to its composition.
The nurse is guiding parents in selecting a day care facility for their child. When making the selection, it is especially important to focus on which consideration? a. Structured learning environment. b. Socioeconomic status of children. c. Cultural similarities of children. d. Teachers knowledgeable about development.
d. Teachers knowledgeable about development. A teacher knowledgeable about development will structure activities for learning. A structured learning environment is not necessary at this age. Socioeconomic status is not the most important factor in selecting a preschool. Preschool is about expanding experiences with others; cultural similarities are not necessary.
The parents of a 9-month-old infant tell the nurse that they have noticed foods such as peas and corn are not completely digested and can be seen in their infant's stool. The nurse bases her explanation on what fact? a. Children should not be given fibrous foods until the digestive tract matures at age 4 years. b. The infant should not be given any solid foods until this digestive problem is resolved. c. This is abnormal and requires further investigation. d. This is normal because of the immaturity of digestive processes at this age.
d. This is normal because of the immaturity of digestive processes at this age. The immaturity of the digestive tract is evident in the appearance of the stools. Solid foods are passed incompletely broken down in the feces but it is not necessity to eliminate solid foods. An excess quantity of fiber predisposes the child to large, bulky stools. This is a normal part of the maturational process, and no further investigation is necessary.
Which parameter correlates best with measurements of the body's total protein stores? a. Height b. Weight c. Skin-fold thickness d. Upper arm circumference
d. Upper arm circumference Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the body's fat content.
A mother tells the nurse that she does not want her infant immunized because of the discomfort associated with injections. The nurse should explain that: a. this cannot be prevented. b. infants do not feel pain as adults do. c. this is not a good reason for refusing immunizations. d. a topical anesthetic, eutectic mixture of local anesthetic (EMLA), will minimize the discomfort.
d. a topical anesthetic, eutectic mixture of local anesthetic (EMLA), will minimize the discomfort. Several topical anesthetic agents can be used to minimize the discomfort associated with immunization injections. These include EMLA and vapor coolant sprays. Pain associated with many procedures can be prevented or minimized by using the principles of atraumatic care. With preparation, the injection site can be properly anesthetized to decrease the amount of pain felt by the infant. Infants have the neural pathways to sense pain. Numerous research studies have indicated that infants perceive and react to pain in the same manner as do children and adults. The mother should be allowed to discuss her concerns and the alternatives available. This is part of the informed consent process.
When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: a. some form of cancer. b. local scalp infection common in children. c. infection or inflammation distal to the site. d. infection or inflammation close to the site.
d. infection or inflammation close to the site. Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes do not usually indicate cancer. A scalp infection usually does not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed.
During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: a. abnormal and requires further investigation. b. abnormal unless it occurs in conjunction with knock-knee. c. normal if the condition is unilateral or asymmetric. d. normal because the lower back and leg muscles are not yet well developed.
d. normal because the lower back and leg muscles are not yet well developed. Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk, not an abnormal finding. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African-American children.
The nurse must assess a child's capillary refilling time. This can be accomplished by: a. inspecting the chest. b. auscultating the heart. c. palpating the apical pulse. d. palpating the skin to produce a slight blanching.
d. palpating the skin to produce a slight blanching. Capillary refilling time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary filling time.
