PNE 136/PrepU 20, 21, 22, 29 & 30

A newborn has been diagnosed recently with transient tachypnea of the newborn. How should the nurse counsel the parents? "Unfortunately, there isn't any treatment for this condition. We will need to show you how to monitor your baby at home, particularly for blueness around the mouth." "This is happening because your baby was born via cesarean. If you had had a vaginal delivery, this wouldn't be happening." "Although this condition is very treatable, it is most likely caused by an infection, and we will need to start him on antibiotics." "I know it's scary now, but this condition most likely will resolve on its own without affecting your baby in the long run."

"I know it's scary now, but this condition most likely will resolve on its own without affecting your baby in the long run." Explanation: Although it is more common for newborns who are born via cesarean delivery to develop TTN, a newborn who is born vaginally may also exhibit TTN. TTN usually resolves on its own and does not affect the newborn in the long run. TTN usually is not caused by infection, although it may be a sign of infection. Although mild respiratory distress is common in newborns who have TTN, cyanosis is not.

The nurse is conducting a class for a group of pregnant women who are enrolled in a methadone maintenance program. The nurse is teaching the women about the effects of heroin use disorder during pregnancy. The nurse determines that additional teaching is needed when a group member makes which statement? "I will have to go cold turkey from the methadone since I am pregnant." "Methadone does not have as many bad effects on my baby as heroin does." "My baby would probably go through withdrawal after he or she is born." "I will be able to breastfeed my baby after he or she is born."

"I will have to go cold turkey from the methadone since I am pregnant." Explanation: Methadone maintenance programs are the standard of care for women with opioid addiction. The woman needs to know that she will need to return consistently to receive the prescribed methadone dose. Methadone is not stopped during pregnancy. With methadone, there is improvement in many of the detrimental fetal effects associated with heroin use. However, withdrawal symptoms are common. The woman can breastfeed her newborn while receiving methadone.

Extremely low birth weight, or ELBW, describes a newborn who weighs less than _______ g.

1000 Explanation: Low birth weight is a newborn who weighs less than 2500 g. A very low birth weight (VLBW) newborn weighs less than 1500 g. An extremely low birth weight (ELBW) newborn weighs less than 1000 g.

The incidence of sudden infant death syndrome (SIDS) peaks at what age? during the neonatal period 1 to 2 months 2 to 4 months 4 to 6 months

2 to 4 months Explanation: The incidence of SIDS is highest at 2 to 4 months of age

The nurse is completing accurate output on a preterm client. The nurse changed the client's diaper, which weighs 50 g. The dry diaper weighs 22 g. Which amount does the nurse record under output? Record your answer using a whole number.

28 Subtract the weight of the diaper from the total amount

A newborn who is large for gestational age will weigh more than ______ grams.

4000 Explanation: A full-term infant who weighs more than 4000 g is large for gestational age.

The nurse is caring for a client who is at her due date. The client asks. "How long is the health care provider going to let me go?" The nurse is correct to state that typical a mother should not pass how many weeks' gestation? 40 weeks 42 weeks 41 weeks 44 weeks

42 weeks Explanation: The nurse is most correct to state that mothers do not progress longer than 42 weeks gestation. At that point, either a cesarean section or an induction would be completed. Actual dates do vary depending on the status of the fetus.

Why is thermoregulation a problem for the preterm newborn? Water cannot escape easily through the skin. A decrease in skin surface to body mass is noted. The CNS is overactive, leading to excessive shivering and use of glucose stores. A preterm infant is not born with brown fat.

A preterm infant is not born with brown fat. Explanation: A preterm infant is not born with brown fat; this leads to easy heat and water loss through the skin. An increase in skin surface to body mass causes heat to be lost more easily. The CNS is immature, and the preterm infant usually cannot shiver.

Click to highlight the findings that will require follow-up. Three minutes after birth, a nurse completes a newborn assessment on a newborn birthed at 43 weeks' gestation. The newborn has an APGAR score of 5 at 1 minute . Other assessment findings include green-stained umbilical cord , the presence of acrocyanosis , dry and peeling skin , and the absence of vernix caseosa . Vital signs: temperature, 95.9°F (35.5°C) . Laboratory values: total bilirubin, 5 mg/dl (85.5 mcmol/l) ; serum glucose 22 mg/dl (1.22 mmol/) .

APGAR score of 5 at 1 minute green-stained umbilical cord the presence of acrocyanosis 95.9°F (35.5°C) serum glucose 22 mg/dl (1.22 mmol/) Explanation: Postterm newborns are newborns birthed after 42 weeks' gestation. An APGAR score of 5 at 1 minute after birth indicates the newborn is having moderate difficulty adjusting to extrauterine life. A normal APGAR score is 7 to 10. A temperature 95.9°F (35.5°C) is abnormal for a newborn. The normal temperature range for a newborn is 99.7°F to 99.5°F (36.5°C to 37.5°C). Postterm newborns may have a bowel movement intrauterine. The green-stained umbilical cord indicates that the newborn had a bowel movement, meconium, while intrauterine. This may cause respiratory problems. A glucose level of 22 mg/dl (1.22 mmol/l) is low. The normal range for a newborn to two years of age is 60 to 110 mg/dl (3.3 to 6.1 mmol/l). Bilirubin of 5 mg/dl (85.5 mcmol/l) at birth is a normal finding. Bilirubin levels in the first 24 hours of life range from 2 to 6 mg/dl (34.2 to 102.6 mcmol/l). The presence of acrocyanosis (cyanosis of extremities at birth) is a normal finding in a newborn. Postterm newborns may have dry, peeling skin due to a lack of nutrients. Placental function starts to decline after 42 weeks' gestation, reducing nutrients for the fetus. Postterm newborns have the least amount of vernix caseosa. After 40 weeks, vernix caseosa is absorbed in the amniotic fluid.

Which clinical manifestation is seen in the child with hydrocephalus? Partial to complete paralysis in the lower extremities An extremely large and rapidly growing head A protruding sac that contains abdominal contents A membrane between the rectum and the anus

An extremely large and rapidly growing head Explanation: An excessively large head at birth is suggestive of hydrocephalus. Rapid head growth with widening cranial sutures is also strongly suggestive and may be the first manifestation of this condition.

Which nursing interventions are provided to the newborn utilizing phototherapy via a fiberoptic blanket? Select all that apply. Assess the newborn's skin. Remove the infant to feed and change. Maintain protective cover around infant. Increase fluid intake. Cover the newborn's eyes.

Assess the newborn's skin. Remove the infant to feed and change. Maintain protective cover around infant. Increase fluid intake. Explanation: Nursing interventions are different when utilizing phototherapy lights and a fiberoptic blanket. The main difference is that the fiberoptic blanket does not require the newborn to maintain eye shields. All the other options are correct.

The licensed practical nurse (LPN) is caring for a neonate who is 24 hours old and notes the apnea and bradycardia monitor alarming. Upon entering the room, the nurse reads a respiratory rate of 84 breaths/minute and a heart rate of 200 beats/minute on the client's monitor. Which action will the LPN take next? Obtain the client's temporal temperature. Report the findings to the registered nurse (RN). Auscultate the neonate's lungs and heart. Review the client's medical history.

Auscultate the neonate's lungs and heart. Explanation: The LPN will first auscultate the neonate's lungs and heart to obtain a manual respiratory and heart rate. The nurse should not solely rely on the monitor for data collection. Although monitoring equipment provides a continual reading, it can be inaccurate if leads are displaced or the equipment malfunctions. The nurse should take apical pulses and monitor respirations periodically, listening to the heart and lungs using a stethoscope for 1 minute so as not to miss an irregularity. After auscultation, the LPN would report to the RN or reposition the client or the leads as needed. Reviewing the medical records are not a priority at this time. Ensuring the client is stable is a priority over reviewing historical data. There is no indication of an alteration in the client's temperature, making it nonessential at this time.

A nurse is providing care to a newborn who was born by cesarean at 39 weeks' gestation about 6 hours ago. Which assessment finding(s) supports the nurse's suspicion that the newborn is experiencing transient tachypnea of the newborn? Select all that apply. Breath sounds: Slightly diminished bilaterally Respiratory rate: 100 breaths/min Arterial blood gas pH: 7.33 Chest-x-ray: Mild symmetric overaeration Nasal flaring: Absent

Breath sounds: Slightly diminished bilaterally Respiratory rate: 100 breaths/min Chest-x-ray: Mild symmetric overaeration Explanation: Within the first few hours of birth, a newborn with transient tachypnea will exhibit tachypnea, expiratory grunting, retractions, labored breathing, nasal flaring, and mild cyanosis. Mild to moderate respiratory distress is present by 6 hours of age, with respiratory rates as high as 100 to 140 breaths/min. Breath sounds may be slightly diminished secondary to reduced air entry. A chest x-ray usually reveals mild symmetric lung overaeration and prominent perihilar interstitial markings and streaking. An arterial blood gas (ABG) assessment is important to ascertain the degree of gas exchange and acid-base balance. It typically demonstrates mild hypoxemia, mildly elevated CO2, and a normal pH (7.35-7.45).

The nurse is preparing to administer a tube feeding to a preterm infant. When checking for residual prior to the feeding, there is a residual of 3 ml. What action should the nurse take? Administer the tube feeding. Call the physician. Reduce the amount of the tube feeding by half. Take the tube out.

Call the physician. Explanation: The nurse should promptly report gradually increasing residual and abdominal girth or return of more than 2 ml of undigested formula. These signs indicate feeding intolerance and could herald the onset of necrotizing enterocolitis (NEC).

A nurse makes a home visit to a new mother and her 5-day-old newborn. Assessment of the newborn reveals slight yellowing of the skin on the face and forehead and slowed skin turgor. The mother tells the nurse that she's been having trouble breastfeeding the newborn. "My baby's been feeding about every 4 to 5 hours." Additional assessment reveals about 3 wet diapers per day and 1 to 2 stools per day. Which action by the nurse would be the priority? Evaluate the mother's technique for breastfeeding. Measure the newborn's abdominal girth. Arrange for home phototherapy. Call the provider to obtain a prescription for a bilirubin level.

Call the provider to obtain a prescription for a bilirubin level. Explanation: The assessment findings and report from the mother suggest late-onset breastfeeding jaundice. The nurse should report the findings to the provider and obtain a prescription for a bilirubin level. Once the results are obtained, then the decision for home phototherapy can be made. Although it would be helpful to evaluate the mother's breastfeeding technique to promote enhanced breastfeeding, the priority is to confirm hyperbilirubinemia and institute measures to lower the bilirubin level. Measuring the newborn's abdominal girth would be unnecessary.

Chapter 20

Chapter 20

Chapter 21

Chapter 21

For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin? Group B streptococcus (GBS) Human immunodeficiency virus (HIV) Herpes simplex type 1 Chlamydia trachomatis

Chlamydia trachomatis Explanation: Ophthalmic erythromycin is routinely provided to the newborn after birth to prevent acquiring a Chlamydia trachomatis or Neisseria gonorrhoeae infection during vaginal birth. IV antibiotics are used to treat a group B streptococcus infection. Antiviral therapy is given to neonates with herpes simplex type 1 and HIV

Which nursing actions limit overstimulation of the preterm infant? Select all that apply. Coordinate nursing care. Speak softly to the infant. Frequently open the isolette portholes. Keep lights low in the nursery. Tap on the isolette before opening the door.

Coordinate nursing care. Speak softly to the infant. Keep lights low in the nursery. Explanation: It is noted that excessive noise can overstimulate the preterm infant. It is up to the nurse to protect the neurologic status of the infant. Minimize overstimulation by speaking softly to the infant and keeping the lights in the nursery low. Also, coordinate nursing care to minimize interruptions. Tapping and opening the isolette portholes can startle the infant.

The nurse is assessing the plantar creases on the newborns for documentation on the Ballard Scale. Which documentation is interpreted as evidence of a full-term infant? Creases covering two-thirds of the anterior foot Middle crease across the palm of the hand No deep creases on the newborn's body Creases extending across the brow

Creases covering two-thirds of the anterior foot Explanation: On the Ballard Scale, an assessment and documentation of a crease covering two-thirds of the anterior foot is interpreted as characteristic of a full-term newborn. The creases are assessed on the foot, not the hand or brow. No creases are indicative of a preterm newborn

What intervention can the nurse provide to reduce pain and stress in the preterm infant? Create minimal stimulation and reduce procedures that cause pain. Give pain medication hourly. Touch the infant frequently to provide stimulation. Speak clearly and loudly around the infant.

Create minimal stimulation and reduce procedures that cause pain. Explanation: Minimal stimulation is a necessary precaution to minimize pain and stress. The nurse should reduce procedures that cause crying, such as routine suctioning. He or she should avoid painful procedures and disturbances when possible. The nurse should administer opioids, as ordered, to treat pain when avoidance is not possible. Additionally, he or she should control the noise level in the environment and provide developmental care and positioning.

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply. Do not allow anyone to smoke around the infant. Place the infant on his or her back. Keep the infant dressed warmly at night. Let the newborn sleep in the same bed as the parents. Avoid using a pacifier when putting the infant to sleep.

Do not allow anyone to smoke around the infant. Place the infant on his or her back. Explanation: Although the specific cause of SIDS cannot be explained, these interventions have been shown to decrease the incidence of the syndrome: place infant on the back to sleep; use a firm sleep surface; breastfeeding; room sharing without bed sharing; routine immunizations; consideration of using a pacifier; avoidance of soft bedding, overheating, and exposure to tobacco smoke, alcohol, and illicit drugs

After birth, an infant experiences meconium aspiration. What does the nurse anticipate the primary care provider prescribing prophylactically to prevent pneumonia? intubation suction of the oropharynx inhaled surfactant antibiotics

Explanation: Prophylactic antibiotics may prevent development of pneumonia.

The nurse is teaching gavage feedings to the mother of a preterm infant. Which instruction is most important? Quantity of bowel movement Amount of feeding Expelling of gas Gastric residual present

Gastric residual present Explanation: Check prefeed gastric residual before infusing the next feeding. If the stomach is not empty by the next feeding, allow more time between feedings or give smaller feedings. The other options are important but not the most important.

In completing the newborn assessment checklist, the nurse documents a meconium stool. This documentation rules out which condition? Hiatal hernia Imperforate anus Spina bifida occulta Epispadias

Imperforate anus Explanation: Clinical manifestations of an imperforate anus include not having a meconium stool within the first 24 hours of birth. A hiatal hernia can cause esophageal reflux. Spina bifida occulta is caused by a neural tube defect and is typically asymptomatic, causing no problems. Epispadias is when the opening of the urethra is on the dorsal aspect of the penis

A nurse is caring for a preterm newborn born at 29 weeks' gestation. Which nursing diagnosis would have the highest priority? Grieving related to the loss of "a healthy full-term newborn" Imbalanced nutrition: Less than body requirements related to the premature digestive system Ineffective thermoregulation related to decreased amount of subcutaneous fat Risk for injury related to the very thin epidermis layer of skin

Ineffective thermoregulation related to decreased amount of subcutaneous fat Explanation: In the condition of hypothermia, newborns typically metabolize brown fat. This requires the newborn to use glucose and oxygen. A premature infant is at risk for respiratory distress and hypoglycemia. The hypoglycemia can increase the infant's need for glucose and oxygen, which, in turn, could cause more severe disease or further complications. The other diagnoses are appropriate but not the highest priority.

When interacting with parents caring for their newborn in opioid withdrawal, which nursing action is most essential? Demonstrate holding the newborn secure and close to chest. Keep the environment dim and quiet for the newborn to rest. Making the parents comfortable while they are visiting. Instruct the parents with a nonjudgmental, caring attitude.

Instruct the parents with a nonjudgmental, caring attitude. Explanation: It is essential to approach the parents with a nonjudgmental and caring attitude. If the parents feel that the nurse cares, they will be open to the instruction being provided. Understanding the instruction is essential in caring for the newborn. All of the options are important considerations in care.

A pregnant client with diabetes is preparing for the birth of a large-for-gestational-age newborn. What intervention(s) will the nurse include in the initial postbirth plan of care for the newborn? Select all that apply. Maintain blood glucose. Initiate a peripheral IV. Assess respiratory status. Collect bilirubin levels. Provide thermoregulation.

Maintain blood glucose. Assess respiratory status. Provide thermoregulation. Explanation: The large-for-gestational-age newborn is defined as a newborn with the weight, length, and head circumference plotted higher than 90% on a standard growth chart. Large-for-gestational-age can also be defined as a newborn weighing greater than 4,000 g. These newborns can appear very healthy, but they can get into trouble quickly. This is especially true for the newborn of a mother with diabetes. These newborns can become hypoglycemic very quickly and need to have their blood glucose stabilized. These newborns need to be monitored and maintained in a neutral thermal environment. Respiratory distress can occur also, so assessing the respiratory rate and evaluating for any respiratory distress is important. A peripheral IV and the collection of bilirubin levels may be necessary, but they are not essentials in the initial plan of care.

At birth, a neonate is diagnosed with brachial plexus palsy. The parent asks how the nurse knows the neonate's positioning of the arm is a result of the palsy and not just a preferred position. The nurse would show the parent that the neonate has asymmetry of which neonatal reflex? Babinski rooting stepping Moro

Moro Explanation: When a neonate has a brachial plexus palsy, there will be asymmetry of the Moro reflex. The stepping reflex assesses movement of the legs. The rooting reflex is used to stimulate sucking and feeding. A positive Babinski sign indicates neurologic immaturity.

When providing care to the newborn withdrawing from a drug such as cocaine or heroin, which drug is given to ease the symptoms and prevent complications? Morphine Ibuprofen Acetaminophen Aspirin

Morphine Explanation: Care of the newborn experiencing substance withdrawal focuses on providing physical and emotional support and also medication administration to ease withdrawal symptoms. Morphine, an opioid, is given to the client to ease the withdrawal symptoms and also gradually remove opioids from the system. The other options do not ease withdrawal symptoms.

Which nursing interventions are essential when caring for a newborn with macrosomia born to a mother with diabetes? Select all that apply. Obtain blood glucose reading. Keep the newborn NPO. Assess for respiratory distress. Anticipate supplemental oxygen. Obtain IV glucose for potential infusion.

Obtain blood glucose reading. Assess for respiratory distress. Anticipate supplemental oxygen. Obtain IV glucose for potential infusion. Explanation: Newborns of mothers with diabetes require careful observation. Frequent blood glucose checks begin after birth. Administering feeding early maintains the blood glucose level. If the newborn cannot tolerate feedings, obtain IV glucose for infusion. Monitor for respiratory distress and anticipate supplemental oxygen therapy and surfactant therapy.

A 6-week-old infant has stopped breathing and the parent stimulates the infant. The infant's respirations resume. The infant is transported to the hospital. What nursing intervention(s) will the nurse include in the immediate plan of care? Select all that apply. Perform a comprehensive assessment. Enroll the parents in cardiopulmonary resuscitation (CPR) class. Connect the infant to continuous monitoring. Obtain a complete history of the event. Teach the parents the "back to sleep" position.

Perform a comprehensive assessment. Connect the infant to continuous monitoring. Obtain a complete history of the event. Explanation: Brief resolved unexplained events (formerly apparent life-threatening event [ALTE]) are a very frightening experience for parents. The infant is found in distress or not breathing. The infant requires at least stimulation or possibly cardiopulmonary resuscitation (CPR). After the event when the infant is seen in the hospital, it is important for the nurse to place the infant on continuous monitoring to detect any cardiac or respiratory problems. The nurse will also perform a comprehensive assessment to determine if any other problems are evident and obtain a history of the event from the parents. There can be multiple reasons for the event to have occurred. Generally, after testing has demonstrated the infant is well, the infant can be discharged on a home apnea monitor. This can be used for up to 1 year. Education is provided to help the parents with "back to sleep" infant sleeping and a class in CPR; however, those interventions are not part of the immediate plan of care.

Which teaching is most helpful in preventing sudden infant death syndrome (SIDS)? Burp the infant before laying him or her down. Use a nursery monitor to hear the infant cry. Place stuffed animals in the crib for stimulation. Place the infant on the back for sleep.

Place the infant on the back for sleep. Explanation: It is most important to instruct new parents and families to place the infant on the back to sleep. Research has shown that this one step has decreased the SIDS rate. It is important to burp an infant after feeding to promote gastrointestinal health. Stuffed animals should not be placed in the crib. Many families use a nursery monitor but that is not helpful in preventing SIDS.

Which classification for gestational age is correct? Preterm is a newborn born before 37 weeks. Post-term is a newborn born after 42 weeks. Preterm is a newborn born before 37 weeks. Post-term is a newborn born after 40 weeks. Preterm is a newborn born before 36 weeks. Post-term is a newborn born after 42 weeks. Preterm is a newborn born before 36 weeks. Post-term is a newborn born after 40 weeks.

Preterm is a newborn born before 37 weeks. Post-term is a newborn born after 42 weeks. Explanation: Newborn classification is as follows: Preterm (premature) is a newborn born before 37 weeks of gestation. Post-term (postmature) is a newborn born after 42 weeks of gestation.

Which environmental consideration is most helpful to promoting comfort when the neonate is withdrawing from alcohol and drugs? Incorporate a massage Provide a dark, quiet environment Offer tactile stimulation Play soothing music

Provide a dark, quiet environment Explanation: A dark and quiet environment provides relaxation and allows the opportunity for the neonate to withdraw from the alcohol and drugs without becoming overstimulated. Massage and tactile stimulation can stimulate the neonate, leading to seizures. A dark environment is more helpful than soothing music.

The nurse is caring for a premature infant born at 29 weeks' gestation. What intervention(s) will be used for the goal of preventing retinopathy of prematurity (ROP)? Select all that apply. Keep the eyes covered. Provide minimal stimulation. Provide cluster care. Refer the infant to an ophthalmologist at 31 weeks' corrected age. Maintain oxygen saturation at 92%.

Refer the infant to an ophthalmologist at 31 weeks' corrected age. Maintain oxygen saturation at 92%. Explanation: Retinopathy of prematurity (ROP) occurs when the retinal blood vessels grow abnormally. This leads to retinal scarring and or retinal detachment. Research has found that higher concentrations of oxygen have a negative impact on the retinal vessels. The most important intervention to prevent ROP is to use lower concentrations of oxygen. The oxygen concentration should be less than 94%. It is also essential to involve a pediatric ophthalmologist in the infant's care. Screening from an ophthalmologist should occur at 31 weeks' corrected age. This is a way to detect the severity of the scarring and develop a treatment plan. All premature infants should have minimal stimulation, and the nurse should cluster care, but these more likely affect the prevention of intraventricular hemorrhage and bradycardia/apnea. The isolette is generally kept dark, but the eyes do not need to be kept covered unless being treated for high bilirubin and lights are in use

The nurse is caring for an intrapartum mother whose fetus has asymmetrical intrauterine growth restriction (IUGR) after the 24th week of gestation. Which nursing action is best? Anticipate a precipitous delivery since the neonate is small-for-gestational-age. Regular assessment of the fetal monitor tracings and preparation for a cesarean birth, if needed. Provide emotional support to the mother and support person as the neonate has anomalies. Use regular assessment techniques as an uncomplicated delivery is anticipated.

Regular assessment of the fetal monitor tracings and preparation for a cesarean birth, if needed. Explanation: The fetus with asymmetrical intrauterine growth restriction is compromised in some manner; thus, regular assessment of the fetal monitor tracings can indicate if the fetus is in distress (a common occurrence). If the fetus is in distress due to the work of birth, be prepared for a cesarean section. Neither a congenital anomaly nor a precipitous delivery is always present with IUGR. Since there is a complication causing IUGR, a complicated delivery is anticipated.

Upon shift handoff the nurse reports meconium staining of the amniotic fluid. Which neonatal system requires close monitoring by the incoming nurse? Gastrointestinal system Endocrine system Respiratory system Cardiovascular system

Respiratory system Explanation: If the incoming nurse is told that the neonate had meconium staining of the amniotic fluid, the nurse realizes that the respiratory system can be affected. Meconium is the thick, pasty, greenish-black substance that is present in the fetal bowel. When the fetus releases the meconium in utero, the fetus can inhale the meconium into the lungs causing respiratory distress. This is called meconium aspiration syndrome.

The LPN is caring for a newborn who measures small for gestational age (SGA). Based on this determination, what action will the nurse take next? Review the gestational parent's history for contributing factors. Initiate the plan of care for the newborn. Complete a neuromuscular maturity screening. Identify potential complications the newborn may experience.

Review the gestational parent's history for contributing factors. Explanation: The LPN would review the gestational parent's history for contributing factors. The RN is responsible for assessing gestational age, identifying potential complications, and initiating the plan of care. The LPN would also be alert for potential complications and risk factors related to respiratory distress, hypothermia, hypoglycemia, polycythemia, and altered parental interaction with the newborn.

The licensed practical nurse (LPN) is caring for a newborn measuring large for gestational age (LGA). Which action(s) by the nurse is appropriate for this client? Select all that apply. Review the gestational parent's history for contributing risk factors. Encourage the parents to allow the newborn to rest in the nursery. Observe the newborn for irritability, pale color, seizures, and poor tone. Monitor the newborn's vital signs daily. Help the registered nurse (RN) perform a gestational age assessment.

Review the gestational parent's history for contributing risk factors. Help the registered nurse (RN) perform a gestational age assessment. Observe the newborn for irritability, pale color, seizures, and poor tone Explanation: The LPN will review the gestational parent's history to assist in determining risk factors to determine the best method of treatment for the newborn and to best guide the parent. The LPN will also assist the RN in assessing and caring for the newborn. The LPN will assess the newborn's vital signs frequently, typically every 4 to 8 hours, to monitor for complications. The LPN will also monitor the newborn for signs and symptoms of hypoglycemia, which include irritability, pale color, limp, seizures, poor feeding, shaking, and poor tone. The LPN would encourage bonding with the parents, not removing the newborn from the room.

The student nurse is performing a Ballard scale on a newborn. The instructor assesses that the student understands methods to check neuromuscular maturity when she gently pulls the newborn's arm in front of and across the top portion of the body until resistance is met and identifies this action as: posture. popliteal angle. arm recoil. Scarf sign. square window.

Scarf sign. Explanation: Scarf sign is accomplished by gently pulling the newborn's arm in front of and across the top portion of the body until resistance is met as a measure of neuromuscular maturity. Popliteal angle and posture do not require manipulation of the arm. Square window and arm recoil do not require the nurse to move the arm across the chest.

The nurse is working in the special care nursery caring for a newborn withdrawing from alcohol. Which nursing intervention promotes client comfort? Administer benzodiazepines Swaddle and decrease stimulation Provide 1 ounce of formula Promote parental bonding

Swaddle and decrease stimulation Explanation: Swaddling and decreasing stimulation is helpful in providing relaxation and comfort for the newborn withdrawing from alcohol. Benzodiazepines are to prevent seizure activity. Providing small amounts of formula frequently supports weight gain. Promoting parental bonding is important for the newborn and parents to help the infant meet developmental milestones

In doing the Ballard assessment of gestational age, which of the following is done to assess what is called the scarf sign? The infant's arm is pulled gently in front of and across the top portion of the body until resistance is met. The infant's foot is moved as close to the head as possible without forcing the foot. It is the measurement of the wrist angle with flexion toward the forearm until resistance is met. It is the measurement of the knee angle when the thigh is flexed and the lower leg extended until resistance is met.

The infant's arm is pulled gently in front of and across the top portion of the body until resistance is met Explanation: Scarf sign (arm pulled gently in front of and across the top portion of the body until resistance is met) is one of the six categories that determine neuromuscular maturity in a newborn.

The nurse is caring for a newborn who is large-for-gestational-age (LGA). Which characteristics are documented as a contributing factor? Select all that apply. The mother has poorly controlled diabetes. The neonate is a female. Both parents are of a larger stature and size. The father is obese but mother is of normal weight. The mother has had previous large-for-gestational-age neonates.

The mother has had previous large-for-gestational-age neonates. The mother has poorly controlled diabetes. Both parents are of a larger stature and size. Explanation: Common contributing factors for a large-for-gestational-age neonate are the mother having a history of previous LGA neonates; the mother having a high glucose level due to a poorly controlled diabetic status; and genetic characteristics of the parents being of a larger size and stature. A larger-sized infant is more correlated with an obese mother than obese father. Males are more likely to be LGA.

The nurse is assessing a male neonate using the Ballard gestational age assessment tool. The neonate has the following characteristics: Deep cracking skin, no vessels Thinning lanugo Creases on the plantar surface Raised areola Formed ear, instant recoil Testes down, good rugae From the above characteristics, which can the nurse determine? The neonate is a term newborn. The neonate has intrauterine growth restriction. The neonate has been born preterm. The neonate has post-term characteristics.

The neonate is a term newborn. Explanation: As the characteristics are stated above, the neonate is born at the term gestational age of between 37-42 weeks. The characteristics are developed. The Ballard gestational age scoring tool is used to determine maturity, not growth restriction.

The nurse is caring for a preterm neonate and has chosen the following goal: improvement of the neonate's respiratory function. Which expected outcome is most appropriate for the first week? The neonate will not use accessory muscles when breathing. The neonate will sleep without apnea periods. The neonate will maintain a temperature under 99.5°F (37.5°C). The neonate will have 99% oxygen saturation.

The neonate will not use accessory muscles when breathing. Explanation: The goal most appropriate for the first week of life is to not use accessory muscles or grunting when breathing. This signifies an improvement in the respiratory status. A 99% oxygen saturation rate is too high for the neonate. Maintaining the temperature and sleeping without apnea are acceptable goals but not most reflective of improvement in the respiratory status.

A nurse is assessing a newly admitted newborn who is 2 hours old. Which assessment findings would concern the nurse? Select all that apply. The newborn is pink except for the hands and feet, which are blue. The newborn has visible bilateral nasal flaring. The newborn responds little to voices. The newborn has visible chest retractions. The newborn has an apical pulse between 140 and 156.

The newborn has visible bilateral nasal flaring. The newborn has visible chest retractions. Explanation: The signs and symptoms of respiratory distress include tachypnea, periodic breathing, apnea, retractions, nasal flaring, grunting, pallor, and cyanosis. These findings require interventions. The blue hands and feet, apical pulse rate, and minimal response to voices are all appropriate for a newborn who is two hours old.

Which assessment finding within the first 24 hours of birth requires immediate health care provider notification? Milia is noted on the nose. The neonate ate 1 to 2 oz of formula. The skin is jaundiced. The neonate slept for 18 hours.

The skin is jaundiced. Explanation: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. This neonate exhibits pathologic jaundice, which needs to be reported immediately. Milia is common on the newborn. It is appropriate for the newborn to sleep for most of the day and eat a couple ounces of formula.

Which of the following is not true regarding preterm birth? Prematurity is the leading cause of perinatal death. The use of tocolytics has reduced the overall number of preterm births. The incidence of preterm birth is on the rise. The cause of preterm labor and birth is generally idiopathic.

The use of tocolytics has reduced the overall number of preterm births. Explanation: The use of tocolytics (drugs with the primary purpose of relaxing the uterus and therefore decreasing contractions) has improved outcomes, but has not affected the occurrence of preterm birth.

The nurse is observing the perineal care of a 2-year-old in a hip spica cast. For which caregiver actions will the nurse provide additional instruction? Select all that apply. Uses the tips of the fingers to handle the cast Completes a skin assessment daily Places a disposable diaper between the legs Cleanses the perineal area with each diaper change Applies powder to the perineal area after a bowel movement

Uses the tips of the fingers to handle the cast Applies powder to the perineal area after a bowel movement Explanation: The nurse would provide additional instruction related to handling the cast with the palms of the hands instead of tips of the fingers. Also, the caregiver would be advised to refrain from using powders as powders can build up and irritate the skin. The other options demonstrate appropriate care.

A nurse is caring for a neonate of 25 weeks' gestation who is at risk for intraventricular hemorrhage (IVH). Which assessment finding should be reported immediately? a sudden drop in hematocrit intake and output for 8 hours pink skin with noted blue extremities soft, flat anterior fontanels (fontanelles)

a sudden drop in hematocrit Explanation: The signs and symptoms of IVH include a sudden decrease in hematocrit, a severe and sudden unexplained deterioration of vital signs, bulging fontanels (fontanelles), changes in activity level, and sudden lethargy. The diagnosis is confirmed by cranial ultrasonography. Pink skin with blue extremities is not a critical sign of IVH, nor is the routine calculation of intake and output a critical assessment for IVH.

The nurse is reviewing the medical record of the antepartum client with an abnormal maternal serum alpha-fetoprotein test. The mother is distraught and states, "How bad can it be?" The nurse is correct to describe which? a cardiac deficit the absence of a kidney a cleft lip and palate a type of spina bifida

a type of spina bifida Explanation: The maternal serum alpha-fetoprotein test is an indicator of a neural tube defect indicating a form of spina bifida. Spina bifida is a bony defect that occurs in various forms and can produce a varied level of disability (ranging from no disability to paralysis). This test is not an indicator of a cardiac deficit, a cleft lip/cleft palate, or a kidney disorder.

The nurse would be concerned about hemolytic disease of the newborn in which case? a woman who has anti-D antibodies and her newborn is A positive a woman who is O negative and her newborn is B positive a woman who has anti-D antibodies and her newborn is O negative a woman who is AB positive and her newborn is O negative

a woman who has anti-D antibodies and her newborn is A positive Explanation: The nurse should be concerned about hemolytic disease of the newborn with a woman who has anti-D antibodies and her newborn is Rh positive (in this question the newborn is A positive). A newborn who is Rh negative will not develop hemolytic disease because he does not have D antibodies and therefore is not subject to attack from the mother's anti-D antibodies. If the woman is Rh negative and her newborn is Rh positive, as long as she does not have anti-D antibodies, she can receive Rho(D) immune globulin after delivery of an Rh-positive newborn.

When examining a newborn for developmental dysplasia of the hip (DDH), which motion would the newborn's hip be unable to accomplish? abduction extension adduction rotation

abduction Explanation: Infants with shallow acetabulums are unable to abduct their hips.

If a newborn whose weight, length, and head circumference falls into the 15th percentile for gestational age, the newborn would be said to be which of the following? small for gestational age appropriate for gestational age preterm for gestational age post-term for gestational age

appropriate for gestational age Explanation: Appropriate for gestational age (AGA) describes a newborn whose weight, length, and/or head circumference falls between the 10th and 90th percentiles for gestational age.

A late preterm newborn is born at: between 32 and 34 weeks. between 32 and 36 weeks. between 34 and 36 weeks. between 34 and 37 weeks.

between 34 and 37 weeks. Explanation: The late preterm newborn is born between 34 and 37 weeks. This is an important classification of newborns because their care may differ from that provided to other preterm infants.

The nurse is caring for an infant born to a mother with cocaine use disorder during her pregnancy. The nurse would likely notice that this infant: weighed above average when born. has facial deformities. cries when touched. sleeps for long periods of time.

cries when touched. Explanation: Developmental delays occur in young children of mothers with a substance use disorder. Infants of mothers with cocaine use disorder do not like to be touched or held and avoid the caregiver's gaze, which contributes to bonding delays. Infants of mothers with cocaine use disorder are often restless and below average weight when born

What clinical manifestations may indicate to the nurse that the preterm infant has developed an intraventricular hemorrhage (IVH)? Select all that apply. cyanosis hypotonia bradycardia sunken fontanels (fontanelles) bulging fontanels (fontanelles)

cyanosis hypotonia bradycardia bulging fontanels (fontanelles) Explanation: Most infants who develop IVH are asymptomatic or have subtle symptoms such as a sudden drop in hematocrit levels, pallor, and poor perfusion. Therefore, the health care provider orders screening examinations to identify bleeding. Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full or bulging fontanel (fontanelle), cyanosis, and increased head circumference. Neurologic signs such as twitching, convulsions, and stupor may be noted.

A nurse in the hospital nursery cares for a preterm newborn, born at 30 weeks' gestation. The newborn had an APGAR score of 6 at 1 minute (1 point for color, 1 point for respiratory effort, 1 point for muscle tone, 1 point for reflex, 2 points for heart rate) and 8 at 5 minutes. The newborn has a lot of vernix on the whole body, acrocyanosis of the hands, a glucose level of 40 mg/dl (2.22 mmol/l), and a temperature of 96.1°F (35.6°C). To prevent problems for the newborn, the action that the nurse must implement first? Followed by? Observe for respiratory distress Observe for hyperglycemia observe for hypothermia monitor for acrocyanosis monitor the newborns glucose level dry newborn to prevent hyperthermia

dry newborn to prevent hyperthermia acrocyanosis Explanation: Lung maturity does not occur until week 37 of gestation, so preterm newborns, which are newborns born prior to 37 weeks, are at high risk for respiratory distress and may require surfactant. Preterm newborns are at high risk for respiratory distress due to undeveloped lungs and a lack of surfactant. Preterm newborns are at risk for hypothermia. Nursing interventions are to dry the newborn, change the blanket, and apply the hat. The preterm newborn is at risk for hypothermia, but this is not the best answer. Nursing interventions that support respiratory function should be a priority. The preterm newborn is at risk for hypoglycemia, not hyperglycemia. A glucose level of 40 mg/dl (2.22 mmol/l) is within normal range for a newborn. Acrocyanosis (bluish discoloration of the extremities) is a normal finding in a newborn.

When providing postpartum teaching to a couple, the nurse correctly identifies what time as when pathologic jaundice may be found in the newborn? between 2 and 4 days of life often with formula-fed babies after 5 days postpartum during the first 24 hours of life

during the first 24 hours of life Explanation: Pathologic jaundice occurs within the first 24 hours of life and is often related to blood incompatibility. Conversely, physiologic jaundice occurs 48 hours or more after birth, peaks at the 5th to 7th day, and disappears between the 7th and 10th day postpartum. Physiologic jaundice is caused by the normal reduction of red blood cells and occurs in both breastfed and bottle-fed babies.

A pregnant client asks the nurse at what point in pregnancy the fetal heart is most susceptible to damage during development. The nurse correctly explains the period as: during the second trimester when the heart begins to beat. during the last trimester when the fetus is growing rapidly. between the 10th and 16th weeks when the central nervous system is developing. during the first 8 weeks of pregnancy when it is forming.

during the first 8 weeks of pregnancy when it is forming. Explanation: The fetal heart develops between the third and eighth week of pregnancy. Teratogenic effects would be most detrimental during this time

At which point is the treatment Rho(D) immune globulin for hemolytic disease of the newborn finished? immediately before delivery during the postpartum period during the prenatal period It is no longer needed after the first pregnancy.

during the postpartum period Explanation: The treatment for Rh incompatibility is Rho(D) immune globulin. It is given to prevent complications during the second pregnancy and is administered in the postpartum period. This prevents antibodies from entering fetal circulation and hemolyzing or destroying the fetus's RBC.

An infant is experiencing transient tachypnea of the newborn (TTN). Symptoms that may be seen in this infant include which of the following? Select all that apply. expiratory grunting nasal flaring retractions respirations of 60 per minute increased appetite

expiratory grunting nasal flaring retractions respirations of 60 per minute Explanation: Newborns with TTN have poor sucking and eating due to increased effort of breathing. Nasal flaring, increased respirations, retractions, and expiratory grunting are symptoms of TTN

A nurse is assessing a newborn. What gestational age assessment findings indicate that the newborn has reached term? flexible wrist with a small angle at a range of 15 degrees thick ear cartilage and a stiff pinna abundance of fine downy lanugo smooth feet with few creases

flexible wrist with a small angle at a range of 15 degrees Explanation: An indicator of term gestational age is a square window: flexible wrists with a small angle, usually ranging from 0 to 30 degrees. A term infant should have thinning of lanugo with balding areas, creases covering at least the anterior two-thirds of the foot, and cartilage present within pinna that has natural recoil when folded.

Which of the following best describes the time between fertilization of the egg and birth? signs of pregnancy gestational age intrauterine growth trimesters

gestational age Explanation: Gestational age is the length of time between fertilization of the egg and birth.

A nurse is assessing a newborn who was born to a woman with diabetes mellitus. The newborn is large-for-gestational age and has a ruddy skin color, short neck, buffalo hump, and distended upper abdomen. Laboratory testing has been completed and the results are as follows: Glucose: 30 mg/dL (1.67 mmol/L) Calcium: 7.2 mg/dL (1.80 mmol/L) Magnesium: 1.5 mg/dL (0.62 mmol/L) Bilirubin: 15 mg/dL (256.56 µmol/L) Hematocrit: 75% (0.75) Which result(s) would the nurse immediately report to the provider? Select all that apply. magnesium hematocrit calcium glucose bilirubin

hematocrit glucose bilirubin Explanation: The newborn's glucose level is low suggesting hypoglycemia, bilirubin level is high suggesting hyperbilirubinemia, and hematocrit is high suggesting polycythemia. These three results should be reported. The newborn's calcium and magnesium levels are within acceptable parameters and are not a cause for concern.

A perinatal nurse is working as a member of a local community health task force to address the impact of substance use during pregnancy. The group is to come up with recommendations for programs that will have a positive impact. After reviewing current research on the topic, on which area(s) will the group likely focus? heroin alcohol cocaine methamphetamines marijuana

heroin alcohol cocaine Explanation: Both heroin and cocaine when used during pregnancy pose significant health risks. In addition, both are associated with the use of other substances further compounding the risks. Moreover, newborns of heroin-addicted mothers are born dependent on heroin. Alcohol also poses risks when used during pregnancy, and is considered one of the fastest growing health care challenges. Use of marijuana and methamphetamines is problematic. However, marijuana has not been shown to be teratogenic. Little research is available about methamphetamine use during pregnancy because its use is less common than cocaine or opioids.

The nurse is caring for a newborn with fetal alcohol spectrum disorder. The nurse knows that the newborn will demonstrate: jitteriness. a large head circumference. lethargy. hyperglycemia. hyperactivity.

hyperactivity. Explanation: Newborns with fetal alcohol spectrum disorder exhibit hyperactivity, a small height and head circumference, hypoglycemia, and irritability.

Newborns born to a mother with diabetes are at risk for which of the following? hypoglycemia, delayed fetal lung maturity, respiratory distress, and shoulder dystocia hypoglycemia, polycythemia, respiratory distress, and hyperviscosity of the blood hyperglycemia, intrauterine hypoxia, hemolytic disease of the newborn, and hyperviscosity of the blood hyperglycemia, meconium aspiration syndrome, cerebral ischemia, and polycythemia

hypoglycemia, delayed fetal lung maturity, respiratory distress, and shoulder dystocia Explanation: Maternal diabetes can lead to a delay in fetal lung maturity, resulting in respiratory distress. Newborns are also susceptible to hypoglycemia because they have been producing a higher level of insulin in utero as a result of high maternal glucose levels. They are at increased risk for LGA and subsequent shoulder dystocia.

What is the responsibility of the registered nurse (RN) after the delivery of the newborn? Select all that apply. ordering a prophylactic antibiotic for possible meconium aspiration initiating the plan of care intubating the infant if there is respiratory compromise identifying potential complications assessing the gestational age

initiating the plan of care identifying potential complications assessing the gestational age Explanation: The RN is responsible for assessing gestational age, identifying potential complications, and initiating the plan of care.

What is the most common reason why an infant will be small-for-gestational-age (SGA)? placenta previa intrauterine growth restriction hyperemesis gravidarum oligohydramnios

intrauterine growth restriction Explanation: Intrauterine growth restriction caused by a multitude of factors is the most common reason why an infant will be small for gestational age.

A preterm newborn is noted to have hypotonia, apnea, bradycardia, a bulging fontanel (fontanelle), cyanosis, and increased head circumference. These signs indicate the newborn has which complication? retinopathy of prematurity (ROP) respiratory distress syndrome cold stress intraventricular hemorrhage (IVH)

intraventricular hemorrhage (IVH) Explanation: Signs that may accompany IVH include hypotonia, apnea, bradycardia, a full or bulging fontanel (fontanelle), cyanosis, and increased head circumference.

A newborn admitted to the nursery weighs 2,000 grams. This newborn is classified as which of the following? high birth weight low birth weight very low birth weight normal birth weight

low birth weight Explanation: The classification of low birth weight (LBW) is a newborn that weighs less than 2,500 grams (g).

The nursing students describe the infant they are caring for as weighing 2000 g. The instructor knows that effective communication among staff members suggests that what term be used to describe the infant? appropriate-for-gestational-age (AGA) low-birth-weight (LBW) extremely-low-birth-weight (ELBW) very-low-birth-weight (VLBW) large-for-gestational-age (LGA)

low-birth-weight (LBW) Explanation: Newborns weighing less than 2400 g but greater than 1500 g are termed low-birth-weight infants. VLBW weigh more than 1000 g but less than 1500 g. ELBW infants weigh less than 1000 g. LGA infants weigh greater than 90th percentile for their gestational age.

The nursing students describe the infant they are caring for as weighing 2000 g. The instructor knows that effective communication among staff members suggests that what term be used to describe the infant? appropriate-for-gestational-age (AGA) very-low-birth-weight (VLBW) extremely-low-birth-weight (ELBW) large-for-gestational-age (LGA) low-birth-weight (LBW)

low-birth-weight (LBW) Explanation: Newborns weighing less than 2400 g but greater than 1500 g are termed low-birth-weight infants. VLBW weigh more than 1000 g but less than 1500 g. ELBW infants weigh less than 1000 g. LGA infants weigh greater than 90th percentile for their gestational age.

By preventing fetal distress during the intrapartum period, which condition is less likely? meconium aspiration syndrome transient tachypnea of the newborn neonatal abstinence syndrome hemolytic disease of the newborn

meconium aspiration syndrome Explanation: A primary cause of meconium aspiration syndrome is fetal distress. Meconium is the thick, pasty, greenish black substance that is present in the fetal bowel. When the fetus releases the meconium in utero, the fetus can inhale the meconium into the lungs. Hemolytic disease of the newborn is caused by blood incompatibility. Transient tachypnea of the newborn is from fluid in the fetal lungs. Neonatal abstinence syndrome is caused by maternal use of drugs or alcohol.

What would the nurse suspect in a premature newborn who has difficulty feeding and maintaining a stable temperature and is vomiting bile? respiratory distress syndrome meconium aspiration syndrome necrotizing enterocolitis intraventricular hemorrhage

necrotizing enterocolitis Explanation: Necrotizing enterocolitis is a disease that is characterized by inflammation in the bowels. It is generally idiopathic and results in difficulty feeding and maintaining thermoregulation, as well as vomiting of bile.

The nurse in the newborn nursery has used the Ballard scoring system to assess the newborn. This gestational assessment evaluation includes which of the following categories of maturity of the newborn? cardiac and psychological respiratory and vision neuromuscular and physical genitourinary and hearing

neuromuscular and physical Explanation: The Ballard scoring system is a common gestational age assessment tool used in newborn nurseries. Gestational age assessment involves evaluation of two main categories of maturity: neuromuscular and physical maturity.

A newborn is found to have hemolytic disease. Which combination would be found related to the blood types of this newborn and the parents of the newborn? newborn who is type O, mother who is type O newborn who is type A, mother who is type O newborn who is type A, father who is type O newborn who is type O, father who is type A

newborn who is type A, mother who is type O Explanation: Hemolytic disease of the newborn may develop when a mother and the unborn fetus have different blood types. The disease occurs when the immune system of the mother sees the fetus's red blood cells as foreign. Antibodies then develop against the fetus's red blood cells. These antibodies attack the red blood cells beginning at birth, causing them to break down too early. There is more than one way in which the fetus's blood type may not match the mother's. Commonly, it is the result of ABO incompatibility. It also occurs with Rh factor incompatibility. Of the options provided, the newborn with type A and the mother with type O will result in hemolytic disease of the newborn.

If the nurse suspects intraventricular hemorrhage (IVH) in a preterm newborn, which of the following would the nurse be likely to find? tachycardia and hyperperfusion redness and bruising on the scalp no signs or only subtle signs restlessness, crying, irritability

no signs or only subtle signs Explanation: Generally, a preterm infant who develops IVH is asymptomatic or has very subtle signs such as a dropping hematocrit level, pallor, and poor perfusion. Although there usually are no signs or are just subtle signs, signs such as apnea, bradycardia, bulging fontanels (fontanelles), cyanosis, twitching, convulsions, and increased head circumference may occur.

It would be best to place an infant with a meningomyelocele in which position prior to surgery? on the left side with the head dependent on the stomach (prone) semi-Fowler in an infant chair supine with the head elevated

on the stomach (prone) Explanation: Placing the infant prone prevents direct trauma to the lesion and reduces the chance that feces will contaminate the lesion.

The nurse is caring for a neonate that is small for gestational age due to intrauterine growth restriction. Which is the most common cause? oxygen and nutrient deficiency prior to birth chromosomal abnormalities mother with diabetes genetic characteristics

oxygen and nutrient deficiency prior to birth Explanation: The most common cause of a small for gestational age neonate is oxygen and nutrition deficiency prior to birth. Though not stated, this broad category includes mothers who smoke, mothers with a poor diet through pregnancy, or a mother with an illness not allowing proper nutrition to be available for the neonate. Genetic characteristics typically do not cause a small-for-gestational-age neonate. Genetic characteristics may result in the infant's height of shorter stature or the neonate's weight lower, but not below the 10th percentile. Although a few chromosomal abnormalities may result in a small-for-gestational-age neonate, these abnormalities are not a common cause of this outcome. A mother with diabetes commonly results in a large-for-gestational-age neonate.

The nurse is providing care to a newborn with severe meconium aspiration syndrome (MAS). The nurse is reviewing the newborn's diagnostic test results. Which finding would the nurse expect? elevated blood pH patchy, fluffy infiltrates on chest X-ray vocal cords negative for meconium increased PaO2

patchy, fluffy infiltrates on chest X-ray Explanation: Chest X-rays show patchy, fluffy infiltrates unevenly distributed throughout the lungs and marked hyperaeration mixed with areas of atelectasis. Arterial blood gases analysis will indicate metabolic acidosis with a low blood pH, decreased PaO2, and increased PaCO2. Direct visualization of the vocal cords for meconium staining using an appropriate size laryngoscope is needed.

When a fetus has chronic hypoxia in utero, what response does the nurse expect to see after birth? polycythemia polyhydramnios iron-deficiency anemia sickle-cell anemia

polycythemia Explanation: In response to chronic hypoxia in utero, the fetus increases red blood cell (RBC) production, leading to polycythemia (excess number of RBCs) and hyperviscosity of the blood.

When a fetus has chronic hypoxia in utero, what response does the nurse expect to see after birth? polyhydramnios polycythemia sickle-cell anemia iron-deficiency anemia

polycythemia Explanation: In response to chronic hypoxia in utero, the fetus increases red blood cell (RBC) production, leading to polycythemia (excess number of RBCs) and hyperviscosity of the blood.

All of the following complications are more likely to develop in a large-for-gestational-age (LGA) newborn as opposed to an appropriate-for-gestational-age (AGA) newborn except: polycythemia shoulder dystocia breech presentation cesarean delivery

polycythemia Explanation: Polycythemia is more likely to occur in a small-for-gestational-age (SGA) newborn as a response to persistent oxygen deprivation. Cesarean delivery, breech presentation, and shoulder dystocia are all more likely to occur in an LGA infant

Which of the following is not a way to determine physical maturity in a newborn using the Ballard scoring system? genitals lanugo posture skin plantar creases

posture Explanation: According to the Ballard scoring system, posture is not a way to determine physical maturity. The ways to evaluate physical maturity are skin, lanugo, plantar creases, breast buds, and genitals. Posture is a way to determine neuromuscular maturity.

The nurse is caring for a baby born to a mother with a history of alcohol use disorder. For what characteristics should the nurse observe to determine if the newborn has a fetal alcohol spectrum disorder? Select all that apply. short palpebral fissures low-set ears flattened nasal bridge increased head circumference reduced ocular growth

reduced ocular growth short palpebral fissures flattened nasal bridge Explanation: The newborn withdrawing from alcohol typically is hyperactive and irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of a fetal alcohol spectrum disorder include low birth weight, small height and head circumference, short palpebral fissures, reduced ocular growth, and a flattened nasal bridge.

A nurse observes in a preterm newborn a respiratory rate of 60, nasal flaring, and retractions. What do these clinical manifestations indicate to the nurse? polycythemia neonatal jaundice Rh incompatibility respiratory distress syndrome

respiratory distress syndrome Explanation: The preterm newborn with RDS may exhibit problems breathing immediately or a few hours after birth. Typically, respirations increase to greater than 60 breaths/min. Nasal flaring and retractions may be noted. Mucous membranes may appear cyanotic. As respiratory distress progresses, the newborn exhibits seesaw-like respirations, in which the chest wall retracts, the abdomen protrudes on inspiration, and then the sternum rises on expiration

A nurse is making a home visit to a new mother who gave birth vaginally to a term newborn 4 days ago. The woman is enrolled in a methadone maintenance program. The woman reports that the newborn has been restless and irritable the last day or so. The nurse assesses the newborn. Which finding(s) from the nurse's assessment would lead the nurse to notify the health care provider that the newborn is experiencing withdrawal? Select all that apply. respiratory rate 65 breaths/min temperature 99.1°F (37.3°C) reflexes 2+ vomiting with each feeding frequent yawning

respiratory rate 65 breaths/min vomiting with each feeding frequent yawning Explanation: In addition to the mother's report of restlessness and irritability, the newborn's frequent yawning and vomiting with each feeding and tachypnea (respiratory rate greater than 60 breaths/min) would suggest withdrawal. Hyperactive reflexes and fever would be additional signs. However, this infant's reflexes are normal and fever is not present.

A pregnant woman at 41 weeks' gestation is scheduled for labor induction. What does the nurse monitor after the birth of the baby? surfactant levels serial blood glucose levels BUN and creatinine levels AST levels

serial blood glucose levels Explanation: The nurse should monitor serial blood glucose levels. The newborn may require intravenous glucose infusions to stabilize the glucose level.

The nurse is caring for a baby born to a mother with a history of alcohol use disorder. For what characteristics should the nurse observe to determine if the newborn has a fetal alcohol spectrum disorder? Select all that apply. low-set ears short palpebral fissures reduced ocular growth flattened nasal bridge increased head circumference

short palpebral fissures reduced ocular growth flattened nasal bridge Explanation: The newborn withdrawing from alcohol typically is hyperactive and irritable, has trouble sleeping, and may have tremors or seizures. Characteristics of a fetal alcohol spectrum disorder include low birth weight, small height and head circumference, short palpebral fissures, reduced ocular growth, and a flattened nasal bridge.

Which preventable cause of intrauterine growth restriction (IUGR) is most common? smoking alcohol use hypertension gestational diabetes

smoking Explanation: Smoking is the most common preventable cause of IUGR. Hypertension and gestational diabetes are not entirely preventable. Alcohol use is not as common as smoking.

What medication does the nurse anticipate administering to the preterm newborn as an inhalant to improve the lungs' ability to mature? heparin neomycin surfactant Rho(D) immune globulin

surfactant Explanation: Treatment begins shortly after birth with synthetic or natural surfactant, obtained from animal sources or extracted from human amniotic fluid. The newborn receives surfactant as an inhalant through a catheter inserted into an endotracheal tube. The therapy may be preventive for development of respiratory distress syndrome in the newborn at risk.

The nurse is caring for a newborn in the 8th percentile for weight, length and head circumference. The newborn would be documented as: appropriate for gestational age. symmetrical growth restricted. asymmetrical growth restricted. preterm.

symmetrical growth restricted. Explanation: When plotted on a standard growth chart, the symmetrically growth-restricted newborn's weight, length, and head circumference fall below the 10th percentile. The asymmetrical growth-restricted newborn falls below the 10th percentile in one or two measurements. Preterm relates to gestation. This newborn would not be appropriate-for- gestational-age.

The registered nurse (RN) is determining a newborn's gestational age. What tool would be best used to evaluate this? the intrauterine scoring system the Ballard scoring system the Lamaze scoring system the Apgar scoring system

the Ballard scoring system Explanation: The Ballard scoring system is a common gestational age assessment tool used in newborn nurseries. Gestational age assessment involves evaluation of two main categories of maturity: neuromuscular and physical maturity.

The nurse is caring for neonates in the neonatal intensive care unit (NICU). In reviewing the records of the neonates, the nurse notes that one of the infants has a common congenital heart defect. She recognizes that the most common of the congenital heart defects is: atrial septal defect. coarctation of the aorta. ductus venosus. ventricular septal defect. hypoplastic left heart.

ventricular septal defect. Explanation: Ventricular septal defect is the most common congenital heart defect.

A nursing instructor teaching about normal growth and development identifies a need for further instruction when the student makes which statement? "From fetal life through adulthood the body proportions change." "A growth chart is used only for comparison." "If a child does not fall into the 'normal' range, it does not mean that there is a problem." "A growth chart is the best tool to diagnose growth problems."

"A growth chart is the best tool to diagnose growth problems." Explanation: A growth chart is used for comparison only, so it is not always the best tool to diagnose a problem. Many times a child will not fall into the "normal" range, and there will not be a problem. Body proportion change from fetal life through adulthood.

A nurse is assessing a 10-year-old at a well-child visit. Which statement by the child would indicate to the nurse that the child is developing a sense of industry? Select all that apply. "I feel like I can't do the things that my friends can." "I get angry when people tell me I'm doing something the wrong way." "I keep trying until I get something done." "I feel like I'm not liked by my friends." "I like to learn about new things."

"I like to learn about new things." "I keep trying until I get something done." Explanation: A 10-year-old is attempting to establish industry, which is evidenced by competence, enjoyment for learning new things, perseverance, and the ability to take criticism well. Inferiority would be evidenced by feelings of inadequacy and inferiority and giving up easily.

The nurse needs to obtain a blood sample from a 7-year-old child. How should the nurse explain this procedure to the client? "The doctor needs to look at your blood to see why you are sick; it will hurt for a second." "I need to draw some blood from you. Will you hold still for me?" "The technician will draw your blood; it will just hurt for a minute." "The doctor needs some of your blood; trust me, it won't hurt."

"The doctor needs to look at your blood to see why you are sick; it will hurt for a second." Explanation: The nurse should offer the child a simple explanation of the procedure such as, "The doctor needs to look at your blood to see why you are sick; it will only hurt for a second." The nurse needs to let the child know you understand how difficult it is to agree to the procedure. Saying that the procedure does not hurt is not being truthful. Asking the client to hold still does not provide enough of an explanation about the venipuncture. Saying that the technician is going to draw the blood and that it will only hurt for a minute does not explain why the blood is needed.

A nurse is caring for a newborn client diagnosed with spina bifida. Which assessment finding would be a priority for the nurse who is monitoring for the risk of hydrocephalus? Assess the motor function of the lower extremities. Assess the newborn's weight. Assess the newborn's neurological response. Assess head circumference measurements.

Assess head circumference measurements. Explanation: Hydrocephalus is the extra accumulation of CSF fluid in the ventricles of the brain, which causes dilation. One of the main symptoms of hydrocephalus is increasing measurements of head circumference. A change in neurological status in hydrocephalus may not occur immediately but may be assessed at a later point. Weighing a newborn and checking motor function will not be a significant indicator of hydrocephalus.

CHAPTER 30

CHAPTER 30

The terms "growth" and "development" often are used interchangeably. To which of the following does "development" refer? A boy grows taller all through early childhood. His brain increases in size until school age. He learns to throw a ball overhand. He triples his weight during the first year.

He learns to throw a ball overhand. Explanation: "Development" refers to the increase in skills, where "growth" refers to the increase in size.

The nursing student is reviewing growth and development of children. The student is interested in how children develop the knowledge of what is right and what is wrong in their younger years of development. Which theorist would the nursing student want to review? Erikson Kohlberg Freud Piaget

Kohlberg Explanation: Kohlberg's theory of moral development examines the why in which children develop morally and spiritually and therefore develop a sense of right and wrong. The other theorists focus on other areas of growth and development.

The nurse is caring for a neonate with epispadias. In which location will the nurse assess the anomaly? On the anterior scrotum On the ventral surface near the chordee At the distal end of the testes On the dorsal end of the penis

On the dorsal end of the penis Explanation: The nurse would assess the epispadias on the dorsal (top) surface of the penis. This condition often occurs with exstrophy of the bladder. The other options are incorrect locations.

A nurse is caring for a newborn with a repaired cleft lip. What intervention can the nurse provide to facilitate drainage of mucus and secretions to prevent aspiration? Place a wedge under the child's crib. Place the child on the back. Place the child on the abdomen. Position the child on the side.

Position the child on the side. Explanation: To facilitate drainage of mucus and secretions, the nurse should position the infant on the side, never on the abdomen, after a cleft lip repair.

The nurse aspirates stomach contents before administering a nasogastric (NG) tube feeding. How will the nurse manage the aspirate? Select all that apply. Determine the pH of the aspirate. Discard the aspirate. Return the aspirate to the stomach. Record the amount of the aspirate.

Return the aspirate to the stomach. Determine the pH of the aspirate. Record the amount of the aspirate. Explanation: Discarding the aspirate would deprive the child of both electrolytes and nutrients. The aspirate should not be discarded. The other measures are the ones to be used.

The nurse is completing a medication history for a client with Turner syndrome. Which medication is anticipated? Albuterol Somatropin Levothyroxine Digoxin

Somatropin Explanation: The nurse anticipates that the client with Turner syndrome will take regular growth hormones (somatropin). Females particularly are prescribed growth hormones as well as estrogen. The other medications are prescribed as needed.

The licensed practical nurse (LPN) enters the room of a child who just finished receiving gavage feeding. The child is resting quietly in bed lying flat on their left side. The caregiver asks the LPN not to wake the child. Which action will the LPN take first? Tell the caregiver to call the nurse when the child wakes up. Consult with a registered nurse (RN) on the unit. Wake the child and turn the child to the right side. Come back intermittently until the child awakes.

Wake the child and turn the child to the right side. Explanation: The nurse will wake the child and reposition them to the right side with the head slightly elevated to facilitate digestion. The nurse will also explain to the caregiver the rationale for waking the client at this time. The nurse would not allow the child to remain in the incorrect position for safety reasons. The LPN would consult with the RN after repositioning the child.

A newborn is scheduled for casting to correct clubfoot (congenital talipes equinovarus). The nurse would advise her parents that the cast will extend: to the waist. above the knee. to the calf. to the hip.

above the knee. Explanation: A cast for clubfoot typically extends above the knee to stabilize the knee, ankle, and foot.

During cardiac surgery, the surgeon reduces the child's body temperature to decrease the effects of the surgery on the brain and other body organs. This process is referred to as inducing which of the following? hypokalemia hypothermia hypotension hypoactivity

hypothermia Explanation: Inducing hypothermia consists of reducing the body temperature to between 68°F and 78.8°F (20°C to 26°C). It is a useful technique that helps to make early surgery possible and increases the time that the circulation may be stopped without causing brain damage.

According to Kohlberg, which of the following considerations is central to human development? morality safety agency influence

morality Explanation: Kohlberg's theory of development focuses specifically on the changes in morality that occur over time.

On the second day after a surgical repair for a cleft lip, which of the following would be most important? protecting the infant's tongue from swelling preventing the infant from vomiting preventing crust formation on the suture line keeping the infant in a prone position

preventing crust formation on the suture line Explanation: If crust forms on the suture line, the suture line can be pushed apart and a large scar could result. A prone position is avoided.

The nurse watches a child arranging sugar packets from his meal trays in order of their weight. This activity of conservation is most typical of what age child? toddler adolescent school-age preschool-age

school-age Explanation: Conservation (ability to appreciate that changes in size and weight do not affect content) is learned during school age.

A parent states, "I do not let my child eat any carbohydrates because they will make her fat." What is the best response by the nurse? "Carbohydrates are a secondary source of fuel and stored as fat." "Carbohydrates must be taken daily to maintain effective levels in the body." "Carbohydrates are a necessary fuel for the body, especially for neurologic functions." "Carbohydrates are essential for the body's process of building muscles."

"Carbohydrates are a necessary fuel for the body, especially for neurologic functions." Explanation: The nurse should understand the importance of carbohydrates, especially for children, and educate the mother on the importance of a balanced diet.

A school-aged child is scheduled for tonsillectomy in a local outpatient surgery center. Which statement by the mother indicates that further education is needed? "I will give him ice chips when he begins to wake up." "I will stay with him until he goes to surgery." "He will need to spend the night here after the surgery is done." "When he wakes up, he may be very drowsy and combative."

"He will need to spend the night here after the surgery is done." Explanation: Parents need to be taught about preoperative and postoperative care of their children and may not retain everything taught to them initially. Since the surgery is being done at an outpatient surgical center, the child will not be spending the night but will be discharged home.

A new mother is concerned because she fears that her infant's head is larger than normal. What would be the nurse's best response? A large head at birth in itself is not indicative of hydrocephalus, but we will keep a check on it. If we do not drain the excessive fluid building up the child will have a problem raising the head when older. A large head at birth suggests hydrocephalus. It will become even larger as the baby grows.

A large head at birth in itself is not indicative of hydrocephalus, but we will keep a check on it. Explanation: An excessively large head at birth suggests hydrocephalus. An apparently large head in itself, however, is not necessarily significant. Normally every newborn's head is measured at birth and the rate of growth is checked at subsequent examinations. It should be measured more frequently if found to be enlarged at birth or if it appears to be enlarging. The other responses are not therapeutic for a mother already worried about her newborn.

Which interaction(s) is an example of a nurse using therapeutic communication with a client? Select all that apply. "Things always look better after a good night's rest." "I am not sure I understand. Can you explain it to me?" "Can you tell me what concerns brought you to the clinic today?" "Yes, I understand. Please go on." "Do not worry about anything. Our staff is here to help you."

"I am not sure I understand. Can you explain it to me?" "Can you tell me what concerns brought you to the clinic today?" "Yes, I understand. Please go on." Explanation: Therapeutic communication includes using open-ended questions, such as "Can you tell me what concerns brought you to the clinic today?" Another therapeutic technique is for the nurse to acknowledge that the client has been heard, and to continue: "Yes, I understand. Please go on." "I am not sure I understand. Can you explain it to me?" is an example of clarifying, another form of therapeutic communication that acknowledges the client has been heard. "Things always look better after a good night's rest." is a cliche and not therapeutic."Do not worry about anything, our staff is here to help you," is false reassurance and not therapeutic.

Which statement by a school-aged child demonstrates Erikson's psychosocial stage of industry versus inferiority? "I can take control, dress myself" versus "What I did is bad." "I have friends and I succeed" versus "I have no friends and am incapable." "I am just not able to trust anyone so I will just have to trust myself." "I am really helping others" versus "I only do things that benefit me."

"I have friends and I succeed" versus "I have no friends and am incapable." Explanation: The positive outcome of a child in Erikson's stage of industry versus inferiority is developing friendships and learning and achieving competence. The negative outcome results in the child feeling inadequate and inferior. The other choices are examples of statements for other stages.

The nurse is caring for a 7-year-old child who will undergo an appendectomy. When teaching the child about the procedure, the child tells the nurse, "I'm scared I'm going to die." How should the nurse first respond? "What makes you say that?" "I was scared when I had to have this done also." "Why are you scared?" "I understand you're scared."

"I understand you're scared." Explanation: Surgery can be very frightening to a child, especially a child who begins to be aware of death and dying. If a child expresses a fear of death or dying, the nurse must first acknowledge the child's fears in order to make the child feel accepted for his or her feelings. The additional questions/statements may be appropriate but only after first acknowledging the child's fears.

A nurse is teaching a parent ways to reduce fever in a child. What statement made by the parent would require further education? "I will be sure to not overdress or heavily cover my child." "I will give my child a tepid sponge bath to reduce the fever." "I will administer acetaminophen if my child develops a fever." "I will give my child fluids so that dehydration is not a problem."

"I will give my child a tepid sponge bath to reduce the fever." Explanation: Because of their ineffectiveness in reducing fever and associated discomfort, tepid sponge baths are no longer recommended for reducing fever.

A parent tells the nurse that a 9-year-old has to go home alone for 2 hours until the parents get off work, and they are afraid the child will begin smoking and drinking. What can the nurse inform them about "latchkey" children? "It is too dangerous in this day and time for your child to be home alone at any time." "I left my child at home from the age of 8 years old and nothing ever happened." "No evidence supports that children will have these behaviors if they are recognized for their dependability." "Can't you hire a babysitter to meet the child at the house after getting off the bus?"

"No evidence supports that children will have these behaviors if they are recognized for their dependability." Explanation: Despite concerns that latchkey children are more likely to become involved with smoking, stealing, or taking drugs, researchers have not found sufficient data to support this fear. Children given responsibility of this kind who are recognized for their dependability usually live up to the expectations of the adults in their social environment.

A 6-year-old child diagnosed with pneumonia is admitted to the hospital for treatment. The child states to the nurse, "I think I am here because I am going to die. This is where my grandmother and uncle both died." Which response by the nurse is most appropriate? "Not all people who are admitted to the hospital die." "People come here for many reasons. We will give you the best care we can." "Did someone in your family or your doctor tell you that you might die?" "No, you are young. I think you are going to be fine and go home in a few days."

"People come here for many reasons. We will give you the best care we can." Explanation: The nurse's best response is to let the child know people are admitted to the hospital for many reasons and that the best possible care will be provided. The nurse should always provide a careful explanation of the illness and give honest answers to questions. The nurse should not provide false reassurance to a client of any age. The nurse does not know the outcome and cannot truthfully state, "You are going to be fine and go home." Stating that not all people die in the hospital is broad and provides little information for the child. The child needs to be aware that the hospital is a place where more than birth and death take place. Asking the child if someone told them they might die does not address the child's concern.

The pregnant woman with diabetes asks the nurse why her last baby weighed 11 pounds. What is the best response by the nurse? "There is no way to control the amount of glucose the mother is producing, because she can't take insulin while she is pregnant and the baby gains too much weight." "The fetus increases insulin production in response to elevated glucose levels of the mother, which acts as a fetal growth hormone." "The fetus maintains elevated levels of glucose in response to the mother's eating patterns and gains too much weight." "Your baby weighed so much because of how you were eating. You must eat less with this child."

"The fetus increases insulin production in response to elevated glucose levels of the mother, which acts as a fetal growth hormone." Explanation: Consistently elevated fetal insulin levels cause the distinctive growth pattern. Because maternal glucose levels are elevated and glucose readily crosses the placenta, the fetus responds by increasing insulin production. Because insulin acts as a fetal growth hormone, consistently high levels cause fetal macrosomia, birth weight of greater than 4,500 g. Insulin also causes disproportionate fat buildup to the shoulders and upper body, increasing the risk for shoulder dystocia and birth trauma.

The nurse is caring for a newborn client newly diagnosed with developmental dysplasia of the hip (DDH). Which response by the nurse educates the parents on the correct plan of treatment for this diagnosis? "Treatment will consist of surgery when your child weighs about 10 pounds." "Treatment will start once your child can bear weight." "Treatment will include bilateral casts at 1 month of age." "Treatment will begin immediately."

"Treatment will begin immediately." Explanation: Developmental dysplasia of the hip (DDH) is a congenital newborn condition that requires immediate intervention. The development of the acetabulum of the hip is defective, and it may or may not be dislocated. Treatment of the defect and dislocated hips involves positioning the hip into a flexed, abducted (externally rotated) position to attempt to press the femur into the acetabulum. This involves splints and halters as the first line of treatment. Treatment should not be delayed. Surgery and casts are typically not used as the first line of treatment.

The nurse is working with a group of caregivers of children in a community setting. The topic of hospitalization and the effects of hospitalization on the child are being discussed. Which statement made by the caregivers supports the most effective way for children to be educated about hospitals? "The school nurse set up posters and displays showing pictures of what the inside of a hospital looked like, and we made sure our daughter saw the display." "My wife brought home several books about hospitalization and surgery, and she and I are reading them to our son." "We are going to take our child to an open house at the hospital so she can see the pediatric unit." "Our next door neighbor was sick and died in the hospital. We explained to our son that usually babies are born and people get well in hospitals."

"We are going to take our child to an open house at the hospital so she can see the pediatric unit." Explanation: One factor in how children deal with hospitalization is the amount of preparation and the type of preparation they have been given prior to being hospitalized. A child's lack of understanding and experience with illness, hospitals, and hospital procedures increases his or her anxiety. Anything parents can do to prepare the child will decrease this anxiety. Families are encouraged to help children develop a positive attitude about hospitals from an early age. The family should avoid negative attitudes about hospitals and should help the child understand that not all experiences will be good. Some hospitals have regular open house programs for healthy children. Children may attend with parents or caregivers or in an organized community or school group. Anytime the child can visually see the hospital and physically touch furniture, equipment, etc. a positive experience can occur. Showing pictures in a book, seeing posters, and talking about the experience are also effective if a tour of the hospital is not available, but these do not replace the actual experience.

A 2-year-old client says "No, me do it!" when the nurse tries to assist with undressing for the physical examination. How will the nurse respond? Explain to the child that buttons are difficult and the nurse will assist. Have the parent assist to undress the child. Allow the child to undress independently. Set 2-minute timer and assist the child after the time is elapsed.

Allow the child to undress independently. Explanation: Toddlers are developing independence and autonomy, and allowing them to undress independently helps to promote normal development. Setting a timer, having the parent undress, or explaining that it is too difficult prevents the toddler from developing independence.

A newborn boy is diagnosed with esophageal atresia and tracheoesophageal fistula. After the nurse provides preoperative teaching, which statement indicates that the parents need additional teaching? "He'll need antibiotics for a bit after the surgery to prevent infection." "We can probably start feeding him with the bottle about a day after the surgery." "The head of his bed will be elevated to prevent him from aspirating." "We can give him a pacifier to help satisfy his need to suck."

"We can probably start feeding him with the bottle about a day after the surgery." Explanation: Preoperatively, the newborn is at risk for pneumonitis due to aspiration of food and secretions. Antibiotics are typically given until the anastomosis is proven intact and patent. Oral feedings are usually started within a week after surgery once the esophageal anastomosis is proven to be intact and patent. Proper position with elevation of the head is important for the newborn with esophageal atresia and tracheoesophageal fistula because he is at risk for aspiration of food and secretions. Using a pacifier to provide nonnutritive sucking helps to meet the newborn's need to suck.

A mother who is vegan, when asked about the nutritional intake of her 18-month-old, tells the nurse not to worry because she is providing plenty of protein to her daughter. "And," she says, "I avoid giving her fats." Which of the following would be the most appropriate response for the nurse to give this mother? "Your child needs fat in the diet at this age, as it is needed for myelination of spinal nerves." "Fat is important in an 18-month-old's diet; it is the secret to strong bones and reduction of osteoporosis later in life." "That's excellent. Protein is essential, but fat intake is not necessary at this age." "You should include some fat in your child's diet, as it can prevent constipation."

"Your child needs fat in the diet at this age, as it is needed for myelination of spinal nerves." Explanation: For children, fat intake does not need to be restricted for the first 2 years of life because fat is necessary for the myelination of spinal nerves. It is fiber, not fat, that can help prevent constipation. Physical activity, balanced with calcium intake, is the secret to strong bones and reduction of osteoporosis, not fat.

A client comes to the clinic because she had positive home pregnancy test results. She tells the nurse that she has a brother with spina bifida and is concerned that her child may be born the same way. When does the nurse tell the client is the best time to perform tests for neural tube defects? 11 to 12 weeks' gestation 6 to 8 weeks' gestation 13 to 15 weeks' gestation 9 to 10 weeks' gestation

13 to 15 weeks' gestation Explanation: Elevated maternal alpha-fetoprotein (AFP) levels followed by ultrasonographic examination of the fetus may show an incomplete neural tube. An elevated AFP level in the maternal serum or amniotic fluid indicates the probability of central nervous system abnormalities. The best time to perform these tests is between 13 and 15 weeks' gestation, when peak levels are reached

A pediatric nurse who cares for newborns with congenital heart defects informs the precepting student nurse that cyanotic heart disease implies an oxygen saturation of the peripheral arterial blood of: 92% or less. 90% or less. 95% or less. 85% or less.

85% or less. Explanation: Cyanotic heart disease implies an oxygen saturation of the peripheral arterial blood of 85% or less

A 6-year-old child will be hospitalized for a surgical procedure. How can the nurse best ease the stress of hospitalization for this child? Tell the parents to bring toys for the child from home. Have another child talk with the child to be hospitalized. There is no way to adequately prepare a child for an impending hospitalization. Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital.

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Following surgery for cleft lip, the infant will have a Logan bar. Which explanation of the Logan bar is most accurate? A Logan bar is an apparatus placed inside the upper lip to stretch the tissue allowing repair of the cleft lip. A Logan bar is an apparatus that may be used to protect the surgical incision following a cleft lip repair. A Logan bar is an apparatus that is used to reshape the nose during a cleft lip repair. A Logan bar is an apparatus that may be used to approximate the two borders during a cleft lip repair.

A Logan bar is an apparatus that may be used to protect the surgical incision following a cleft lip repair. Explanation: A Logan bar is used to protect the suture line from the infant rubbing the face against bedding or other surfaces following a cleft lip repair.

Which health care provider assessment technique does the nurse anticipate being used to determine developmental dysplasia of the hip (DDH) on a newborn? Assessing leg kicks for extension Visual inspection of the hip Full range of motion of the hip Barlow sign and Ortolani click

Barlow sign and Ortolani click Explanation: The nurse anticipates that a Barlow sign and Ortolani assessment will be done by an experienced health care provider when the newborn is in the nursery. This includes range of motion of the hip. Leg kicks and visual inspection are not helpful in determining congenital hip dysplasia.

A newborn was diagnosed as having hypothyroidism at birth. The parent asks the nurse how the disease could be discovered this early. Which is the nurse's best answer? A newborn has a typical rash at birth that suggests the diagnosis. A simple blood test to diagnose hypothyroidism is required in most states. The newborn is already severely impaired at birth, and this suggests the diagnosis. Hypothyroidism is usually detected at birth by the newborn's physical appearance.

A simple blood test to diagnose hypothyroidism is required in most states. Explanation: With hypothyroidism there is insufficient production of the thyroid hormones required to meet the body's metabolic as well as growth and developmental needs. Without these hormones, cognitive impairment occurs. Hypothyroidism is diagnosed by a newborn screening procedure. This screening procedure is required by most states. With early diagnosis the condition can be treated by replacing the missing hormones. The later the diagnosis is made, the more irreversible cognitive impairment becomes. At birth, a newborn with hypothyroidism will be a poor feeder. Other symptoms, such as lethargy and hypotonicity, become evident after the first month of life. There are no other outward manifestations, such as rashes or appearances, that can be seen. These are not part of the condition.

A 6-year-old client is scheduled for removal of her tonsils and adenoids. She appears anxious and is tearful. Which statement by the nurse would best alleviate her fears? "Someone will be with you when you go to surgery and when you wake up." "Your throat will be very sore afterward but I will need you to drink anyhow." "A special doctor will give you some medicine to make you sleep so you will not know anything that is happening." "You look scared. There is nothing to be afraid of."

A special doctor will give you some medicine to make you sleep so you will not know anything that is happening." Explanation: A young child needs to have an explanation consistent with his or her developmental level; a 6-year-old understands that she is having surgery and that it will hurt afterward. Reassuring the child that she will be asleep and not feel anything is comforting and will reduce anxiety. Telling the child that it will hurt afterward and that she will have to drink is not helpful. Telling the child that she looks scared only makes matters worse. It is reassuring that someone will be there both before and after surgery but does not address the primary concern of pain and her fears.

A school nurse is teaching a group of parents with adolescents about normal development at this stage in life, based on Erikson's theory. Which statement by a parent indicates the need for further teaching? "Stress, anxiety, and mood swings are typical of this age group." "Adolescents are rebellious, antisocial, and unpleasant to be around." "Relationships with peers are more important to adolescents than ever before." "Adolescents seek independence, realizing they will soon be responsible for their own lives."

Adolescents are rebellious, antisocial, and unpleasant to be around." Explanation: Erikson describes the stage experienced from 12 to 18 years as identity versus role confusion. In this stage, adolescents are confronted by marked physical and emotional changes and the knowledge that soon they will be responsible for their own lives. Adolescents develop a sense of being an independent person with unique ideals and goals and may feel that parents, caregivers, and other adults refuse to grant that independence. Adolescents may break rules just to prove that they can. Stress, anxiety, and mood swings are typical of this phase. Relationships with peers are more important than ever. Adolescents are not rebellious, antisocial, and unpleasant to be around. These are normal behaviors for this age group to strive for independence and to spend more time with their peers than with their parents. If parents can understand these as normal behaviors, then it is easier to be around their adolescents. If they do not understand the needs of adolescents, then the adolescents may appear unpleasant to the uninformed parents.

A nurse is caring for a child with complex esophageal atresia who will be undergoing surgery for repair. What comment by the parents indicates further teaching is required? "After this surgery is done tomorrow, my baby will be able to eat and drink." "Intravenous fluids are going to be needed so that the baby won't get dehydrated." "They will be placing a tube in the stomach during surgery." "The baby will have tubes in the chest to drain chest fluids."

After this surgery is done tomorrow, my baby will be able to eat and drink." Explanation: The newborn will need IV fluids to maintain optimal hydration. The first stage of surgery may involve a gastrostomy and a method of draining the proximal esophageal pouch. A chest tube is inserted to drain chest fluids. If the repair is complex, surgery may need to be done in stages.

Which approach by the nurse best demonstrates the correct way to prepare a Hispanic child for a planned hospital admission? Tell the child that the procedure will not hurt because we have "magic medicine." Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening. Since the family is Hispanic, all preparation needs to be in Spanish. Discourage questions so as to not frighten the child.

Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening. Explanation: Allowing the child to put on surgical attire lets him or her see that hospital equipment is "not scary" and prepares the child for what will be seen on the day of surgery. Both the child and parents should be encouraged to ask questions. Honesty is the most important part of the program, so the nurse would never tell the child that the procedure will be painless because even the best care by the nurse may not eliminate all pain. Assuming that the family only speaks Spanish is inappropriate and could be considered profiling and rude. The nurse needs to determine the family's preference of language.

A nurse is preparing to obtain vital signs for a 3-year-old. What interventions can the nurse provide to keep the child calm and cooperative? Select all that apply. Tell the child that nothing that you will do is going to hurt. Allow the child to handle the equipment prior to beginning the procedure. Be honest and tell the child how he or she will feel. Take the child from the parent and hold him or her on the lap. Allow the parent to hold the child when procedures are being performed.

Allow the parent to hold the child when procedures are being performed. Be honest and tell the child how he or she will feel. Allow the child to handle the equipment prior to beginning the procedure. Explanation: The nurse should allow the caregiver to hold the young child as conversation is initiated, and begin observing the child, caregiver, and their interactions. When appropriate, the nurse should ask the caregiver permission to hold the child or to place him or her on an examination table or bed. The nurse should explain to them how they will feel or what they can do. Experiences of others have no relevance. Another positive measure is to allow the child to handle or explore equipment that will come in contact with them.

An infant is scheduled to have a painful procedure performed. Which nursing action provides the best support for the parents and infant? Have the parents remain outside the room while the procedure is occurring. Ask the parents to hold the child down during the procedure. Explain to the parents that infants do not experience pain. Allow the parents to hold the infant during the procedure.

Allow the parents to hold the infant during the procedure. Explanation: It is important for the nurse to advocate for parents to remain in the procedure room to provide support to the infant. The parent may choose to hold the infant during a painful procedure, but it is best that the parent not restrain the infant during the procedure. Their role should be supportive and comforting, not one that causes pain. Having the parents remain outside the room leaves the infant without needed support. Infants experience pain but express it differently than adults.

Immediately after birth, the nurse is caring for a newborn with a myelomeningocele. What intervention should the nurse provide to prevent drying out of the sac to avoid damage? Allow the sac to dry out to "toughen" it. Cover the sac with a water-soluble lubricant and a dry sterile dressing. Apply a sterile dressing moistened in a warm, sterile saline solution. Cover the sac with petroleum jelly and a dry sterile dressing.

Apply a sterile dressing moistened in a warm, sterile saline solution. Explanation: Until surgery is performed, the sac must be covered with a sterile dressing moistened in a warm, sterile solution (often saline). The nurse should change this dressing every 2 hours and not allow it to dry to avoid damage to the covering of the sac.

A hospitalized 5-year-old child tells the nurse, "I am lonely and bored, and it's not fair I cannot see other people more." The child is on transmission-based precautions. Which action by the nurse is appropriate? Encourage the child's family and friends to come visit with the child more. Arrange the daily care schedule to spend extra time in the child's room. Ask the child life specialist to make craft kits the child can do independently. Rearrange the furniture in the child's room to position the bed near the door.

Arrange the daily care schedule to spend extra time in the child's room. Explanation: The nurse will arrange care activities to be able to spend more time in the child's room, instead of performing care quickly and exiting the room. Crafts would help with the boredom the child is experiencing, but not the loneliness. Immediate caregivers could be encouraged to visit more, but it is not appropriate to encourage friends with the child being on transmission-based precautions. A child of this age would have a difficult time maintaining proper precautions, which can result in a risk to the child's friends. The nurse would not want to place the child's bed at the door, because this placement increases the risk of exposure to others in the hallway if the door were left open to allow for more interaction with others. The nurse would want to place the child near a window to allow the child to see others outside.

A child's caregiver tells the nurse, "I plan to room-in with my child." Which action will the nurse take? Explain to the caregiver that "rooming-in" with the child may prolong recovery, because the child will be getting less sleep. Inform the caregiver overnight stays are allowed, but that the caregiver will need to provide their own cot. Give the caregiver the child's prescribed medications and the schedule indicating when to administer them. Ask if the caregiver would like to help the nurse with bathing the child and with the next dressing change.

Ask if the caregiver would like to help the nurse with bathing the child and with the next dressing change. Explanation: The nurse will attempt to include the caregiver in the child's care plan. Offering activities that are performed at home (e.g., bathing) and activities that will be continued at home (e.g., dressing changes) are great ways to involve the caregiver while providing education and learning the home routine. The caregiver cannot administer medications to the hospitalized child; this is the role of the nurse. Caregivers are allowed to stay in the same room as the child and the facility will provide a place to sleep, such as a chair or recliner. Cots are not typically allowed due to the small size of rooms. The child would probably sleep better with the caregiver present, because the child would feel safer and comforted.

The nurse is providing developmentally appropriate care for a toddler hospitalized for observation following a fall down the steps. Which measures might the nurse consider when caring for this child? Select all that apply. Allow the child to select meals and activities. Avoid leaving small objects that can be swallowed in the bed. Explain activities in concrete, simple terms. Encourage parents to stay to prevent separation anxiety. Use a bed for toddlers who have an adult present. Use the en face position when holding the toddler.

Avoid leaving small objects that can be swallowed in the bed. Encourage parents to stay to prevent separation anxiety. Explanation: For a toddler, the nurse would avoid leaving small objects that can be swallowed in the bed and encourage parents to stay to prevent separation anxiety. The nurse would use the en face position when holding an infant and use a bed only for the older toddler who has an adult present in the room at all times. The nurse would explain activities in concrete, simple terms for a preschooler and allow a school-age child to select meals and activities.

What can a nurse do during an emergency admission to alleviate some of the child's and family's fears/anxieties over the situation? Select all that apply. Ask the family members health history questions while the child is being initially treated. Undress the child for a physical examination as soon as they arrive. Place an identification bracelet on the child, explaining that this will help the hospital staff know who he or she is at all times. Remain calm, explaining procedures to both the family and the client in a caring manner. Recommend that the family remain in the waiting room until the child is fully admitted and treatment completed.

Ask the family members health history questions while the child is being initially treated. Place an identification bracelet on the child, explaining that this will help the hospital staff know who he or she is at all times. Remain calm, explaining procedures to both the family and the client in a caring manner. Explanation: Children who undergo an emergency admission to the hospital are often frightened and anxious, so the nurse needs to provide education about everything done to the child. Explaining the reason for the identification bracelet, involving the family in providing client information (if they cannot remain with the child), and describing what is being done to the child all help alleviate anxiety and fear in both parents and the child.

The nurse is preparing a family to visit their child, who has been admitted to the pediatric intensive care unit (PICU) following a motor vehicle accident. What actions by the nurse would reduce the family's anxiety? Select all that apply. Ask the parents what the doctor has told them to ensure their understanding. Provide written information about visiting hours. Prepare the family for what the child will look like when they first visit. Tell the family that the child will be fine soon. Ask the parents to not bring in personal items such as stuffed animals or toys.

Ask the parents what the doctor has told them to ensure their understanding. Provide written information about visiting hours. Prepare the family for what the child will look like when they first visit. Explanation: Parents need preparation for visiting their child in the PICU to help them and the child adjust to this serious medical situation. Providing information on visiting hours, following up on information provided to them by the physician, and preparing the family for the child's appearance (especially following a traumatic accident) will serve to reduce the family's anxieties. The nurse never tells family members that a child will be fine, nor would the nurse discourage toys or stuffed animals, which can provide emotional security.

A nursing student realizes that which of the following is true about Kohlberg's theory of moral development? At age 2 to 3 years, the child determines right or wrong by the physical consequence of a particular act. During the first 2 years, children already have moral sensitivity. During the first 2 years, the child realizes how behavior affects others. In stage 1, the child obeys a person and understands the principle for this.

At age 2 to 3 years, the child determines right or wrong by the physical consequence of a particular act. Explanation: In Kohlberg's theory of moral development, children have no moral sensitivity during the first 2 years. The child is not aware of how his or her behavior affects others. In stage 1 the child determines right and wrong by the physical consequence of a particular act. The child simply obeys the person in power with no understanding of the underlying moral principle.

A nurse is providing care to a newborn diagnosed with gastroschisis who is being prepared for surgery. Which intervention will the nurse include in this newborn's preoperative plan of care? Select all that apply. Keep the newborn warm using a radiant heat source. Avoid allowing the newborn to suck on a pacifier for comfort. Cover any exposed bowel with warm, saline-soaked gauze. Maintain the newborn on nothing by mouth (NPO) status. Offer frequent gavage feedings with a high-protein formula.

Avoid allowing the newborn to suck on a pacifier for comfort. Cover any exposed bowel with warm, saline-soaked gauze. Maintain the newborn on nothing by mouth (NPO) status. Explanation: Newborns with gastroschisis are maintained on total parenteral nutrition (TPN) prior to surgery. A nasogastric tube for decompression is inserted at birth to prevent intestinal distention, which would enlarge the bowel lumen and make it even more difficult to replace. The nurse will not feed the newborn orally nor allow the newborn to suck on a pacifier until the bowel repair is complete, because doing so would distend the exposed bowel with food or air and would also make its return to the abdomen more difficult. It is important not to leave a newborn with either gastroschisis or an omphalocele under a radiant heat source, because this will quickly dry the exposed bowel. The nurse will place the newborn in a warmed incubator instead. In both instances, the nurse will also cover the herniated bowel with either sterile, warm, saline-soaked gauze or a sterile plastic bowel bag until surgery can be scheduled.

Which feeding method is best for the infant with a cleft lip and palate? Breastfeeding Use of an eyedropper Use of an Asepto syringe Use of a crosscut nipple

Breastfeeding Explanation: Not only is breastfeeding nutritionally best for the infant, it is also best because of the ability of the breast to mold, therefore helping to close the gap in the lip and palate. All of the other options are appropriate but breastfeeding is best in this situation.

Chapter 22

Chapter 22

Chapter 29

Chapter 29

A mother of a recently discharged preschooler calls the pediatric floor that provided care to her child a week ago. She reports that the child is having elimination accidents, temper tantrums and is waking up at night with nightmares. How should the nurse respond to the mother's concerns? Reassure her that this is typical behavior following a traumatic event and she needs to pay more attention to him. Recommend that she sternly tell the child to quit acting out or he will be punished. Children this age often show regressive behaviors and have nightmares following hospitalization due to fear of another separation. The entire family needs to spend more time with the child, directing their attention to him.

Children this age often show regressive behaviors and have nightmares following hospitalization due to fear of another separation. Explanation: Preschoolers who have been hospitalized often show regression, have temper tantrums, or have nightmares following their discharge. The family is advised to be understanding but not dote on the child. Discipline should remain consistently firm and loving and parents should reward positive behavior.

The nurse needs to provide instructions to a school-age girl about how to obtain a clean catch midstream urine specimen. Which instructions are best? Attach the urine collection bag, then urinate directly into the bag to obtain the specimen. Urinate directly into the cup, holding it under the perineum to ensure catching the urine. Clean the labia from front to back, then void a small amount into the toilet before collecting in the cup. We will need to catheterize you in order to obtain a sterile specimen.

Clean the labia from front to back, then void a small amount into the toilet before collecting in the cup. Explanation: For girls, clean the labia from front to back using a cleansing pad or cotton balls saturated with the agency's designated cleaning solution. During the child's voiding, ask the parent to collect a "midstream" sample into a sterile container provided. It is unnecessary to catheterize a school-age child to get a clean catch urine specimen. Urinating into the cup is part of the process, but it follows cleaning the labia and voiding a small amount into the toilet. A urine collection bag is used for infants, not school-age children.

A nursing instructor informs the class that for the child to be successful at achieving maturation, he or she must first master milestones. The instructor determines that the students understand when they correctly identify these milestones as what tasks? cephalocaudal developmental proximodistal maturation

developmental Explanation: Developmental tasks or milestones are basic achievements associated with each stage of development. These tasks must be mastered to move successfully to the next stage developmental stage.

A nurse is teaching a 7-year old diabetic child who is in Piaget's concrete operational stage about insulin injections. Based on Piaget's theory, what would be the nurse's best method of preparation for this child? Give the child a pamphlet on diabetes to read. Explain the procedure to the child in detail. Demonstrate the procedure on a teddy bear. Show the child a video about diabetes and insulin.

Demonstrate the procedure on a teddy bear. Explanation: During this stage, children learn by manipulating concrete or tangible objects and can classify articles according to two or more characteristics. A child in this stage would best learn the procedure by handling the equipment and having it demonstrated on a teddy bear or doll.

A child has been admitted to the pediatric intensive care unit (PICU). The parents are extremely anxious. What action(s) can the nurse take to help the parents understand their child's care and reduce their anxiety? Select all that apply. Provide support services, such as a chaplain, to help the family cope. Allow for visitation at any time. Have the parents sign a one-time blanket consent for all treatment options. Explain all technical terms in ways parents can understand. Describe what the child will look like before parents visit.

Describe what the child will look like before parents visit. Explain all technical terms in ways parents can understand. Provide support services, such as a chaplain, to help the family cope. Allow for visitation at any time. Explanation: Having a child in the pediatric intensive care unit (PICU) is usually a very frightening experience for the family. It means the child is seriously ill, and the whole environment is threatening to the parents. To help alleviate some of the anxiety, the nurse and health care team members should answer the parent's questions truthfully. Before the parents see the child for the first time in the PICU setting, the nurse should explain what the child will look like. This could be that the child is on a ventilator, has multiple lines for monitoring, etc. All information given to the parents should be in terms the parents can understand. The parents should be allowed to ask any and all questions about their child's care and have their questions answered truthfully. The nurse can enlist the help of services, such as chaplain or social worker, to provide support to the parents during their period of stress. Most PICUs allow for visitation at any time. Some close the unit during shift changes. The nurse should provide the family with the visitation policy. Parents do not have to sign a blanket consent for any and all procedures. These will be obtained as procedures are needed.

The nurse is caring for a preoperative pediatric client. What would it be best for the nurse to do with this client? Teach technical terminology to the caregivers so they will understand what is being said postoperatively. Keep the child away from any food or drinks to ensure the child is NPO. Determine how much the child knows and is capable of understanding. Explain how the therapeutic plan can be used in preparing the child for surgery.

Determine how much the child knows and is capable of understanding. Explanation: The nurse must determine how much the child knows and is capable of learning in order to best prepare the child for surgery. Keeping terminology at the child's and caregivers' level of understanding is important when doing teaching. Teaching the therapeutic plan is important, but it has to be done on the level of the child's and caregivers' knowledge and build on what they already know. The child going to surgery will be NPO, but the nurse needs to know on what level to teach the child the reason for this.

The parent has brought a 2-year-old to the public clinic for immunizations. The nurse documents the following characteristics: A duck waddle gait Shortened extremity Asymmetry of the gluteal folds Protruding abdomen The nurse then refers the toddler to the health care provider for potential diagnosis of which? clubfoot (congenital talipes equinovarus) Muscular dystrophy Scoliosis Developmental dysplasia of the hip (DDH)

Developmental dysplasia of the hip (DDH) Explanation: Developmental dysplasia of the hip (DDH) exhibits signs of asymmetry of the gluteal folds, lordosis, swayback, protruding abdomen, shortened extremity, and a duck-like waddle. Congenital talipes equinovarus is clubfoot. Scoliosis is a curvature of the spine. Muscular dystrophy is a chronic degenerative muscular condition.

The clinic nurse is caring for a child being seen for fever. The caregiver asks the nurse how to care for the child at home if the fever returns. Which teaching will the nurse reinforce? Select all that apply. Encourage the child to drink fluids or eat popsicles. Call the health care provider for a fever higher than 100°F (37.8°C). Keep the child's room temperature cool. Administer aspirin every 8 hours as needed. Do not overdress the child when febrile.

Do not overdress the child when febrile. Keep the child's room temperature cool. Encourage the child to drink fluids or eat popsicles. Explanation: The nurse will reinforce the following: keep the child cool by (a) not overdressing, (b) not using heavy blankets, and (c) keeping the environment cool. To maintain hydration, the child should be encouraged to drink fluids often. Popsicles can be offered if the child does not show interest in drinking or if swallowing causes discomfort. Acetaminophen or ibuprofen are recommended, not aspirin, due to the risk for Reye syndrome. The health care provider should be notified for a temperature of 105°F (40.6°C) or higher.

The nurse is assessing a neonate brought into the newborn nursery. The nurse notes a dimple on the lower back with a tuft of hair over the site. Which nursing intervention is most appropriate? Notify the health care provider immediately. Place the neonate on the left or right lateral side for sleep. Document the assessment finding and report in shift handoff. Place an absorbent, sterile dressing over the site.

Document the assessment finding and report in shift handoff. Explanation: During the assessment, the nurse documents a dimple on the lower back with a tuft of hair as characteristics of spina bifida occulta. The neonate is typically asymptomatic and presents no problems. The nurse would document the assessment finding and pass on the information in shift handoff. The neonate does not need to have special positioning, a dressing over the site or have immediate medical attention

A newborn has been diagnosed with a congenital heart defect. When taking the health history, what question(s) will the nurse ask the parents to help determine the cause? Select all that apply. Was the defect seen on prenatal ultrasound? Does anyone in either parent's family have a heart defect? Did the mother drink alcohol during the pregnancy? Was the mother exposed to rubella during the first trimester? What medications did the mother take during the pregnancy?

Does anyone in either parent's family have a heart defect? Did the mother drink alcohol during the pregnancy? Was the mother exposed to rubella during the first trimester? What medications did the mother take during the pregnancy? Explanation: Congenital heart defects can be caused by a variety of conditions. Many times they can be present with other defects. It is important to determine what, if anything, had an impact on the cause of the heart defect. Many medications or alcohol taken by the mother in the first trimester can cause the fetus's heart not to develop correctly. The family histories of the mother and father also play a role. A biological parent having a sibling or first-generation family member with a heart defect increases the risk for the fetus to develop a heart defect. Maternal exposure to rubella in the first trimester can cause heart defects as well as hearing and vision defects. Whether the defect was seen on ultrasound during the pregnancy plays no role in the development of the heart defect

The pediatric nurse is caring for a 5-year-old child who is admitted to the hospital prior to a planned surgical repair of a radial fracture. Which statement(s) will the nurse include in the presurgical education for the child? Select all that apply. "This procedure will fix your broken arm." "Don't drink anything because you don't want your tummy to be upset." "The doctor will put pins and screws in your arm." "When you wake up, you may feel a little funny." "Do you know why you are here?"

Don't drink anything because you don't want your tummy to be upset." "This procedure will fix your broken arm." When you wake up, you may feel a little funny." Explanation: When caring for a child during the presurgical period, the nurse must consider the child's developmental age and the appropriateness of the teaching. The nurse should explain to the child about the procedure, using appropriate language according to the child's developmental stage. Telling the child that the procedure will "fix" something that is broken is appropriate. However, describing the procedure as using "pins and screws" may frighten the young child and should be avoided. Additionally, the nurse may tell the child that he or she cannot eat or drink because it may upset the "tummy." Also, explaining to the child that he or she may not feel well upon waking up prepares the child for after the procedure. Asking the child why he or she is at the hospital is a closed-ended question and does not allow the child to elaborate.

A nurse is inspecting the surgical dressing on a school-age child and notes that there is bloody drainage on it. What actions should the nurse take? Change the dressing, initial it, then chart it. Reinforce the dressing and tape it down securely. Remove the dressing and keep it to show the physician. Draw a circle around the drainage with a permanent marker, recording the date and time on it.

Draw a circle around the drainage with a permanent marker, recording the date and time on it. Explanation: If the nurse notes bloody drainage in a surgical dressing, the nurse should draw a line around the drainage with a marker, and record the time and date on it. That way, if further bleeding occurs, there will be evidence of the amount of additional drainage there is and the time frame of the drainage.

When teaching parents, what information should the nurse include related to healthy diets for children? Select all that apply. Eat a high grain diet, with vegetables and fruits. Exercise is more important than dietary intake. Eat sugars in moderation for obesity control. Children should experience a variety of foods. Heavy salt is needed for thyroid health.

Eat sugars in moderation for obesity control. Children should experience a variety of foods. Explanation: Children should be exposed to and eat a variety of foods. Sugar should be consumed in moderation for both dental health and obesity control.

Which nursing action should be a priority when the parents first meet their infant who has an open spinal defect? Have the parents feed the infant. Emphasize the infant's normal and positive features. Provide written information reinforcing health care provider education. Encourage discussion of fears and concerns.

Emphasize the infant's normal and positive features. Explanation: All parents, especially those with a child who has a disability or defect, need to hear positive comments that emphasize what is normal or beautiful about their child. Discussing fears and concerns and reinforcing teaching are not a priority on the first visit. Feeding the infant will need to wait until the open defect is repaired, usually within 24 hours of birth.

How will the nurse properly collect and care for the child's 24-hour urine specimen? Send each individual void directly to the laboratory. Collect each void in a sterile container and handle with sterile gloves. Empty each void into a designated container that keeps the urine cool. Push clear fluids to ensure that an adequate amount of urine is collected.

Empty each void into a designated container that keeps the urine cool. Explanation: The 24-hour urine collection is cumulative over this time period and is sent to the laboratory when complete. The urine is kept cool to keep the bacterial count to a minimum. Sterile collection procedures are not needed. Hydration of the child should reflect the youngster's norm. Pushing clear fluids is not necessary.

The caregiver of an 8-month-old child in the pediatric intensive care unit (PICU) states a strong desire to hold the child. The caregiver states, "I know I cannot hold my child due to the equipment and their condition, but I wish I could touch my child." Which action by the nurse is appropriate? Reinforce education on why the caregiver cannot hold the child at this time. Encourage the caregiver to sit beside the child, caressing and stroking the child. Tell the caregiver they are still able to visit with and talk to the child. Reassure the caregiver that the equipment will be removed soon and they will then be allowed to hold their child.

Encourage the caregiver to sit beside the child, caressing and stroking the child. Explanation: The nurse will encourage the caregiver to caress and stroke the child. The caregiver wants to physically touch the child and this is an appropriate alternative option to holding. To promote the relationship between the family caregiver and the child, the nurse will encourage the caregiver to caress and stroke the child when holding is not appropriate. Reinforcing education is not needed, because the caregiver provides the rationale. Telling the caregiver to talk with the child does not address the desire to touch the child. The nurse should not provide potentially false reassurance to the caregiver. This could damage the trusting relationship.

A baby is born with spina bifida with meningocele. The parents are visibly upset. The father states, "What did we do wrong? How will I ever love this child?" What is the priority action by the nurse? Inform the parents that once the child has a surgical repair, there will be no further problems. Inform the father that he will love this baby just as if it were normal. Inform the parents that the baby will be taken to the nursery and they won't have to see the baby until they are ready. Encourage the parents to express their feelings and emotions openly.

Encourage the parents to express their feelings and emotions openly. Explanation: The family of a newborn with such a major anomaly is in a state of shock on first learning of the problems. The nurse should be especially sensitive to their needs and emotions. He or she should encourage family members to express their feelings and emotions as openly as possible.

The nurse is caring for a 10-year-old boy who is in traction. The boy has a nursing diagnosis of deficient diversional activity related to confinement in bed that is evidenced by verbalization of boredom and lack of participation in play, reading, and schoolwork. What would be the best intervention? Offer the child reading materials. Encourage the child to complete his homework. Ask for the parents' assistance. Enlist the aid of a child-life specialist.

Enlist the aid of a child-life specialist. Explanation: The nurse should enlist the aid of a child-life specialist to provide suggestions for appropriate activities. Offering the child reading materials or encouraging him to complete his homework would most likely be met with resistance as he has already verbalized his boredom and disinterest in play, reading, and schoolwork. The parents could offer the child life specialist ideas about the boy's likes and dislikes; however, the child life specialist could offer expertise in assisting hospitalized children.

The nurse is preparing a school-age child for a diagnostic procedure. What is an important nursing role in relation to obtaining informed consent for this procedure for this client? Allow the child to determine the timing of the procedure. Ensure the child understands and assents to the test. Present education and preparation to the parents only. Inform the parents of all benefits and risks.

Ensure the child understands and assents to the test. Explanation: Although the parents are the ones who sign the consent form, it is important to ensure that the child understands the procedure and assents to accept the proposed care. It is the health care provider's responsibility to inform the parents of all benefits and risks. Presenting education and preparation to the parents only is inappropriate unless the child is an infant or toddler because children need information to prepare them as well. Children do not determine the timing of procedures.

Like many 4-year-olds, Ethan is constantly seeking out and exploring new experiences and repeatedly asking his parents why-type questions. Ethan's behavior suggests that he is successfully navigating an important developmental task within the developmental theory of: Erikson. Kohlberg. Fowler. Freud.

Erikson. Explanation: Erikson characterized development as a series of crises. The preschool-age child typically must choose between initiative (seeking new experiences and learning) and guilt. Freud focuses on psychosexuality while Kohlberg prioritizes moral development. Fowler explains development through the lens of faith.

When caring preoperatively for a neonate with a diagnosed tracheoesophageal fistula, which symptoms are anticipated? Select all that apply. Excessive drooling Bradypnea Cyanosis Heartburn with feedings Elevated heart rate Frothing

Excessive drooling Cyanosis Elevated heart rate Frothing Explanation: Symptoms resulting from a diagnosed tracheoesophageal fistula include frothing, excessive drooling, cyanosis from mucus production, an elevated heart rate from anxiety of coughing, and difficulty breathing. Once the tracheoesophageal fistula is diagnosed, no oral feedings will be given. This neonate does not have bradypnea.

A preschooler is admitted to the pediatric floor for dehydration and is frightened. Which nursing intervention would be least effective in alleviating the child's anxiety? Assign the child to the same nurse each day. Allow the child to handle the blood pressure cuff before using it. Encourage a caregiver to stay with the child when possible. Explain all procedures using medical terminology.

Explain all procedures using medical terminology. Explanation: Using medical terminology will ensure that the child will not understand what is happening and only increase his or her anxiety. Allowing touching of equipment, assigning the child to the same nurse, and encouraging caregivers to stay with the child all help alleviate anxiety and reduce the child's fears.

The nurse is caring for a 4-year-old child who has been hospitalized for more than 1 week with severe burns. Which intervention would be appropriate in caring for the child? Explain necessary procedures in simple language the child will understand. Encourage friends to visit as much as possible and share notes and cards. Suggest that a family member always be with, or near, the child. Allow the child to make choices about meals and activities as much as permitted.

Explain necessary procedures in simple language the child will understand. Explanation: Preschool-age children fear mutilation and are afraid of intrusive procedures since they do not understand the body's integrity. They interpret words literally and have an active imagination; therefore, procedures should be demonstrated and/or explained in simple terms. Adolescents typically have anxiety about being away from friends, so having friends visit and share notes/cards would be appropriate for an adolescent. Toddlers are especially susceptible to separation anxiety and would benefit from a family member being present as much as possible. School-age children are accustomed to controlling self-care and they would benefit from being involved in choices about meals and activities.

When working on a pediatric unit, the nurse will perform which action(s) to minimize client fear and anxiety? Select all that apply. Encourage the child to inform the nurse of fears. Include the child's family when providing education. Remain calm and empathetic with caring for the child. Perform as many activities of daily living as possible for the child. Allow the child to bring a security blanket from home. Explain procedures to the child beforehand in age-appropriate terms.

Explain procedures to the child beforehand in age-appropriate terms. Include the child's family when providing education. Remain calm and empathetic with caring for the child. Encourage the child to inform the nurse of fears. Allow the child to bring a security blanket from home. Explanation: It is vital the nurse minimize the child's and family's fears and anxiety to allow for the best care and experience possible. Some actions that will help do this include the nurse explaining things before they occur; limiting the use of medical terminology; including the family so they may help reduce the child's fears/anxiety; remaining calm, empathetic, and talking in a soft, friendly, comforting tone; and allowing the child to have a security item. The nurse would allow the child to play out and discuss fears/concerns. The nurse would also promote independence.

The nurse is attempting to insert an intravenous (IV) line in a child. The child will not remain still, moving constantly. The caregiver asks, "Can you use a restraint? The IV has to be in for my child to get the medicine needed to get better." Which action will the nurse take? Determine if the child has required restraints in the past. Gather appropriate restraints for the child and apply. Notify the child's primary health care provider. Explain that restraints are used only as a last resort.

Explain that restraints are used only as a last resort. Explanation: The nurse will explain that restraints are used as a last resort. Thus, the nurse would first try other means to attempt inserting the IV line. The nurse could have the caregiver assist in holding and consoling the child if the caregiver is able. If not, another nurse could attempt to distract the child during the procedure. There is no need to determine if restraints were used in the past. Prior use does not indicate whether restraints are necessary at this time. The nurse would not notify the primary health care provider at this time. If IV access cannot be obtained after several attempts while following facility policy, the nurse would notify the primary health care provider

A school-age child is scheduled for a diagnostic procedure. Which nursing approach is best for this age group? Offer to bring the child a favorite snack after the procedure is over. Encourage the parents to discuss the procedure with their child. Provide a brief overview of the procedure to reduce anxiety. Explain the procedure and the theory and reason behind it.

Explain the procedure and the theory and reason behind it. Explanation: School-age children and adolescents are concrete thinkers and are interested in the theory and reason for procedures. It is best for the nurse to provide the instructions directly to the child and not expect parents to do so. A brief overview is appropriate for toddlers, and bribing the child with food is not an appropriate tool for teaching.

The LPN enters a 3-year-old client's room and states it is time to go to the treatment room for their daily intramuscular ceftriaxone injection. The parent responds, "It has been a long day. Can we just do it in here?" Which action by the nurse is appropriate? Ask the client which location they prefer for the injection to take place. Continue with the procedure in the client's room. Consult with the registered nurse (RN) in charge of the unit. Explain why it is necessary to take the client to the treatment room.

Explain why it is necessary to take the client to the treatment room. Explanation: The nurse will provide the parent with the rationale for taking the client to the treatment room. The nurse wants to maintain the safe environment of the client's room; therefore, treatments and procedures are completed in the designated treatment room if at all possible. The nurse would not continue with the procedure in the client's room, because this action jeopardizes the safe space of the room. There is no need to consult with the RN; the LPN can provide the rationale. The nurse would not consult the client due to the client's age and inability to make such a decision. The nurse would follow the unit's protocol.

A nurse is preparing to administer a prescribed bolus gavage feeding to an infant with a nasogastric tube in place. Before beginning the feeding, the nurse ensures that the gavage tube is in the proper location based on which assessment? Air inserted via tube is auscultated in the stomach area. Testing of gastric aspirate is alkaline. External tube length measurement matches the length documented on insertion. Fluid aspirated from the tube appears light yellow in color.

External tube length measurement matches the length documented on insertion. Explanation: Placement of the tube is confirmed by measuring the length of the external part of the tube (from the marking on the tube at the nose or mouth to the end of tube) and comparing measurement to the documented measurement which should be the same or by aspirating stomach contents and checking the pH of the fluids aspirated. The pH of gastric contents is acidic, rather than alkaline, which would be noted if the fluids were respiratory in nature. The color of the fluid provides no information about placement. Verifying positioning of the feeding tube by inserting air (using an asepto syringe) and listening with a stethoscope for sounds in the stomach is considered an unreliable method of checking for tube placement and is not recommended.

Using Erikson's theory, a nurse asks a young adult questions about family, friends, and support systems. Why is this important during assessments of adolescents? Fear of commitments may lead to loneliness and isolation. Restrictions on new experiences may lead to feelings of guilt. Without peer acceptance, feelings of inferiority may result. Overprotection by parents may result in feelings of shame and doubt.

Fear of commitments may lead to loneliness and isolation. Explanation: The tasks for the young adult, in Erikson's theory, are to unite self-identity with identities of friends and to make commitments to others. Fear of such commitments leads to loneliness and isolation. The other choices relate to different age groups.

A cardiac catheterization is done prior to heart surgery as a diagnostic tool to obtain information about the child's heart condition. Which of the following is accurate related to a cardiac catheterization? For at least six hours after the procedure, the head must remain elevated. During the procedure, a radiopaque catheter is inserted into the brachial artery. Following the procedure, the extremities are monitored for edema. One hour prior to the procedure the child is given analgesics to control pain.

Following the procedure, the extremities are monitored for edema. Explanation: Following a cardiac catheterization carefully monitor the site used and check the extremity for pulses, edema, skin temperature and color, and any other signs of poor circulation or infection. The child remains flat for several hours and the femoral vein is a common site of access.

Many researchers have theories relating to the stages of growth and development. Which stage(s) of accepted theories relates to the preschool-aged child from ages 4 to 6 years? Select all that apply. Freud's oral stage Erikson's stage of initiative vs. guilt Formal operational phase Freud's phallic stage Piaget's preoperational phase Kohlberg's pre-conventional level stage 1

Freud's phallic stage Erikson's stage of initiative vs. guilt Piaget's preoperational phase Kohlberg's pre-conventional level stage 1 Explanation: The child who is 4 to 6 years of age is in the phallic stage according to Freud, the stage of initiative versus guilt according to Erikson, the preoperational phase according to Piaget, and the pre-conventional level according to Kohlberg. The infant is in the oral stage, according to Freud.

A father brings his toddler in for the 2-year-well visit. When providing anticipatory guidance on toilet/potty training the father states, "We are letting him tell us when he is interested in using the toilet." The nurse recognizes that this philosophy is most in line with which theories of development? Erikson's theory of psychosocial development Kohlberg's theory of moral development Freud's theory of psychosexual development Piaget's theory of cognitive development

Freud's theory of psychosexual development Explanation: Freud's theory holds that toddlers are in the anal stage when they are learning to control urination and defecation. He believed that parents should help children achieve bowel and bladder control without undue emphasis on its importance. The other theories are not as relevant to this attitude.

From which pair of metabolic disorders must the nurse instruct the parents to eliminate breast and cow's milk from the diet? Congenital hypothyroidism and phenylketonuria Turner syndrome and maple syrup urine disease Maple syrup urine disease and galactosemia Galactosemia and phenylketonuria

Galactosemia and phenylketonuria Explanation: Both phenylketonuria and galactosemia are hereditary disorders in which the body cannot have milk. Maple syrup urine disease is an inborn error of metabolism of the branched chain amino acid. Congenital hypothyroidism is an error with the thyroid gland.

A 6-year-old has just returned to his room after a spinal tap. What could the nurse do to make this unpleasant procedure less memorable for the child? Tell him he should not have to do this again. Give him a little toy that he has been wanting. Tell him he was very brave even though he cried. Tell him that his parents are very proud of him.

Give him a little toy that he has been wanting. Explanation: Children given a treat or small toy after an uncomfortable procedure tend to remember the experience as not totally bad. The nurse should never say that any client will not have to go through an uncomfortable experience again. Saying the child was brave when maybe he was not could foster mistrust in the nurse.

The nurse is caring for a hospitalized adolescent. What intervention can the nurse use to promote a sense of control for the adolescent? Allow the adolescent to indicate how many people come to visit. Give the adolescent a meal card to select food choice options for each meal. Let the adolescent pick the route to receive a prescribed antibiotic. Ask the adolescent in which room on the unit they want to be placed.

Give the adolescent a meal card to select food choice options for each meal. Explanation: The nurse will allow the adolescent to make food choices based on the adolescent's prescribed diet. Including the adolescent in planning daily activities that are flexible in timing helps promote control. The route of a medication is determined by the primary health care provider and cannot be changed by the adolescent. The amount of people allowed to visit the client is based on the facility's policy, which is set for safety and rest. The adolescent cannot indicate room assignment, because this should be done based on age and severity and type of diagnosis for all clients on the unit.

The nurse is doing an examination on an infant with a diagnosis of developmental dysplasia of the hip (DDH). Which finding would be an indication of this diagnosis? Gluteal fold higher on one side than the other Respiratory rate of 30 breaths per minute Head circumference of 18 inches (46 cm) Sac protruding on the lower back

Gluteal fold higher on one side than the other Explanation: Signs that indicate DDH include asymmetry of the gluteal skin folds (higher on the affected side), limited abduction of the affected hip, and shortening of the femur.

Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which type of restraints would the nurse most likely use for this child? mummy restraint elbow restraint clove hitch restraint jacket restraint

elbow restraint Explanation: An elbow restraint prevents the child from being able to bend the elbows and thus prevents the child from reaching or touching the face or head areas.

A nurse is admitting a 7-year-old child to the pediatric unit of the hospital. While the nurse is showing the child and parents the room and explaining where things are, the child becomes upset and frightened. What is the best action by the nurse? Go slowly with the acquaintance process. Tell the child that there is nothing to be afraid of and that nobody will hurt the child during hospitalization. Ask the parents to leave the room while explaining procedures to the child. Keep on showing and explaining to the parents and do not include the child.

Go slowly with the acquaintance process. Explanation: The child who reacts with fear to well-meaning advances and who clings to the caregiver is telling the nurse to go slowly with the acquaintance process. The child who knows that the caregiver may stay is more quickly put at ease. To provide security for the child and to provide family-centered care, it is the responsibility of the nurse to form good partnerships with families. Asking the family to leave the room in this situation would only frighten the child more. The nurse should never provide false reassurance. Telling the child there is nothing to be afraid of or nothing will hurt him or her are promises the nurse cannot make to the child.

The parent of a newborn diagnosed with Turner syndrome asks the nurse about the treatment that will be required for their newborn. Complete the following sentence(s) by choosing from the lists of options. The nurse should educate the parents on the primary treatments used in the treatment of Turner syndrome, which includes Antibiotics Growth Hormones Corticosteroids Thyroid Medications Estrogen Therapy Desmopressin

Growth Hormones Estrogen Therapy Explanation: The primary treatments for Turner syndrome is growth hormone and estrogen. Even though children with Turner syndrome produce growth hormone, it is given exogenously to increase height. The reproductive system in children with Turner syndrome do not function properly. Estrogen is administered to prompt and maintain sexual development. Corticosteroids, antibiotics, desmopressin, nor thyroid medications are used in the treatment of Turner syndrome.

A parent is comparing a child's development on the growth chart with those of another child and is concerned that her child is not in the "normal" range. What can the nurse inform the parent to alleviate her anxiety? "Growth charts are just a standard measurement. If your child doesn't fall into the 'normal' range, it doesn't indicate something is wrong." "Everyone is scared that their child will not be normal. Let's just wait and see what will happen with your child." "I can certainly understand your fear. If your child is not falling into the 'normal' range, it can indicate that there may be some developmental delays." "Maybe the other child is advanced and your child is growing slower. We will keep a close eye or your baby to make sure nothing is wrong."

Growth charts are just a standard measurement. If your child doesn't fall into the 'normal' range, it doesn't indicate something is wrong." Explanation: A growth chart is used for comparison only; if a child does not fall into the "normal" range, it does not necessarily indicate that there is something of concern for that child.

A trend with growth and development of the infant is that development is proximodistal. This means: All humans experience the same growth patterns. Both sides of the body grow equally. Growth progresses from gross motor movements to fine motor movements. As nerve pathways develop, they become more specialized.

Growth progresses from gross motor movements to fine motor movements. Explanation: Cephalocaudal (proceeding from head to tail) development is the first trend, with the head and brain developing first, followed by the trunk, legs, and feet. The second trend is proximodistal development, which means that growth progresses from gross motor movements (such as learning to lift one's head) to fine motor movements (such as learning to pick up a toy with the fingers). The last trend is symmetric development of the body, with both sides of the body developing equally.

For the nurse to avoid the transmission of microorganisms, what is the best method of prevention? Handwashing standard precautions transmission-based precautions keeping clients in private rooms instead of sharing rooms

Handwashing Explanation: Handwashing is the cornerstone of all infection control. The nurse must wash hands conscientiously between seeing each client, even when he or she wears gloves for a procedure.

A nasogastric tube for enteral feedings has just been inserted in a 6-month-old infant. Which method would the nurse anticipate being used to confirm placement? Have an abdominal X-ray completed Administer 1 ml of fluid and observe for coughing. Listen at the distal end of the tube for bowel sounds. Aspirate the tube for stomach contents.

Have an abdominal X-ray completed Explanation: Because tubes are radiopaque, their placement or that they extend into the stomach can be confirmed by X-ray. It is necessary to use a syringe to aspirate the tube for any stomach residual before a feeding because it helps to ensure the tube's placement in the stomach. Fluid should not be introduced through the nasogastric tube until placement has been confirmed. Listening for bowel sounds is not appropriateto assess for nasogastric tube placement in an infant.

A nasogastric tube for enteral feedings has just been inserted in a 6-month-old infant. Which method would the nurse anticipate being used to confirm placement? Have an abdominal X-ray completed Aspirate the tube for stomach contents. Listen at the distal end of the tube for bowel sounds. Administer 1 ml of fluid and observe for coughing.

Have an abdominal X-ray completed Explanation: Because tubes are radiopaque, their placement or that they extend into the stomach can be confirmed by X-ray. It is necessary to use a syringe to aspirate the tube for any stomach residual before a feeding because it helps to ensure the tube's placement in the stomach. Fluid should not be introduced through the nasogastric tube until placement has been confirmed. Listening for bowel sounds is not appropriateto assess for nasogastric tube placement in an infant.

A school-aged child is in isolation at the hospital and her family members ask what they can do to help the child feel less lonely. What would the nurse suggest to this family? Select all that apply. Have parents bring the child's electronic game system. Limit the time the nurse spends with the child when performing procedures. Have the child's classmates send cards to the child. Have the child wear a gown and mask so he or she will feel like everyone else. Draw a smile on the nurse's mask before entering the room.

Have the child's classmates send cards to the child. Have parents bring the child's electronic game system. Draw a smile on the nurse's mask before entering the room. Explanation: Being in isolation causes a child to feel lonely and depressed. Parents are encouraged to visit and bring items from home that the child likes to play with, such as a gaming system. Having classmates send cards makes the child feel that he or she is not forgotten. Since wearing a gown and mask may frighten a young child, doing something as simple as drawing a smile on the nurse's mask helps the child relax and often brings laughter.

The nurse is caring for an 8-year-old boy hospitalized for a bone marrow transplant. His parents are in and out of his room throughout the day. Which behaviors of the child would alert the nurse that he is in the second stage of separation anxiety? He sits quietly and is uninterested in playing and eating. He forms superficial relationships with his caregivers. He cries uncontrollably whenever they leave. He ignores his parents when they return to his room.

He sits quietly and is uninterested in playing and eating. Explanation: Separation anxiety consists of three stages—protest, despair, and detachment. In the protest stage, the child reacts aggressively to separation and exhibits great distress by crying, expressing agitation, and rejecting others who attempt to offer comfort. In the despair phase the child displays hopelessness by withdrawing from others, becoming quiet without crying, and exhibiting apathy, depression, lack of interest in play and food, and overall feelings of sadness. In the detachment stage the child shows interest in the environment, starts to play again, and forms superficial relationships with the nurses and other children. If the parents return, the child ignores them. A child in this phase of separation anxiety exhibits resignation, not contentment.

When an infant is scheduled for a painful procedure, what is the most important action by the nurse? Help to soothe and comfort the baby before and after the procedure. Explain the procedure to the client. Explain the procedure to the caregiver. Nothing—the infant is too young to know what is going on.

Help to soothe and comfort the baby before and after the procedure. Explanation: Infants undergoing procedures can experience pain. Thus, the important action is to help soothe and comfort the child before and after the procedure. The nurse should explain everything to the care provider, but the client's comfort is the highest priority.

A 2-year-old child is admitted to the hospital for dehydration. This is the first time the child has been in the hospital, and the caregiver has not arrived but is en route. The child is crying and appears afraid. Which intervention by the nurse is appropriate for this child? Inform the child the caregiver will be there soon. Hold and rock the child until the caregiver arrives. Turn on the television for the child to watch a movie. Place the child in crib with the side rails up and door closed.

Hold and rock the child until the caregiver arrives. Explanation: The nurse will attempt to console the child by holding and rocking them until the caregiver arrives. Telling the child the caregiver is en route is not appropriate for this age. A 2-year-old child does not have an understanding of time or distance. Leaving the room with the child alone would potentially cause increased separation anxiety in the child. The child is also too young for television. Personal interaction would best facilitate a trusting relationship.

A nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. What would be the most appropriate method to clean and secure the gastrostomy tube? Use adhesive tape to tape the tube in place and prevent movement. If any drainage is present, use a presplit 2 × 2 and place it loosely around the site. Make sure the tube cannot be moved in and out of the child's stomach. Place a transparent dressing over the site whether there is drainage or not.

If any drainage is present, use a presplit 2 × 2 and place it loosely around the site. Explanation: Skin around the gastrostomy or jejunostomy insertion site may become irritated from movement of the tube, moisture, leakage of stomach or intestinal contents, or the adhesive device holding the tube in place. Keeping the skin clean and dry is important and will help prevent most of these problems. If any drainage is present, a presplit 2 × 2 can be placed loosely around the site and changed when soiled. If no drainage is present, the nurse should not place a dressing as it can cause undue pressure and trap moisture, leading to skin irritation. Preventing movement of the tube helps reduce skin irritation; however, the tube should be able to move slightly in and out of the child's stomach.

The nurse is caring for a client needing oxygen. Many forms of oxygen delivery can be used. Which of the following is the most difficult to manage the oxygen concentration? oxygen tent oxygen hood nasal prongs mask

oxygen tent Explanation: It is most difficult to manage the oxygen concentration in a tent because it is opened frequently.

The nurse is preparing a hospitalized 7-year-old girl for a lumbar puncture. Which actions would help reduce her stress related to the procedure? Select all that apply. Tell her not to pay attention to any sounds she might hear. Do not allow her to see or touch the equipment. Explain the procedure to her in medical terms. Introduce her to the health care personnel. Teach her the steps of the procedure. Pretend to perform the procedure on her doll.

Introduce her to the health care personnel. Teach her the steps of the procedure. Pretend to perform the procedure on her doll. Explanation: Useful techniques for reducing stress in children include the following: perform nursing care on stuffed animals or dolls and allow the child to do the same; teach the child the steps of the procedure or inform him or her exactly what will happen during the hospital stay; introduce the child to the health care personnel with whom he or she will come in contact' avoid the use of medical terms; allow the child to handle some equipment; show the child the room where he or she will be staying; explain the sounds the child may hear; and let the child sample the food that will be served.

A nurse will explain to a child's caregiver any procedure that is to be done. What is the primary reason for this explanation? It gives the nurse an opportunity to get to know the caregiver. It helps to establish rapport with the child. It helps to reduce anxiety. It is the client's right.

It helps to reduce anxiety. Explanation: Although it is a client's right to know everything about his or her care, in this case the caregiver is not the client. Communication helps to develop rapport and trust, but the main purpose of explaining procedures to the caregiver of a child is to reduce anxiety. Doing this also will help decrease the child's anxiety.

The nurse is caring for a 3-year-old child at an outpatient pediatric clinic. The child asks her mother, "What is a hospital?" Which statement by the child's mother requires additional teaching? "It is where mommies go to have babies." "Doctors and nurses work there to help people who are sick or with boo boo's." "It is where sick people go sometimes." "Sometimes people go there to get a boo boo fixed."

It is where mommies go to have babies." Explanation: It is important that the child understands that hospitals are more than just a place where mommies go to have babies. The child should be told that it is a place where sick people go sometimes, where "boo boo's" are fixed, and where doctors and nurses work.

Caregivers of a hospitalized toddler are being given safety instructions upon admission to the pediatric floor. Which action by the caregiver would be most important to the toddler's safety? Keep the crib at the highest setting so the nurse can assess the child easily. Show the child how to push the nurse call button. If side rails are down, never be more than 3 feet away from the child. Keep the crib side rails up at all times.

Keep the crib side rails up at all times. Explanation: Many toddlers are climbers and are always curious. So side rails must be kept fully up at all times, except when direct care is being provided. If side rails are down, the nurse or caregiver must keep a hand firmly on the child. Providing a call button to a toddler is not a good idea since the child will be pushing it all the time. Beds and cribs are kept at the lowest setting to minimize the possibility of injury if the child does fall out.

Which theorist believes that the child progresses from making decisions with no moral sensitivity to making decisions based on personal standards and values? Erikson Piaget Freud Kohlberg

Kohlberg Explanation: Kohlberg's theory relates to the development of moral reasoning in children. The child progresses from making decisions with no moral sensitivity to making decisions based on personal standards and values.

The nurse is caring for a preschooler who requires postsurgical breathing exercises. Which approach will best elicit the child's cooperation? "Do you want to play a breathing exercise game with me?" "You will need to cooperate. Otherwise, you might not feel better." "Let's see who can blow these cotton balls off the table first." "You need to do the breathing or you could get pneumonia."

Let's see who can blow these cotton balls off the table first." Explanation: Any intervention should be developmentally appropriate, and play can often serve as a vehicle for care. Turning breathing exercises into a game is likely to engage the preschooler. Telling the child he needs to do breathing exercises or he will develop another illness or not feel better is not likely to impress the young child. Connecting the two events in a meaningful way is beyond his cognitive ability. Asking if the child "wants" to play a breathing game is an open invitation for a "No" answer.

A child is reporting pain where an IV infiltrated his hand earlier in the shift. The doctor orders warm compresses to the right hand every 4 hours. What precautions would the nurse implement for this client? Have the parents apply the warm compresses if the nurse is tied up elsewhere. Heat the moistened towels in the microwave. Limit treatments to 20 minutes at a time. Use hot water on gauze for the warm compress.

Limit treatments to 20 minutes at a time. Explanation: Warm compresses are used to increase circulation to an area of the body and to promote pain relief. For a child having warm compresses, the length of each session is a maximum of 20 minutes to prevent skin damage. Towels used in warm compresses are never heated in a microwave because of uneven heating. Parents are not to apply compresses because the nurse needs to assess the skin before and after the treatment. Gauze is not a good material for compresses; it does not hold heat well.

A nurse is admitting a 7-year-old to the hospital. The child's parents will be unable to stay with him. What can the nurse do to help the child meet his developmental, emotional, and intellectual needs? Provide constant one-on-one care for the child. Make a referral to the child-life program. Allow the child to interact with other children on the unit. Tell the parents that one of them will have to stay with the child.

Make a referral to the child-life program. Explanation: Many hospitals have a child-life program to make hospitalization less threatening for children and their parents. These programs are usually under the direction of a child-life specialist whose background is in psychology and early childhood development. This person works with nurses, physicians, and other health team members to help them meet the developmental, emotional, and intellectual needs of hospitalized children.

Which action would be most important to do for an infant following surgery for meningomyelocele? Measure a daily head circumference. Measure total 24-hour urine output. Elicit a paracervical reflex daily. Assess a blink reflex hourly.

Measure a daily head circumference. Explanation: Because some absorbing surface is removed with surgery, cerebrospinal fluid can accumulate and lead to hydrocephalus

How will the nurse determine the length of orogastric tubing needed to gavage the 14-month-old infant? Measure from bridge of the nose to tip of the xiphoid. Measure from nose tip to earlobe to halfway between xiphoid and umbilicus. Measure from nose tip to earlobe to end of sternum. Measure from mouth to umbilicus.

Measure from nose tip to earlobe to end of sternum. Explanation: Measuring from the tip of the infant's nose to the earlobe and then to the end of the sternum determines how far the orogastric and nasogastric tubes should be inserted for an infant over age 12 months. Measuring bridge of nose to xiphoid or mouth to umbilicus is not an accurate way to determine length of tube insertion. The tip of the nose to the earlobe to halfway between the end of the sternum and the umbilicus is used for infants younger than 12 months of age.

The nurse is reviewing a chart for a male client with Klinefelter syndrome. Which physical characteristics does the nurse anticipate? The client has a small stature and features Cognitive deficits with emotional outbursts No development of secondary sex characteristics An enlarged heart with arrhythmias

No development of secondary sex characteristics Explanation: The male client with Klinefelter syndrome will not develop secondary sex characteristics. Klinefelter syndrome has an extra X chromosome. The other characteristics are of other syndromes.

A nurse is conducting an assessment of a 13-month-old infant. The parent notes that the infant cannot pull oneself into a standing position. To help determine a cause, which assessment will the nurse conduct? Perform a Weber test. Observe symmetry of gluteal skin folds. Palpate the anterior fontanel (fontanelle). Elicit a Babinski sign.

Observe symmetry of gluteal skin folds. Explanation: An infant can pull oneself to a standing position generally by 10 months of age, and begins walking generally by 15 months of age. If these developmental milestones are not reached, then physical and neurologic symptoms should be assessed. One common physical reason for not standing or walking is developmental dysplasia of the hip (DDH). The nurse can easily assess if this is a contributing factor by observing the symmetry of the gluteal folds. If the folds are unequal, the finding should be reported to the health care provider for further evaluation. The Weber test is a test for hearing. The Babinski test determines neurologic impairment and would be present until 18 months of age. Assessing the anterior fontanel (fontanelle) would determine if it is closed prematurely or bulging, which indicates a neurological disorder

A nurse inserts a nasogastric (NG) tube into a child for enteral feeding. How will the nurse ensure appropriate placement of the tube after insertion? Inject 30 mL of air and listen over the epigastrium. Obtain radiologic confirmation. Conduct pH testing. Aspirate gastric contents.

Obtain radiologic confirmation. Explanation: The nurse confirms placement by radiologic confirmation, the most accurate method of verifying tube placement and position. Because of the risks of repeated radiation exposure, this procedure cannot be used before each feeding. The best method of confirmation before each feeding is to test the aspirated contents for pH. The normal value should be between 1.5 and 3.5. If the tube has migrated to the lungs the pH would be between 7.38 and 7.42. Testing with 30 mL of air injected into the epigastrium is not evidence-based practice.

After cleft palate repair at 18 months, a child will begin a liquid diet. Which method of initiating the diet is best? Offer the child 6-8 ounces of fluid at a sitting. Teach the child to suck through a straw. Feed the child small sips at a time from a spoon. Offer the child sips from a small glass.

Offer the child sips from a small glass. Explanation: Offering sips from a glass allows the child to ingest fluid and not disturb the suture line. Using a straw or spoon could injure the suture line; children generally do better with small rather than large (6-8 ounce) amounts.

At which time does the nurse obtain the Guthrie inhibition assay test to rule out phenylketonuria (PKU)? On the second day of life On the infant's first birthday At the newborn's first checkup Immediately after birth

On the second day of life Explanation: The nurse is correct to obtain the Guthrie inhibition assay test on the second day of life. At this time, the newborn has ingested either breast milk or cow's milk and the test will be able to determine if the newborn has PKU. Immediately after birth, the newborn has not ingested any milk. It is too long to wait for the test in 3 to 4 weeks as permanent damage to the brain may be done. Deficits are seen by the first birthday.

A nursing instructor is discussing oxygen therapy with a group of pediatric nursing students. Which of the following statements made by one of the students indicates a need for further teaching? Maintain good oral care. Avoid the use of wool or synthetic blankets. Oxygen should be removed immediately upon receiving the physician's order to stop therapy. Use signs indicating that oxygen is in use. Oxygen should be warmed and humidified.

Oxygen should be removed immediately upon receiving the physician's order to stop therapy. Explanation: Oxygen should be weaned or removed slowly.

The health care provider orders a urinalysis on a 15-month-old toddler. The mother states that the child is not potty-trained. What is the best way for the nurse to collect the specimen? Clean off the penis with a commercial cleaning pad and catheterize the client. Place a urine collection bag on the child after cleaning off the perineum. Observe the child for signs he needs to urinate and quickly pull the diaper down and catch the urine when he voids. Aspirate urine out of the diaper with a syringe and place it in a specimen cup.

Place a urine collection bag on the child after cleaning off the perineum. Explanation: In clients that are not potty-trained, the best method for collecting a urine specimen is to place a urine collection bag on the child and wait for them to void. The doctor did not order a urine culture, so a catheterized urinalysis is not needed and would be traumatic for the child. Trying to catch urine from a voiding toddler is nearly impossible. Aspirating urine out of the diaper is not the best approach or one that ensures the best results.

If a urine specimen for analysis is ordered for an 8-month-old girl, which intervention would you use? Wait until she voids and attempt to obtain a clean-catch specimen. Wait an hour after a feeding and then apply a collection bag. Place a diaper on her; when it is wet, send the diaper to the laboratory. Place a urine collector on her just prior to feeding.

Place a urine collector on her just prior to feeding. Explanation: Most infants void following a feeding, so placing a urine collector just before a feeding will usually allow a urine specimen to be obtained.

The nurse is caring for a 2-year-old child in the pediatric unit. The child was being fed by unlicensed assistive personnel and had a temper tantrum and spit out the food. The child now needs to be taken for a diagnostic procedure. Which nursing action would be the best method of transporting this child? Allow the child to sit in a stroller after reminding him temper tantrums are not acceptable. Place the child in a crib with high side rails or in a crib with a bubble top. Walk alongside the child with age-appropriate toys at hand. Request the UAP carry the child in his or her arms to the other department.

Place the child in a crib with high side rails or in a crib with a bubble top. Explanation: When moving infants and small children in a health care setting, the safety of the child is the biggest concern. The toddler may be transported in a crib with high side rails or a high-topped crib.

A child is admitted with a highly contagious infection. Which nursing action is a priority? Place the child on appropriate precautions for the diagnosis. Monitor the child for loneliness and anxiety. Determine age-appropriate diversional activities for the child. Orient the child and family to the unit.

Place the child on appropriate precautions for the diagnosis. Explanation: The priority action by the nurse is to ensure everyone's safety by placing the child on the appropriate precautions. The nurse does not want to spread the infection to other clients, visitors, or staff. The nurse will orient the child and family to the unit and determine appropriate activities soon, but these are not priorities over the safety of other clients, staff, and visitors. The child will be monitored for loneliness and anxiety once placed on precautions because this limits interactions with others.

The nurse is preparing a postsurgical care plan for an infant girl located on a general hospital unit that only occasionally admits children. To ensure the infant's safety, what should the nurse include in the plan? Place the infant in a room with an ambulatory adolescent. Ask the family to stay with the infant at all times. Place the infant in a room close to the nurses' station. Put the infant in a carrier and bring her to the nurses' station.

Place the infant in a room close to the nurses' station. Explanation: The infant will need close monitoring, and having the child nearby will promote frequent checks and awareness of her status. Family cannot be required to stay at all times. That may be impossible for some. One client should never be responsible for another. The infant is the nurses' responsibility. Putting the infant in a carrier and bringing her to the nurses' station is not safe.

A nurse is caring for a newborn client who is diagnosed with myelomeningocele. Which nursing intervention would protect the newborn from injury? Place the newborn in a prone or lateral position. Place petroleum jelly gauze on the spinal sac to keep it moist. Place a urine collection bag on newborn for the continuous leakage. Delay the parents from holding the newborn.

Place the newborn in a prone or lateral position. Explanation: The nurse should place the newborn in a prone or lateral position to keep pressure off the spinal sac and avoid newborn injury. Parents should be allowed to hold the stable infant with assistance. The spinal sac should be kept covered and moist until surgery to avoid rupture. Collecting urine decreases the risk of urine stasis, which is sometimes common in spinal defects.

A school-aged child is hospitalized and is in contact isolation and must remain in his room. Which activity could the nurse use to entertain the client to reduce his sense of loneliness? Play "I Spy" with items in his room. Make a lunch-bag puppet and play pretend games with it. Make a contest out of seeing how many words the child can make out of the letters from his name. Bring a large-piece puzzle in for the child to put together.

Play "I Spy" with items in his room. Explanation: A school-aged child would enjoy playing "I Spy" with the nurse. Putting a large-piece puzzle together and playing with a lunch-bag puppet are for younger children. Making words out of the letters of his name is a bit advanced for him. That is appropriate for an adolescent client.

While performing a preoperative assessment on a 3-year-old client, a nurse should be aware of what type of cognitive thought process by the child? Formal operations - The child requires no formal introduction to the equipment. Sensorimotor - Responses to the assessment are based off of reflex activity. Concrete operations - The child will understand the order of the assessment. Preoperational - The child will want to play with the equipment.

Preoperational - The child will want to play with the equipment. Explanation: The child focuses on an object without the concept of effect and therefore may want to play with the assessment equipment.

A preschool teacher calls the hospital and wants to introduce the concept of a hospital to her preschool class in case they ever get sick and need to be admitted. What resources could the child life specialist provide for this group to aid in their learning? Select all that apply. Offer to let them see and play with the injection equipment such as syringes and needles. Provide a room for the class with hospital gowns, masks and equipment used on children. Tour the hospital, including the playrooms on the pediatric floors. Let the children lie in the beds, use the call lights and practice being a patient. Tell the children that hospitals are places for sick people to come and sometimes they don't leave.

Provide a room for the class with hospital gowns, masks and equipment used on children. Tour the hospital, including the playrooms on the pediatric floors. Let the children lie in the beds, use the call lights and practice being a patient. Explanation: Preschoolers are curious and love to manipulate the equipment used at the hospital. By making admission to the hospital less frightening for them, they will adjust better if they have to be admitted. Mentioning people not leaving the hospital indicates they died; this is scary to the children and inappropriate for this session. Children are never allowed to play with needles or syringes - it is too dangerous.

The nurse is caring for a 10-year-old child who is in a contact isolation room. Which intervention would be appropriate for this child? Put on a mask prior to entering the room. Provide age-appropriate toys and games. Discourage visitors from entering the room. Reduce noise as much as possible.

Provide age-appropriate toys and games. Explanation: Children in this setting may experience sensory deprivation due to the limited contact with others and the use of personal protective equipment such as gloves and gowns. The nurse should stimulate the child by playing with the child using age-appropriate toys and games. Reducing noise would be appropriate if the child was experiencing sensory overload. The nurse should encourage the family to visit often and introduce oneself before entering the room. A mask is not needed for contact isolation.

An adolescent is scheduled for outpatient arthroscopic surgery on his knee next week. As part of preparing him for the procedure, which action would be most appropriate? Discussing the events with the adolescent and his mother upon arrival the morning of the procedure. Providing detailed explanations of the procedure at least a week in advance of the procedure. Telling the adolescent that his/her questions will be answered by the surgeon. Encouraging the parent to stay with the adolescent as much as possible before the procedure.

Providing detailed explanations of the procedure at least a week in advance of the procedure. Explanation: The adolescent needs a detailed explanation about the procedure at least 7 to 10 days beforehand. Waiting until the morning of the procedure would be inappropriate. However, information could be clarified and additional questions could be answered at this time. Having the parent stay with the adolescent is something that the adolescent would need to decide; he may or may not want a parent present. Referring the adolescent to the surgeon for his questions is inappropriate and ignores the adolescent's desire for control and information.

A 7-year-old child is upset because the family has to wear personal protective equipment (PPE) while in their room. When the family enters, the child cries and requests the PPE be removed. Which action by the nurse is appropriate? Reinforce teaching to the child of why the PPE is required. Permit the family to visit up to 5 minutes without PPE. Encourage the child to watch videos on PPE usage. Have the family visit the client through the glass in the door.

Reinforce teaching to the child of why the PPE is required. Explanation: The nurse will reinforce teaching the child why personal protective equipment (PPE) is required. A careful explanation should help the child accept the PPE requirement. Not requiring PPE for any length of time places the family at risk. This would not be permitted. The family should not be limited to visiting the child only through the glass in the door, because this would further upset and stress the child while hospitalized. This action would also isolate the child and could lead to additional emotional concerns. Having the child watch a video on PPE does not directly address the child's concern and is not appropriate for the child's age. Verbal communication is best at this age.

The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the appropriate action by the nurse? Replace the stomach contents and hold the feeding. Discard the stomach contents and continue with the feedings as prescribed. Replace the stomach contents and continue with the feedings as prescribed. Discard the stomach contents and notify the health care provider of the aspiration amount.

Replace the stomach contents and continue with the feedings as prescribed. Explanation: The nurse should always aspirate nasogastric or gastrostomy tubes for stomach contents to check for tube placement and assess gastric residual amounts prior to administering feedings. The nurse will return any amount of stomach residue aspirated so the child does not lose large amounts of stomach acid. 15 ml is a very small amount of gastric contents and should not interfere with feedings.

A child is admitted to the hospital for an extended time period following a new diagnosis. The family appears stressed and anxious about what to expect while the child is hospitalized. They express concerns about how to ensure the child will be able to cope and continue to develop while in the hospital and not at home or school. The family asks lots of questions but remains anxious and concerned. Which intervention by the nurse is best? Notify the primary health care provider of the need to consult a social worker. Tell the family the nursing staff will be glad to continue answering any questions. Provide the family and client with age-appropriate educational material on the diagnosis. Request the child life specialist to come and visit with the client and family.

Request the child life specialist to come and visit with the client and family. Explanation: The nurse will request a child life specialist come visit and work with the child and family. The child life specialist is someone who works to help children meet developmental, emotional, and intellectual needs while hospitalized. Providing educational material will help increase knowledge about the diagnosis; however, overall hospitalization is the indicated concern at this time. The nursing staff would continue to answer questions; however, having the child life specialist present adds another person to discuss concerns with and provide assistance to the family. The child life specialist has a background in psychology and early childhood development, making them more equipped to help. A social worker would be consulted to help guide the family with financial and resource needs.

Colin, age 1, has been admitted for an injury on his head that requires sutures to be placed. He is crying and trying to sit up when he is placed on the examining table. To keep him safe during the procedure, the nurse would choose which method to restrain him? Restrain him in a jacket restraint and release it every 15 minutes. Allow his caregiver to hold him during and after the procedure. Restrain him with a mummy restraint and release it as soon as the procedure is completed. Use a clove hitch restraint to keep his arms still and loosen them every 2 hours.

Restrain him with a mummy restraint and release it as soon as the procedure is completed. Explanation: Restraints often are needed to protect a child from injury during a procedure or an examination, or to ensure the infant's or child's safety and comfort. A mummy restraint can be used for an infant or small child during a procedure. This device is a snug wrap that is effective when performing a scalp venipuncture, inserting a nasogastric tube, or performing other procedures that involve only the head or neck.

The nurse caring for a preschool child prepares to use therapeutic play to put the child at ease and decrease the child's anxiety. Which game is best for the child, according to the child's developmental stage? Ring-around-the-rosy I-spy Patty-cake Hangman

Ring-around-the-rosy Explanation: Therapeutic play is a technique used to help the child have a better understanding of what will be happening to him or her in a specific situation. Games played with the child should be appropriate to the child's developmental stage. Ring-around-the-rosy is a game appropriate for the preschooler. I-spy and Hangman would be appropriate for an older child. Patty-cake would be appropriate for the infant child.

Which nursing action is required when caring for the post-term infant? IV initiation temperature checks every 2 hours Serial blood glucose levels Echocardiogram at the end of pregnancy

Serial blood glucose levels Explanation: Of the options provided, the one that is required is serial blood glucose levels. The newborn may require IV glucose infusion to stabilize glucose level. The rest of the options are on an as-needed basis.

A parent calls the nurse in the emergency department and reports giving a tepid bath to decrease temperature in a feverish child. The parent states the child is shivering and wants to know if this means the bath was effective. What is the best response by the nurse? "The child may be getting ready to have seizure activity." "Shivering means the child is chilling, which will cause the body temperature to increase." "The child's fever is going to go down after the bath because of the shivering." "You should pour more hot water in the tub so the child will not shiver."

Shivering means the child is chilling, which will cause the body temperature to increase." Explanation: If a child begins to shiver, whatever method is being used to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase.

The pediatric nurse is caring for a group of children. Which clinical situation will the nurse identify as being a safety concern? Child playing with a rubber ball while wearing supplemental oxygen. Infant who can stand placed in a crib with a top on it. Infant placed in a crib with all railings in the up position. Sleepy mother holding her sleeping child at the child's bedside.

Sleepy mother holding her sleeping child at the child's bedside. Explanation: Safety is the priority for the pediatric nurse. The nurse should not allow a sleepy family member to hold a sleeping child because the family member may accidentally drop the child. Friction toys should not be allowed when supplemental oxygen is used; and a rubber ball would not be considered a friction toy. The infant who can stand should be placed in a crib with the top on it to prevent the infant from climbing out. An infant in a crib should have all railings in the up position.

A 4-year-old is being seen in the emergency department after a fall down the steps. How can the nurse communicate with the child to develop rapport? Select all that apply. Speak in a slow, clear, positive voice. Speak to the parent and have him or her relay the information to the child. Stand above the child when speaking to the child. Speak in short sentences. Stand at eye level with the child when speaking to him or her.

Speak in a slow, clear, positive voice. Speak in short sentences. Stand at eye level with the child when speaking to him or her. Explanation: When speaking with young children, the nurse should not stand over and talk down to them. Instead, he or she should get down on eye level with them; speak in a slow, clear, positive voice; use simple words; keep sentences short; and express statements and questions positively.

A 6-year-old with leukemia is placed on reverse isolation. What nursing actions could prevent depression and loneliness in this client? Select all that apply. Quickly exit the room when possible. Spend extra time to talk while in the room. Do all nursing tasks at one time. Read a story while in the room. Play a game while in the room.

Spend extra time to talk while in the room. Read a story while in the room. Play a game while in the room. Explanation: A child on isolation is subject to loneliness, which can be prevented by arranging to spend extra time in the room during treatments. Also, while in the room the nurse might read a story, play a game, or just talk to the child. Quickly exiting the room and providing cluster care will increase social isolation and may make the child feel punished.

The nurse is assessing the neonate shown. From the assessment, the nurse notes that there is paralysis of the lower extremities. For which condition does the nurse anticipate performing care? Spina bifida major Spina bifida occulta Spina bifida with myelomeningocele Spina bifida with meningocele

Spina bifida with myelomeningocele Explanation: The neonate shown was born with spina bifida myelomeningocele, which is a sac containing the spinal cord and meninges with nerves roots embedded in the wall. Spina bifida occulta is a bony defect that occurs without soft tissue involvement. These neonates are asymptomatic and present no problems. A neonate with spina bifida with a meningocele would have spinal meninges protrude through a bony defect forming a sac. There is no condition as spina bifida major

A 6-month-old infant requires a routine urine specimen for analysis. Which action by the nurse would be appropriate? Aspirate a specimen for a wet diaper. Place a diaper on the baby, sending the diapter to the lab when saturated. Squeezing the diaper to obtain the urine sample. urine Place a urine collector on the baby just prior to feeding. Apply a collection bag just before the next feeding.

Squeezing the diaper to obtain the urine sample. urine Place a urine collector on the baby just prior to feeding. Explanation: An infant who has not been toilet trained cannot be expected to urinate on command, so a collecting device must be attached to the genitalia to collect the next voiding. Most infants void shortly after a feeding, so if the collector is applied just before a regular feeding, voiding will probably result soon afterward. Remove the collector as soon as the infant voids and transfer the specimen to a specimen cup by cutting the bottom corner of the bag. Waiting an hour after a feeding might not produce the needed urine for the specimen. It is inappropriate to send a saturated diaper to the laboratory for a urine specimen or to attempt to squeeze urine from the diaper. Current disposable diapers, however, are designed to trap urine in the material so effectively, they can make it impossible to squeeze out a specimen. Urine may be aspirated from diapers for tests such as specific gravity, dipstick protein, pH, or glucose but not a routine urinalysis.

The nurse is caring for a child receiving oxygen. The nurse observes the caregiver remove petroleum-based cream from a bag and prepare to apply the cream to the child. The caregiver states the child has dry skin and this cream is applied daily at home. Which action will the nurse take? Obtain a prescription for hospital use. Assist the caregiver to apply the cream. Stop the caregiver from applying the cream. Notify respiratory therapy.

Stop the caregiver from applying the cream. Explanation: The nurse will stop the caregiver. Only water-based products should be applied to the child receiving oxygen. The use of petroleum-based products is prohibited because these products are highly flammable and should not be used near oxygen. There is no need to notify respiratory therapy because the cream has not yet been applied to the child. The nurse would have intervened immediately. A prescription for a water-based product would be obtained if needed.

A nurse working with a client who has an elevated temperature notices that the child is beginning to shiver. Which of the following should the nurse do immediately? Apply cool compresses. Lower the room temperature. Stop whatever intervention is being done to lower the temperature. Remove more clothing.

Stop whatever intervention is being done to lower the temperature. Explanation: Removing clothing and excess covering from a child with a fever permits additional cooling through evaporation. If a child starts to shiver, whatever method is being used to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase.

A 3-year-old who has just been admitted with pneumonia needs to have an intravenous (IV) line inserted for antibiotic therapy. What is the best nursing action? Take the patient to the treatment room to have the IV inserted. Tell the patient that it will feel like a bumble bee sting when inserted. Inform the patient's mother that she can stay in the room and hold the child while the IV is inserted. Tell the patient to stay with the mother in his room while the IV is inserted.

Take the patient to the treatment room to have the IV inserted. Explanation: Treatments should be performed in a treatment room, not in the child's room. Using a separate room to perform procedures promotes the concept that the child's bed is a safe place. Having the mother hold the child is helpful but not the best action in this case. It is very difficult for mother to hold her child still while the child is in pain and it is a negative emotional experience for the mother. Telling the patient that it will feel like a bee sting would only make the child more apprehensive and it is also not being truthful to the child.

A community health nurse is giving a lecture to parents of children home alone in the afternoons ("latchkey" children). What advice should the nurse include? Select all that apply. Let the child know if you are going to be delayed. Say the child can do whatever he or she wants as long as it is safe. Teach the child to keep the house key hidden. Teach the child to show friends where the key is hidden in case its location is forgotten. Tell the child to open the door only to friends. Plan a telephone contact on the child's arrival home.

Teach the child to keep the house key hidden. Let the child know if you are going to be delayed. Plan a telephone contact on the child's arrival home. Explanation: Some tips for parents include the following: teach the child to keep the key hidden and not show it to anyone, plan with the child the routine to follow when arriving home, always let the child know if you are going to be late, plan a telephone contact on the child's arrival home, teach the child not to open the door for anyone, and be specific about what activities are allowed and not allowed.

The nurse is admitting a 9-year-old child for a surgical procedure. Which statement would be most appropriate for the nurse to initially make to this child? "I will have your mom go and fill out the paperwork while you and I talk." "You aren't very heavy. Would you like to sit on your mom's lap while I check your temperature?" "Tell me the reason you came to the hospital today." "Would you like to use my stethoscope to listen to your heartbeat?"

Tell me the reason you came to the hospital today." Explanation: The nurse should use her knowledge of growth and development to talk to the child at his or her level of development and understanding. Doing so will enable the nurse to quickly establish rapport and begin a trusting relationship with the child. Remember to begin by calming down or connecting with the school-age child.

Which observation by the nurse indicates that an adolescent's cognitive thinking is developing at an expected level? The adolescent tells the parent that the dog moved the bicycle into the driveway. The adolescent says that all plastic remote controls break easily. The adolescent asks the mother to provide the sharp item needed to cut meat. The adolescent explains how working a part-time job will help pay for a car.

The adolescent explains how working a part-time job will help pay for a car. Explanation: The adolescent is capable of abstract reasoning, which would be observed when the adolescent explains how working a part-time job will help pay for a car. All plastic remote controls breaking would be concrete thinking. Asking for a sharp item to cut meat is an example of preschool-age thinking. Saying that the dog moved the bicycle into the driveway is an example of preschool-age thinking.

What health teaching would you plan with the parents of a child with a cleft palate following surgery? The child may have a poor appetite from a decreased sense of taste. The child may have increased episodes of otitis media. The child will have difficulty sensing the temperature of food. The child can expect to have chronic maxillary pain.

The child may have increased episodes of otitis media. Explanation: Surgery for cleft palate changes the slant of the eustachian tube, allowing bacteria from the posterior throat to enter the middle ear easily.

A 4-year-old child is being assessed in the clinic for growth and development milestones. The nurse is using Piaget's stages of development. What milestone(s) does the nurse expect to observe? Select all that apply. The child describes what will happen tomorrow. The child is able to describe the best friend as sad. The child says the teddy bear is "my best friend." The child engages in role-playing. The child pretends the wooden horse is real.

The child says the teddy bear is "my best friend." The child engages in role-playing. The child pretends the wooden horse is real. Explanation: A 4-year-old child is in the preoperational stage as described by Piaget. The stage goes from 2 years to 7 years of age. During this period the child is developing memory and imagination. The child engages in symbolic play. The child has the ability to make one thing, a word, or an object, stand for something other than itself. For example, the child can take a wooden stick horse and role-play riding a huge horse and defending the good guys. Role-playing is a huge part of this stage. The child engages in make-believe. That is why a teddy bear can be the child's best friend. Describing what will happen tomorrow or describing one's friend as sad is not accomplished during this stage.

A child has returned to the unit after having a lumbar puncture. Which instructions are important for the nurse to provide the parents and child? The child should be up and ambulating as soon as possible. This procedure needs to be repeated again in 24 hours to determine the results. The child may be fearful of staff after having this procedure. The child will need to remain flat to prevent a headache.

The child will need to remain flat to prevent a headache. Explanation: After a lumbar puncture, remind children to remain quiet and with their head flat to help prevent a postdural puncture (spinal) headache. Typically, children will not be fearful of staff nor will the child be up ambulating until later. The procedure should not need to be repeated in 24 hours.

The nursing instructor is discussing congenital heart disease with a group of students. Which statement indicates that students need further teaching? "Oxygenated blood goes out to the body through the aorta." "Blood returns to the heart from the inferior vena cava." "The ductus arteriosus carries deoxygenated blood from the aorta to the pulmonary artery during fetal life." "The foramen ovale allows blood to pass from the right atrium to the left atrium during fetal life."

The ductus arteriosus carries deoxygenated blood from the aorta to the pulmonary artery during fetal life." Explanation: The students need additional teaching if they report that the ductus arteriosus takes deoxygenated blood from the aorta to the pulmonary artery during fetal life. The ductus arteriosus carries oxygenated blood from the pulmonary artery to the aorta during fetal life. Blood returns to the heart from the inferior vena cava, and oxygenated blood travels to the body through the aorta

An infant is born with an omphalocele. Which explanation by the nurse is the best description of the feeding plan for the infant? The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool. The infant will be NPO and given a pacifier to stimulate the sucking reflex. The infant will receive a continuous enteral feeding to maintain bowel activity. The infant will be fed breast milk because it is easier to digest and obtains protective properties.

The infant will be fed by TPN to supply nutrients and keep the bowel from filling with air or stool. Explanation: The infant is fed by TPN, and no enteral feedings are given, to prevent the bowel from filling with air and stool. Pacifiers are not given because they distend the bowel with air, which makes the surgical repair more difficult.

An 82-year-old resident of a long-term care facility often tells stories of the role that he played in the Korean War. According to Erikson, which of the following needs may underlie the resident's storytelling? The need to show that his life was characterized by moral integrity. The need to show that others were dependent on him in earlier stages of life. The need to demonstrate that he was capable of physical aggression in earlier adulthood. The need to demonstrate that his life was meaningful and purposeful.

The need to demonstrate that his life was meaningful and purposeful. Explanation: Erikson's final developmental stage is ego integrity versus despair, in which older adults reminisce to identify fulfillment and purpose in the lives they have lived. Morality, aggression, and independence may be components of this, but these concepts are superseded by the importance of the larger considerations of fulfillment and purpose.

The nurse is most correct to assess for transient tachypnea of the newborn (TTN) in which neonate? The neonate delivered by cesarean section The neonate born at 41 weeks' gestation The neonate whose mother received limited prenatal care The large-for-gestational-age neonate

The neonate delivered by cesarean section Explanation: While every neonate has the respiratory system assessed, some are at higher risk of complications than others. The neonate born via cesarean section is at highest risk for TTN since this infant did not have the opportunity of having fluid expressed from the lungs as he/she descended down the birth canal. The other options are not in the high-risk category.

The nurse is mentoring a new graduate in the newborn nursery. Which statement regarding a neonate with hypospadias would require the mentoring nurse to clarify? The neonate is voiding without difficulty. The neonate will be scheduled for surgery in a few months. The neonate is in regular newborn diapers. The neonate will be circumcised before discharge.

The neonate will be circumcised before discharge. Explanation: Male neonates with hypospadias will not be circumcised right away, as the foreskin is used for repair of the hypospadias. All other statements are correct.

The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority? The neonate will urinate 2 to 3 ml/kg/hour The neonate will be free from infection. The neonate will exhibit signs of bonding with parents. The neonate will not cry during diapering.

The neonate will be free from infection. Explanation: The highest priority goal is that the neonate will be free from infection. This neonate has open mucosa of the bladder. In addition, the neonate's urinary tract is developed and leads to the bladder and then the kidneys. Nursing intervention must include frequent vital signs; inspection of the site; observation for drainage, color and clarity of urine in diaper; and frequent urinalysis as ordered until surgical correction. Bonding is always a goal when caring for a neonate and family. Having an adequate urine output is an appropriate goal. Due to the sensitive nature of the mucosa, it is imp

The nurse is caring for a neonate with an exstrophy of the bladder. When the nurse is planning care, which client goal is the priority? The neonate will urinate 2 to 3 ml/kg/hour The neonate will not cry during diapering. The neonate will be free from infection. The neonate will exhibit signs of bonding with parents.

The neonate will be free from infection. Explanation: The highest priority goal is that the neonate will be free from infection. This neonate has open mucosa of the bladder. In addition, the neonate's urinary tract is developed and leads to the bladder and then the kidneys. Nursing intervention must include frequent vital signs; inspection of the site; observation for drainage, color and clarity of urine in diaper; and frequent urinalysis as ordered until surgical correction. Bonding is always a goal when caring for a neonate and family. Having an adequate urine output is an appropriate goal. Due to the sensitive nature of the mucosa, it is important for the neonate to not experience discomfort, particularly when the area is being cleansed.

The nurse has assisted the provider in performing a spinal tap on a 6-month-old infant. Which of the following should the nurse include in documenting the procedure? The nurse documents how the contaminated linen was disposed of. The nurse documents the child's response to the procedure. The nurse documents any questions the caregiver asks. The nurse documents the method used to clean the equipment and procedure room.

The nurse documents the child's response to the procedure. Explanation: Documentation includes the procedure, the child's response, and the description and characteristics of any specimen obtained.

The nurse is preparing a 7-year-old child for surgery. Which nursing action is the highest priority? The nurse should share with the child the way pain will be managed. The nurse should follow the facility's policies. The nurse should explain the child's prognosis to him or her. The nurse should discuss the benefits of the surgery with the caregivers.

The nurse should follow the facility's policies. Explanation: It is important to follow the facility's policies to ensure that legal requirements and safety precautions are met. Explaining the prognosis or risks and benefits of surgery is not normally the role of the nurse. The child does not likely need teaching about the detailed approach to pain management postoperatively.

The nurse is caring for a hospitalized 8-year-old child whose parents have been divorced. Which of the following is most important for the nurse to do for this child? The nurse should respect the child's wishes regarding the parents visiting. The nurse should introduce the child to other children from divorced families. The nurse should have clear information about who may contact the child. The nurse should interpret the child's feelings.

The nurse should have clear information about who may contact the child. Explanation: When a child of a divorce is hospitalized, be certain to have clear information about who is the custodial parent, as well as who may visit or otherwise contact the child. The custodial parent's instructions and wishes should be honored.

A nurse is caring for a hospitalized child with divorced parents. What intervention is important for the nurse to provide when caring for this child? The nurse should ask the child which parent is responsible for the child. The nurse should be sure to allow the same access to both parents. It is not the nurse's responsibility to worry about the guidelines of custody agreements. The nurse should have clear information about who the custodial parent is and adhere to his or her wishes.

The nurse should have clear information about who the custodial parent is and adhere to his or her wishes. Explanation: When a child of a divorce is hospitalized, the nurse should be certain to have clear information about who is the custodial parent, as well as who may visit or otherwise contact the child. The custodial parent's instructions and wishes should be honored.

The nurse is caring for a preschool aged child following abdominal surgery. Of the following nursing actions, which is the highest priority? The nurse uses pain assessment tools. The nurse encourages caregivers to express concerns. The nurse notes any report of nausea. The nurse documents as frequently as possible

The nurse uses pain assessment tools. Explanation: Pain is a concern of postoperative clients in any age group. Most adult clients can verbally express the pain they feel, so they request relief. However, infants and young children cannot adequately express themselves and need help to tell where or how great the pain is.

A nurse is caring for a child in the emergency department who has had a cast applied for a fractured arm. The nurse is providing information to the parent on cast care and asks the parent if there are further questions about the cast. The parent stares at the nurse and shrugs. What might this indicate to the nurse? The parent does not care about the cast care. The parent probably already knows how to care for the cast and just wants to go home. The parent does not want to take the child home. The parent may have a further concern and does not know how to express it.

The parent may have a further concern and does not know how to express it. Explanation: The chief complaint might not relate to the real reason the parent has brought the child to the health care facility. The nurse should create a trusting atmosphere that allows parents to be open about all concerns and ask facilitating questions.

When caring for parents whose neonate is newly diagnosed with a congenital disorder, which parents would be referred to pediatric hospice services? The parent with a neonate diagnosed with hydrocephalus The parent with a neonate diagnosed with spina bifida occulta The parent with a neonate diagnosed with Down syndrome The parent with a neonate diagnosed with maple syrup urine disease

The parent with a neonate diagnosed with maple syrup urine disease Explanation: The parent with a neonate diagnosed with maple syrup urine disease (MSUD) would be referred to pediatric hospice services due to the prognosis of the disease. The disease is rapidly progressive and often fatal. The parents with a neonate diagnosed with Down syndrome and hydrocephalus will grieve the loss of the perfect child. The nurse must provide much education and support throughout the child's life. Most neonates with spina bifida occulta are asymptomatic. Instruction is needed for understanding the disease process.

The nurse is providing instruction to the parents of a neonate following ventriculoperitoneal shunting (VP shunt) related to hydrocephalus. For which parent action would the nurse provide additional teaching? The parents hold the neonate's hand while she/he is sleeping. The parents carefully support the head and neck when moving. The parents lay the neonate in an elevated infant seat. The parents play with the neonate using rattles and bright objects.

The parents lay the neonate in an elevated infant seat. Explanation: Postoperatively, the neonate is to be kept flat to prevent a rapid decrease in intracranial pressure. Touch is important to the neonate and holding the child's hand and playing promotes bonding. Supporting the neonate's head and neck are appropriate.

The nurse is reinforcing discharge teaching with the mother of an infant who is being discharged prior to having a required blood test done. The nurse explains to this mother that she needs to bring the newborn back to check the infant's phenylalanine level. Which statement is most accurately related to this blood test? The test is done after the newborn has ingested protein. If the test is not done the newborn could be intellectually disabled. It is common to perform this test after the newborn is 5 days old. The test is done by drawing blood from the infant's umbilical cord.

The test is done after the newborn has ingested protein. Explanation: As soon as the newborn with phenylketonuria begins to take milk, phenylalanine builds up in the blood serum to as much as 20 times the normal level. This build-up occurs so quickly that increased levels of phenylalanine appear in the blood after only 1 or 2 days of ingestion of milk.

A nurse is preparing to insert a feeding tube into a child and lubricates the tube with water or a water-soluble jelly first. Why does the nurse avoid the use of an oil-based lubricant? Oil costs more for the client. There is a danger of oil aspiration into the lungs. Oil does not lubricate as well. Oil is too messy.

There is a danger of oil aspiration into the lungs. Explanation: When inserting a gavage feeding tube, the nurse lubricates the end of the tube to be inserted with sterile water or water-soluble lubricating jelly. Oily substances are never used because of the danger of oil aspiration into the lungs.

The parent of a preschool-age child pours the client's glass of juice into a shorter cup with a lid. The child is watching the parent pour the juice from one container to the other. The preschool-age child would interpret this action as reflecting which concept? The cup is a different shape so the juice is no longer juice. There is less juice in the cup with the lid. The amount of juice did not change, only how it appears. Pouring the juice into the lidded cup changed the juice's flavor.

There is less juice in the cup with the lid. Explanation: The preschool-age child has not developed conservation or the ability to discern truth, even though physical properties change. This is why the child will think that there is less juice in the shorter cup. The preschool-age child will not interpret this action as the juice or its flavor changing. An older child will understand that the appearance of the juice changed but not the amount.

For which client would the nurse question the doctor's orders for a throat culture swab? a school-age child with high fever and enlarged tonsils an adolescent with a suspected strep infection an infant with the diagnosis of "rule out bronchiolitis" and fever a toddler suspected to have epiglottitis

a toddler suspected to have epiglottitis Explanation: Anytime a child is suspected to have epiglottitis, there is never manipulation of the throat because the child can have a throat spasm and airway occlusion. For all the other clients, a throat culture is an appropriate order.

A nurse is presenting a review class for a group of neonatal nurses about congenital conditions in the newborn. The nurse determines that the teaching was effective based on which statement made by the group? "Usually a definitive cause can be identified." "A congenital condition is an anomaly that develops immediately after birth." "These conditions are responsible for nearly half the deaths in term newborns." "Congenital conditions typically affect a specific body system."

These conditions are responsible for nearly half the deaths in term newborns." Explanation: A birth defect is any structural anomaly present at birth. They can be caused by genetic abnormalities or environmental exposures; many have unknown etiologies. Congenital conditions can arise from many etiologies, including single-gene disorders, chromosome aberrations, exposure to teratogens, and many sporadic conditions of unknown cause. Congenital conditions may be inherited or sporadic, isolated or multiple, apparent or hidden, gross or microscopic. They cause nearly half of all deaths in term newborns and cause long-term sequelae for many

The nurse is educating the parents of a neonate with Down syndrome regarding nutrition. Which provides the biggest challenge in feeding the neonate? Decreased gastric motility Thick, fissured tongue Brachycephaly Cognitive ability

Thick, fissured tongue Explanation: When feeding the neonate with Down syndrome, the biggest challenge includes the status of the tongue. In infancy, the child's large tongue and poor muscle control contribute to difficulty with breastfeeding or ingesting formula; this can cause great problems when it comes to beginning table foods. The majority of children with Down syndrome feed themselves. Shortness of the head, brachycephaly, and decreased gastric motility do not impact the ability for feeding

The parent of a 4-year-old child seeks advice from the clinic. The parent states, "My child seems to stutter and does not link sounds together well. My child is able to say the correct thing after a hesitant start." What is the best response by the nurse? "This is a normal component of language development for preschoolers." "We recommend you have the child interact with more children of the same age." "We will have your child referred to a speech therapist for specific intervention." "Be aware of how often you hesitate when reading books to your child."

This is a normal component of language development for preschoolers." Explanation: Broken fluency, or the hesitation and repeating of words (often considered as stuttering by parents) is normal for preschoolers as their language skills grow and develop. Reading books is recommended to model language consistency. A therapy evaluation may be needed if the concern continues beyond the preschool years. Interacting with similar-aged children will not remedy the concern because they are likely in the same stage of language development.

The parents of a 2-year-old ask the nurse the purpose of administering the Denver II Developmental Screening Test and the Revised Prescreening Development Questionnaire (R-PDQ). Which response should the nurse give the parents? The testing will indicate difficulties with intellectual abilities. This is a screening to assess overall development. The testing detects early language developmental delays. This is developmental surveillance for suspected growth delays.

This is a screening to assess overall development. Explanation: The Denver II test and the Revised Prescreening Development Questionnaire (R-PDQ) are among the most common developmental screening tests. The Denver II test provides an overall assessment of development that can be administered in a 15-to-20-minute period by individuals who have received training in the test administration and interpretation. The tests evaluate a child's development and constitute a major approach to identification of children with developmental problems. The tests assess normal achievements or specific tasks for a particular age. They are given to all children, not just to children with suspected growth delays for early detection and intervention. The tests do not predict intellectual abilities. The tests evaluate not just language development but tasks and skill achievements for a certain age. The healthcare practitioner employs developmental surveillance to identify at-risk children

A toddler has entered the phallic stage as described by Freud. What teaching does the nurse provide to parents about this phase? "This is a stage where your child should be having dry diapers at night." "This is a stage when potty training starts." "This is a stage where your child knows the differences between boys and girls." "This is a stage when your child asks questions about sex."

This is a stage when potty training starts." Explanation: The major developmental task of toddlers during the phallic stage according to Freud is potty training. It is not associated with being dry during the night. Knowing the differences between boys and girls occurs between the ages of 3 and 6 years, which is when children have a fascination with their genitalia. They learn to ask questions about sex, such as where babies come from.

The nurse observes a mother telling a toddler that pasta and potatoes will make the child fat. What should the nurse instruct the mother about these food items? No more than 30% of all food should be from carbohydrate sources. The child should be instructed to restrict carbohydrates after the age of 5 years. Toddlers need carbohydrates for brain function. It is more important to restrict protein than carbohydrates.

Toddlers need carbohydrates for brain function. Explanation: Carbohydrates are the main and preferred fuel of the body to supply energy and are essential to the functioning of body systems, the neurologic system in particular. This makes carbohydrates important to toddlers because their brain cells are actively growing. Protein should not be restricted in the toddler. Carbohydrates should not be restricted to 30% or after the age of 5 years.

Which congenital condition is an immediate emergency requiring notification of the health care provider? Hypospadias Tracheoesophageal fistula Atrial septal defect Cleft palate

Tracheoesophageal fistula Explanation: The congenital condition which is a medical emergency is a tracheoesophageal fistula. This condition can lead to respiratory distress and pneumonitis. Hypospadias is the urethra opening terminating on the ventral surface of the penis, instead of the tip. Cleft palate is the opening in the roof of the mouth. An atrial septal defect is an opening between the right and left atrial. Hypospadias, cleft palate, and an atrial septal defect may be surgically repaired but are not immediate emergencies.

A child has been admitted to the pediatric unit with diarrhea. The nurse must collect a stool specimen for ova and parasites. The nurse knows that the proper procedure must be followed for detection of the ova and parasites. The proper procedure includes: Only use stool from a bed pan. Use tongue blades to separate the stool from urine. Transport the stool specimen to the laboratory promptly. Refrigerate the specimen until it can be taken to the laboratory. Place the stool specimen in a sterile container.

Transport the stool specimen to the laboratory promptly. Explanation: The stool specimen must go to the laboratory immediately so that it does not have to be redone. Refrigeration destroys ova and parasites. Urine should not be in contact with the stool, and the stool needs to be in a clean container. Stools are collected from diapers as well as bed pans.

The nurse is caring for a 4-month-old infant who is running a fever. The mother questions what can be done to get the child's temperature down. Which methods are acceptable to manage fever in an infant? Select all that apply. Place the infant in a cool bath. Use acetaminophen or other antipyretics. Encourage the infant to drink fluids. Prevent overdressing the infant. Use a hypothermic blanket.

Use a hypothermic blanket. Encourage the infant to drink fluids. Use acetaminophen or other antipyretics. Prevent overdressing the infant. Explanation: Infants should not be placed in a cool bath to lower body temperature. The nurse should recommend giving antipyretics and fluids, using a hypothermic blanket if necessary, and avoiding overdressing.

The nurse notes that parents accompanying their child for a procedure appear tense and nervous. What intervention by the nurse will best assist the young child to relax? Distract the child with rhymes and songs. Use measures to reduce the parents' anxiety. Take the child's security object (teddy, blanket) to the procedure. Repeat the earlier explanation of the procedure.

Use measures to reduce the parents' anxiety. Explanation: Reducing the parents' anxiety will also reduce the child's anxiety. Anxious parents transmit their anxiety to the child and are less effective in providing support. The other nursing interventions are helpful, but relaxed parents are the key.

A nurse working in the emergency department (ED) is caring for a newborn brought to the ED for increased respiratory rate and subcostal retractions. The nurse performs an assessment on the newborn. Findings include: awake, alert, periods of irritability, subcostal retractions that increase when crying, cardiac murmur auscultated. Vital signs: temperature 97.8°F (36.5°C); heart rate, 180 beats/min; blood pressures: left arm, 68/43 mm Hg; right arm, 67/40 mm Hg; left leg, 73/38 mm Hg; right leg, 75/40 mm Hg; respiratory rate, 62 breaths/min; oxygen saturation, 93% on room air. Complete the following sentence(s) by choosing from the lists of options. The nurse suspects the client is exhibiting signs of? Heart Failure Hypotension Ventricular Septal Defect (VSD) As evidence by? Blood Pressure Irritability Heart Rate And? Decreased Oxygen Saturation Subcostal Retractions Respiratory Rate

Ventricular Septal Defect (VSD) Blood Pressure Decreased Oxygen Saturation Explanation: The client is exhibiting signs and symptoms of ventricular septal defect (VSD), as evidenced by the client's increased blood pressure and low oxygen saturation levels. VSD causes an increase in blood pressure. In VSD, there is a shift from the left-to-right shunt. The blood mixes with deoxygenated blood, causing a decrease in oxygen-carrying capacity. Hypertension occurs in VSD, not hypotension. Heart failure may occur as a result of VSD due to decreased cardiac output. Irritability is most likely caused by decreased oxygen saturation levels. The brain does not store oxygen. Confusion and irritability are the first signs of hypoxemia. The newborn's heart rate of 180 beats/min is higher than normal limits for the age group, which is 100 to 150 beats/min. This finding is not specific to VSD. Subcostal retractions indicate the newborn is experiencing some respiratory distress, but this finding is not specific to VSD. The newborn's respiratory rate of 62 breaths/min is higher than normal limits for the age group, which is 30 to 50 breaths/min, indicating some respiratory distress. This finding is not specific to VSD.

The nurse is administering a prescribed bolus gavage feeding. Which action would be incorrect in performing this procedure? Elevate the child's head and shoulders during the feeding. Verify placement by auscultating for sounds in the stomach when air is inserted. Flush the tube with water following the feeding and place child on the right side. Aspirate, measure, and return residual stomach contents.

Verify placement by auscultating for sounds in the stomach when air is inserted. Explanation: Auscultating for sounds when air is injected into the stomach is no longer considered recommended for verifying tube placement because it has been found unreliable as a confirmation of position.

Which safety and legal responsibilities does the nurse need to maintain when performing or assisting with procedures on children? Select all that apply. Utilize the electronic health record to verify the prescription for the procedure. Coordinate and collaborate with other health care providers to ensure the safety and efficacy of all procedures. Assess a child's response to the procedure. Verify that an informed consent is obtained, as needed. Document the outcome of the procedure and the child's reaction to the procedure. Explain the procedure to the child and parents to ensure both are well informed.

Verify that an informed consent is obtained, as needed. Utilize the electronic health record to verify the prescription for the procedure. Explain the procedure to the child and parents to ensure both are well informed. Coordinate and collaborate with other health care providers to ensure the safety and efficacy of all procedures. Assess a child's response to the procedure. Document the outcome of the procedure and the child's reaction to the procedure. Explanation: When performing or assisting with procedures on children, the nurse must maintain safety and legal responsibilities for care. The nurse should perform the following actions: verify that an informed consent is obtained, as needed utilize the electronic health record to verify the prescription for the procedure explain the procedure to the child and parents to ensure both are well informed schedule the procedure prepare the child physically and psychologically obtain necessary equipment for the procedure accompany the child to a treatment room or hospital department where the procedure will be performed coordinate and collaborate with other health care providers to ensure the safety and efficacy of all procedures provide support during the procedure, using the least amount of restraint possible ensure adherence to standard infection precautions assess a child's response to the procedure provide care to a child and specimens obtained once the procedure is completed document the outcome of the procedure and the child's reaction to the procedure

A 10-year-old is scheduled for an appendectomy in 6 hours. The child is placed on NPO status and wants to know why he cannot have anything to eat or drink. What is the best explanation by the nurse? "The surgeon ordered you to be NPO and we have to abide by that rule." "We cannot give you anything to eat or drink before your procedure because we do not want you to get an upset stomach." "Having surgery is a serious matter and we do not want you to have any complications from taking anything by mouth." "We cannot give you anything to eat or drink because you could vomit during the procedure and aspirate."

We cannot give you anything to eat or drink before your procedure because we do not want you to get an upset stomach." Explanation: Children may better understand why they are NPO if they are told that food and drink are being withheld to prevent an upset stomach.

The nurse is discussing the latchkey child with a group of working caregivers. Which of the following statements made by the caregivers indicates an understanding of an important responsibility of the caregiver of the latchkey child? "We have a list of phone numbers of our family and neighbor by the phone." "Since our daughter is 3 years older than our son, she has permission to correct any inappropriate behavior of our son." "My son wears the house key on a special chain around his neck." "I have a pretty consistent schedule but I tell my child not to worry if I am running late, that I will be home as soon as I can."

We have a list of phone numbers of our family and neighbor by the phone." Explanation: A list of emergency phone numbers and backup for the child if he or she needs help is the responsibility of the caregiver. The child needs to know that an adult is available to them if a situation were to arise that causes fear or uncertainty.

A nurse is providing teaching to a group of parents and their children about nutrition. The parents have children ranging in age from 2 to 5 years. The nurse determines that the teaching was successful based on which statement(s)? Select all that apply. "Two servings or about 2 cups of dairy is what our children need each day." "Our children need about 8 to 10 servings or about 10 ounces of grain foods each day." "They need 3 servings or cups of yellow vegetables but 5 servings or cups of green ones daily." "We should make sure we give our children 2 servings or about 5 ounces of protein daily." "Our kids should have about 2 servings or about 2 cups of fruit each day."

We should make sure we give our children 2 servings or about 5 ounces of protein daily." "Our kids should have about 2 servings or about 2 cups of fruit each day." "Two servings or about 2 cups of dairy is what our children need each day." Explanation: Children between the ages of 2 and 6 need about 6 servings of grains (which is about 3 to 6 ounces), 1 to 2 cups of vegetables (yellow and green), 1 to 2 cups or about 2 servings of fruit, 2 cups or servings of dairy, and 2 to 5 1/2 ounces (or about 2 servings) of protein each day

While assisting a registered nurse (RN) in the admission of a child to the pediatric unit, the licensed practical nurse (LPN) hears the RN state the following statements about the unit. Which statement will the LPN ask the RN to clarify? "We encourage your caregivers to visit as much as they can." "We try to assign different nurses each shift so you get to know everyone." "We will involve your caregivers in as much of your care as we can." "We do our best to include foods you like on each meal tray."

We try to assign different nurses each shift so you get to know everyone." Explanation: The LPN will seek clarification of assigning different nurses each shift. It is best to make nursing assignments so that the same nurse is with the child as much as possible. This approach provides the opportunity to establish a trusting relationship with the child. Caregivers should be included in care. This helps promote an understanding of care that may continue following discharge and provides continued routine from home for the child. Caregivers should also be encouraged to visit as much as possible, possibly even "rooming-in" with the child at night. Meals should include the child's favorite foods if at all possible. Foods following the child's prescribed diet may also be brought from home.

A nurse is teaching the parents of a preschool-aged child how to collect a stool specimen at home for ova and parasites? The nurse determines that the teaching was successful based on which statement? "We need to put the specimen in the freezer once we collect it." "We will throw out the specimen if the color isn't yellow or green." "We will take the specimen to the laboratory immediately." "We need to add alcohol to the specimen container before collecting the stool."

We will take the specimen to the laboratory immediately." Explanation: If a stool specimen is for ova and parasites, do not refrigerate it because refrigeration destroys the organisms to be analyzed. The specimen needs to arrive in the laboratory in less than 1 hour after collection so the parasites can be readily detected. Alcohol should not be added to the specimen container. The color of the stool sample is of no consequence.

A pediatric nurse wants to determine an accurate amount of urine output for a diapered baby. Which is the most effective method? Count the number of wet diapers during the shift. Apply a urine collection device inside the diaper and measure urine output. It is impossible to get an accurate measurement of urine output in a diaper. Weigh a diaper before use and mark with weight, then weigh after and subtract the weight of the diaper.

Weigh a diaper before use and mark with weight, then weigh after and subtract the weight of the diaper. Explanation: Diapers can be readily used as a method of measuring urine output. Weigh a diaper before it is placed on an infant and record this weight conspicuously (e.g., mark it on the front of the plastic covering with a ballpoint pen). Reweigh the diaper after it is wet and subtract the difference to determine the amount of urine present. This difference will be in grams, but because 1 g = 1 ml, the amount can be recorded in milliliters. This is the most accurate measure of output for an infant. This knowledge makes the answer that measuring output is impossible an incorrect answer. For just everyday intake and output, counting the number of wet diapers is adequate. Using a urine collection device is not always accurate because many times urine leaks around the bag.

How will the nurse measure urine output in the hospitalized toddler who is partially potty trained? Apply a self-adhesive urine bag to the perineum. Weigh the wet pull-up or diaper and subtract the weight of a dry diaper. Obtain a potty for the child and measure urine. Don gloves and press urine from training pants or diaper and measure.

Weigh the wet pull-up or diaper and subtract the weight of a dry diaper. Explanation: A toddler who is partially potty trained is likely to regress during the stress of hospitalization and need diapering. Subtracting dry weight in grams from wet weight reveals the number of milliliters of urine excreted. The other output measurement methods will not be accurate.

While the nurse is admitting a 5-year-old client, the caregiver asks, "What can I do to make my child feel secure? This is our first hospitalization." Which nursing response is best? "Bring your child's favorite toy from home to play with." "It is clear you love your child, so I do not think you need to worry." "You staying with your child will provide the most security." "We can discuss your concerns after I finish admitting your child."

You staying with your child will provide the most security." Explanation: The nurse would recommend the caregiver stay with the child. Rooming-in minimizes the hospitalized child's separation anxiety and fears. One of the biggest advantages of rooming-in is the measure of security the child feels. Telling the caregiver to bring the child's favorite toy is okay; however, this does not address the concern of security. Stating "not to worry" and not addressing the caregiver's concerns at this time are not appropriate forms of therapeutic communication from the nurse. There is no indication the child is unstable, so the nurse could stop long enough to speak to the caregiver.

An older infant is scheduled to have a cleft palate repair. The mother asks if she will still be able to breastfeed the baby during the postoperative phase. What is the best response by the nurse? "No, you will have to put the baby on regular formula." "Yes, you will be able to breastfeed but will have to interrupt the feedings frequently." "Yes, the surgery will not interfere with breastfeeding your child." "You will not be able to breastfeed immediately after, but you can pump and feed the child with a cup."

You will not be able to breastfeed immediately after, but you can pump and feed the child with a cup." Explanation: For an infant who has had a palate repair, no nipples, spoons, or straws are permitted; only a drinking glass or a cup is recommended. A favorite cup from home may be reassuring to the older infant.

The nurse is working with a 4-year-old child whose parent has a terminal illness. The parents ask for advice about how to tell the child about the illness. Which response does the nurse tell the parent to anticipate based on this child's stage of development? Your child will worry about what classmates will say or think. Your child will feel responsible for the parent's illness. Your child will be unable to understand that death is permanent. Your child will not be able to conceptualize illness or death.

Your child will feel responsible for the parent's illness. Explanation: 4-year-old children are in Piaget's preoperational stage of cognitive development and often have magical thinking that can lead to feeling responsible for the parent's illness and death. Worrying about classmates is more common in older children who are influenced by peer acceptance. An inability to understand the permanence of death and conceptualizing illness and death are typical of younger children.

The pediatric nurse is caring for a child who is recovering after abdominal surgery several days ago. After the child's sutures are removed, the child asks the nurse, "Will my insides fall out now?" How should the nurse respond? "What makes you say that?" "Your insides will not fall out and it is not something you need to worry about." "What do you mean by 'insides'?" "Your insides are healed and the cut you see on the outside is not what it looks like inside."

Your insides are healed and the cut you see on the outside is not what it looks like inside." Explanation: Children are often fearful that their insides will "fall out" when sutures are removed. The nurse should ease the child's fears and tell him or her that the wound has healed from the inside and that the child's insides will not fall out. The remaining answer choices do not address the child's fear.

Which client does the nurse understand would be the best candidate for patient-controlled analgesia (PCA)? a 7-year-old who understands that when the button is pushed he will get medication to help relieve pain a cognitively impaired 12-year-old with severe pain from an automobile accident an 8-year-old with multiple trauma wounds, a head injury, and disorientation a 4-year-old with burns to the left lower leg and whose parent is staying with her

a 7-year-old who understands that when the button is pushed he will get medication to help relieve pain Explanation: Patient-controlled analgesia may be used with children 7 years or older who have no cognitive impairment and undergo a careful evaluation.

The nurse is caring for an infant diagnosed with a ventricular septal defect. Which assessment findings does the nurse anticipate? slow weight gain a harsh murmur fatigue cyanosis

a harsh murmur Explanation: The infant diagnosed with a ventricular septal defect exhibits a characteristic loud, harsh murmur. Otherwise, the child may be asymptomatic. There is no cyanosis as blood does not shunt to the left due to pressure gradients. Normal activity and growth and development are anticipated.

Which nurse is most likely to care for clients who are trying to resolve identity versus role confusion? a nurse who works in long-term care facility a pediatric nurse an occupational health nurse based at a lumber mill a nurse who provides care in a large junior high school

a nurse who provides care in a large junior high school Explanation: According to Erikson, the crisis of identity versus role confusion is characteristic of adolescence. Consequently, a nurse who provides care in a junior high school is likely to see frequent manifestations of this crisis. Early childhood, middle adulthood, and late adulthood are not typical life stages for the resolution of this crisis.

In the infant diagnosed with spina bifida with myelomeningocele, the infant will likely have: a protruding sac that contains abdominal contents. a partial to complete paralysis in the lower extremities. an extremely large and rapidly growing head. a membrane between the rectum and the anus.

a partial to complete paralysis in the lower extremities. Explanation: In spina bifida with myelomeningocele, there is a protrusion of the spinal cord and the meninges, with nerve roots embedded in the wall of the cyst. The effects of this defect vary in severity from sensory loss/partial paralysis below the lesion to complete flaccid paralysis of all muscles below the lesion.

During the newborn examination, the nurse would suspect spina bifida occulta if what finding is present? Select all that apply. continuous dribbling of urine abnormal tufts of hair at the base of spine discolored skin at the base of spine a dimpling at the base of spine head circumference above the 90th percentile

abnormal tufts of hair at the base of spine discolored skin at the base of spine a dimpling at the base of spine Explanation: Spina bifida occulta may be first noticed as a dimpling at the point of poor fusion; abnormal tufts of hair or discolored skin may also be present. Hydrocephalus or enlarged head circumference is found with meningomyelocele. Continuous dribbling of urine is found with meningomyelocele due to loss of bladder function.

While teaching parents how to effectively reduce the child's fever, the nurse should emphasize avoiding which intervention? acetaminophen acetylsalicylic acid dressing the child in lightweight clothing placing a cool cloth on the forehead

acetylsalicylic acid Explanation: Caution parents to never give acetylsalicylic acid (aspirin) to children with fever because aspirin is associated with Reye syndrome, a severe neurologic disorder. Acetaminophen is safe for children, and cool cloths and dressing lightly will help reduce fever.

What genetic and environmental factors influence the growth and development of children? Select all that apply. DNA transcription adaptability activity level rhythmicity temperament

adaptability activity level rhythmicity temperament Explanation: All factors except DNA transcription affect growth and development. These factors include: temperament or reaction pattern of the individual, adaptability or ability to change one's reaction to stimuli over time, activity level, and rhythmicity or predictable regular pattern individuals.

A nurse is teaching an unlicensed assistive personnel (UAP) about giving enemas on a pediatric unit. Which situation would indicate the UAP understood the teaching? helps a parent give a 10-year-old a tap water enema administers a normal saline enema to a 5-year-old gives a Fleet enema to an 18-month-old provides a soapsuds enema to an 8-year-old

administers a normal saline enema to a 5-year-old Explanation: Commercial enemas, such as Fleet enemas, are not routinely administered to children younger than 2 years of age because of the harsh action of the sodium biphosphate and sodium phosphate they contain. Tap water is not used either because, as it is not isotonic, it causes a rapid shift of fluid in body compartments, possibly leading to water intoxication. Although a solution of milk and molasses may be used in an emergency department to relieve a fecal impaction, normal saline (0.9% sodium chloride) is the usual solution used. Soapsuds enemas are not used because they are too harsh for children's intestines.

The nurse is caring for a pediatric client with a complex medical diagnosis. During which stage of development will the client begin to understand the diagnosis or "what if" relational questions? adolescence young adulthood school-age period preschool period

adolescence Explanation: Scientific thought (the ability to think in abstract terms) is learned at adolescence and continues through adulthood.

A seasoned pediatric nurse realizes that a hospitalized child's need for identity is strongest in which of the following groups? adolescents infants toddlers school-aged children

adolescents Explanation: The adolescent develops a sense of being an independent person with unique ideals and goals and may feel that parents, caregivers, and other adults refuse to grant that independence. They are struggling to find an identity, and nurses should help to foster this identity.

Health care providers follow transmission-based precautions when caring for children with documented pathogens or children suspected of having highly transmissible pathogens. Which of the following are included in transmission-based precautions? contact precautions droplet precautions airborne precautions protective precautions

airborne precautions droplet precautions contact precautions Explanation: For clients documented or suspected of having highly transmissible pathogens, health care providers must follow transmission-based precautions. These precautions are in addition to the standard precautions. Transmission-based precautions include three types: airborne precautions, droplet precautions, and contact precautions.

When the nurse examines a toddler, she suggests to his mother that the activity that could most appropriately foster his developmental task according to Erikson would be to: feed him his lunch. allow him to pull a talking-duck toy. have him watch a puppet show on television. read him a story every night.

allow him to pull a talking-duck toy. Explanation: Toddlers need experiences with toys that they can manipulate to stimulate a sense of autonomy.

A mother is scheduled for rooming-in with her infant prior to discharge from the hospital. The nurse realizes that rooming-in is done for what purpose? to allow the infant to bond with the parent reduce the cost of the hospital stay since rates for rooming-in are less allow the caregiver to practice treatments and procedures that will be necessary once the infant is home take overall care of the infant in the hospital

allow the caregiver to practice treatments and procedures that will be necessary once the infant is home Explanation: Rooming-in allows parents and caregivers the opportunity, under nursing supervision and guidance, to provide care and perform treatments that will be necessary after discharge. There is no reduction of cost for rooming-in. The caregivers do not take over care of the child and the infant is already bonded to the parent.

The pediatric nurse would use standard precautions in caring for which client on her floor? a toddler with chickenpox an adolescent who has a broken arm a child who is diagnosed with pertussis an infant with diarrhea

an adolescent who has a broken arm Explanation: Standard precautions involve avoidance of handling blood or body fluids from a client and involve use of personal protective equipment (PPE). In this case, with a fracture, there is minimal risk of exposure to body fluids so the nurse would wear gloves only. The other three clients would be in transmission-based precautions: airborne precautions for the toddler with chickenpox; contact precaution for the infant with diarrhea, or droplet precautions for the child with pertussis.

The nurse is preparing an infant with a myelomeningocele for surgery. Which environment does the nurse select to best meet the infant's needs? swaddled in an open crib skin-to-skin (kangaroo) care with parent an incubator a radiant warmer

an incubator Explanation: An incubator is the best environment because it provides warmth and good visualization of the lesion. A radiant warmer can dry the lesion, resulting in cracking and leaking of fluid. An open crib does not provide warmth, and the lesion should not be covered by blankets. Placing the infant skin-to-skin with the parent risks damage to the membrane covering the lesion and limits visualization of the lesion.

According to Sigmund Freud's theory of development, which infant is most likely to be experiencing a significant conflict in his or her development? an infant who is in daycare 3 mornings per week a baby boy who is being raised by a single mother and who has minimal contact with adult males an infant whose mother is weaning him in order to facilitate her return to work a baby whose impoverished mother is unable to afford nutritious food

an infant whose mother is weaning him in order to facilitate her return to work Explanation: Freud's theory of development characterizes the stage from birth through 18 months as the oral stage. Consequently, the changes in sucking behavior that accompany weaning are a major conflict. This event is considered to be more developmentally significant than contact with the opposite sex, temporary separation from the mother, or deficits in nutrition.

A hospitalized 2-year-old is toilet training and excited to show the nurse the product created in the toilet. What stage does the nurse recognize this child is in according to Freud? oral stage Oedipal stage anal stage phallic stage

anal stage Explanation: The anal stage is the child's first encounter with the serious need to learn self-control and take responsibility. The child has pride in the product created. Cleanliness and this natural pride do not always go together, so it may be necessary to help direct this pride and interest into more acceptable behaviors

The practical nurse is assisting the registered nurse with a neonate following ventriculoperitoneal shunting (VP shunt) related to hydrocephalus. Which assessment findings are communicated with the registered nurse immediately? Select all that apply. incision site slightly pink; no drainage heart rate 116 beats/min temperature of 100.7ºF (38.2ºC) neonate alert, pleasant head circumference decreased postoperatively anterior fontanels (fontanelles) noted as raised

anterior fontanels (fontanelles) noted as raised temperature of 100.7ºF (38.2ºC) Explanation: The registered nurse must assess the neonate's condition following surgery. The LPN/LVN provides follow-up care and will notify the RN immediately if signs of infection or increased intracranial pressure are noted. An elevated temperature is noted as is a raised fontanel (fontanelle). Though not bulging, the LPN/LVN would refer to the RN and note past documentation. A decreased head circumference; heart rate of 116 beats/min; incision slightly pink with no drainage; and an alert, pleasant neonate are normal assessment findings for this stage of recovery.

Preventing injuries in children is a nursing responsibility accomplished through which of the following? keeping children restricted and confined locking medicine cabinets until the child is 3-years-old prevent running, jumping, and climbing anticipatory guidance education

anticipatory guidance education Explanation: Anticipatory guidance is giving instructions to keep children safe and promote growth and development. Medicine cabinets need to be locked even past 3 years of age. Running, jumping, and climbing are normal behaviors of children.

The following assessments are gathered from an 8-year-old pediatric client returning from surgery. Which information would need to be reported to the physician promptly? anuria for 7 hours axillary temperature of 99°F (37.2°C) heart rate of 82 pain rating of 4

anuria for 7 hours Explanation: Lack of urinary output for more than 6 hours needs to be reported to the physician because inadequate urinary output may indicate urinary retention, dehydration, or inadequate blood flow to the kidneys. All other data are within normal limits.

All humans learn from both formal and informal experiences. What orderly pattern of changes results in part from learning? maturity growth aging development

development Explanation: Development is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation experiences and learning. It is a dynamic and continuous process as one proceeds through life, characterized by a series of ascents, plateaus, and declines. Growth is an increase in body size or changes in body cell structure, function, and complexity.

A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following? It is not necessary to check each time. aspirating stomach contents and checking pH x-ray inserting air into the tube and listening for sounds in the stomach

aspirating stomach contents and checking pH Explanation: Confirmation of placement by radiologic examination is the most accurate method of verifying placement and position of a feeding tube. Because of the risks of repeated radiation exposure, however, this procedure cannot be used before each feeding. The nurse should verify placement of the tube by aspirating stomach contents and checking the pH. Verifying position by inserting air into the feeding tube and listening for sounds in the stomach is now considered an unreliable method of checking for tube placement.

The priority for the nurse caring for a newborn with esophageal atresia is to observe for which finding? aspiration constipation vomiting bleeding

aspiration Explanation: In the newborn with esophageal atresia, any mucus or fluid that the newborn swallows enters the blind pouch of the esophagus. This pouch soon fills and overflows, usually resulting in aspiration into the trachea.

A 2-year-old child is in which stage of Erikson's theory of psychosocial development? trust versus mistrust autonomy versus shame and doubt identity versus role confusion initiative versus guilt

autonomy versus shame and doubt Explanation: According to Erikson, during the toddler years the developmental task is to form a sense of autonomy; therefore, the toddler is in the autonomy versus shame and doubt stage.

A 2-year-old child is in which stage of Erikson's theory of psychosocial development? trust versus mistrust identity versus role confusion initiative versus guilt autonomy versus shame and doubt

autonomy versus shame and doubt Explanation: According to Erikson, during the toddler years the developmental task is to form a sense of autonomy; therefore, the toddler is in the autonomy versus shame and doubt stage.

A 2-year-old wants to feed herself and becomes agitated when the nurse attempts to feed her. What does the nurse understand is the developmental age of this child according to Erikson? autonomy vs. doubt and shame initiative vs. guilt industry vs. inferiority trust vs. mistrust

autonomy vs. doubt and shame Explanation: The toddler gains reassurance from self-feeding, crawling, walking alone where it is safe, and being free to handle materials and learn about things in the environment. This phase (autonomy vs. shame and doubt) happens during ages 1 to 3 years.

A pediatric nurse is preparing to use a jacket restraint with a client. After making sure it is the correct size and applying the jacket, the nurse will secure the ties to which of the following? client's wrists side rails client's waist bed frame

bed frame Explanation: Jacket restraints are used to secure the child from climbing out of bed or a chair. Ties must be secured to the bed frame, not the side rails, so that the jacket is not pulled when the side rails are moved up and down.

After inserting a nasogastric tube (NG) into a young child, how will the nurse tape the tube in place? to cheek and behind ear to side of mouth and cheek to nose and forehead below nose and to cheek

below nose and to cheek Explanation: The nurse will tape the tube below the nose and to the side of the cheek to avoid pressure on the naris, as also happens when taping to the forehead is done. Taping to the cheek and behind the ear will not stabilize the tube adequately. It will not be taped to the side of the mouth. A nasogastric tube enters the nose.

The nurse is caring for a hospitalized toddler who is prescribed bedrest. Which item(s) would the nurse recognize as appropriate for the toddler? Select all that apply. boxes to put toys in and/or take out toys coins, small tokens, or marbles to organize and sort nursery rhymes or sing-along songs on tape jigsaw puzzle with pieces 1/2 in (1.25 cm) or smaller fine-print books or magazines to read stacking blocks or small boxes

boxes to put toys in and/or take out toys stacking blocks or small boxes nursery rhymes or sing-along songs on tape Explanation: Hospitalized toddlers on bedrest benefit from toys that can be interacted with and that are age-appropriate. Examples would be stacking boxes, blocks, and sing-along-songs or nursery rhymes. Small piece puzzles, coins, tokens, and marbles are a choking risk for the toddler. Fine-print books and magazines are not age-appropriate and would not be of interest to a toddler.

A newborn infant has been diagnosed with Down syndrome. What assessment finding(s) of the hand and feet does the nurse expect to document on this infant's medical record? Select all that apply. long feet and toes thin fingers broad, short hands wide space between first and second toes transverse palmar crease

broad, short hands wide space between first and second toes transverse palmar crease Explanation: The physical characteristics of the child with Down syndrome determine the medical and nursing management. The infant can have all characteristics of Down syndrome or only a few of the symptoms. It is important for the nurse to conduct a thorough assessment. When assessing the hands, the nurse will see a palmar crease on the hand, the hands would be small and broad and the fingers will be short and stubby. There may also be a curved fifth finger. The feet are short with stubby toes. There would be wide spaces between the first and second toes

Which diagnostic procedure is anticipated prior to heart surgery in an infant with a congenital heart defect? cardiac catheterization magnetic resonance imaging (MRI) a chest x-ray computed tomography (CT) of the chest

cardiac catheterization Explanation: Prior to heart surgery in an infant with a congenital heart defect, the infant may have a cardiac catheterization to obtain more accurate information about the infant's condition. While this is the most invasive procedure, it provides the best information.

A nurse is preparing a teaching plan for the parents of a newborn. When explaining the neurologic development, how should the nurse point out that this occurs? outward-to-inward toe-to-head lateral-to-medial center-to-outside

center-to-outside Explanation: Neurologic development follows a cephalocaudal (head-to-toe) and proximal-distal (center-to-outside) pattern. The other choices are the opposite of what happens.

The child has learned to crawl and walk, and later throws a ball and knows the names of colors. Which principle of growth and development is the child demonstrating? predictable patterns and maturation directional growth and adaptability hereditary determinants cephalocaudal and proximodistal progress

cephalocaudal and proximodistal progress Explanation: Development progresses in a head-to-toe fashion called cephalocaudal, and in a proximodistal, or midline to the periphery, progression. The example illustrates the child developing in this manner. Hereditary determinants specify patterns of growth and organization. Growth does occur in predictable patterns as maturation occurs; however, the example does not demonstrate these terms. Directional growth and adaptability are terms that do not apply to the example.

In the child diagnosed with hydrocephalus, an obstruction occurs that blocks the normal process of: genitourinary tract. circulatory blood flow. lymphatic system. cerebrospinal fluid.

cerebrospinal fluid. Explanation: In congenital hydrocephalus, an obstruction occurs and cerebrospinal fluid is not able to pass between the ventricles and the spinal cord.

A pediatric nurse practitioner is assessing the development of a child. The nurse's assessment of development will focus on which of the following? changes in the body's cell structure, function, and complexity changes in thoughts, feelings, and behaviors a static process that occurs during childhood increases in the child's body size

changes in thoughts, feelings, and behaviors Explanation: Development is an orderly pattern of change in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning. Development is a dynamic and continuous process as one proceeds through life, characterized by a series of ascents, plateaus, and declines. Growth, on the other hand, is an increase in body size, or changes in body cell structure, function, and complexity.

A group of boys ages 9 to 10 have formed a "boys only" club that is open to neighborhood and school friends who have skateboards. The school nurse should interpret this as which behavior? behavior that reinforces poor peer relationships characteristics of children at risk for joining a gang behavior that encourages bullying and sexism characteristics of social development at this age

characteristics of social development at this age Explanation: During the school age years and into early adolescence, children begin to transition from the family being the primary influence to the importance of friends and social networks. Having a boy's only club is developmentally normal for this age.

A nurse is performing a newborn assessment and notes the blood pressures in the upper extremities are higher than the lower extremities. The nurse should suspect which congenital newborn abnormality? truncus arteriosus ventricular septal defect coarctation of the aorta patent ductus arteriosus

coarctation of the aorta Explanation: In congenital heart defects, coarctation of the aorta occurs when there is a narrow or constricted area of the aorta. This causes blood pressures to be higher in the upper extremities and lower in the lower extremities. Patent ductus arteriosus refers to an open patent foramen ovale after birth, and a ventricular septal defect is an opening in the ventricle. Both of these latter disorders cause increased pulmonary flow in the heart. Truncus arteriosus means there is one main branch for all vessels coming off the top of the heart.

During their school-aged years, children understand concepts best if they can see the concept illustrated. This type of thinking is termed: formal thought. concrete thought. black-and-white reasoning. school-aged rhetoric.

concrete thought. Explanation: Concrete thought (understanding concepts only if illustrated) is typical of school-aged children.

During a health history, a middle-aged man tells the nurse, "I will always take care of my children because my parents took care of me." Based on Kohlberg's theory, what level of moral development is the man demonstrating? postconventional conventional goodness preconventional

conventional Explanation: The conventional level of moral development in Kohlberg's theory involves identifying with significant others and conforming to their expectations. The person respects the values and ideals of family and friends, regardless of consequences.

The nurse is aware that which of the following might cause a fetus to be prone to certain diseases? spirituality food preferences religion culture

culture Explanation: Some cultural groups are more prone to certain diseases and disorders. Many of these are genetically passed. Being aware of these and sensitive to the concerns, fears, and feelings of people from various cultures helps the nurse remain supportive and objective.

The nurse is caring for a child who has been hospitalized for 6 days and whose caregivers are unable to stay with the child. The child cried most of the day for the first 3 days but now is quiet and withdrawn. This behavior in the child is an example of which stage of separation? depression despair protest denial

despair Explanation: Children often go through three characteristic stages of response to separation: protest, despair, and denial. When the caregiver does not appear, the child enters the second stage of despair. The child withdraws, is quiet without crying, is apathetic and depressed. The child has little interest in food or play and fails to react with health care personnel when they administer medications or perform procedures which are painful. Protest, denial, and depression are not forms of separation anxiety.

Which assessment findings are most prominent in the infant with tetralogy of Fallot and significant pulmonary stenosis? poor weight gain, nausea, decreased muscle tone dyspnea on limited exertion, fatigue, cyanosis dry mucous membranes, poor urine output irregular heart rate, fatigue, pink-tinged skin

dyspnea on limited exertion, fatigue, cyanosis Explanation: The infant with tetralogy of Fallot and significant pulmonary stenosis exhibits prominent signs of dyspnea, fatigue, and cyanosis. Other symptoms include feeding difficulties and poor weight gain, retarded growth and development, and breathlessness. Irregular heart rate, dry mucous membranes, nausea, and decreased muscle tone may be present in some form but are not the prominent signs.

What is the appropriate time when children should be taught genitalia terminology and about personal privacy? middle childhood early childhood late childhood preadolescence

early childhood Explanation: Children in early childhood can identify their sex. Language is progressing and children can learn the appropriate terms to use for body parts. Children explore their body parts and ask questions. This is also the time when children should be taught when exploration of the body is acceptable and who and under what condition may be permitted to touch "private" parts (genitals)

While in the waiting room, a child begins to cry when a toy has been taken away. The mother immediately hands the child another toy and the crying stops. How should the nurse interpret the child's behavior? short attention span extreme intensity of reaction negative mood quality easily distractible

easily distractible Explanation: Children who are easily distracted or who can easily shift their attention to a new situation are easy to care for. If they are crying over the loss of a toy, they can be appeased by the offer of a different one. Attention span is the ability to remain interested in a project or activity for an average length of time. Negative mood quality is when the child is unhappy or whining. A child who has an intensity of reaction responds to situations with their whole being. They cry loudly, thrash their arms, and have temper tantrums.

A 7-year-old boy has been admitted to the hospital with a diagnosis of fever of unknown origin. He has numerous tests ordered for diagnosis. When preparing him for the blood tests ordered, the best explanation would be: "The doctor needs some of your blood; trust me, it won't hurt." "The doctor needs to look at your blood to see why you are sick; it will hurt for a second." "I need to draw some blood from you. Will you hold still for me?" "The technician will draw your blood; it will just hurt for a minute."

elbow Explanation: The elbow restraint is indicated to prevent children from touching the head or face after facial surgery. The jacket restraint is to restrain children younger than 6 months in a supine position. This will not prevent the baby from touching the face. The mummy restraint temporarily immobilizes young children for a procedure involving the head, neck, or throat. This might be the restraint used for the surgery but not for the postoperative care. The clove hitch restraint is used to secure one arm or leg for a procedure, such as an intravenous infusion.

The nurse will apply which type of restraint for the infant recovering from cleft lip repair? jacket clove hitch mummy elbow

elbow Explanation: The reason for the restraint is to keep the infant from touching the lip and interfering with healing. The elbow restraint will do this while allowing all other movement. This device is the least restrictive while promoting safety. The other restraints would not be effective.

A nurse is starting an intravenous (IV) line in the antecubital fossa of a small child. What restraint would be best for the nurse to use to maintain patency of the IV? mummy restraint elbow restraint papoose board jacket restraint

elbow restraint Explanation: Elbow restraints are wrapped around the child's arm and tied securely to prevent the child from bending the elbow. They are often made of muslin or other materials in two layers. Pockets wide enough to hold tongue depressors are placed vertically in the width of the fabric. The top flap folds over to close the pockets. Care must be taken to ensure that the elbow restraints fit the child properly.

The nurse is reinforcing teaching with a group of caregivers regarding steps that can be taken to lower a child's elevated temperature. Which action would the nurse include in the discussion? Select all that apply. lower the room temperature administer acetaminophen bathe in warm water dress in pajamas with sleeves and covered feet encourage fluids

encourage fluids administer acetaminophen lower the room temperature Explanation: Methods used to reduce fever include maintaining hydration by encouraging fluids and administering acetaminophen. Keep room environment cool. Dress the child in lightweight clothing. Because of their ineffectiveness in reducing fever and the discomfort they cause, tepid or lukewarm sponge baths are no longer recommended for reducing fever.

The nurse is caring for a client prescribed gavage feeding. Which equipment will the nurse gather for the procedure? Select all that apply. marking pen catheter-tip syringe water-soluble lubricant gown and mask pH tape sterile gloves enteral feeding tube

enteral feeding tube water-soluble lubricant marking pen catheter-tip syringe pH tape Explanation: The nurse will gather the enteral feeding tube, water-soluble lubricant, a marking pen or tape, a catheter-tip syringe, pH tape, and the feeding solution for the procedure. Standard precautions are followed with nonsterile gloves. A gown, mask, and sterile gloves are not necessary for this procedure. Using unnecessary supplies results in inappropriate use of supplies and equipment and is not financially responsible.

A nurse in the newborn nursery has noticed that an infant is frothing and appears to have excessive drooling. Further assessment reveals that the baby has episodes of respiratory distress with choking and cyanosis. What disorder should the nurse suspect based on these findings? cleft palate coarctation of the aorta cleft lip esophageal atresia

esophageal atresia Explanation: Any swallowed mucus or fluid enters the blind pouch of the esophagus when a newborn suffers from esophageal atresia. The newborn with this disorder will have frothing, excessive drooling, and periods of respiratory distress with choking and cyanosis. If this happens, no feedings should be given until the newborn has been examined.

Children ages 8 to 9 years of age are playing games together. Everyone takes turns and has an opportunity to play and share equally. This describes which of the following perspectives? moral relativism moral realism Freud's superego fairness

fairness Explanation: The sharing, taking turns, and being fair is Piaget's sense of 'give and take' with "Fairness" being a prominent issue. The superego is Freud's drive to be good. Piaget's moral realism is sacred, literal, and inflexible. The view of other people is not taken into account. Moral relativism occurs in the 11- to 12-year-olds and then the intentions of others are taken into account.

A new graduate nurse is asking the nurse preceptor about enemas in pediatrics. The preceptor explains that the use of enemas in children is warranted under which circumstances? Select all that apply. fecal impaction preparation for surgery constipation bloating Hirschsprung disease preparation for a colonoscopy

fecal impaction Hirschsprung disease preparation for surgery preparation for a colonoscopy Explanation: Enemas are rarely used with children unless they are used as therapy for fecal impaction, Hirschsprung disease, a part of preparation for surgery, or a diagnostic test. Enemas would not be used for bloating or constipation.

A 4-month-old infant comes to the clinic for immunizations and a routine well-baby check-up (above). What is priority for the nurse to assess? parental work schedule and child care developmental milestones of smiling and sitting up cardiac system and oxygen saturation feeding patterns and intake

feeding patterns and intake Explanation: The nurse should first assess the child's feeding patterns and intake, because the child is demonstrating a slowing of weight gain and decline in weight percentiles. Cardiac anomalies may lead to decreased growth, but this is a less common cause and not the priority assessment. Smiling is usually seen earlier and sitting seen later, so these are not appropriate choices for developmental milestones to assess at this age. If a return to work precipitated the slowing of weight gain, this should be included in the assessment, but intake and feeding are the priority.

A nursing student has read that cleft lip is diagnosed at birth based on inspection of physical appearance and that cleft palate is diagnosed by which method? ultrasound X-ray feeling the palate with a gloved finger or using a tongue blade blood work

feeling the palate with a gloved finger or using a tongue blade Explanation: Diagnosis of cleft palate is made at birth with close inspection of the newborn's palate. To be certain that a cleft palate is not missed, the examiner must insert a gloved finger into the newborn's mouth to feel the palate to determine that it is intact. The other tests cannot confirm a cleft palate.

When the nurse is holding an infant, which positions are the most common methods used? Select all that apply. horizontal position upright position prone position football hold vertical position

football hold horizontal position upright position Explanation: When a child is held, he or she needs to be safe and feel secure. The three most common methods of holding a child are the horizontal position, upright position, and football hold. When holding an infant, the nurse should always support the infant's head and back.

Which of the following is a biological factor that has influence on growth and development? illicit drugs genetics illness poor diet

genetics Explanation: Genetics is a biological factor that influences the structure and function of every cell in the body. Illness is an example of a health status that can affect and delay growth and development. Illicit drugs and poor diet are environmental factors.

After teaching a group of nursing students about factors affecting growth and development, the instructor determines that the teaching was successful when the group identifies which of the following as a biological factor that has influence on growth and development? genetics poor diet sensory stimulation illicit drugs

genetics Explanation: Genetics is a biological factor that influences the structure and function of every cell in the body. Sensory stimulation, illicit drugs, and poor diet are environmental factors.

When planning care for children, the nurse knows that which factor has the largest impact but is not able to be altered to influence the growth and development of children? genetics environment family socialization

genetics Explanation: Of the factors listed, the options environment, family, and socialization are all important to the growth and development of children, but all of those factors can be altered. The only factor that cannot be changed is the genetics of the child.

A child gains weight and becomes taller each year. What is this process called? orderly change growth development progression

growth Explanation: Growth is an increase in body side or change in body cell structure, function, and complexity. Development is an orderly pattern of changes in structure, thoughts, feelings, or behaviors resulting from maturation, experiences, and learning.

When giving directions on safety protection of a toddler's intravenous site, the nurse should: tell the child it is his or her job to keep it safe. use a picture to support the information. have the parents reinforce the information being given. talk to the parents.

have the parents reinforce the information being given. Explanation: Toddlers will respond to the authority of the parents even if another adult is making a request.

Which intervention is most important in assuring a child's cooperation and reducing his or her fear during an emergency room visit? having the parent stay with the child providing distractions for the child during all procedures offering the child a popsicle for being good allowing the child to draw and color while in the emergency room

having the parent stay with the child Explanation: The most effective way to enlist a child's cooperation and reduce his or her stress in an emergency room visit is to have the parent remain with the child and comfort him or her.

According to Piaget, one basic concept that a child will learn during the first year is that: he is separate from his parents. he cannot be fooled by changing shapes. most procedures can be reversed. his parents are not perfect.

he is separate from his parents. Explanation: Part of learning permanence is learning where body boundaries begin or end or that the child is separate from parents.

A nursing student will correctly identify that growth is measured by which of the following patterns? height and weight developmental tasks changes in maturation milestones

height and weight Explanation: Each child has a unique pattern of growth, which is related to height and weight. Developmental tasks are the same as milestones and are basic achievements associated with each stage of development.

The nurse notes a diminished level of consciousness in an infant with hydrocephalus. What is a priority action at this time? taking the apical pulse obtaining the blood pressure testing the urine for protein palpating the anterior fontanel (fontanelle)

palpating the anterior fontanel (fontanelle) Explanation: A full or bulging anterior fontanel (fontanelle) indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant.

A hospitalized child is placed in droplet isolation. What intervention(s) will the nurse teach the parents and family to follow? Select all that apply. good handwashing technique how to put on and dispose of a gown benefits of bringing books from home how to properly wear a mask using gloves when bathing child

how to put on and dispose of a gown good handwashing technique how to properly wear a mask Explanation: Droplet isolation is used when a child has a disease that is transmitted via coughing, sneezing, and talking. An example of diseases where droplet isolation would be needed is influenza and pertussis. For this type of isolation, a gown and mask would be necessary for visitors. The nurse will teach the parents how to properly use the personal protective equipment and how to properly dispose of the equipment. Good handwashing is essential to prevent the transmission of organisms. If the parents want to bring personal items for the child, these items will need to be disinfected or cleaned. Books are porous and can hold droplets on their surfaces. Therefore, they are not a good choice for the child in droplet isolation. Gloves are not necessary for the parent when bathing the child.

The nurse is caring for a client placed on droplet precautions. Which teaching is priority for the nurse to reinforce for the caregivers? how to use and apply personal protective equipment appropriate methods to clean and disinfect the home the unit's policy for visitors of clients on droplet precautions how to prevent the client from becoming lonely while hospitalized

how to use and apply personal protective equipment Explanation: It is a priority for the nurse to reinforce teaching on the use and application of personal protective equipment (PPE) to keep the caregivers safe while in the client's room. If there is a need to clean the home, this would be done before discharge and therefore is not currently a priority. Knowing the unit's policy and how to prevent loneliness are important, but these do not take priority over the safety of the caregivers. Safety is always priority.

For which condition would the nurse commonly assess in an infant following surgery for a meningomyelocele? dehydration urinary tract infection hydrocephalus cerebrovascular accident

hydrocephalus Explanation: Surgery includes removing a portion of the meninges; without the surface to absorb cerebral spinal fluid, hydrocephalus can result.

The adolescent is in an auto accident and sustained a cut above his forehead and needs stitches. Which developmental task would be a major concern for the adolescent at this stage? inferiority industry identity intimacy

identity Explanation: According to Erickson, identity vs. role confusion is the stage of development the adolescent needs to accomplish. The cut could affect his self-image and interfere with establishing his identity. Intimacy, inferiority, and industry are all developmental stages of younger children.

A nursing student is learning about congenital disorders in newborns and correctly associates the causes for central nervous system defects to be which factors? Select all that apply. dysfunction of the lymphatic system malformation of the circulatory system imbalanced cerebrospinal fluid malformation of the neural tube during embryonic development

imbalanced cerebrospinal fluid malformation of the neural tube during embryonic development Explanation: Central nervous system defects include disorders resulting from an imbalance of cerebrospinal fluid (e.g., hydrocephalus) and a range of disorders resulting from malformations of the neural tube during embryonic development (often called neural tube defects). The other options do not cause defects of the central nervous system.

A school-aged child needs to have an IV started. Where would be the best place for the nurse to perform this procedure? in the child's room, ensuring privacy off the floor in a procedural suite in the playroom where there are distractions in a treatment room

in a treatment room Explanation: All treatments are performed in a treatment room so the child's room remains a "safe zone" for the child. By maintaining the client's room as a safe place, the child is reassured that nothing bad will happen when he or she is in the room. Procedures are never performed in public places such as a playroom to maintain the child's privacy. Distractions are provided in the treatment room.

A nurse is preparing to apply heat therapy to a client who has a back abscess. Heat has which of the following benefits? Select all that apply. increases circulation prevents drainage of abscess promotes muscle relaxation causes vasoconstriction causes vasodilation

increases circulation causes vasodilation promotes muscle relaxation Explanation: Local application of heat increases circulation by vasodilation and promotes muscle relaxation, thereby relieving pain and congestion. It also speeds the formation and drainage of superficial abscesses.

A nursing instructor asks the class to describe growth and development using only one word. Which of the following would be the best choice? simple unorderly individualized slow

individualized Explanation: Growth and development is complex. Growth is the physical increase in the body's size, and development is the progression of changes in the child toward maturity. Some stages are fast, while others take more time. It follows an orderly process and is individualized.

A nurse is preparing to assist a physician to suture a scalp laceration for a toddler. Which restraint would be most appropriate to use for this procedure? papoose board clove hitch restraint elbow restraint jacket restraint

papoose board Explanation: Papoose boards are used with toddlers or preschoolers for procedures that involve only the head and neck.

A father discusses with the nurse how his daughter, who recently started first grade, is extremely conscientious about her school work and is constantly asking her teachers if she is doing the work correctly. According to Erikson, which of the following developmental tasks is this girl currently learning? identity versus role confusion autonomy versus shame industry versus inferiority initiative versus guilt

industry versus inferiority Explanation: Erikson viewed the developmental task of the school-age period as developing industry versus inferiority, or accomplishment rather than inferiority. During school age, children learn how to do things well. A school-age child, while doing a project will ask, "Am I doing this right? Is it okay to use blue?" The developmental task of the preschool period is learning initiative versus guilt or learning how to do things. The new interpersonal dimension that emerges during adolescence is the development of a sense of identity versus role confusion. The developmental task of the toddler is to learn autonomy versus shame or doubt.

A 10-year-old girl is excited when she receives the "most improved player" award on her softball team. Although she was not the strongest player on the team, she always tried to perform at her best level and never gave up on practicing her skills. What stage of psychosocial development according to Erik Erikson is this child demonstrating? identity versus role confusion industry versus inferiority autonomy versus shame and doubt initiative versus guilt

industry versus inferiority Explanation: Industry versus inferiority focuses on end results of achievements, and the school-aged child gains pleasure from finishing projects and receiving recognition for accomplishments. Autonomy versus shame and doubt occurs during toddlerhood, as the child learns about the environment and gains independence. Initiative versus guilt occurs during the preschool years and is characterized by confidence gained as the child takes the initiative in learning. Identity versus role confusion occurs during adolescence as physical changes occur. The individual also works to acquire a sense of self and the direction in life to follow.

The nurse is reviewing growth and development for infants. Place the following developmental milestones in the correct order, from first to last for the growing and developing infant. Use all options. infant crawls infant sits independently, unsupported infant turns head when lying in prone position infant rolls over from back to front or front to back infant pulls to standing position

infant turns head when lying in prone position infant rolls over from back to front or front to back infant sits independently, unsupported infant crawls infant pulls to standing position Explanation: Infants develop in a "head to tail" pattern. The infant will learn head control first and move down the body ending with leg/foot coordination (standing, walking, etc).

A nursing instructor is teaching students about cardiac congenital disorders in newborns and informs them that, like other diseases, risk factors increase the incidence of heart defects. Which of these are considered risk factors? Select all that apply. ingestion of certain drugs during pregnancy young maternal age (younger than 24 years) maternal alcoholism maternal diabetes maternal irradiation advanced maternal age (older than 40 years)

ingestion of certain drugs during pregnancy maternal alcoholism maternal diabetes maternal irradiation advanced maternal age (older than 40 years) Explanation: Maternal alcoholism, maternal irradiation, ingestion of certain drugs during pregnancy, maternal diabetes, and advanced maternal age (older than 40 years) increase the incidence of heart defects in newborns. Young maternal age does not appear to be a factor.

The parent reports that the health care provider said that the infant had a hernia but cannot remember which type. When recalling what the health care provider said, the parent said that a surgeon will repair it soon and there is no problem with the testes. Which hernia type is anticipated? inguinal hernia diaphragmatic hernia hiatal hernia umbilical hernia

inguinal hernia Explanation: An inguinal hernia occurs primarily in males and allows the intestine to slip into the inguinal canal, resulting in swelling. If the intestine becomes trapped and circulation is impaired, surgery is indicated within a short period of time. The diaphragmatic hernia has implications with the respiratory system. An umbilical hernia typically spontaneously closes by age 3. A hiatal hernia produces digestive issues.

A 4-year-old is in the hospital playroom with the nurse playing a game. The child informs the nurse that he has to know the rules of the game so that no one cheats. What stage of development, according to Erikson, does the nurse recognize in this child? trust vs. mistrust initiative vs. guilt industry vs. inferiority autonomy vs. doubt and shame

initiative vs. guilt Explanation: During the period of initiative versus guilt (ages 3 to 6 years), the child engages in active, assertive play. These children want to know what the rules are and enjoy "being good," along with the adult approval that action gains.

Erik Erikson described human psychosocial development as a series of tasks that must be mastered before moving on to the next task. The stage in which the child is more assertive and starts to accept punishment for doing wrong is which stage? trust vs. mistrust identity vs. role confusion autonomy vs. doubt and shame initiative vs. guilt

initiative vs. guilt Explanation: In the stage of development referred to as initiative vs. guilt, the child engages in active, assertive play and develops a conscience. The child accepts punishment for doing wrong because it relieves feelings of guilt.

During a home visit, the nurse observes an 8-year-old child pick up toys and place them in the toy box. The child then looks to the mother who says, "Thank you for helping me." Which stage of Kohlberg's moral development is this child demonstrating? punishment/obedience orientation maintenance of social order individualism interpersonal relations of mutuality

interpersonal relations of mutuality Explanation: In the stage of interpersonal relations of mutuality, the child will follow rules because of a need to be a "good" person in their own eyes and in the eyes of others. The mother's praise reinforces this behavior. In the punishment/obedience stage, the child does "right" to avoid punishment. In the individualism stage, the child will carry out actions to satisfy own needs rather than others. In the maintenance of social order stage, the child will follow rules of authority figures as well as parents in an effort to keep the "system" working.

The nurse suspects that an infant is experiencing pain postoperatively. What behaviors would validate this suspicion? Select all that apply. knees flexed heart rate of 100 bpm crying but quieting down immediately when picked up facial grimacing rigid body posture

knees flexed facial grimacing rigid body posture Explanation: An infant in pain will display physical cues to the nurse to indicate that he or she is in pain. Those include facial grimacing, knees drawn up, crying that is not easily consolable, acting active and fussy, stiffened posture, and elevated vital signs (heart rate and blood pressure). A heart rate of 100 bpm is normal for a child this age.

A nurse recognizes that a pregnant homeless woman has challenges that other pregnant women may not. What problems should the nurse anticipate that the homeless pregnant client will have? Select all that apply. lack of prenatal care poor nourishment delivery of low-birth-weight infants delivery of large-for-gestational-age babies

lack of prenatal care poor nourishment delivery of low-birth-weight infants Explanation: Pregnant homeless women with their attendant problems receive little if any prenatal care, are poorly nourished, and bear low-birth-weight infants. Most of the children of homeless families do not have adequate immunizations.

A 10-year-old boy tells his mother that he is going to be just like his father when he grows up. According to Freud, what stage of development is this child experiencing? phallic anal latency genital

latency Explanation: The latency stage marks the transition to the genital stage during adolescence. Increasing sex-role identification with the parent of the same sex prepares the child for adult roles and relationships.

An 8-year-old boy is looking at his father's razor and shaving cream in the bathroom medicine cabinet. He watches his father shave daily and asks his father when he will need to start shaving. This child is demonstrating characteristics common during which of Freud's psychoanalytic developmental stages? latency stage genital stage phallic stage anal stage

latency stage Explanation: The latency stage (ages 7 to 12 years) makes the transition to the genital stage during adolescence and is characterized by increasing sex-role identification with the parent of the same sex. This stage prepares the child for adult roles and relationships. The anal stage (ages 8 months to 4 years) begins with the development of neuromuscular control to allow control of the anal sphincter. The phallic stage occurs between the ages of 3 and 7 years and the child demonstrates an increased interest in gender differences and his or her own gender. The genital stage (ages 12 to 20 years) is characterized by sexual interest that can be expressed in overt sexual relationships.

According to the theories of child development of Sigmund Freud, the child who is between 6 and 10 years old is in which stage? genital stage anal stage latency stage phallic stage

latency stage Explanation: The latency stage is the time of primary schooling, ages 6-10, when the child is preparing for adult life but must await maturity to exercise initiative in adult living. The child's sense of moral responsibility (the superego) develops based on what has been taught through the parents' words and actions.

A newborn is diagnosed with congenital hypothyroidism prior to discharge from the hospital. What medication does the nurse anticipate administering to the newborn? radioactive iodine levothyroxine tapazole inderal

levothyroxine Explanation: The thyroid hormone must be replaced as soon as the diagnosis is made. Levothyroxine sodium, a synthetic thyroid hormone replacement, is the drug most commonly used

A young child has been admitted to the hospital and is displaying signs of the second stage of separation response. Which behavior by the child demonstrates this stage? The child: begins to take interest in the surroundings and accepts the situation. refuses to engage with the caregivers. cries loudly, refusing to be comforted by others. lies in the bed, looking at the wall.

lies in the bed, looking at the wall. Explanation: In the second stage of the separation response, despair, the child is apathetic and listless. In the first stage of separation, protest, the child cries loudly and latches onto the caregiver, refusing to let others hold them. In the third stage of separation, denial, the child appears to be accepting of his circumstances and shows interest in his environment but rejects the primary caregivers.

A child's temperament makes the child easy to care for. The child's characteristics probably include: low persistence level, rhythmicity. high activity, strong withdrawal. long attention span, high level of persistence. low adaptability, positive mood quality.

long attention span, high level of persistence. Explanation: Temperament characteristics, such as a long attention span, make a child easier to care for compared to being nonadaptable and high activity.

The nurse is caring for an infant with a myelomeningocele prior to surgical repair. Which nursing consideration is the highest priority? performing passive range of motion ensuring balanced nutrition maintaining a clean environment placing the client in the supine position

maintaining a clean environment Explanation: Prior to surgical repair, the highest nursing consideration is to prevent infection. Care is required to maintain a clean environment. Surgery is typically completed within 48 hours. Balanced nutrition is appropriate to maintain but it's not the highest priority. Physical therapy will be considered after surgical repair. The newborn will not be placed on the myelomeningocele

The nurse approaches a client room and notes a sign stating the client is on droplet precautions. Which personal protective equipment (PPE) will the nurse use for this client? N95 respirator mask with face shield gloves only gloves and gown

mask with face shield Explanation: A client on droplet precautions has a disease that is spread by coughing and sneezing; anyone entering the room needs protection from the infected droplets. Droplet precautions require a mask and eye protection (face shield or goggles) for all people who enter the client's room. An N95 respiratory is used for airborne precaution.

Microorganisms are sometimes spread by what is called a vehicle. Of the following, which would fit into this category of transmission? Select all that apply. microorganisms spread by direct contact microorganisms spread by blood microorganisms spread by water microorganisms spread by mosquitoes microorganisms spread by food

microorganisms spread by food microorganisms spread by water microorganisms spread by blood Explanation: Microorganisms are spread by contact (direct, indirect, or droplet), vehicle (food, water, blood, or contaminated products), airborne (dust particles in the air), or vector (mosquitoes, vermin) means of transmission.

A school-aged child always follows the rules and obeys traffic lights when crossing the street. Based on Kohlberg's theory, what type of development is being demonstrated? moral cognitive psychosocial intellectual

moral Explanation: Kohlberg's theory of moral development includes the stages individuals move through. School-aged children obey rules and regulations established by society and enforced by authority figures.

The nurse is explaining to a group of parents about characteristics that can influence a child's overall growth and development. Which statement(s) will the nurse include in the teaching? Select all that apply. mother's general health during the pregnancy parents' genetics mother's nutrition during the pregnancy child's nutrition child's environment father's general health during the pregnancy

mother's general health during the pregnancy parents' genetics mother's nutrition during the pregnancy child's nutrition child's environment Explanation: There are many influences on a child's growth and development. Prenatal factors that influence fetal and child growth include the mother's, not the father's, general health and nutrition during pregnancy. These factors as well as genetic, nutritional, and environmental factors all affect the growth and development of the child.

The nursing student is describing a protrusion of the spinal cord and the meninges. The nursing instructor realizes that the student is correctly describing which neural tube defect? spina bifida occulta meningocele spinal cyst myelomeningocele

myelomeningocele Explanation: Myelomeningocele is a defect in the neural tube that includes the spinal cord and the meninges in a cyst. Spina bifida occulta does not have a cyst. Meningocele does not include the spinal cord. A spinal cyst does not include the spinal cord or the meninges.

The floor nurse is making rounds on her clients and discovers that an 8-month-old admitted with pneumonia has an oxygen saturation of 91% on room air. The physician has standing orders to keep saturations at 96% or above. Which oxygen delivery system would the nurse choose for this client? face mask nasal cannula non-rebreather mask oxygen tent

nasal cannula Explanation: For infants and older children, the nasal cannula is the most appropriate oxygen delivery system for this oxygenation level. It is the least invasive and most comfortable for the infant. A face mask or a non-rebreather mask are used if the nasal cannula is not successful in keeping the infant's oxygen saturations within the set parameters. Oxygen tents are rarely used due to the difficulty in maintaining a constant O2 level in the tent.

The nurse is caring for an 11-year-old admitted with a respiratory condition. The child requires occasional administration of low-flow oxygen. Which of the following methods of oxygen administration would likely be used for this child? hood nasal prongs mask tent

nasal prongs Explanation: Depending on the child's age and oxygen needs, many different methods are used to deliver oxygen. Nasal prongs or a nasal cannula are used appropriately for an 11-year-old child, especially if the child has modest needs for supplementation.

A 2-year-old child is hospitalized for a surgical procedure. Although previously all fluids were taken from a cup, the toddler wants a bottle to suck on. The nurse recognizes this behavior as: proof that the child is sick. normal regression. abnormal behavior. totally unacceptable.

normal regression. Explanation: Based on the principles and theories of growth and development, the nurse recognizes possible regression during difficult periods or times of crisis, accepting and supporting a return to a forward progression in development. It is acceptable, normal behavior for the hospitalized toddler.

A new mother brings her 6-month-old to the clinic and informs the nurse that her son has what she thinks is an umbilical hernia. Upon examination the diagnosis of umbilical hernia is confirmed. What should the treatment be for this child? surgery within 2 to 3 months nothing taping of a coin to the hernia to reduce it immediate surgery

nothing Explanation: Although upsetting to parents, umbilical hernias are associated with little or no morbidity. Almost all these hernias close spontaneously by the age of 3 years, and those that do not close should be closed before the child enters school. Taping a coin on it could result in a serious problem and should not be done.

When planning preoperative care for a newborn with a cleft lip and palate, the nurse would plan interventions for which major need? nutrition prevention of oral infection visual stimulation prevention of pneumonia

nutrition Explanation: An infant with a cleft lip is unable to suck effectively, so obtaining adequate nutrition is a major concern.

The nurse is playing with the 8-month-old infant. The nurse hides the toy to assess cognitive function of the infant. The infant tries to find the toy. The nurse is assessing which characteristic of Piaget's stages of cognitive development? concept of causality preconceptual stage object permanence primary circular reactions

object permanence Explanation: Object permanence occurs when the infant realizes the object exists even when not seen. Primary circular reaction involves active efforts to reproduce a behavior that was first performed by chance, usually between 1 to 4 months of age. The preconceptual stage reflects the formation of symbolic through and egocentrism, usually around 2 to 4 years of age. The concept of causality is understood when the child reaches 18 to 24 months of age.

At the beginning of the second trimester of pregnancy, a client has an elevated maternal serum α-fetoprotein (MS-AFP). Based on this result, the nurse explains that a follow-up sonogram will be performed to look for which conditions in the fetus? Select all that apply. omphalocele gastroschisis tracheoesophageal fistula umbilical hernia spina bifida

omphalocele gastroschisis spina bifida Explanation: At the 15th week of pregnancy, the level of MS-AFP will be abnormally increased if there is an open spinal or abdominal lesion such as omphalocele, gastroschisis, or spina bifida. An umbilical hernia and tracheoesophageal fistula are not open lesions.

Put the following psychosexual stages of Freud's theory of childhood development in the correct order: Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 4oral stage 2genital stage 1anal stage 3phallic stage 5latent stage

oral stage anal stage phallic stage latent stage genital stage Explanation: The correct order of psychosexual stages is as follows: 1) oral stage (infant); 2) anal stage (toddler); 3) phallic stage (preschooler); 4) latent stage (school-age child); 5) genital stage (adolescent).

A client asks if a school-age child is going to be tall like others in the family. What should the nurse explain as having the least impact on the child's ultimate height? ingestion of nutritious food participation in sports occupations of parents inherited genetic material

participation in sports Explanation: Although children cannot grow taller than their genetically programmed height potential, their adult height can be considerably less than their genetic potential if their environment hinders their growth. Environmental influences on height include socioeconomic status or occupations of parents, genetic material inherited, and availability and ingestion of nutritious foods. Participation in sports will not influence the child's ultimate height.

A mother is concerned about her 2-year-old son acquiring sufficient protein while following the family's vegan diet. Which of the following foods would be appropriate for the nurse to recommend to this mother? eggs peanut butter and wheat bread milk and cheese broccoli

peanut butter and wheat bread Explanation: A vegan diet excludes all animal products—including dairy products and eggs—and consists of only vegetables, fruits, and grains. Vegan diets can supply essential amino acids by cereal and legume combinations such as peanut butter and wheat bread, corn and lima beans, pasta and beans, corn tortillas and beans, or chickpeas and sesame seeds. Broccoli is a good source of calcium but not of protein.

A 5-month-old is having a cleft lip/palate repair. What games could the nurse play with the child to provide comfort and diversion postoperatively while the baby is in elbow restraints? arts and crafts a board game peek-a-boo blowing a pinwheel

peek-a-boo Explanation: Playing peek-a-boo and other infant games will help to comfort and entertain the infant in restraints; however, "patty cake" does not work well with an infant in elbow restraints. Blowing a pinwheel will stress the suture line.

A pediatric nurse caring for children of all ages knows that children learn about themselves, the environment, and relationships best through: play. parents. reading. school.

play. Explanation: Throughout the stages of growth and development, the role and types of play differ. Through play, children learn about themselves, their environment, and relationships with others.

A child has been admitted to the pediatric unit with vomiting and diarrhea. The physician orders strict monitoring of intake and output. The mother asks the nurse what fluids she will need to measure. The nurse responds that fluid intake can include which of the following? Select all that apply. Jell-O popsicles IV fluids applesauce Gatorade

popsicles Gatorade Jell-O IV fluids Explanation: Applesauce is a food item and not counted as liquid intake. IV fluids, jello, Gatorade, and popsicles are all considered liquid intake.

In what stage of Kohlberg's Moral Development Theory do people make judgments based solely on their own needs? preconventional conventional preoperational postconventional

preconventional Explanation: In the preconventional stage of Kohlberg's moral development theory, people make judgments based solely on their own needs. In the postconventional stage, people base judgments on abstract personal principles not necessarily defined by society's laws. In the conventional stage, people consider society's expectations and laws when making moral decisions.

After a child plays in the yard, his mother asks him to pick up his toys and put them in the toy bin in the garage. Knowing that he does not want to spend time in his room as a punishment, the child follows his mother's directions. What stage of moral development, according to Kohlberg, is this child demonstrating? preconventional level: stage 2 conventional level: stage 1 preconventional level: stage 1 conventional level: stage 2

preconventional level: stage 1 Explanation: The preconventional level is based on external control as the child learns to conform to rules imposed by authority figures. At stage 1, punishment and obedience orientation, the motivation for choices of action is fear of physical consequences of authority's disapproval. At stage 2, instrumental relativist orientation, the thought of receiving a reward overcomes fear of punishment, so actions that satisfy this desire are selected. The conventional level involves identifying with significant others and conforming to their expectations

A nurse is assessing a child and determines that the child reflects the temperament of an easy child. Which characteristics did the nurse observe? withdrawal in new situations shyness slow adaptability predominantly positive mood

predominantly positive mood Explanation: An easy child is characterized by flexibility, a positive approach to new stimuli, adaptability to change, and a predominately positive mood. The difficult child is characterized by irregularity in biologic functions, negative approach to new stimuli, slow adaptability, and intense mood expressions that are usually negative. The slow-to-warm-up child is characterized by a combination of behaviors that are marked by withdrawal tendencies to new situations, slow adaptability, and negative mood expressions of low intensity. Less irregularity is noted in biologic functions. This child is often labeled "shy."

A 13-year-old mother delivers a low-birth-weight neonate, and the neonate is transferred to the neonatal intensive care unit. The mother reports receiving occasional prenatal care and has a history of excessive alcohol consumption. The growth and development of this neonate has been influenced by which of the following? caregiver factors individual factors spiritual factors prenatal factors

prenatal factors Explanation: Fetal development can be altered by prenatal factors such as maternal age (with risk greater in those younger than 15 years of age or older than 35 years of age), maternal substance use, inadequate prenatal care, and inadequate maternal nutrition. Individual factors might result in altered development from birth through adolescence and may include congenital or genetic disorders, brain damage from accidents, or abuse, sensory impairments, and substance abuse. Caregiver factors that negatively affect development are neglect and abuse, mental illness, intellectual disability, or a severe learning disability. Spiritual factors such as religious beliefs are not a factor in this situation.

A nurse is providing preoperative care to a female newborn client with the congenital abnormality myelomeningocele. Which intervention is the priority? preventing infection preserving newborn GI function promoting newborn nutrition maximizing newborn motor function

preventing infection Explanation: A congenital condition of the newborn with a spinal deformity puts the newborn at risk for infection. A myelomeningocele is a fluid-filled sac on the spine that includes part of the spinal cord defect and the meninges. This cyst on the outside of the newborn requires surgical intervention. Although nutrition, GI function, and motor function are all important to the health of the newborn, the spinal and meninges defect puts the newborn at high risk for infection.

A 3-year-old client had blood drawn for lab work by the nurse. Which documentation would the nurse make for this procedure? Select all that apply. child's response type of specimen and its appearance client name parent at bedside procedure performed

procedure performed type of specimen and its appearance child's response Explanation: If a nurse collects a specimen from a client, the nurse must label the specimen and send it to the appropriate department using standard precautions. Then the nurse must document collecting the specimen. The documentation will include the procedure, how the child tolerated the procedure, the appearance of the specimen, and what was done with the specimen (e.g. sent to the lab).

When a child is hospitalized and must be away from the caregiver, the child goes through stages of response to the separation. The child who cries and refuses to let the nurse or anyone else provide comfort and is continually looking out the door to see if the caregiver is returning is in which stage of separation? protest anger despair denial

protest Explanation: Children often go through three characteristic stages of response to the separation: protest, despair, and detachment. During the first stage (protest), the young child cries, often refuses to be comforted by others, and constantly seeks the primary caregiver at every sight and sound. Despair is the second stage of separation. In this stage the child withdraws, is quiet without crying and becomes apathetic. Anger and denial are not included in stages of separation.

On the first postoperative day, a 4-year-old child who was hospitalized for an emergency appendectomy has begun to cry relentlessly, will not let the nurse touch him or her, and keeps asking for the parent. The pediatric nurse is aware that this client is in which stage of separation? grief despair denial protest

protest Explanation: Separation anxiety is very real for the hospitalized child who is separated from parents or caretakers. Separation anxiety has three stages. This child is displaying symptoms of the first stage of separation, which is protest. The child reacts aggressively, cries, and exhibits great distress. The child rejects others who would attempt to provide care or comfort. The second stage is despair. During this stage the child displays hopelessness, is quiet without crying, and lacks any interest in play or food. The third stage is denial. During this phase, the child is detached and has formed coping mechanisms to avoid any further emotional pain. Grief is not a stage of separation anxiety.

A pediatric nurse observes an infant holding a rattle. Upon dropping the rattle, the baby cannot pick it up with his fingers on his own. The nurse correctly identifies this to be an example of which type of growth? abnormal growth proximodistal cephalocaudal abnormal development

proximodistal Explanation: The ability to hold something in the hand before being able to use the fingers to pick up the object is proximodistal growth. Cephalocaudal is the pattern referred to when the child can control the head and neck before the arms and legs. This is neither abnormal growth nor abnormal development.

Using Erikson's theory, which of the following activities would the nurse use to provide a sense of fulfillment and purpose in later adulthood? making a commitment to others trying on new and different roles reminiscing about life events becoming involved within the community

reminiscing about life events Explanation: Using Erikson's theory, the nurse would use reminiscence about life events with older adults to facilitate a sense of fulfillment and purpose. The other choices are not appropriate for older adults.

The nurse is caring for a child who has a gastrostomy tube in place. The nurse is about to give a feeding when it becomes evident that the tube is filled with dark brown fluid. The nurse's best action would be to: report to the health care provider that a complication may be occurring. assess whether the skin surrounding the tube is bleeding. give the feeding quickly to keep the tube from plugging. assess the drainage for pH; if this is above 7.35, give the feeding.

report to the health care provider that a complication may be occurring. Explanation: A potential complication of gastrostomy tubes is that they may migrate through the pyloric valve into the duodenum and cause obstruction. Brown fluid suggests this has happened, because the tube is filled with feces. An alkaline pH suggests the complication has occurred, because bowel secretions are alkaline, while stomach secretions are acidic.

An adolescent reporting leg pain and has received the maximum amount of analgesics allowed on the patient-controlled analgesia (PCA) pump. What other intervention(s) can the nurse initiate for this adolescent? Select all that apply. encourage the adolescent to walk reposition the adolescent from one side to another play a video game with the adolescent play the adolescent's favorite music provide massage to the adolesent

reposition the adolescent from one side to another play a video game with the adolescent play the adolescent's favorite music provide massage to the adolesent Explanation: Nonpharmacologic measures are implemented when a client cannot receive any more analgesics at the present time. Measures such as massage, distraction, playing a favorite game with the client or repositioning are all comfort measures that the nurse can use to make the client more comfortable.

Which of the following is the highest priority related to positioning during pediatric nursing procedures? holding communication safety none of the above

safety Explanation: Safety is the most important nursing responsibility when positioning a child for procedures. The child's safety and comfort must be a priority when using restraints or transporting children.

The nurse obtains a stool specimen for ova and parasites. It would be important for the nurse to: discard it if it is not yellow to green. add alcohol to prevent odor. keep this refrigerated. see that it arrives at the laboratory promptly.

see that it arrives at the laboratory promptly. Explanation: Stool specimens for ova and parasites should not be refrigerated or have additives because these can kill the organisms. They need to be examined by laboratory personnel promptly.

Which of the following can have an influence over the individual's physiologic growth and development trajectory? temperament intelligence ethnicity and culture sensory stimulation and nutrition

sensory stimulation and nutrition Explanation: There are certain expected growth or developmental norms; each child as an individual may grow and mature faster or slower than the norm while maintaining a consistent and predictable pattern of growth and development. All factors listed can have some influence; however, each individual's physiologic growth and development trajectory are affected significantly by environmental factors such as nutrition and sensory stimulation. The nurse is responsible for developmental surveillance, which includes assessing the adequacy of sensory stimulation and nutrition for the child. Environmental factors can negatively or positively affect the child's growth and developmental patterns. Ethnicity and culture refer to the common social and cultural values, mores, and traditions that are learned behaviors. Temperament is an intrinsic personality factor in which each individual responds to his or her environment in different ways. Intelligence is the intellectual capacity of the individual

The nurse is caring for an 8-year-old girl who requires numerous venipunctures and injections daily. The nurse understands that the child is exhibiting signs of sensory overload and enlists the assistance of the child-life specialist. What should the therapeutic play involve to best deal with the child's stressors? drawing paper and crayons wooden hammer and pegs puppets and dolls sewing puppets with needles

sewing puppets with needles Explanation: The nurse understands that the child may benefit from supervised needle play to assist the child undergoing frequent blood work, injections, or intravenous procedures. The child life specialist can determine what form of therapeutic play is best, but the nurse can recommend interventions based on his or her knowledge of the specific child.

According to Freud, which of the following influences is the primary force that drives an individual's development? sexuality security autonomy faith

sexuality Explanation: According to Sigmund Freud, the stages of development are based on sexual motivation. Sexuality supersedes security and autonomy, though both are highly significant and are influenced by sexual motivation. Faith is not a central construct in Freud's theory of development.

Following surgery for an imperforated anus, care of the infant should include which nursing intervention? Select all that apply. side-lying position rectal temperature to detect signs of infection prone position for sleep clean suture line with saline after each bowel movement daily stool softener to prevent straining

side-lying position clean suture line with saline after each bowel movement daily stool softener to prevent straining Explanation: The goal is to prevent disruption or infection of the suture line. A daily stool softener and a side-lying position as well as cleaning the suture line after each bowel movement are part of the plan of care. Rectal temperatures are not done because they can disrupt the sutures. Infants in the prone position tend to pull their legs up and under the body, which increases the tension on the suture line

A pediatric nurse is instructing a new mother on the best position to burp her infant after feeding. Which of the following positions does the nurse recommend? football hold sitting position horizontal position upright position

sitting position Explanation: During and after feedings the caregiver should hold the infant in a sitting position on the lap for burping. The other positions can be used when holding the infant at all other times.

A nursing student is caring for a newborn with a defect in the neural arch where the posterior laminae of the vertebrae have failed to close. The nurse knows that this infant is suffering from which disorder? cleft palate esophageal atresia hydrocephalus spina bifida

spina bifida Explanation: Spina bifida is a failure of the posterior laminae of the vertebrae to close, leaving an opening through which the spinal meninges and spinal cord may protrude. Hydrocephalus is a condition characterized by excess cerebrospinal fluid (CSF) within the ventricular and subarachnoid spaces of the cranial cavity. Cleft palate is a result of failure of the primary and secondary palates to fuse. Esophageal atresia is the absence of a normal opening or abnormal closure of the esophagus

A nurse is performing a newborn assessment and notices a small dimple on the sacral area. The infant has a normal neurological assessment and moves all extremities well. What does the nurse suspect that the dimple indicates? spina bifida with meningocele spina bifida occulta a normal spinal closure spina bifida with myelomeningocele

spina bifida occulta Explanation: Spina bifida occulta is a bony defect that occurs without soft-tissue involvement. A dimple in the skin or a tuft of hair over the site may arouse suspicion of its presence, or it may be overlooked

The nurse is planning play activities for a toddler admitted to the hospital. What play activity(ies) would the nurse include in the plan of care? Select all that apply. putting together a large-piece puzzle pulling a toy train in the room or hallway watching a mobile with play animals, as it rotates stacking different-colored blocks keeping a journal of favorite play items and activities

stacking different-colored blocks pulling a toy train in the room or hallway putting together a large-piece puzzle Explanation: Pulling a toy train encourages movement and the development of gross motor skills important to the toddler. Stacking blocks and putting together a puzzle uses fine motor skills and an understanding of shapes, colors, and space and are stimulating cognitively. Watching a mobile is appropriate for infants and may be unsafe if the toddler could reach it. Keeping a journal is an activity appropriate for an older child who can read and write.

What supply is best to use to catheterize a young toddler for a urine specimen? sterile feeding tube with small lumen straight urinary catheter with small lumen small suction catheter, well-lubricated Foley catheter with 3 ml balloon

sterile feeding tube with small lumen Explanation: The feeding tube (#5 or #8) is a good choice. It is thin and flexible yet rigid enough to pass easily through the meatus and into the bladder. Narrow straight and Foley urinary catheters are often soft, making movement into the urinary tract difficult. The configuration of the openings in a suction catheter makes it impractical for collecting urine.

The nurse should consider which stool sample collected from a child as contaminated and not acceptable for analysis? stool removed from surrounding urine formed stool obtained from a bed pan a sample scraped from a diaper stool retrieved from a potty

stool removed from surrounding urine Explanation: Stool specimens should be collected without contamination by urine. Equipment used to collect stool should be clean. The other methods of collecting the stool sample are acceptable. Specimens should be sent to the laboratory promptly.

The nurse caring for a 6-month-old infant can best reduce the stress of hospitalization by: supporting the parent and his or her caregiving efforts. providing opportunity for nonnutritive sucking. holding and rocking the infant. keeping the infant warm and dry.

supporting the parent and his or her caregiving efforts. Explanation: All the actions by the nurse would be helpful in reducing stress. However, the 6-month-old infant, who prefers his parents to other caregivers, will be stressed the least by having that person available to provide basic care and give comfort.

A preschool child has been admitted to the hospital. Which prescription should the nurse question? tap water enema 500 ml IV normal saline 25 ml/hour NPO nasogastric tube to suction

tap water enema 500 ml Explanation: Tap water is not used in enemas with children because, as it is not isotonic, it causes a rapid shift of fluid in body compartments, possibly leading to water intoxication. The nurse would want to question the health care provider about the prescription for a large tap water enema. The other prescriptions could be completed safely for a preschool-age child.

Genetics have an influence on many aspects of growth and development. The genetic influence that has to do with the way a person thinks, behaves, and reacts is referred to as: development. growth. maturation. temperament.

temperament. Explanation: Temperament is the combination of all of an individual's characteristics, the way the person thinks, behaves, and reacts to something that happens in his or her environment.

A 5-year-old scheduled for surgery in the morning wakes at 2 am and asks the nurse for something to eat and drink. What should the nurse tell this client? that not having food or drink before surgery will prevent an upset stomach that the client could aspirate if eating or drinking anything so close to surgery that the client is NPO for surgery that the client cannot have anything until after surgery

that not having food or drink before surgery will prevent an upset stomach Explanation: Children may better understand why they are NPO if they are told that food and drink are being withheld to prevent an upset stomach. During general anesthesia, food and drink are withheld to prevent vomiting and aspiration, but a young child will not comprehend this information.

Question 10 of 20 If a pre-school age child sees you pour his liquid medicine from a tall, thin glass into a short, wide one, he will probably reason that: the amount of medicine did not change, only the appearance. the glass changed shape to accommodate the medicine. the amount of medicine is less (the glass is not as full). pouring medicine hurts it in some way because it changes.

the amount of medicine is less (the glass is not as full). Explanation: The concept of conservation (not being fooled by a change in shape) is not developed until school age.

The nurse is providing education to the parents of an infant who was just diagnosed with transposition of the great arteries. The parents ask, "Which vessels were involved?" The nurse is correct to educate about: the inferior vena cava and pulmonary vein. the aorta and pulmonary artery. the pulmonary vein and pulmonary artery. the superior and inferior vena cava.

the aorta and pulmonary artery. Explanation: The nurse is correct to educate that in the congenital condition known as transposition of the great arteries, it is the aorta and the pulmonary artery that are reversed. In this condition, the aorta rises from the right ventricle and the pulmonary artery arises from the left.

When working with school-aged children the nurse should direct the conversation by focusing on: all the family present. the parent. the client. the client and caregiver.

the client. Explanation: When caring for school-aged children, the nurse should begin by calming the child down or connecting with the child. The nurse should briefly acknowledge any caregivers present and then focus on the child.

When working with school-aged children the nurse should direct the conversation by focusing on: the client and caregiver. the client. the parent. all the family present.

the client. Explanation: When caring for school-aged children, the nurse should begin by calming the child down or connecting with the child. The nurse should briefly acknowledge any caregivers present and then focus on the child.

The nurse is providing education on hospitalizations to parents of children with chronic disorders. Which statement will the nurse include about the purpose of rooming-in on pediatric units? "It is to ensure someone is there for the child when the staff is busy." "It is to assist in providing the child's basic care while hospitalized." "It is to provide the child security and stability while hospitalized." "It is to ensure parents are readily available to provide consent."

the pediatric treatment room Explanation: The nurse would perform procedures on stable pediatric clients in the pediatric treatment room. Using a separate room to perform procedures promotes the concept that the child's room is a "safe" place. The other "safe" place for a child in the hospital is the playroom and should not be used for any procedures or medication administrations. The client would not be allowed to select a location as the client may select one's room or the playroom

The nurse is preparing to start an intravenous (IV) line on a stable pediatric client in the hospital. Which location is most appropriate for the nurse to use for this procedure? the unit's playroom the child's hospital room room selected by the client the pediatric treatment room

the pediatric treatment room Explanation: The nurse would perform procedures on stable pediatric clients in the pediatric treatment room. Using a separate room to perform procedures promotes the concept that the child's room is a "safe" place. The other "safe" place for a child in the hospital is the playroom and should not be used for any procedures or medication administrations. The client would not be allowed to select a location as the client may select one's room or the playroom.

The nurse in the emergency center admits a 16-year-old girl who looks like she weighs more than her stated weight. After collecting data from the adolescent, the nurse suspects the child is a runaway. Which of the following topics would be most important for the nurse to gather data about? where the adolescent has been sleeping the eating patterns and habits of the adolescent what substances the adolescent may have abused the possibility that the adolescent is pregnant

the possibility that the adolescent is pregnant Explanation: A sexually transmitted disease, pregnancy, acquired immunodeficiency syndrome (AIDS), or drug overdose are the usual reasons that runaways are seen at a health care facility.

The nurse assesses a 6-month-old. What body part should show significant growth? the abdomen the trunk the head the legs

the trunk Explanation: In early fetal life, the head grows faster than the rest of the body and is thus proportionately larger. During infancy, the trunk portion grows significantly. The legs grow rapidly during childhood, again changing the body proportions. As the child grows into an adolescent, the trunk portion grows and the body proportions are those of an adult.

The nurse is caring for a 10-year-old child admitted for a surgical procedure to be done the next day. The nurse takes the child to a special area in the playroom and lets the child "start" an IV on a stuffed bear. This is an example of: age-related activity. play therapy. positive reinforcement. therapeutic play.

therapeutic play. Explanation: Therapeutic play is a play technique used to help the child have a better understanding of what will be happening to him or her in a specific situation. It is nondirected and focuses on helping the child cope with feelings and fears. Positive reinforcement is offering praise for doing well so that the good behavior will happen again. Play therapy or emotional outlet play is used for the child to act out or dramatize life stressors. An age-related activity would be one where the play was directed to the ability of the child's age, such as a toddler stacking blocks. The 10-year-old child would have the capability to start the IV on the bear, but a toddler or preschooler would not.

A 2-year-old with pneumonia has recently been hospitalized. When the lunch tray arrives to the floor, the nurse caring for the client sets up the tray and allows the child to self-feed with a spoon despite the mess. What is the nurse's best reason for these actions? to foster industry to foster initiative to foster trust to foster autonomy

to foster autonomy Explanation: The toddler gains reassurance from self-feeding even when this takes a long time or makes a mess. Even the smallest child wants to feel in control and needs to learn to perform tasks independently. Trust should be learned during 0 to 1 year, initiative is fostered from 3 to 6 years, and industry is sought during 6 to 12 years.

Which of the following are situations that might warrant a restraint of a pediatric client? Select all that apply. to protect the child from injury during a procedure or examination to ensure the child's safety to keep an active child confined to bed to teach a child how to be cooperative

to protect the child from injury during a procedure or examination to ensure the child's safety Explanation: Restraints are sometimes needed to protect a child from injury during a procedure or examination or to ensure the child's safety and comfort. They should never be used as a form of punishment.

The nurse is caring for a newborn with hydrocephalus. To protect the newborn from injury in the postoperative period, the nurse should position the head: in Trendelenburg position. turned away from the operative site. turned toward the operative site. supported on a pillow.

turned away from the operative site. Explanation: In the early postoperative period, the infant's head should be placed turned away from the operative site to promote comfort until the physician instructs otherwise. Trendelenberg would facilitate additional fluid accumulation. Infants should not be placed on pillows. If turned toward the operative site, additional pain and fluid accumulation would result.

After teaching a group of students about therapeutic play, the instructor determines that additional teaching is needed when the students identify what as a characteristic of therapeutic play? use of a highly structured format expression of feelings dramatization of emotions focus on coping

use of a highly structured format Explanation: Therapeutic play is nondirected play, focused on helping the child cope with feelings and fears. Real-life stressors and emotions can be acted out or dramatized, allowing the child to express his or her feelings.

A nurse caring for a 5-year-old who had abdominal surgery yesterday is trying to teach the child how to take deep breaths. The best way that the nurse can accomplish this is by: using a flow meter. teaching pursed-lip breathing. using a spirometer. using a pinwheel.

using a pinwheel. Explanation: Postoperative care for children includes coughing, turning, and deep breathing every 2 hours. A useful and fun way to teach deep breathing to a child is by using a pinwheel. Pursed-lip breathing does not help in deep breathing. It is used for a client with chronic obstructive pulmonary disease who take shallow breaths. A flow meter regulates the flow of oxygen. Using an incentive spirometer will achieve the goal, but a child will be more inclined to do deep breathing if it involves some type of fun activity.

The nurse is performing a cardiac assessment on a newborn and hears a loud, harsh murmur associated with a systolic thrill. What congenital heart defect does the nurse suspect? ventricular septal defect atrial septal defect patent ductus arteriosus coarctation of the aorta

ventricular septal defect Explanation: Small, isolated defects are usually asymptomatic and often are discovered during a routine physical examination. A characteristic loud, harsh murmur associated with a systolic thrill occasionally is heard on examination.

A student nurse is learning about congenital heart defects in newborns and correctly identifies which of the following to be the most common intracardiac defect? coarctation of the aorta patent ductus arteriosus ventricular septal defect atrial septal defect

ventricular septal defect Explanation: Ventricular septal defect is the most common intracardiac defect. It consists of an abnormal opening in the septum between the two ventricles.

The nurse needs to transport her preschool client to radiology for a chest X-Ray. Which transportation device would be most appropriate? wagon wheelchair stretcher crib

wagon Explanation: When transporting a child off the floor, the nurse needs to select the correct means of transportation based upon the child's age and developmental level. For a preschooler, a wagon would be the best choice for both safety and for enjoyment. A stretcher or wheelchair are both too large for such a young child and a crib is too small for them.

What is the best technique for preventing the spread of infection in hospitalized clients? wearing gloves washing hands between each client wearing a mask wearing a gown, gloves, and mask

washing hands between each client Explanation: Handwashing is the cornerstone of all infection control. One must wash hands conscientiously between seeing each client, even when gloves are worn for a procedure. Gowning with gloves and a mask is not a necessary action for standard precautions.

In caring for pediatric clients, which statement best describes when the will nurse follow standard precautions to provide care for a client? when providing care to any client when starting an intravenous (IV) line when completing a dressing change when assisting a client with eating

when providing care to any client Explanation: The nurse will follow standard precautions when caring for all clients of any age and diagnosis. The nurse would wear gloves when performing a dressing change and potentially additional personal protective equipment, depending on the severity of the wound and diagnosis. The nurse would wear gloves to start an IV but this is not the only time. The nurse would also follow standard precautions with feeding a client but, again, not only for this action.

The public health nurse is educating parents of young children about awareness of the hospital. When is the best time to educate the children about the hospital? when the children begin to recognize emergency workers when the children are capable of understanding basic functions of community resources when the children are capable of understanding death and dying when the children begin to show interest in emergency vehicles

when the children are capable of understanding basic functions of community resources Explanation: The best time to educate the children about awareness of the hospital is when the children are capable of understanding the basic function of community resources. Children do not fully understand death and dying until later in childhood, and it is not necessary to fully comprehend death/dying in order for younger children to understand hospitals. Showing interest and recognizing emergency workers and vehicles does not mean the children are capable of understanding the function of the hospital.

The nurse is working in the emergency department when a 2-week-old is brought in for restlessness, a cry that has become high-pitched and projectile vomiting. The infant's head circumference has grown by 4 cm from birth measurements. What nursing action is most appropriate? Arranging a medical workup Planning a discharge witnessing a consent for surgey

witnessing a consent for surgery Explanation: Hydrocephalus is anticipated from the data provided. Surgical intervention is the only effective means of relieving pressure and preventing additional damage to the brain from hydrocephalus. Hydrocephalus is not a terminal illness needing hospice care, unless no medical intervention is obtained. There is little further work-up which needs to be completed. Surgery is the main option. The infant will not be discharged to a home setting.