Pediatrics Final
An infant who weighs 7 pounds at birth would be expected to weigh how many pounds at age 1 year? 16 14 18 21
21
The earliest age at which a satisfactory radial pulse can be taken in children is: 6 years 2 years 3 years 1 year
2
When caring for an infant with an upper respiratory tract infection and elevated temperature, an appropriate nursing intervention is to: Encourage food intake to maintain caloric needs. Have child wear heavy clothing to prevent chilling. Give small amounts of favorite fluids frequently to prevent dehydration. Give tepid water baths to reduce fever.
Give small amounts of favorite fluids frequently to prevent dehydration.
The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse that she wants her mother with her "like before." The most appropriate nursing action is to: Explain why this is not possible. Offer to provide support to her during the procedure. Grant her request. Identify an appropriate substitute for her mother.
Grant her request.
Which problem is most often associated with myelomeningocele? Esophageal atresia Hydrocephalus Craniosynostosis Biliary atresia
Hydrocephalus
What are modes of heat loss in the newborn (Select all that apply)? Conduction Convection Radiation Perspiration Urination
Conduction Convection Radiation
A nurse prepares to administer an intramuscular injection to a 4 month old infant. The nurse selects which site to administer the injection? a. Ventrogluteal b. Dorsal gluteal c. Rectus femoris d. Vastus lateralis
D
Infants in whom cephalhematomas develop are at increased risk for: Infection. Erythema toxicum. Caput succedaneum. Jaundice.
Jaundice.
The most common problem of children born with a myelomeningocele is: Intellectual impairment. Cranioschisis. Neurogenic bladder. Respiratory compromise.
Neurogenic bladder.
The nurse is teaching a group of new parents about the experience of role transition. Which statement by a parent indicates a correct understanding of the teaching? "A parent's previous experience with children makes the role transition more difficult." "My marital relationship can have a positive or negative effect on the role transition." "Young parents can adjust to the new role more easily than older parents." "If an infant has special care needs, the parents' sense of confidence in their new role is strengthened."
"My marital relationship can have a positive or negative effect on the role transition."
A child is brought to the emergency department after experiencing a seizure at school. There is no previous history of seizures. The father tells the nurse that he cannot believe the child has epilepsy. The nurse's best response is: "The seizure may or may not mean that your child has epilepsy." "Epilepsy is easily treated." "Your child has had only one convulsion; it probably won't happen again." "Very few children have actual epilepsy."
"The seizure may or may not mean that your child has epilepsy."
What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture? "This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less." "Be a big boy and hold still. This will be over in just a second." "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be over soon." "You must hold still or I'll have someone hold you down. This is not going to hurt."
"This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less."
Parents have understood teaching about prevention of childhood otitis media if they make which statement? "We will only prop the bottle during the daytime feedings." "We will place the child flat right after feedings." "Breastfeeding will be discontinued after 4 months of age." "We will be sure to keep immunizations up to date."
"We will be sure to keep immunizations up to date."
A client is warm and asks for a fan in her room for her comfort. The nurse enters the room to assess the mother and her infant and finds the infant unwrapped in his crib with the fan blowing over him on "high." The nurse instructs the mother that the fan should not be directed toward the newborn and the newborn should be wrapped in a blanket. The mother asks why. The nurse's best response is: "Your baby may lose heat by evaporation, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." "Your baby may lose heat by conduction, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him." "Your baby will get cold stressed easily and needs to be bundled up at all times." "Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
"Your baby may lose heat by convection, which means that he will lose heat from his body to the cooler ambient air. You should keep him wrapped and prevent cool air from blowing on him."
While assessing the newborn, the nurse should be aware that the average expected apical pulse range of a full-term, quiet, alert newborn is: 150 to 180 beats/min. 120 to 160 beats/min. 80 to 100 beats/min. 100 to 120 beats/min.
120-160
By what age does birth length usually double? 6 years 4 years 1 year 2 years
4
With regard to umbilical cord care, nurses should be aware that: A. the stump can easily become infected. b. a nurse noting bleeding from the vessels of the cord should immediately call for assistance. c.the cord clamp is removed at cord separation. d. the average cord separation time is 5 to 7 days.
A
A 4- year old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention would be most appropriate to alleviate the child's fears? a. Encourage the child's parents to stay with the child. b. Provide a private room, allowing the child to bring the favorite toys from home. c. Advise the family to visit only during the scheduled visiting hours. d. Encourage play with other children of the same age.
A
With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight? 10th percentile 95th percentile 9th percentile 85th percentile
85th
A male client is recovering from an ileostomy that was performed to treat inflammatory bowel disease. During discharge teaching, the nurse should stress the importance of: a. increasing fluid intake to prevent dehydration. b. wearing an appliance pouch only at bedtime. c. consuming a low-protein, high-fiber diet. d. taking only enteric-coated medications.
A
A male infant at 26 weeks of gestation arrives from the delivery room intubated. The nurse weighs the infant, places him under the radiant warmer, and attaches him to the ventilator at the prescribed settings. A pulse oximeter and cardiorespiratory monitor are placed. The pulse oximeter is recording oxygen saturations of 80%. The prescribed saturations are 92%. The nurse's most appropriate action is to: a. Listen to breath sounds and ensure the patency of the endotracheal tube, increase oxygen, and notify a physician. b. Continue to observe and make no changes until the saturations are 75%. c. Continue with the admission process to ensure that a thorough assessment is completed. d. Notify the parents that their infant is not doing well.
A
A mother tells the nurse she and her husband are going through a divorce. The mother needs advice on helping her 10-year-old daughter deal with the situation. Which of the following would be the best response? a. Reassure the child it is not her fault. b. Let the child be included on the conflicts between you and the father. c. If the child starts bed wetting, seek immediate attention. d. Assure her that the child will feel secure even though the parents are going through a divorce.
A
A nurse assesses the vital signs of a 12-month-old infant with a respiratory infection and notes that the respiratory rate is 35 breaths/min. Base on this finding, which action is appropriate? a. Document the findings b. Notify the physician c. Administer oxygen d. Reassess the respiratory rate in 15 minutes
A
A young child from Mexico is hospitalized for a serious illness. The father tells the nurse that "the child is being punished by God for being bad." The nurse should recognize this as: a. A health belief common in this culture. b. An early indication of potential child abuse. c. A misunderstanding of the family's common beliefs. d. A belief common when fortune tellers have been used.
A
An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed. What type of head injury should the nurse suspect? a. Brainstem b. Skull fracture c. Subdural hemorrhage d. Epidural hemorrhage
A
The maternity nurse must be cognizant that cultural practices have significant influence on infant feeding methods. Many regional and ethnic cultures can be found within the United States. One cannot assume generalized observations about any cultural group will hold for all members of the group. Which statement related to cultural practices influencing infant feeding practice is correct? A. A common practice among Mexican women is known as los dos. B. Muslim cultures do not encourage breastfeeding due to modesty concerns. C. Latino women born in the United States are more likely to breastfeed. D. East Indian and Arab women believe that cold foods are best for a new mother.
A
The nurse is caring for a client admitted who has sustained a motor vehicle accident (MVA). Which of the following symptoms would be consistent with a diagnosis of a cervical injury? A. Paralysis or weakness of extremities, a pulse rate of 45 beats per minute and nasal flaring. b. Loss of skin sensation, absent bowel sounds, and a blood pressure of 80/40. c. Bladder distension, a pulse rate of 75 beats per minute, and flaccid paralysis d. Absent bowel sounds, areflexia, and a blood pressure of 98/64
A
The nurse is developing a plan of care for a child who is at risk for seizures. Which interventions do NOT apply if the child has a seizure? a. Restrain the child. b.Stay with the child. c. Place the child in a prone position. d. Move furniture away from the child.
A
The nurse taught new parents the guidelines to follow regarding the bottle-feeding of their newborn. They will be using formula from a can of concentrate. The parents would demonstrate an understanding of the nurse's instructions if they: A. wash the top of the can and can opener with soap and water before opening the can. b. adjust the amount of water added according to the weight gain pattern of the newborn. c. add some honey to sweeten the formula and make it more appealing to a fussy newborn. D. warm formula in a microwave oven for a couple of minutes before feeding.
A
There are three most common types of spina bifida. Which one is the most serious type of spina bifida which contains a sac of fluid through an opening in the baby's back and contains part of the spinal cord and nerves which are damaged? a. Myelomenigocele b. Menigocele c. Spina Bifida Occulta d. Spina Bifida Paralysis
A
What would be a warning sign of ineffective adaptation to extrauterine life if noted when assessing a 24-hour-old breastfed newborn before discharge? Apical heart rate of 90 beats/min, slightly irregular, when awake and active Acrocyanosis Harlequin color sign Weight loss representing 5% of the newborn's birth weight
A
Which TORCH infection could be contracted by the infant because the mother owned a cat? a. Toxoplasmosis b. Varicella-zoster c. Parvovirus B19 d. Rubella
A
Which aspect of cognition develops during adolescence? a. Capability to use a future time perspective b. Ability to place things in a sensible and logical order c. Ability to see things from the point of view of another d. Progress from making judgments based on what they see to making judgments based on what they reason
A
Which of the following nursing interventions should the nurse perform for a female client receiving enteral feedings through a gastrostomy tube? a. Change the tube feeding solutions and tubing at least every 24 hours. b. Maintain the head of the bed at a 15-degree elevation continuously. c. Check the gastrostomy tube for position every 2 days. d. Maintain the client on bed rest during the feedings.
A
The nurse discovers welts on the back of a Vietnamese child during a home health visit. The child's mother says that she has rubbed the edge of a coin on her child's oiled skin. The nurse should recognize that this is: child discipline measure common in the Vietnamese culture. Child abuse. A cultural practice to treat enuresis or temper tantrums. A cultural practice to rid the body of disease.
A cultural practice to rid the body of disease.
Many pregnant teens wait until the second or third trimester to seek prenatal care. The nurse should understand the reasons behind this delay. What is NOT a contributing factor? Lack of realization that they are pregnant. A desire to gain control over their situation. Wanting to hide the pregnancy as long as possible. Uncertainty as to where to go for care
A desire to gain control over their situation.
A nurse prepares to administer digoxin (Lanoxin) to a 3 year old child with a diagnosis of congestive heart failure and notes that the apical heart rate is 110 beats/min. Based on this finding which nursing action is appropriate? a. Hold the medication b. Notify the physician c. Administer the digoxin d. Recheck the apical rate in 15 mins.
C
The use of methamphetamine (meth) has been described as a significant drug problem in the United States. In order to provide adequate nursing care to this client population the nurse must be cognizant that methamphetamine: a. Is similar to opiates. b. Is a stimulant with vasoconstrictive characteristics. c. Should not be discontinued during pregnancy. d. Is associated with a low rate of relapse.
B
A nurse obtains a history from a single, breastfeeding mother with a small 3-month-old infant who has been vomiting. Which of the following would give the nurse an indication this infant had severe dehydration? a. The pulse is elevated b. Decreased skin turgor c. The infant is having a seizure d. Mucous membranes are dry
C
The nurse is assessing a 10-year-old Emergency Department client's level of consciousness. Which of the following questions would NOT be important to ask the child or the patient? a. "Has the child had recent head trauma?" b. "Does the child have animals at home?" c. "Has the child been sick?" d. "Has the child been huffing (ingesting) any household products?"
B
At a 2-month well-baby examination, it was discovered that a breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse agree that, to gain weight faster, the infant needs to: Start iron supplements. Have a bottle of formula after every feeding. Add at least one extra breastfeeding session every 24 hours. Begin solid foods.
Add at least one extra breastfeeding session every 24 hours.
The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which interventions should NOT be included in the child's care Administer antibiotics Place on noninvasive oxygen monitoring Institute cluster care to encourage adequate rest Encourage infant to drink 8 ounces of formula every 4 hours
Administer antibiotics
Which statement is true about toy safety? Government agencies inspect all toys on the market. Adults should be alert to notices of recalls by manufacturers. Adults should be the only ones who select toys. Evaluation of toy safety is a joint effort between children and adults.
Adults should be alert to notices of recalls by manufacturers.
Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to: Ask her mother to explain to her why she cannot wear them. Explain in a kind, matter-of-fact manner that this is hospital policy. Discuss with her mother why this is important to Katie. Allow her to wear her underpants.
Allow her to wear her underpants.
Plantar creases should be evaluated within a few hours of birth because: Heel sticks may be required. The newborn has to be footprinted. Creases will be less prominent after 24 hours. As the skin dries, the creases will become more prominent.
As the skin dries, the creases will become more prominent.
The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? Use what the adolescent says to determine, in correct medical terminology, what the problem is. Interview the parent away from the adolescent to determine the chief complaint. Ask the adolescent, "Why did you come here today?" Ask for a detailed listing of symptoms.
Ask the adolescent, "Why did you come here today?"
A child has a chronic, nonproductive cough and diffuse wheezing during the expiratory phase of respiration. This suggests: Bronchoiolitis Foreign body in the trachea Pneumonia Asthma
Asthma
The nurse must administer erythromycin ophthalmic ointment to a newborn after birth. The nurse should: a. instill within 15 minutes of birth for maximum effectiveness. b. cleanse eyes from inner to outer canthus before administration. c. apply directly over the cornea. d. flush eyes 10 minutes after instillation to reduce irritation.
B
The nurse would increase the comfort of the patient with appendicitis by: a. Having the patient lie prone b. Flexing the patient's right knee c. the patient upright in a chair d. Turning the patient onto his or her left side
B
Decongestant nose drops are recommended for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops should include: Administering drops after feedings and at bedtime. Keeping drops to use again for nasal congestion. Administering drops until nasal congestion subsides. Avoiding use for more than 3 days.
Avoiding use for more than 3 days.
A 10 yr old child with asthma is treated for acute exacerbation in the emergency department. A nurse caring for the child monitors which of the following, knowing that it indicates a worsening of the condition? a. Warm, dry skin b. Decreased wheezing c. Pulse rate of 90 beats/min d. Respirations of 18 breaths/min
B
A 10-year-old child with asthma is treated for acute exacerbation in the emergency departmten. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? a. Warm, dry skin b. Decreased wheezing c. 3.Pulse rate of 90 beats/minute d. Respirations of 18 breaths/minute
B
A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items such as Jell-O, Popsicles, and juices are left. What would best explain this? a. The parent is trying to feed child only what child likes most. b. The parent is trying to restore normal balance through appropriate "hot" remedies. c. Hispanics believe that the "evil eye" enters when a person gets cold. d. Hispanics believe that an innate energy called chi is strengthened by eating soup.
B
A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse NOT include in the plan of care? a. Provide a soft diet. b. Position the child on the left side. c. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed. d. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.
B
A clinic is preparing to examine a Hispanic child who was brought to the clinic by the mother. During assessment of the child, the nurse would avoid which of the following? a. Asking the mother questions about the child b. admiring the child c. taking the child's temperature d. obtaining an interpreter as necessary
B
A mother arrives at the emergency department with her child, stating that she just found the child sitting on the floor next to an empty bottle of aspirin. On assessment, the nurse notes that the child is drowsy but conscious. The nurse anticipates that the physician will prescribe which of the following? a. ipecac syrup b. activated charcoal c. magnesium citrate d. magnesium sulfate
B
A nurse is evaluating the developmental level of a 2 year old. Which of the following does the nurse expect to observe in this child? a. Uses a fork to eat b. Uses a cup to drink c. Pours own milk into a cup d. Uses a knife for cutting food
B
After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question? a. Monitor for bleeding. b. Suction every 2 hours. c. Give no milk or milk products. d. Give clear, cool liquids when awake and alert
B
An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period? a. Test the urine for protein. b. Reposition the infant frequently. c. Provide a stimulating environment. d. Assess blood pressure every 15 minutes.
B
The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms? a. Watery diarrhea b. Projectile vomiting c. Increased urine output d. Vomiting large amounts of bile
B
When planning care for an infant with a fractured clavicle, the nurse should recognize that, in addition to gentle handling: a. prone positioning will facilitate bone alignment. b. no special treatment is necessary. c. parents should be taught range-of-motion exercises. d. the shoulder should be immobilized with a splint.
B
Which action of a breastfeeding mother indicates the need for further instruction? a. Holds breast with four fingers along bottom and thumb at top. b. Leans forward to bring breast toward the baby. c. Stimulates the rooting reflex and then inserts nipple and areola into newborn's open mouth. d. Puts her finger into newborn's mouth before removing breast.
B
A clinic nurse instructs the mother of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which of the following if identified by the mother as a precipitating factor, indicates the need for further instructions? a. Stress b. Trauma c. Infection d. Fluid overload
D
A breastfeeding woman develops engorged breasts at 3 days' postpartum. What action would help this woman achieve her goal of reducing the engorgement? The woman: Breastfeeds her infant every 2 hours. Reduces her fluid intake for 24 hours. Skips feedings to let her sore breasts rest. Avoids using a breast pump.
Breastfeeds her infant every 2 hours.
The nurse observes some children in the playroom. Which play situation exhibits the characteristics of parallel play? Brian playing with his truck next to Kristina playing with her truck Kimberly and Amanda sharing clay to each make things Adam playing a board game with Kyle, Steven, and Erich Danielle playing with a music box on her mother's lap
Brian playing with his truck next to Kristina playing with her truck
Which clinical manifestations would suggest hydrocephalus in a neonate? Constant low-pitched cry and restlessness Bulging fontanel and dilated scalp veins Depressed fontanel and decreased blood pressure Closed fontanel and high-pitched cry
Bulging fontanel and dilated scalp veins
A new mother wants to be sure that she is meeting her daughter's needs while feeding her commercially prepared infant formula. The nurse should evaluate the mother's knowledge about appropriate infant care. The mother meets her child's needs when she: Burps her infant during and after the feeding as needed. Warms the bottles using a microwave oven. Refrigerates any leftover formula for the next feeding. Adds rice cereal to her formula at 2 weeks of age to ensure adequate nutrition.
Burps her infant during and after the feeding as needed.
A 5-year-old girl sustained a concussion when she fell out of a tree. In preparation for discharge, the nurse is discussing home care with her mother. Which statement made by the mother indicates a correct understanding of the teaching? a. "I should expect my child to have a few episodes of vomiting." b. "If I notice sleep disturbances, I should contact the physician immediately." c. "I should expect my child to have some behavioral changes after the accident." d. "If I notice diplopia, I will have my child rest for 1 hour."
C
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse in charge anticipates that the doctor will order which laboratory test? a. Total iron-binding capacity b. Hemoglobin c. Total protein d. Serum transferring
C
A moderately depressed client who was hospitalized 2 days ago suddenly begins smiling and reporting that the crisis is over. The client says to the nurse, "I'm finally cured." How should the nurse interpret this behavior as a cue to modify the treatment plan? a. Suggesting a reduction of medication b. Allowing increased "in-room" activities c. Increasing the level of suicide precautions d. Allowing the client off-unit privileges as needed
C
A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, the nurse should explain that: a. Traction is tried first. c. Surgical intervention is needed. d. Frequent, serial casting is tried first. e. Children outgrow this condition when they learn to walk.
C
A nurse is providing home care instructions to the mother of a 10 yr old child with hemophilia. Which of the following activities should the nurse suggest that the child could participate in safely with peers? a. Soccer b. Basketball c. Swimming d. Field hockey
C
A nurse provides medication instructions to a mother. Which statement by the mother indicates a need for further instructions? a. I should cuddle my child after giving the medication. b.I can give my child a frozen juice bar after he swallows the medication c. I should mix the medication in the baby food and give it when I feed my child. d. If my child does not like the taste of the medicine, I should encourage him to pinch his nose and drink the medication through a straw.
C
An 8-year-old is diagnosed with a urinary tract infection (UTI). Which statement indicates that the parent understands your instructions about UTIs? a. "It's OK for my daughter to use bubble bath." b. "I should teach her to wipe from back to front." c. "She should take the antibiotics until all the pills are used." d. "She shouldn't drink too much water."
C
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time? a. Prone position b. On the stomach c. Left lateral position d. Right lateral position
C
An infant weighing 4.1 kg was born 2 hours ago at 37 weeks of gestation. The infant appears chubby with a flushed complexion and is very tremulous. The tremors are most likely the result of: a. birth injury. b. hypocalcemia. c. hypoglycemia. d. seizures.
C
Following the circumcision of a newborn, the nurse provides instructions to his or her parents regarding post-circumcision care. The nurse should tell the parents to: a. apply topical anesthetics with each diaper change. b. apply constant pressure to the site if bleeding occurs and call the physician. c. expect a yellowish exudate to cover the glans after the first 24 hours. d. change the diaper every 2 hours and cleanse the site with soap and water or baby wipes.
C
In caring for a mother who has abused (or is abusing) alcohol and for her infant, nurses should be aware that: A. the pattern of growth restriction of the fetus begun in prenatal life is halted after birth, and normal growth takes over. b. two thirds of newborns with fetal alcohol syndrome (FAS) are boys. c. alcohol-related neurodevelopmental disorders (ARNDs) not sufficient to meet FAS criteria (learning disabilities, speech and language problems) are often not detected until the child goes to school. d. both the distinctive facial features of the FAS infant and the diminished mental capacities tend toward normal over time.
C
The birth weight of a breastfed newborn was 8 lbs, 4 oz. On the third day the newborn's weight was 7 lbs, 12 oz. On the basis of this finding, the nurse should: a. suggest that the mother switch to bottle-feeding since the breastfeeding is ineffective in meeting newborn needs for fluid and nutrients. b. notify the physician since the newborn is being poorly nourished. c. encourage the mother to continue breastfeeding since it is effective in meeting the newborn's nutrient and fluid needs. d. refer the mother to a lactation consultant to improve her breastfeeding technique.
C
The neonatal nurse explains to new parents that infants are at greater risk for fluid and electrolyte imbalance than older children. Which of the following parent comments would indicate that further education is needed? a. Infants have a higher metabolic rate than older children do. b. An infant has little body water for reserve, as compared with an adult. c. Infants maintain their temperature by losing heat through their heads. d. Infants lose water through their skin and they have a larger proportion of skin surface area than older children do.
C
The nurse administers vitamin K to the newborn for what reason? a. Most mothers have a diet deficient in vitamin K, which results in the infant being deficient. b. Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection. c. Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract. d. The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.
C
The nurse is assigned to care for a client with systemic lupus erythematosus. The nurse plan's care, knowing that this disorder is a(n): a. local rash that occurs as a result of allergy b. disease caused by overexposure to sunlight c. inflammatory disease of collagen contained in connective tissue d. disease caused by the continuous release of histamine in the body
C
The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder? a. Bile-stained fecal emesis b. The passage of currant jelly-like stools c. Failure to pass meconium stool in the first 24 hours after birth d. Sausage-shaped mass palpated in the upper right abdominal quadrant
C
The parents of a 15-year-old girl are concerned that their adolescent spends too much time looking in the mirror. Which statement is the most appropriate for the nurse to make? a. "Your teenager needs clearer and stricter limits about her behavior." b. "Your teenager needs more responsibility at home." c. "During adolescence this behavior is not unusual." d. "The behavior is abnormal and needs further investigation."
C
Which infant is at risk for developing vitamin D-deficient rickets? a. An infant who has a lacto-ovovegetarian mother b. An infant who is breastfed exclusively c. An infant who takes yogurt as primary source of milk d. An infant who is exposed to daily sunlight
C
Which interventions should the nurse NOT include when preparing a care plan for a child with hepatitis? a. Providing a low-fat, well-balanced diet. b. Teaching the child effective hand-washing techniques. c. Notifying the health care provider (HCP) if jaundice is present. d. Instructing the parents to avoid administering medications unless prescribed.
C
Which of the following differentiates ulcerative colitis from Crohn's disease? a. Crohn's disease primarily affects the left colon and rectum and ulcerative colitis most often affects the right colon and distal ileum. b. Crohn's disease presents with shallow ulcerations and ulcerative colitis presents with a cobblestone appearance of the mucosal lining. c. The extent of involvement is noncontiguous and segmented with Crohn's disease and it is contiguous and diffuse with ulcerative colitis. d. Crohn's disease has primarily mucosal involvement and it is transmural with ulcerative colitis.
C
Which statement is most descriptive of a concussion? a. A slight lesion develops remote from the site of trauma. b. Petechial hemorrhages cause amnesia. c. It is a transient, reversible neuronal dysfunction. d. Visible bruising and tearing of cerebral tissue occur.
C
A common, serious complication of rheumatic fever is: Seizures. Cardiac valve damage. Cardiac arrhythmias. Pulmonary hypertension.
Cardiac valve damage.
Concerning the use and abuse of legal drugs or substances, nurses should be aware that: Caucasian women are more likely to experience alcohol-related problems. Coffee is a stimulant that can interrupt body functions and has been related to birth defects. Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise, they would not have been prescribed. Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health.
Caucasian women are more likely to experience alcohol-related problems.
The nurse approaches a group of school-age patients to administer medication to Sam Hart. To identify the correct child, the nurse should: Ask each child, "What's your name?" Check the patient's identification name band. Ask the group, "Who is Sam Hart?" Call out to the group, "Sam Hart?"
Check the patient's identification name band.
A new mother asks whether she should feed her newborn colostrum, because it is not "real milk." The nurse's most appropriate answer is: Colostrum is lower in calories than milk and should be supplemented by formula. Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. Colostrum is unnecessary for newborns. Colostrum is high in antibodies, protein, vitamins, and minerals.
Colostrum is high in antibodies, protein, vitamins, and minerals.
The mother of a school-age child tells the school nurse that she and her spouse are going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as: Common reaction to divorce. Suggestive of lack of adequate parenting. Indicative of maladjustment. Unusual response that indicates need for referral.
Common reaction to divorce.
What type of family is one in which all members are related by blood? Family of origin Affinal Household Consanguineous
Consanguineous
The primary nursing intervention necessary to prevent bacterial endocarditis is to: Observe children for complications such as embolism and heart failure. Encourage restricted mobility in susceptible children. Counsel parents of high risk children about prophylactic antibiotics. Institute measures to prevent dental procedures.
Counsel parents of high risk children about prophylactic antibiotics.
Which term best describes a group of people who share a set of values, beliefs, practices, social relationships, law, politics, economics, and norms of behavior? Culture Ethnicity Social group Race
Culture
A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is performed. Which nursing intervention is most appropriate to facilitate normal growth and development postoperatively? a. Encourage the child to rest and read. b. Encourage the parents to room in with the child. c. Allow the family to bring in the child's favorite computer games. d. Allow the child to interact with others in his or her same age group.
D
A 2 yr old child is treated in the emergency room for a burn to the chest and abdomen. The child sustained the burn by grabbing a cup of hot coffee that was left on the kitchen counter. The nurse reviews safety principles with the parents before discharge. Which statement by the parents indicates an understand of measures to provide safety in the home? a. We will install a safety gate as soon as we get home so the children cannot get into the kitchen. b. We will be sure that the children stay in their rooms when we work in the kitchen c. I guess my children need to understand what the word hot means. d. We will be sure not to leave hot liquids unattended.
D
A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? a. Tell the mother that the child must stay in the tent. b. Place a toy in the tent to make the child feel more comfortable. c. Call the health care provider and obtain a prescription for a mild sedative. d. Let the mother hold the child and direct the cool mist over the child's face
D
A depressed client on an inpatient unit says to the nurse, "My family would be better off without me." What is the nurse's best response? 1."Have you talked to your family about this?" 2."Everyone feels this way when they are depressed." 3."You will feel better once your medication begins to work." 4."You sound very upset. Are you thinking of hurting yourself?"
D
A nurse is preparing to care for a 5 yr old who has been placed in traction following a fracture of the femur. The nurse plans care, knowing that which of the following is the most appropriate activity for this child? a. A radio b. A sports video c. Large picture books d. Crayons and a coloring book
D
A nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom of this disorder documented? a. Watery diarrhea b. Ribbon-like stools c. Profuse projectile vomiting d. Bright red blood and mucus in the stools
D
Antidepressant medication is the mainstay treatment for maternal depression, with selective serotonin reuptake inhibitors (SSRIs) being the first line of pharmacotherapy. Reports of cardiac defects have been associated with the use of which SSRI? a. Citalopram b. Fluoxetine c. Sertraline d. Paroxetine
D
During a well-child visit in the clinic, the nurse observes a mother tell her child to sit in a chair and be quiet. When the child begins to protest, the mother states for the child to sit and behave. This parenting style would be considered: a. Authoritative b. Permissive c. Neglectful d. Authoritarian
D
Penicillin G procaine (Wycillin), 1,000,000 units IM is prescribed for a child with an infection. The medication label reads "1,200,000 units per 2 mL." A nurse has determined that the dose prescribed is safe. The nurse administers how many milliliters per dose to the child? a. 0.8mL b. 1.2mL c. 1.44mL d.1.66mL
D
The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen (Motrin IB) is not effective. Which instruction should the nurse provide to the mother? a. Increase the dose of ibuprofen. b. Increase the frequency of ibuprofen. c. Encourage the child to lie on the left side. d. Encourage the child to lie on the right side.
D
The nurse is caring for a neonate with suspected meningitis. Which clinical manifestation should the nurse prepare to assess if meningitis is confirmed? a. Headache b. Photophobia c. Respiratory apnea d. Bulging anterior fontanel
D
The nurse is caring for an infant who is suspected to have neonatal sepsis. Which neonatal risk factor for an infant with suspected neonatal sepsis would the nurse expect to observe? a. Large for gestational age (LGA) and an infant of a diabetic mother b. Small for gestational age (SGA) and intrauterine growth restriction c. Singleton gestation and female d. Multiple gestation and low birth weight
D
The nurse is performing a Glasgow Coma Scale (GCS) on a school-age child with a head injury. The child opens eyes spontaneously, obeys commands, and is oriented to person, time, and place. Which is the score the nurse should record? a. 8 b. 11 c. 13 d. 15
D
The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? a. Provide less frequent, larger feedings. b. Burp the infant less frequently during feedings. c. Thin the feedings by adding water to the formula. d. Thicken the feedings by adding rice cereal to the formula.
D
Which laboratory test result would be a cause for concern if exhibited by an Rh-positive newborn 12 hours after birth? A. Direct Coombs': negative b. Hematocrit (Hct): 58% and hemoglobin (Hgb): 18 g/dL c. Blood glucose level: 55 mg/dL d. Rapid Plasma Reagin (RPR)/Venereal Disease Research Laboratories (VDRL): reactive
D
With regard to hemolytic diseases of the newborn, nurses should be aware that: a. Rh incompatibility matters only when an Rh-negative offspring is born to an Rh-positive mother. b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia. c. Exchange transfusions frequently are required in the treatment of hemolytic disorders. d. The indirect Coombs' test is performed on the mother before birth; the direct Coombs' test is performed on the cord blood after birth.
D
In providing nourishment for a child with cystic fibrosis (CF), which factor should the nurse keep in mind? Most fruits and vegetables are not well tolerated. Diet should be high in easily digested carbohydrates and fats. Diet should be high in carbohydrates and protein. Fats and proteins must be greatly curtailed.
Diet should be high in carbohydrates and protein.
An important nursing intervention when caring for a child who is experiencing a seizure is to: Describe and record the seizure activity observed. Restrain the child when seizure occurs to prevent bodily harm. Suction the child during a seizure to prevent aspiration. Place a tongue blade between the teeth if they become clenched.
Describe and record the seizure activity observed.
A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. Which nursing care intervention is not needed for this child? Monitoring and maintaining systemic blood pressure. Administering corticosteroids. Discussing long-term care issues with the family. Monitoring for respiratory complications.
Discussing long-term care issues with the family.
The nurse gives an injection in a patient's room. What should the nurse do with the needle for disposal? Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patient's room. Cap needle immediately after giving injection and dispose of in proper container. Cap needle, break from syringe, and dispose of in proper container. Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room.
Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room.
When does idiopathic scoliosis become most noticeable? When child starts to walk During the first year in the newborn period During preadolescent growth spurt During adolescence and young adulthood
During preadolescent growth spurt
Which type of croup is always considered a medical emergency? Spasmodic croup Epiglottitis Laryngitis Laryngotracheobronchitis (LTB)
Epiglottitis
The priority nursing intervention when a child is unconscious after a fall is to: Determine whether a neck injury is present. Monitor intercranial pressure. Establish an adequate airway. Perform neurologic assessment.
Establish an adequate airway.
An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: Determine why she is so anxious. Explain in simple terms how it works. Tell her she will see how it works as it is used. Ask her why she wants to know.
Explain in simple terms how it works.
The nurse is preparing a child for possible alopecia from chemotherapy. Which suggestion should be included in the teaching? Explaining to the child that hair usually regrows in 1 year. Explaining to the child that, when hair regrows, it may have a slightly different color or texture. Advising the child to expose the head to sunlight to minimize alopecia. Explaining to the child that wearing a hat or scarf is preferable to wearing a wig.
Explaining to the child that, when hair regrows, it may have a slightly different color or texture.
Which statement expresses accurately the genetic implications of cystic fibrosis (CF)? It is a genetic defect found primarily in non-Caucasian population groups. There is a 50% chance that siblings of an affected child also will be affected. It is inherited as an autosomal dominant trait. If it is present in a child, both parents are carriers of this defective gene.
If it is present in a child, both parents are carriers of this defective gene.
A nurse is caring for an African-American child recently admitted to the hospital. What broad cultural characteristic should the nurse be aware of for this child when planning care Seeking another doctor's opinion No importance is attached to nonverbal behavior. Illness may be seen as the "will of God." Self-care and folk medicine do not play a role in health care.
Illness may be seen as the "will of God."
The parents of a child with cerebral palsy ask the nurse if any drugs can decrease their child's spasticity. The nurse's response should be based on knowing that: Anticonvulsant medications are sometimes useful for controlling spasticity. Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available. Medications that would be useful in reducing spasticity are too toxic for use with children. Many different medications can be highly effective in controlling spasticity.
Implantation of a pump to deliver medication into the intrathecal space to decrease spasticity has recently become available.
Vasoconstriction Hypothermia Increased cardiac output Angioneurotic edema
Increased cardiac output
A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle-feeding. Which statement is most accurate? Bottle-feeding using commercially prepared infant formulas: Helps the infant sleep through the night. Increases the risk that the infant will develop allergies. Requires that multivitamin supplements be given to the infant. Ensures that the infant is getting iron in a form that is easily absorbed.
Increases the risk that the infant will develop allergies.
When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: Some form of cancer. Infection or inflammation distal to the site. Local scalp infection common in children. Infection or inflammation close to the site.
Infection or inflammation close to the site.
A school-age child is diagnosed with systemic lupus erythematosus (SLE). The nurse should plan to implement which interventions for this child Instructions to avoid exposure to sunlight Instructions regarding dietary restrictions Preparation for home schooling Restricted activity
Instructions to avoid exposure to sunlight
Late in pregnancy, the woman's breasts should be assessed by the nurse to identify any potential concerns related to breastfeeding. Some nipple conditions make it necessary to provide intervention before birth. These include (Select all that apply): Inversted nipples Cracked nipples Flat nipples Everted nipples Nipples that contract when compressed
Inversted nipples Flat nipples Nipples that contract when compressed
Which statement describing the first phase of the transition period is inaccurate? It may involve the infant's suddenly sleeping briefly. It includes the passage of meconium. It is marked by spontaneous tremors, crying, and head movements. It lasts no longer than 30 minutes.
It may involve the infant's suddenly sleeping briefly. The first phase is an active phase in which the baby is alert. Decreased activity and sleep mark the second phase. The first phase is the shortest, lasting less than 30 minutes. Such exploratory behaviors include spontaneous startle reactions. In the first phase the newborn also produces saliva.
Which postoperative intervention should be questioned for a child after a cardiac catheterization? Assess peripheral circulation on the affected extremity. Continue intravenous (IV) fluids until the infant is tolerating oral fluids. Check the dressing for bleeding. Keep the affected leg flexed and elevated.
Keep the affected leg flexed and elevated.
Which term is used to describe an abnormally increased convex angulation in the curvature of the thoracic spine? Kyphosis Ankylosis Scoliosis Lordosis
Kyphosis
When preparing a school-age child and the family for heart surgery, the nurse should consider: Letting child hear the sounds of an electrocardiograph monitor. Explaining that an endotracheal tube will not be needed if the surgery goes well. Avoiding mentioning postoperative discomfort and interventions. Not showing unfamiliar equipment.
Letting child hear the sounds of an electrocardiograph monitor.
The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is: Vital signs. Posturing. Focal neurologic signs Level of consciousness
Level of consciousness
An infant with hydrocephalus is hospitalized for surgical placement of a ventriculoperitoneal shunt. Which interventions should NOT be included in the child's postoperative care Maintain Trendelenburg position to decrease pressure on the shunt. Monitor for abdominal distention. Maintain an accurate record of intake and output. Observe closely for signs of infection.
Maintain Trendelenburg position to decrease pressure on the shunt.
Which drug would be used to treat a child who has increased intracranial pressure (ICP) resulting from cerebral edema? Sodium bicarbonate Atropine sulfate Mannitol Epinephrine hydrochloride
Mannitol
A child with cystic fibrosis is receiving recombinant human deoxyribonuclease (rhDNase). This drug: Is not indicated for children younger than 12 years. Is given subcutaneously. May cause voice alterations. May cause mucus to thicken.
May cause voice alterations.
A collection of blood between the skull bone and its periosteum is known as a cephalhematoma. To reassure the new parents whose infant develops such a soft bulge, it is important that the nurse be aware that this condition: May occur with spontaneous vaginal birth. Happens only as the result of a forceps or vacuum delivery. Is present immediately after birth. Will gradually absorb over the first few months of life.
May occur with spontaneous vaginal birth.
Which immunization should not be given to a child receiving chemotherapy for cancer? Tetanus vaccine Diphtheria, pertussis, tetanus (DPT) Inactivated poliovirus vaccine Measles, rubella, mumps
Measles, rubella, mumps
An African-American woman noticed some bruises on her newborn girl's buttocks. She asks the nurse who spanked her daughter. The nurse explains that these marks are called: Nevus flammeus. Vascular nevi. Mongolian spots. Lanugo.
Monogolian spots A Mongolian spot is a bluish black area of pigmentation that may appear over any part of the exterior surface of the body. It is more commonly noted on the back and buttocks and most frequently is seen on infants whose ethnic origins are Mediterranean, Latin American, Asian, or African. Lanugo is the fine, downy hair seen on a term newborn. A vascular nevus, commonly called a strawberry mark, is a type of capillary hemangioma.
The vector reservoir for agents causing viral encephalitis in the United States is: Tarantula spiders. Mosquitoes and ticks. Carnivorous wild animals. Domestic and wild animals.
Mosquitoes and ticks.
The nurse is closely monitoring a child who is unconscious after a fall and notices that the child suddenly has a fixed and dilated pupil. The nurse should interpret this as: Neurosurgical emergency Indication of brain death Eye trauma Severe brainstem damage
Neurosurgical emergency
During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: Abnormal and requires further investigation. Normal because the lower back and leg muscles are not yet well developed. Abnormal unless it occurs in conjunction with knock-knee. Normal if the condition is unilateral or asymmetric.
Normal because the lower back and leg muscles are not yet well developed.
In administering vitamin K to the infant shortly after birth, the nurse understands that vitamin K is: Necessary in the production of platelets. Not initially synthesized because of a sterile bowel at birth. Responsible for the breakdown of bilirubin and prevention of jaundice. Important in the production of red blood cells.
Not initially synthesized because of a sterile bowel at birth.
Which term is used to describe a child's level of consciousness when the child can be aroused with stimulation? Disorientation Stupor Confusion Obtundation
Obtundation
Nurses should be able to teach breastfeeding mothers the signs that the infant has latched on correctly. Which statement indicates a poor latch? She hears a clicking or smacking sound. She feels a firm tugging sensation on her nipples but not pinching or pain. The baby's jaw glides smoothly with sucking. The baby sucks with cheeks rounded, not dimpled.
She hears a clicking or smacking sound.
The parents of a young child with congestive heart failure tell the nurse that they are "nervous" about giving digoxin. The nurse's response should be based on knowing that: It is difficult to either overmedicate or undermedicate with digoxin. Parents must learn specific, important guidelines for administration of digoxin. Parents lack the expertise necessary to administer digoxin. It is a safe, frequently used drug.
Parents must learn specific, important guidelines for administration of digoxin.
A meconium stool can be differentiated from a transitional stool in the newborn because the meconium stool is: Seen at age 3 days. Passed in the first 12 hours of life. The residue of a milk curd. Lighter in color and looser in consistency.
Passed in the first 12 hours of life.
An 8-month-old infant has a hypercyanotic spell while blood is being drawn. The nurse's first action should be to: Begin cardiopulmonary resuscitation. Place the child in the knee-chest position. Assess for neurologic defects. Prepare the family for imminent death.
Place the child in the knee-chest position.
The nurse is observing parents playing with their 10-month-old daughter. What should the nurse recognize as evidence that the child is developing object permanence? She looks for the toy the parents hide under the blanket. She recognizes that a ball of clay is the same when flattened out. She returns the blocks to the same spot on the table. She bangs two cubes held in her hands.
She looks for the toy the parents hide under the blanket.
A child with pulmonary atresia exhibits cyanosis with feeding. On reviewing this child's laboratory values, the nurse is not surprised to notice which abnormality? Polycythemia Dehydration Infection Anemia
Polycythemia
The psychologic effects of being obese during adolescence include: Accurate body image but self-deprecating attitude. Sexual promiscuity. Memory having no effect on eating behavior. Poor body image.
Poor body image.
To prevent nipple trauma, the nurse should instruct the new mother to: Assess the nipples before each feeding. Wash the nipples daily with mild soap and water. Position the infant so the nipple is far back in the mouth. Limit the feeding time to less than 5 minutes.
Position the infant so the nipple is far back in the mouth.
The nurse is explaining Tanner staging to an adolescent and her mother. Which statement best describes Tanner staging? Predictable stages of puberty that are based on chronologic age Staging of puberty based on the initiation of primary sexual characteristics Predictable stages of puberty that are based on primary and secondary sexual characteristics Staging of puberty based on the initiation of menarche and nocturnal emissions
Predictable stages of puberty that are based on primary and secondary sexual characteristics
A young child with leukemia has anorexia and severe stomatitis. The nurse should suggest that the parents try which intervention? Serve foods that are either hot or cold. Firmly insist that child eat normally. Relax any eating pressures. Begin gavage feedings to supplement diet.
Relax any eating pressures.
During life in utero, oxygenation of the fetus occurs through transplacental gas exchange. When birth occurs, four factors combine to stimulate the respiratory center in the medulla. The initiation of respiration then follows. Which is not one of these essential factors? Thermal Psychologic Mechanical Chemical
Psychologic
Which structural defects constitute tetralogy of Fallot? Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy
Children are taught the values of their culture through observation and feedback relative to their own behavior. In teaching a class on cultural competence, the nurse should be aware that factors of behavior and choices may be culturally determined. Which of the following is NOT one of those factors? Social roles Determination of status Racial variation Degree of competition
Racial variation
A young boy has just been diagnosed with pseudohypertrophic (Duchenne's) muscular dystrophy. The management plan should include: Explaining that the disease is easily treated. Suggesting ways to limit the use of muscles. Recommending genetic counseling. Assisting the family in finding a nursing facility to provide his care.
Recommending genetic counseling.
Which term refers to those times in an individual's life when he or she is more susceptible to positive or negative influences? Sensitive period Differentiation points Sequential period Terminal points
Sensitive period
An inherited immunodeficiency disorder characterized by absence of both humoral and cell-mediated immunity is: Acquired immunodeficiency syndrome. Fanconi syndrome. Wiskott-Aldrich syndrome. Severe combined immunodeficiency syndrome (SCIDS).
Severe combined immunodeficiency syndrome (SCIDS).
The parent of an infant with nasopharyngitis should be instructed to notify the health care Shows signs of an earache. Has a cough. Has a fever over 99° F. Becomes fussy.
Shows signs of an earache.
The most frequently used test for measuring visual acuity is the: Allen picture card test. Denver Eye Screening test. Ishihara vision test. Snellen letter chart.
Snellen letter chart.
Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis? Sweat chloride test Bronchoscopy Urine creatinine Serum calcium
Sweat chloride test
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow? Atrial septal defect Tetralogy of Fallot Patent ductus arteriosus Ventricular septal defect
Tetralogy of Fallot
Which behavior suggests appropriate psychosocial development in the adolescent? The adolescent is self-absorbed and self-centered and has sudden mood swings. The adolescent seeks validation for socially acceptable behavior from older adults. Adolescents move from peers and enjoy spending time with family members. Adolescents move from peers and enjoy spending time with family members.
The adolescent is self-absorbed and self-centered and has sudden mood swings.
A first-time dad is concerned that his 3-day-old daughter's skin looks "yellow." In the nurse's explanation of physiologic jaundice, what fact should be included? Physiologic jaundice is caused by blood incompatibilities between the mother and infant blood types. Physiologic jaundice occurs during the first 24 hours of life. This condition is also known as "breast milk jaundice." The bilirubin levels of physiologic jaundice peak between the second and fourth days of life.
The bilirubin levels of physiologic jaundice peak between the second and fourth days of life.
The parents of a 14-year-old girl express concerns about the number of hours their daughter spends with her friends. The nurse explains that peer relationships become more important during adolescence because: They provide adolescents with a feeling of belonging Adolescents dislike their parents. Adolescents no longer need parental control. They promote a sense of individuality in adolescents
They provide adolescents with a feeling of belonging
What information is true about Lymphoid tissues such as lymph nodes? Adult size by age 13 years Half their adult size by age 5 years. Twice their adult size by age 10 to 12 years. Adult size by age 1 year.
Twice their adult size by age 10 to 12 years.
What infant response to cool environmental conditions is either not effective or not available to them? Constriction of peripheral blood vessels Metabolism of brown fat Increased respiratory rates Unflexing from the normal position
Unflexing from the normal position
The mother of a 1-month-old infant tells the nurse that she worries that her baby will get meningitis like her oldest son did when he was an infant. The nurse should base her response on knowing that: Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children. Vaccination to prevent all types of meningitis is now available. Meningitis rarely occurs during infancy. Often a genetic predisposition to meningitis is found.
Vaccination to prevent Haemophilus influenzae type b meningitis has decreased the frequency of this disease in children.
A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. The nurse can facilitate the infant's correct latch-on by helping the woman hold the infant: With his head and body in alignment. Curled up in a fetal position. With his head cupped in her hand. With his arms folded together over his chest.
With his head and body in alignment.
Play serves many purposes. In teaching parents about appropriate activities, the nurse should inform them that play serves the following function (Select all that apply): a. development b. Physical development c. Self awareness d. Creativity e. Temperament development
a.c.d
An examiner who discovers unequal movement or uneven gluteal skinfolds during the Ortolani maneuver: a.tells the parents that one leg may be longer than the other, but they will equal out by the time the infant is walking. b. alerts the physician that the infant has a dislocated hip. c. informs the parents and physician that molding has not taken place. d. suggests that if the condition does not change, surgery to correct vision problems might be needed.
b
Surgical closure of the ductus arteriosus would a. Stop the loss of unoxygenated blood to the systemic circulation b. Prevent the return of oxygenated blood to the lungs c. Decrease the edema in the legs and feet d. Increase the oxygenation of blood
b
The nurse notes that, when placed on the scale, the newborn immediately abducts and extends the arms, and the fingers fan out with the thumb and forefinger forming a "C." This response is known as a: Tonic neck reflex. Moro reflex. Cremasteric reflex. Babinski reflex.
b
When caring for a newborn, the nurse must be alert for signs of cold stress, including: a. decreased activity level. b. increased respiratory rate. c. hyperglycemia. d. shivering.
b
With regard to the classification of neonatal bacterial infection, nurses should be aware that: a. congenital infection progresses slower than health care-associated infection. b. health care-associated infection can be prevented by effective handwashing; early onset cannot. c. infections occur with about the same frequency in boy and girl infants, although female mortality is higher. d. the clinical sign of a rapid, high fever makes infection easier to diagnose.
b
A clinic nurse reviews the record of a child just seen by a physician and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? A. Pallor b. Hyperactivity c. Exercise intolerance d. Gastrointestinal disturbances
c
Vitamin K is given to the newborn to: reduce bilirubin levels increase the production of red blood cells enhance ability of blood to clot stimulate the formation of surfactant
c
Which tool measures body fat most accurately? Cloth tape measure Calipers Paper or metal tape measure Stadiometer
calipers
A clinic nurse is providing instructions to a mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement would the nurse make to the mother? a."The immunization schedule will need to be altered." b. "The child should not receive any hepatitis vaccines." c. The child will receive all the immunizations except for the polio series." d. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."
d
A nurse provides home care instructions to the parents of a child with congestive heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the need for further instructions? a. I will not mix the medication with food b. If more than one dose is missed, I will call the physician. c. I will take the child's pulse before administering the medication. d. If the child vomits after medication administration, I will repeat the dose.
d
Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them about pumping, storing, and transporting the milk needs to assess their knowledge of lactation. What statement is valid? a. A glass of wine just before pumping will help reduce stress and anxiety. b. The mother should only pump as much as the infant can drink. c. The mother should pump every 2 to 3 hours, including during the night. d. A premature infant more easily digests breast milk than formula.
d
An adolescent boy tells the nurse that he has recently had homosexual feelings. The nurse's response should be based on knowledge that: This indicates that the adolescent is homosexual. he adolescent should be encouraged to share his feelings and experiences. This indicates that the adolescent will become homosexual as an adult. The adolescent should be referred for psychotherapy.
he adolescent should be encouraged to share his feelings and experiences.
