5 Questions (Ch. 10), 3 Questions (Ch. 29), 4 Questions (Ch. 30), 5 Questions (Ch. 35), 4 Questions (Ch. 34), 6 Questions (Ch. 33), 4 Questions (Ch. 32), 5 Questions (Ch. 31), 10 Questions (Ch. 28), 8 Questions (Ch. 40)

Which tool measures body fat most accurately? *a.* Stadiometer. *b.* Calipers. *c.* Cloth tape measure. *d.* Paper or metal tape measure.

*b.* Calipers. (Calipers are used to measure skin-fold thickness, which is an indicator of body fat content. Stadiometers are used to measure height. Cloth tape measures should not be used because they can stretch. Paper or metal tape measures can be used for recumbent lengths and other body measurements that must be made.)

Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose" test. The nurse is testing for: *a.* Deep tendon reflexes. *b.* Cerebellar function. *c.* Sensory discrimination. *d.* Ability to follow directions.

*b.* Cerebellar function. (The finger-to-nose test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Although this test enables the nurse to evaluate the child's ability to follow directions, it is used primarily for cerebellar function.)

The nurse is testing an infant's visual acuity. By what age should the infant be able to fix on and follow a target? *a.* 1 month. *b.* 1 to 2 months. *c.* 3 to 4 months. *d.* 6 months.

*c.* 3 to 4 months. (Visual fixation and following a target should b present by ages 3 to 4 months. Ages 1 to 2 months are too young for this developmental milestone. If the infant is not able to fix and follow by 6 months of age, further opthalmologic evaluation is needed.)

When interviewing the mother of a 3-year-old child, the nurse asks about developmental milestones such as the age of walking without assistance. This should be considered because these milestones are: *a.* Unnecessary information because the child is age 3 years. *b.* An important part of the family history. *c.* An important part of the child's past growth and development. *d.* An important part of the child's review of systems.

*c.* An important part of the child's past growth and development. (Information about the attainment of developmental milestones is important to obtain. It provides data about the child's growth and development that should be included in the history. Developmental milestones provide important information about the child's physical, social, and neurologic health. The developmental milestones are specific to this child. If pertinent, attainment of milestones by siblings would be included in the family history. The review of systems does not include the developmental milestones.)

An 8-year-old girls asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: *a.* Ask her why she wants to know. *b.* Determine why she is so anxious. *c.* Explain in simple terms how it works. *d.* Tell her she will see how it works as it is used.

*c.* Explain in simple terms how it works. (School-age children require explanations and reasons for everything. They are interested in the functional aspect of all procedures, objects, and activities. It is appropriate for the nurse to explain how equipment works and what will happen to the child. A nurse should respond positively to requests for information about procedures and health information. By not responding, the nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification or what will be occurring. The nurse must explain how the blood pressure cuff works so the child can observe during the procedure.)

Where is the best place to observe for the presence of petechiae in dark-skinned individuals? *a.* Face. *b.* Buttocks. *c.* Oral mucosa. *d.* Palms and soles.

*c.* Oral mucosa. (Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.)

Where in the health history should the nurse describe all details related to the chief complaint? *a.* Past history. *b.* Chief complaint. *c.* Present illness. *d.* Review of systems.

*c.* Present illness. (This history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present. Past history refers to information that relates to previous aspects of the child's health, not to the current problem. The chief complaint is the specific reason for the child's visit to the clinic, office. or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.)

During a routine health assessment, the nurse notes that an 8-month-old infant has significant head lag. Which is the nurse's most appropriate action? *a.* Teach the parents appropriate exercises. *b.* Recheck head control at the next visit. *c.* Refer the child for further evaluation. *d.* Refer the child for further evaluation if the anterior fontanel is still open.

*c.* Refer the child for further evaluation. (Significant head lag after age 6 months strongly indicates cerebral injury and is referred for further evaluation. Reduction of head lag is part of normal development. Exercises will not be effective. The lack of achievement of this developmental milestone must be evaluated.)

Which action is most likely to encourage parents to talk about their feelings related to their child's illness? *a.* Be sympathetic. *b.* Use direct questions. *c.* Use open-ended questions. *d.* Avoid periods of silence.

*c.* Use open-ended questions. (Closed-ended questions should be avoided when attempting to elicit parent's feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.

When palpating the child's cervical lymph nodes, the nurse notes that they are tender, enlarged, and warm. The best explanation for this is: *a.* Some form of cancer. *b.* Local scalp infection common in children. *c.* Infection or inflammation distal to the site. *d.* Infection or inflammation close to the site.

*d.* Infection or inflammation close to the site. (Small nontender nodes are normal. Tender, enlarged, and warm lymph nodes may indicate infection or inflammation close to their location. Tender lymph nodes do not usually indicate cancer. A scalp infection usually does not cause inflamed lymph nodes. The lymph nodes close to the site of inflammation or infection would be inflamed.)

26. Intrauterine growth restriction (IUGR) is associated with numerous pregnancy-related risk factors (Select all that apply). a. Poor nutrition b. Maternal collagen disease c. Gestational hypertension d. Premature rupture of membranes e. Smoking

A, B, C, E

Because children younger than 5 years are egocentric, the nurse should do which when communicating with them? a. Focus communication on the child. b. Use easy analogies when possible. c. Explain experiences of others to the child. d. Assure the child that communication is private.

ANS: A Because children of this age are able to see things only in terms of themselves, the best approach is to focus communication directly on them. Children should be provided with information about what they can do and how they will feel. With children who are egocentric, analogies, experiences, and assurances that communication is private will not be effective because the child is not capable of understanding.

4. A 41-week pregnant multigravida presents in the labor and delivery unit after a nonstress test indicated that her fetus could be experiencing some difficulties in utero. Which diagnostic tool would yield more detailed information about the fetus? a. Ultrasound for fetal anomalies b. Biophysical profile (BPP) c. Maternal serum alpha-fetoprotein (MSAFP) screening d. Percutaneous umbilical blood sampling (PUBS)

b. Biophysical profile (BPP)

24. Which nursing intervention is necessary before a second-trimester transabdominal ultrasound? a. Place the woman NPO for 12 hours. b. Instruct the woman to drink 1 to 2 quarts of water. c. Administer an enema. d. Perform an abdominal preparation.

b. Instruct the woman to drink 1 to 2 quarts of water.

Which method should the nurse use to view the tonsils and oropharynx of a cooperative 6-year-old child? A) Ask child to open mouth wide and say "aah." B) Ask child to open mouth wide and then place the tongue blade in the center back area of the tongue. C) Examine the mouth when the child is crying to avoid use of tongue blade. D) Pinch nostrils closed until the child opens his or her mouth and then insert the tongue blade.

*A) Ask child to open mouth wide and say "aah."* Rationale: If the child is cooperative, the child can open his or her mouth and move the tongue around for the examiner. A tongue blade is not necessary to visualize the tonsils and oropharynx if the child cooperates. During crying there is insufficient opportunity to completely visualize the tonsils and oropharynx. D is traumatic. There is no reason to use such measures, especially with cooperative children.

During an otoscopic examination on an infant, in which direction is the pinna pulled? A) Down and back B) Down and forward C) Up and forward D) Up and back

*A) Down and back* Rationale: Correct position for an *infant's ear examination is to pull the pinna down and back*. *Pulling the pinna down and forward is the correct position for a child age 3 years and over.* Pulling the pinna up and forward will not allow sufficient visualization of the ear. Pulling the pinna up and back will not allow sufficient visualization of the ear.

Guidelines for a nurse using an interpreter in developing a care plan for an 8-year-old admitted to rule out epilepsy include: A) explaining to the interpreter what information is necessary to obtain from the patient and family. B) encouraging the interpreter to ask several questions at a time to make the best use of time. C) not giving the interpreter too much information so the interview evolves. D) discouraging the interpreter and client from discussing topics that are deemed irrelevant to the original intent of the interview.

*A) explaining to the interpreter what information is necessary to obtain from the patient and family. * Rationale: The interpreter should be given guidance about what information is necessary to obtain during the interview. One question should be asked at a time, leaving sufficient time for the family to answer. The interpreter should not have to guess what to ask and what information to obtain during the interview. The interpreter should gain as much information from the family as they are willing to share based on the questions posed. Limits should not be placed on the interview.

The charge nurse is observing a student nurse obtain a temperature on a pediatric patient. The nurse should intervene when observing the student: (Select all that apply.) A) obtain a rectal thermometer probe for a child with diarrhea. B) attempt to take an oral temperature on a child who is receiving oxygen. C) take an oral temperature on a 12-year-old child who ate ice cream 2 hours ago. D) documenting an axillary temperature for a 3-year-old child. E) taking an axillary temperature on a 3-week-old infant.

*A) obtain a rectal thermometer probe for a child with diarrhea.* *B) attempt to take an oral temperature on a child who is receiving oxygen.* *D) documenting an axillary temperature for a 3-year-old child* Rationale: IN EVOLVE IT LISTS D AS AN ANSWER, BUT IN THE RATIONALE IT STATES: An oral temperature is appropriate for a 12-year-old child who has not had anything hot or cold to eat or drink recently. An axillary temperature is appropriate for a 3-year-old child. BUT THEN IT ALSO STATES: Axillary temperatures are inconsistent and insensitive in infants and children over 1 month old. *Rectal* measurement remains the clinical gold standard for the precise diagnosis of fever in infants and children compared with other methods. However, this procedure is more invasive and is *contraindicated for infants less than 1 month old, children with recent rectal surgery, children with diarrhea or anorectal lesions, and children receiving chemotherapy.* *Oral temperatures* are considered the standard for temperature measurement but are *contraindicated in children who have an altered level of consciousness, are receiving oxygen, are mouth breathing, are experiencing mucositis, had recent oral surgery or trauma, or are under 5 years old.* This is inconsistent and insensitive in infants and children over 1 month old. Axillary temperatures are inconsistent and insensitive in infants and children over 1 month old. The charge nurse should intervene to assess if a definitive temperature is needed. The temperature may need to be taken by a different route. For infants less than 1 month old, the American Academy of Pediatrics (2001) recommends axillary temperatures.

A nurse is conducting a health history on an adolescent. Components of the health history include: (Select all that apply.) A) sexual history. B) review of systems. C) physical assessment. D) growth measurements. E) family medical history.

*A) sexual history.* *B) review of systems.* *E) family medical history.* Rationale: Sexual history is a component of the health history. Review of systems is a component of the health history. Review of family medical history is a component of the health history. Physical assessment is a component of the physical examination. Growth measurements are a component of the physical examination.

The nurse is ready to begin a physical examination on an 8-month-old infant. The child is sitting contentedly on his mother's lap, chewing on a toy. What should the nurse do FIRST? A) Elicit reflexes B) Auscultate heart and lungs C) Examine eyes, ears, and mouth D) Examine head, systematically moving toward feet

*Auscultate heart and lungs* Rationale: Auscultation should be performed while the child is quiet. A and C may disturb or upset the child, making auscultation and the remainder of the physical examination difficult. Although D is the way most physical examinations proceed, the *nurse should perform the assessment for a child in an order that moves from least disturbing to most disturbing from the child's perspective.*

What explains the importance of detecting strabismus in young children? A) Color vision deficit may result. B) Amblyopia, a type of blindness, may result. C) Epicanthal folds may develop in affected eye. D) Ptosis may develop secondarily.

*B) Amblyopia, a type of blindness, may result.* Rationale: Amblyopia may develop if the eyes do not work together. The brain may ignore the visual cues from one eye, resulting in blindness. Color vision depends on rods and cones in the retina, not muscle coordination. Epicanthal folds are present at birth. Ptosis, or drooping eyelids, is not related to strabismus (or cross-eyes).

The nurse is interviewing the mother of Adam, 9 years old. As the nurse begins to assess Adam's school performance, the MOST appropriate question to ask is: A) "Did Adam go to preschool?" B) "Does Adam have problems at school?" C) "How is Adam doing in school?" D) "How well does Adam seem to be doing in school?"

*C) "How is Adam doing in school?"* Rationale: This is an open-ended question without any descriptive terms that may limit the mother's responses. A is a close-ended question, which will elicit a yes or no answer. B is a close-ended question that implies that Adam is not doing well. D is a close-ended question that will have a short answer and assumes that Adam is doing well.

Which statement is true concerning the increased use of telephone triage by nurses? A) Telephone triage has led to an increase in health care costs. B) Emergency department visits are not recommended by nurses and thus are not a Perry component of telephone triage. C) Access to high-quality health care services has increased through telephone triage. D) Home care is often recommended when it is not appropriate.

*C) Access to high-quality health care services has increased through telephone triage.* Rationale: Health care costs have decreased because of fewer visits to emergency departments. Based on the response to screening questions, the triage nurse determines whether the child needs to be referred to emergency medical services. The nurse can then initiate the call if needed. The judicious use of telephone triage has decreased the number of unnecessary visits, allowing time for improved care. Home care is recommended only when indicated on the basis of the screening questions.

Superficial palpation of the abdomen is often perceived by the child as tickling. Which measure by the nurse is MOST likely to minimize this sensation and promote relaxation? A) Palpating another area simultaneously B) Asking the child not to laugh or move if it tickles C) Beginning with deeper palpation and gradually progressing to superficial palpation D) Having the child "help" with palpation by placing his or her hand over the palpating hand

*D) Having the child "help" with palpation by placing his or her hand over the palpating hand* Rationale: This allows the nurse to perform the assessment while including the child in the care. A would not promote relaxation and would make it more difficult to perform the abdominal assessment. B may only contribute to the child's laughter or may prove frustrating to both the child and the nurse. C - Deeper palpation enhances the "tickling" sensation, not lessen it.

Which statement explains why it can be difficult to assess a child's dietary intake? A) No systematic assessment tool has been developed for this purpose. B) Biochemical analysis for assessing nutrition is expensive. C) Families usually do not understand much about nutrition. D) Recall of children's food consumption is frequently unreliable.

*D) Recall of children's food consumption is frequently unreliable.* Rationale: It is difficult for parents to recall exactly what their child has eaten. Concurrent food diaries are somewhat more reliable. Systematic tools have been developed and are available. Nutrients for different foods are known; it is the quantity and type of food consumed that are difficult to ascertain. The family does not need nutrition knowledge to describe what the child has eaten.

The nurse is assessing skin turgor in a child. The nurse grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. The tissue remains suspended, or tented, for a few seconds, then slowly falls back on the abdomen. Which evaluation can the nurse correctly assume? A) The tissue shows normal elasticity. B) The child is properly hydrated. C) The assessment is done incorrectly. D) The child has poor skin turgor.

*D) The child has poor skin turgor.* Rationale: In normal elasticity the skin would return immediately to its original position. If the child is properly hydrated, skin turgor would be elastic. This is the correct way to assess turgor. "Tenting" is the term for poor skin turgor.

When assessing a preschooler's chest, the nurse would expect: A) respiratory movements to be chiefly thoracic. anteroposterior diameter to be equal to the transverse diameter. B) intercostal retractions on respiratory movement. C) movement of the chest wall to be symmetric D) bilaterally and coordinated with breathing.

*D) bilaterally and coordinated with breathing.* Rationale: The preschool-age child should have symmetric chest movement bilaterally and a coordinated breathing pattern. At this age breathing is a coordinated function and is primarily abdominal or diaphragmatic. Thoracic breathing occurs in older children, particularly girls. Anteroposterior diameter is equal to transverse diameter in infants. As the child grows, the chest normally increases in the transverse direction; thus the anteroposterior diameter is less than the lateral diameter. Intercostal retractions indicate respiratory distress.

The nurse needs to give an injection in the deltoid to a 4-year-old child. The BEST approach to use is to: A) smile while giving the injection to help child relax. B) tell the child that you will be so quick that the injection will not even hurt. C) explain that the child will experience a little stick in the arm. D) explain with concrete terms, such as putting medicine under the skin.

*D) explain with concrete terms, such as putting medicine under the skin.* Rationale: Children at this age are very literal. By using concrete terms the nurse helps the child understand what the nurse is going to do. A is too abstract. The young child will not correlate a smile with relaxation. Distraction techniques are more appropriate. The nurse does not know that the injection will not hurt the child. Lying or distorting the truth is never appropriate. This response will block trust, especially if the injection does hurt the child. The child may visualize an actual stick being placed in the arm.

The nurse needs to take the blood pressure of a small child. Of the cuffs available, one is too large, and one is too small. The BEST nursing action is to: A) use the small cuff. B) use the large cuff. C) use either cuff, using palpation method. D) locate the proper size cuff before taking the blood pressure.

*D) locate the proper size cuff before taking the blood pressure.* Rationale: To obtain an accurate blood pressure reading, it is preferable to use the proper-size cuff. Thus locating one before taking the blood pressure is the best nursing action. The *smaller cuff* gives a *falsely increased blood pressure* and is not the method of choice. The *larger cuff*, which may give a *falsely lowered blood pressure*, is preferable to the smaller cuff, which gives a falsely increased blood pressure, but neither is the method of choice. Auscultation is preferred to palpation.

The most accurate method of determining the length of a child less than 12 months of age is: A) standing height. B) estimation of length to the nearest centimeter or ½ inch. C) recumbent length measured in the prone position. D) recumbent length measured in the supine position.

*D) recumbent length measured in the supine position.* Rationale: Infants are generally unable to stand to obtain a height measurement. Measurement should not be estimated since an accurate measurement is required to determine growth. The infant should be measured in the supine, not the prone, position. The crown-heel length measurement is the most accurate measurement in infants.

During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that his is: *a.* A normal finding. *b.* An abnormal finding; the child needs referral to an opthalmologist. *c.* A sign of a possible visual defect; the child needs vision screening. *d.* A sign of small hemorrhages, which usually resolve spontaneously.

*a.* A normal finding. (A brilliant, uniform red reflex is an important normal and expected finding. It rules out many serious defects of the cornea, aqueous chamber, lens, and vitreous chamber.)

The nurse is interviewing the mother of an infant. She reports, "I had a difficult delivery, and my baby was born prematurely." This information should be recorded under which heading? *a.* Birth history. *b.* Present illness. *c.* Chief complaint. *d.* Review of systems.

*a.* Birth history. (The birth history refers to information that relates to previous aspects of the child's health, not to the current problem. The mother's difficult delivery and prematurity are important parts of the past history of an infant. The history of the present illness is a narrative of the chief complaint from its earliest onset through it progression to the present. Unless the chief complaint is directly related to the prematurity, this information is not included in the history of present illness. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It would not include the birth information. The review of systems is a specific review of each body system. It does not include the premature birth. Sequelae such as pulmonary dysfunction would be included.)

A nurse is performing an assessment on a school-age child. Which findings suggest the child is receiving an excess of vitamin A? (Select all that apply) *a.* Delayed sexual development. *b.* Edema. *c.* Pruritus. *d.* Jaundice. *e.* Paresthesia.

*a.* Delayed sexual development. *c.* Pruritus. *d.* Jaundice. (Excess vitamin A can cause delayed sexual development, pruritus, and jaundice. Edema is seen with excess sodium. Paresthesia occurs with excess riboflavin.)

A nurse is planning to use an interpreter during a health history interview of a non-English speaking patient and family. Which nursing care guidelines should the nurse include when using an interpreter? (Select all that apply) *a.* Elicit one answer at a time. *b.* Interrupt the interpreter if the response from the family is lengthy. *c.* Comments to the interpreter about the family should be made in English. *d.* Arrange for the family to speak with the same interpreter, if possible. *e.* Introduce the interpreter to the family.

*a.* Elicit one answer at a time. *d.* Arrange for the family to speak with the same interpreter, if possible. *e.* Introduce the interpreter to the family. (When using an interpreter, the nurse should pose questions to elicit only one answer at a time, such as: "Do you have pain?" rather than "Do you have any pain, tiredness, or loss of appetite?" Refrain from interrupting family members and the interpreter while they are conversing. Introduce the interpreter to family and allow some time before the interview for them to become acquainted. Refrain from interrupting family members and the interpreter while they are conversing. Avoid commenting to the interpreter about family members because they may understand some English.)

The nurse must assess a 10-month-old infant. The infant is sitting on the father's lap and appears to be afraid of the nurse and of what may happen next. Which initial action by the nurse would be most appropriate? *a.* Initiate a game of peek-a-boo. *b.* Ask the father to place the infant on the examination table. *c.* Undress the infant while he is still sitting on his father's lap. *d.* Talk softly to the infant while taking him from his father.

*a.* Initiate a game of peek-a-boo. (Peek-a-boo is an excellent means of initiating communication with infants while maintaining a safe, nonthreatening distance. The child will most likely become upset if separated from his father. As much of the assessment as possible should be done while the child is on the father's lap. The nurse should have the father undress the child as needed for the examination.)

The nurse is seeing an adolescent boy and his parents in the clinic for the first time. What should the nurse do first? *a.* Introduce himself or herself. *b.* Make the family comfortable. *c.* Explain the purpose of the interview. *d.* Give an assurance of privacy.

*a.* Introduce himself or herself. (The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. During the initial part of the interview the nurse should include general conversation to help make the family feel at ease. Next, the purpose of the interview and the nurse's role should be clarified. The interview should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.)

The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. The rationale for this position is that: *a.* It prevents cremasteric reflex. *b.* Undescended testes can be palpated. *c.* This tests the child for inguinal hernia. *d.* The child does not yet have a need for privacy.

*a.* It prevents cremasteric reflex. (The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its contraction, which pulls the testes into the pelvic cavity. Undescended testes cannot be predictably palpated. Inguinal hernias are not detected by this method. This position is used for inhibiting the cremastic reflex. Privacy should always be provided for children.)

The nurse has just started assessing a young child who is febrile and appears very ill. There is hyperextension of the child's head (opisthotonos) with pain on flexion. The most appropriate action is to: *a.* Refer for immediate medical evaluation. *b.* Continue the assessment to determine the cause of the neck pain. *c.* Ask the parent when the child's neck was injured. *d.* Record "head lag" on the assessment record and continue the assessment of the child.

*a.* Refer for immediate medical evaluation. (These symptoms indicate meningeal irritation and need immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag.)

Which data would be included in a health history? (Select all that apply) *a.* Review of systems. *b.* Physical assessment. *c.* Sexual history. *d.* Growth measurements. *e.* Nutritional assessment. *f.* Family medical history.

*a.* Review of systems. *c.* Sexual history. *e.* Nutritional assessment. *f.* Family medical history. (The review of systems, sexual history, nutritional assessment, and family medical history are part of the health history. Physical assessment and growth measurements are components of the physical examination.)

When introducing hospital equipment to a preschooler who seems afraid, the nurse's approach should be based on which principle? *a.* The child may think the equipment is alive. *b.* The child is too young to understand what equipment does. *c.* Explaining the equipment will only increase the child's fear. *d.* One brief explanation is enough to reduce the child's fear.

*a.* The child may think the equipment is alive. (Young children attribute human characteristics to inanimate objects. They often fear that the objects my jump, bite, cut , or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. The child should be given simple concrete explanations about what the equipment does and how it will feel to the child. Simple, concrete explanations help alleviate the child's fear. The preschooler will need repeated explanations as reassurance.)

What type of breath sound is normally heard over the entire surface of the lungs, except for the upper intrascapular area and the area beneath the manubrium? *a.* Vesicular. *b.* Bronchial. *c.* Adventitious. *d.* Bronchovesicular.

*a.* Vesicular. (Vesicular breath sounds are heard of the entire surface of the lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate.)

The earliest age at which a satisfactory radial pulse can be take in children is: *a.* 1 year. *b.* 2 years. *c.* 3 years. *d.* 6 years.

*b.* 2 years. (Satisfactory radial pulses can be used in children older than 2 years. In infants and young children the apical pulse is more reliable. The radial pulse can be used for assessment at ages 3 and 6 years.)

Binocularity, the ability to fixate on one visual field with both eyes simultaneously, is normally present by what age? *a.* 1 month. *b.* 3 to 4 months. *c.* 6 to 8 months. *d.* 12 months.

*b.* 3 to 4 months. (Binocularity is usually achieved by ages 3 to 4 months. Age 1 month is too young for binocularity. If binocularity is not achieved by 6 months, the child must be observed for strabismus.)

The nurse is meeting a 5-year-old child for the first time and would like the child to cooperate during a dressing change. The nurse decides to do a simple magic trick using gauze. This should be interpreted as: *a.* Inappropriate, because of child's age. *b.* A way to establish rapport. *c.* Too distracting, when cooperation is important. *d.* Acceptable, if there is adequate time.

*b.* A way to establish rapport. (A magic trick or other simple game may help alleviate anxiety for a 5-year-old. It is an excellent method to build rapport and facilitate cooperation during a procedure. Magic tricks appeal to the natural curiosity of young children. The nurse should establish rapport with the child. Failure to do so may cause the procedure to take longer and be more traumatic.)

When the nurse interviews an adolescent, it is especially important to: *a.* Focus the discussion on the peer group. *b.* Allow an opportunity to express feelings. *c.* Emphasize that confidentiality will always be maintained. *d.* Use the same type of language as the adolescent.

*b.* Allow an opportunity to express feelings. (Adolescents, like all children, need an opportunity to express their feelings. Often they will interject feelings into their words. The nurse must be alert to the words and feelings expressed. Although the peer group is important to this age group, the focus of the interview should be on the adolescent. The nurse should clarify which information will be shared with other members of the health care team and any limits to confidentiality. The nurse should maintain a professional relationship with adolescents. To avoid misinterpretation of words and phrases that the adolescent may use, the nurse should clarify terms frequently.)

The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: *a.* Ask her, "Are you sexually active?" *b.* Ask her, "Are you having sex with anyone?" *c.* Ask her, "Are you having sex with your boyfriend?" *d.* Ask both the girl and her parent if she is sexually active.

*b.* Ask her, "Are you having sex with anyone?" (Asking the adolescent girl if she is having sex with anyone is a direct question that is well understood. The phrase "sexually active" is broadly defined and may not provide specific information to the nurse to provide necessary care. The word "anyone" is preferred to using gender-specific terms such as boyfriend or girlfriend. Because homosexual experimentation may occur, it is preferable to use gender-neutral terms. Questioning about sexual activity should occur when the adolescent is alone.)

The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? *a.* Ask for a detailed listing of symptoms. *b.* Ask the adolescent, "Why did you come here today?" *c.* Use what the adolescent says to determine, in correct medical terminology, what the problem is. *d.* Interview the parent away from the adolescent to determine the chief complaint.

*b.* Ask the adolescent, "Why did you come here today?" (The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A listing of symptoms will make it difficult to determine the chief complain. The adolescent should be prompted to tell which symptom caused him or her to seek help at this time. The chief complaint is usually written in the words that the parent or adolescent uses to describe the reason for seeking help. The parent and adolescent may be interviewed separately, but the nurse should determine the reason the adolescent is seeking attention at this time.)

A school nurse is screening children for scoliosis. Which assessment findings should the nurse expect to observe for scoliosis? (Select all that apply) *a.* Complaints of a sore back. *b.* Asymmetry of the shoulder. *c.* An uneven hemline. *d.* Inability to bend at the waist. *e.* Unequal waist angles.

*b.* Asymmetry of the shoulder. *c.* An uneven hemline. *e.* Unequal waist angles. (The assessment findings associated with scoliosis include asymmetry of the shoulder and hips, trouser pant leg length appearing shorter on one side, or an uneven hemline on a skirt, indicating unequal leg length. The child may also complain of a sore back. The child is able to bend at the waist adequately.)

The nurse must check vital signs on a 2-year-old boy who is brought to the clinic for his 24-month checkup. Which criteria should the nurse use in determining the appropriate-size blood pressure cuff? (Select all that apply) *a.* The cuff is labeled "toddler." *b.* The cuff bladder width is approximately 40% of the circumference of the upper arm . *c.* The cuff bladder length covers 80% to 100% of the circumference of the upper arm. *d.* The cuff bladder covers 50% to 66% of the length of the upper arm.

*b.* The cuff bladder width is approximately 40% of the circumference of the upper arm. *c.* The cuff bladder length covers 80% to 100% of the circumference of the upper arm. (Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. This size cuff is a representative size that may not be suitable for any individual child. Choosing a cuff by limb circumference more accurately reflects arterial pressure than choosing a cuff by length.)

The appropriate placement of a tongue blade for assessment of the mouth and throat is the: *a.* The center back area of the tongue. *b.* The side of the tongue. *c.* Against the soft palate. *d.* On the lower jaw.

*b.* The side of the tongue. (The side of the tongue is the correct position. It avoids the gag reflex yet allows visualization. Placement on the center back area of the tongue elicits the gag reflex. Against the soft palate and on the lower jaw are not appropriate places for the tongue blade.)

What is an important consideration for the nurse who is communicating with a very young child? *a.* Speak loudly, clearly, and directly. *b.* Use transition objects such as a doll. *c.* Disguise own feelings, attitudes, and anxiety. *d.* Initiate contact with the child when the parent is not present.

*b.* Use transition objects such as a doll. (Using a transition object allows the young child an opportunity to evaluate an unfamiliar person (the nurse). This facilitates communication with this age child. Speaking loudly, clearly, and directly tends to increase anxiety in very young children. The nurse must be honest with the child. Attempts at deception lead to a lack of trust. Whenever possible, the parent should be present for interactions with young children.)

By what age do the head and chest circumferences generally become equal? *a.* 1 month. *b.* 6 to 9 months. *c.* 1 to 2 years. *d.* 2.5 to 3 years.

*c.* 1 to 2 years. (Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference at ages 1 month and 6 to 9 months. Chest circumference is larger that head circumference at age 2.5 to 3 years.)

With the National Center for Health Statistics (NCHS) criteria, which body mass index (BMI)-for-age percentile indicates a risk for being overweight? *a.* 10th percentile. *b.* 9th percentile. *c.* 85th percentile. *d.* 95th percentile.

*c.* 85th percentile. (Children who have BMI-for-age greater than or equal to the 85th percentile and less than the 95th percentile are at risk for being overweight. Children in the 9th and 10th percentiles are within normal limits. Children who are greater than or equal to the 95th percentile are considered overweight.)

When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: *a.* Indicates that they live in poverty. *b.* Is lacking protein. *c.* May provide sufficient amino acids. *d.* Should be enriched with meat and milk.

*c.* May provide sufficient amino acids. (The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat of dairy protein is low. Many cultures use diets that contain this combination of foods. It does not indicate poverty. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.)

What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood? *a.* S1, S2 *b.* S3, S4 *c.* Murmur. *d.* Physiologic splitting.

*c.* Murmur. (Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. S1 is the closure of the tricuspid and mitral valves, and both are considered normal heart sounds. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.)

Which age group is most concerned with body integrity? *a.* Toddler. *b.* Preschooler. *c.* School-age child. *d.* Adolescent.

*c.* School-age children. (School-age children have a heightened concern about body integrity. They place importance and value on their bodies and are overly sensitive to anything that constitutes a threat or suggestion of injury. Body integrity is not as important a concern to children in the toddler, preschooler, and adolescent age groups.)

What is the single most important factor to consider when communicating with children? *a.* The child's physical condition. *b.* The presence of absence of the child's parent. *c.* The child's developmental level. *d.* The child's nonverbal behaviors.

*c.* The child's developmental level. (The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Although the child's physical condition is a consideration, developmental level is much more important. The parents' presence is important when communicating with young children, but it may be detrimental when speaking with adolescents. Nonverbal behaviors vary in importance based on the child's developmental level.)

An appropriate approach to performing a physical assessment on a toddler is to: *a.* Always proceed in a head-to-toe direction. *b.* Perform traumatic procedures first. *c.* Use minimal physical contact initially. *d.* Demonstrate use of equipment.

*c.* Use minimal physical contact initially. (Parents can remove the child's clothing, and the child can remain on the parent's lap. The nurse should use minimal physical contact initially to gain the child's cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age group.)

What term is used to describe breath sounds that are produced as air passes through narrowed passageways? *a.* Rubs. *b.* Rattles. *c.* Wheezes. *d.* Crackles.

*c.* Wheezes. (Wheezes are produced as air passes through narrowed passageways. The sound is similar when the narrowing is caused by exudates, inflammation, spasm, or tumor. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friciton rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture.)

The nurse should expect the anterior fontanel to close at age: *a.* 2 months. *b.* 2 to 4 months. *c.* 6 to 8 months. *d.* 12 to 18 months.

*d.* 12 to 18 months. (Ages 2 through 8 months are too early. The expected closure of the anterior fontanel occurs between 12 and 18 months; if it closes at these earlier ages, the child should be referred for further evaluation.)

The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique may be most helpful? *a.* Suggest that the child keep a diary. *b.* Suggest that the parent read fairy tales to the child. *c.* Ask the parent whether the child is always uncommunicative. *d.* Ask the child to draw a picture.

*d.* Ask the child to draw a picture. (Drawing is one of the most valuable forms of communication. Children's drawings tell a great deal about them because they are projections of the child's inner self. It would be difficult for a 6-year-old child to keep a diary because the child is most likely learning to read. Reading fairy tales to the child is a passive activity involving the parent and child. It would not facilitate communication with the nurse. The child is in a stressful situation and is probably uncomfortable with strangers, not necessarily uncommunicative.)

During examination of a toddler's extremities, the nurse notes that the child is bowlegged. The nurse should recognize that this finding is: *a.* Abnormal and requires further investigation. *b.* Abnormal unless it occurs in conjunction with knock-knee. *c.* Normal if the condition is unilateral or asymmetric. *d.* Normal because the lower back and leg muscles are not yet well developed.

*d.* Normal because the lower back and leg muscles are not yet well developed. (Lateral bowing of the tibia (bowlegged) is common in toddlers when they begin to walk, not an abnormal finding. It usually persists until all of their lower back and leg muscles are well developed. Further evaluation is needed if it persists beyond ages 2 to 3 years, especially in African-American children.)

The nurse must assess a child's capillary filling time. This can be accomplished by: *a.* Inspecting the chest. *b.* Auscultating the heart. *c.* Palpating the apical pulse. *d.* Palpating the skin to produce a slight blanching.

*d.* Palpating the skin to produce a slight blanching. (Capillary filling time is assessed by pressing lightly on the skin to produce blanching and then noting the amount of time it takes for the blanched area to refill. Inspecting the chest, auscultating the heart, and palpating the apical pulse will not provide an assessment of capillary filling time.)

The most frequently used test for measuring visual acuity is the : *a.* Denver Eye Screening test. *b.* Allen picture card test. *c.* Ishihara vision test. *d.* Snellen letter chart.

*d.* Snellen letter chart. (The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. Single cards (Denver--letter E; Allen--pictures) are used for children 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for color vision.)

The nurse is using the NCHS growth chart for an African-American child. The nurse should consider that: *a.* This growth chart should not be used. *b.* Growth patterns of African-American children are the same as for all other ethnic groups. *c.* A correction factor is necessary when the NCHS growth chart is used for non-Caucasian ethnic groups. *d.* The NCHS charts are accurate for U.S. African-American children.

*d.* The NCHS charts are accurate for U.S. African-American children. (The NCHS growth charts can serve as reference guides for all racial or ethnic groups. U.S. African-American children were included in the sample population. The growth chart can be used with the perspective that different groups of children have varying normal distributions on the growth curves. No correction factor exists.)

Which parameter correlates best with measurements of the body's total protein stores? *a.* Height. *b.* Weight. *c.* Skin-fold thickness. *d.* Upper arm circumference.

*d.* Upper arm circumference. (Upper arm circumference is correlated with measurements of total body mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the body's fat content.)

27. Transvaginal ultrasonography is often performed during the first trimester. While preparing your 6-week gestation patient for this procedure, she expresses concerns over the necessity for this test. The nurse should explain that this diagnostic test may be indicated for a number of situations (Select all that apply). a. Multifetal gestation b. Obesity c. Fetal abnormalities d. Amniotic fluid volume e. Ectopic pregnancy

A, B, C, E

The nurse is reviewing lab values to determine Rh incompatibility between mother and fetus. The nurse should assess which specific lab result? A. Indirect Coombs test B. Hemoglobin level C. hCG level D. Maternal serum alpha-fetoprotein (MSAFP)

A. Indirect Coombs test The indirect Coombs test is a screening tool for Rh incompatibility. If the maternal titer for Rh antibodies is greater than 1:8, amniocentesis for determination of bilirubin in amniotic fluid is indicated to establish the severity of fetal hemolytic anemia. Hemoglobin reveals the oxygen carrying capacity of the blood. hCG is the hormone of pregnancy. Maternal serum alpha-fetoprotein (MSAFP) levels are used as a screening tool for NTDs in pregnancy

Prior to the patient undergoing amniocentesis, the most appropriate nursing intervention is to: A: administer RhoD immunoglobulin. B. send the patient for a computed tomography (CT) scan before the procedure. C. assure the mother that short-term radiation exposure is not harmful to the fetus. D. administer anticoagulant.

A: administer RhoD immunoglobulin. Because of the possibility of fetomaternal hemorrhage, administering RhoD immunoglobulin to the woman who is Rh negative is standard practice after an amniocentesis. Anticoagulants are not administered before amniocentesis as this would increase the risk of bleeding when the needle is inserted transabdominally. A CT is not required before amniocentesis, because the procedure is ultrasound guided. The mother is not exposed to radiation during amniocentesis.

The nurse is seeing an adolescent and the parents in the clinic for the first time. Which should the nurse do first? a. Introduce him- or herself. b. Make the family comfortable. c. Give assurance of privacy. d. Explain the purpose of the interview.

ANS: A The first thing that nurses must do is to introduce themselves to the patient and family. Parents and other adults should be addressed with appropriate titles unless they specify a preferred name. Clarification of the purpose of the interview and the nurse's role is the second thing that should be done. During the initial part of the interview, the nurse should include general conversation to help make the family feel at ease. The interview also should take place in an environment as free of distraction as possible. In addition, the nurse should clarify which information will be shared with other members of the health care team and any limits to the confidentiality.

The nurse's approach when introducing hospital equipment to a preschooler who seems afraid should be based on which principle? a. The child may think the equipment is alive. b. Explaining the equipment will only increase the child's fear. c. One brief explanation will be enough to reduce the child's fear. d. The child is too young to understand what the equipment does.

ANS: A Young children attribute human characteristics to inanimate objects. They often fear that the objects may jump, bite, cut, or pinch all by themselves without human direction. Equipment should be kept out of sight until needed. Simple, concrete explanations about what the equipment does and how it will feel will help alleviate the child's fear. Preschoolers need repeated explanations as reassurance.

Which is considered a block to effective communication? a. Using silence b. Using clichés c. Directing the focus d. Defining the problem

ANS: B Using stereotyped comments or clichés can block effective communication. After the nurse uses such trite phrases, parents often do not respond. Silence can be an effective interviewing tool. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions. To be effective, the nurse must be able to direct the focus of the interview while allowing maximum freedom of expression. By using open-ended questions and guiding questions, the nurse can obtain the necessary information and maintain a relationship with the family. The nurse and parent must collaborate and define the problem that will be the focus of the nursing intervention.

Which is the single most important factor to consider when communicating with children? a. Presence of the child's parent b. Child's physical condition c. Child's developmental level d. Child's nonverbal behaviors

ANS: C The nurse must be aware of the child's developmental stage to engage in effective communication. The use of both verbal and nonverbal communication should be appropriate to the developmental level. Nonverbal behaviors vary in importance based on the child's developmental level and physical condition. Although the child's physical condition is a consideration, developmental level is much more important. The presence of parents is important when communicating with young children but may be detrimental when speaking with adolescents.

What is an indicator for performing a contraction stress test? A. Increased fetal movement and small for gestational age B. Maternal diabetes mellitus and postmaturity C. Adolescent pregnancy and poor prenatal care D. History of preterm labor and intrauterine growth restriction

B. Maternal diabetes mellitus and postmaturity Decreased fetal movement is an indicator for performing a contraction stress test; the size (small for gestational age) is not an indicator. Maternal diabetes mellitus and postmaturity are two indications for performing a contraction stress test. Although adolescent pregnancy and poor prenatal care are risk factors of poor fetal outcomes, they are not indicators for performing a contraction stress test. Intrauterine growth restriction is an indicator; but history of a previous stillbirth, not preterm labor, is the other indicator.

A nonstress test (NST) is ordered on a pregnant women at 37 weeks gestation. What are the most appropriate teaching points to include when explaining the procedure to the patient? (Select all that apply) A. After 20 minutes, a nonreactive reading indicates the test is complete. B. Vibroacoustic stimulation may be used during the test. C. Drinking orange juice before the test is appropriate. D. A needle biopsy may be needed to stimulate contractions. E. Two sensors are placed on the abdomen to measure contractions and fetal heart tones.

B. Vibroacoustic stimulation may be used during the test. C. Drinking orange juice before the test is appropriate. E.Two sensors are placed on the abdomen to measure contractions and fetal heart tones. A nonreactive test requires further evaluation. The testing period is often extended, usually for an additional 20 minutes, with the expectation that the fetal sleep state will change and the test will become reactive. During this time vibroacoustic stimulation (see later discussion) may be used to stimulate fetal activity. Vibroacoustic stimulation is often used to stimulate fetal activity if the initial NST result is nonreactive and thus hopefully shortens the time required to complete the test (Greenberg, Druzin, and Gabbe, 2012). Care providers sometimes suggest that the woman drink orange juice or be given glucose to increase her blood sugar level and thereby stimulate fetal movements. Although this practice is common, there is no evidence that it increases fetal activity (Greenberg, Druzin, and Gabbe, 2012). A needle biopsy is not part of a NST. The FHR is recorded with a Doppler transducer, and a tocodynamometer is applied to detect uterine contractions or fetal movements. The tracing is observed for signs of fetal activity and a concurrent acceleration of FHR.

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement by the woman would indicate a correct understanding of the test? A. "I will need to have a full bladder for the test to be done accurately." B. "I should have my husband drive me home after the test because I may be nauseous." C. "This test will help to determine if the baby has Down syndrome or a neural tube defect." D."This test will observe for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby."

D. "This test will observe for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." An ultrasound is the test that requires a full bladder. An amniocentesis would be the test that a pregnant woman should be driven home afterward. A maternal alpha-fetoprotein test is used in conjunction with unconjugated estriol levels, and human chorionic gonadotropin helps to determine Down syndrome. The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.

The health care provider has ordered a magnetic resonance imaging (MRI) study to be done on a pregnant patient to evaluate fetal structure and growth. The nurse should include which instructions when preparing the patient for this test? (Select all that apply.) A. A lead apron must be worn during the test. B. A full bladder is required prior to the test. C. An intravenous line must be inserted before the test. D. Jewelry must be removed before the test. E. Remain still throughout the test.

D. Jewelry must be removed before the test. E. Remain still throughout the test. Magnetic resonance imaging (MRI) is a noninvasive radiologic technique used for obstetric and gynecologic diagnosis. Similar to computed tomography (CT), MRI provides excellent pictures of soft tissue. Unlike CT, ionizing radiation is not used. Therefore vascular structures within the body can be visualized and evaluated without injecting an iodinated contrast medium, thus eliminating any known biologic risk. Similar to sonography, MRI is noninvasive and can provide images in multiple planes, but no interference occurs from skeletal, fatty, or gas-filled structures, and imaging of deep pelvic structures does not require a full bladder. The woman is placed on a table in the supine position and moved into the bore of the main magnet, which is similar in appearance to a CT scanner. Depending on the reason for the study, the procedure may take from 20 to 60 minutes, during which time the woman must be perfectly still except for short respites.

15. Nurses should be aware of the strengths and limitations of various biochemical assessments during pregnancy, including that: A. chorionic villus sampling (CVS) is becoming more popular because it provides early diagnosis. B. screening for maternal serum alpha-fetoprotein (MSAFP) levels is recommended only for women at risk for neural tube defects. C. percutaneous umbilical blood sampling (PUBS) is one of the quad-screen tests for Down syndrome. D. MSAFP is a screening tool only; it identifies candidates for more definitive procedures.

D. MSAFP is a screening tool only; it identifies candidates for more definitive procedures. CVS does provide a rapid result, but it is declining in popularity because of advances in noninvasive screening techniques. MSAFP screening is recommended for all pregnant women. MSAFP, not PUBS, is part of the quad-screen tests for Down syndrome. This is correct. MSAFP is a screening tool, not a diagnostic tool. Further diagnostic testing is indicated after an abnormal MSAFP.

21. A pregnant woman's biophysical profile score is 8. She asks the nurse to explain the results. The nurse's best response is: a. "The test results are within normal limits." b. "Immediate delivery by cesarean birth is being considered." c. "Further testing will be performed to determine the meaning of this score." d. "An obstetric specialist will evaluate the results of this profile and, within the next week, will inform you of your options regarding delivery."

a. "The test results are within normal limits."

8. A client asks her nurse, "My doctor told me that he is concerned with the grade of my placenta because I am overdue. What does that mean?" The best response by the nurse is: a. "Your placenta changes as your pregnancy progresses, and it is given a score that indicates the amount of calcium deposits it has. The more calcium deposits, the higher the grade, or number, that is assigned to the placenta. It also means that less blood and oxygen can be delivered to your baby." b. "Your placenta isn't working properly, and your baby is in danger." c. "This means that we will need to perform an amniocentesis to detect if you have any placental damage." d. "Don't worry about it. Everything is fine."

a. "Your placenta changes as your pregnancy progresses, and it is given a score that indicates the amount of calcium deposits it has. The more calcium deposits, the higher the grade, or number, that is assigned to the placenta. It also means that less blood and oxygen can be delivered to your baby."

3. The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what other tool would be useful in confirming the diagnosis? a. Doppler blood flow analysis b. Contraction stress test (CST) c. Amniocentesis d. Daily fetal movement counts

a. Doppler blood flow analysis Doppler blood flow analysis allows the examiner to study the blood flow noninvasively in the fetus and the placenta. It is a helpful tool in the management of high-risk pregnancies because of intrauterine growth restriction (IUGR), diabetes mellitus, multiple fetuses, or preterm labor. Because of the potential risk of inducing labor and causing fetal distress, a CST is not performed on a woman whose fetus is preterm. Indications for an amniocentesis include diagnosis of genetic disorders or congenital anomalies, assessment of pulmonary maturity, and the diagnosis of fetal hemolytic disease, not IUGR. Fetal kick count monitoring is performed to monitor the fetus in pregnancies complicated by conditions that may affect fetal oxygenation. Although this may be a useful tool at some point later in this woman's pregnancy, it is not used to diagnose IUGR.

16. Compared with contraction stress test (CST), nonstress test (NST) for antepartum fetal assessment: a. Has no known contraindications. b. Has fewer false-positive results. c. Is more sensitive in detecting fetal compromise. d. Is slightly more expensive.

a. Has no known contraindications.

13. Nurses should be aware that the biophysical profile (BPP): a. Is an accurate indicator of impending fetal death. b. Is a compilation of health risk factors of the mother during the later stages of pregnancy. c. Consists of a Doppler blood flow analysis and an amniotic fluid index. d. Involves an invasive form of ultrasound examination.

a. Is an accurate indicator of impending fetal death.

22. Which analysis of maternal serum may predict chromosomal abnormalities in the fetus? a. Multiple-marker screening b. Lecithin/sphingomyelin (L/S) ratio c. Biophysical profile d. Type and crossmatch of maternal and fetal serum

a. Multiple-marker screening

9. A woman is undergoing a nipple-stimulated contraction stress test (CST). She is having contractions that occur every 3 minutes. The fetal heart rate (FHR) has a baseline of approximately 120 beats/min without any decelerations. The interpretation of this test is said to be: a. Negative. b. Positive. c. Satisfactory. d. Unsatisfactory.

a. Negative.

2. A 39-year-old primigravida thinks that she is about 8 weeks pregnant, although she has had irregular menstrual periods all her life. She has a history of smoking approximately one pack of cigarettes a day, but she tells you that she is trying to cut down. Her laboratory data are within normal limits. What diagnostic technique could be used with this pregnant woman at this time? a. Ultrasound examination b. Maternal serum alpha-fetoprotein (MSAFP) screening c. Amniocentesis d. Nonstress test (NST)

a. Ultrasound examination

18. A woman has been diagnosed with a high risk pregnancy. She and her husband come into the office in a very anxious state. She seems to be coping by withdrawing from the discussion, showing declining interest. The nurse can best help the couple by: a. Telling her that the physician will isolate the problem with more tests. b. Encouraging her and urging her to continue with childbirth classes. c. Becoming assertive and laying out the decisions the couple needs to make. d. Downplaying her risks by citing success rate studies.

b. Encouraging her and urging her to continue with childbirth classes.

12. In the first trimester, ultrasonography can be used to gain information on: a. Amniotic fluid volume. b. Location of Gestational sacs c. Placental location and maturity. d. Cervical length.

b. Location of Gestational sacs

20. Risk factors tend to be interrelated and cumulative in their effect. While planning the care for a laboring client with diabetes mellitus, the nurse is aware that she is at a greater risk for: a. Oligohydramnios. b. Polyhydramnios. c. Postterm pregnancy. d. Chromosomal abnormalities.

b. Polyhydramnios.

7. Maternal serum alpha-fetoprotein (MSAFP) screening indicates an elevated level. MSAFP screening is repeated and again is reported as higher than normal. What would be the next step in the assessment sequence to determine the well-being of the fetus? a. Percutaneous umbilical blood sampling (PUBS) b. Ultrasound for fetal anomalies c. Biophysical profile (BPP) for fetal well-being d. Amniocentesis for genetic anomalies

b. Ultrasound for fetal anomalies

23. While working with the pregnant woman in her first trimester, the nurse is aware that chorionic villus sampling (CVS) can be performed during pregnancy at: a. 4 weeks b. 8 weeks c. 10 weeks d. 14 weeks

c. 10 weeks

5. At 35 weeks of pregnancy a woman experiences preterm labor. Tocolytics are administered and she is placed on bed rest, but she continues to experience regular uterine contractions, and her cervix is beginning to dilate and efface. What would be an important test for fetal well-being at this time? a. Percutaneous umbilical blood sampling (PUBS) b. Ultrasound for fetal size c. Amniocentesis for fetal lung maturity d. Nonstress test (NST)

c. Amniocentesis for fetal lung maturity

19. In the past, factors to determine whether a woman was likely to develop a high risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted today. There are now four categories based on threats to the health of the woman and the outcome of pregnancy. Which of the following is not one of these categories? a. Biophysical b. Psychosocial c. Geographic d. Environmental

c. Geographic

17. The nurse providing care for the antepartum woman should understand that contraction stress test (CST): a. Sometimes uses vibroacoustic stimulation. b. Is an invasive test; however, contractions are stimulated. c. Is considered negative if no late decelerations are observed with the contractions. d. Is more effective than nonstress test (NST) if the membranes have already been ruptured.

c. Is considered negative if no late decelerations are observed with the contractions.

10. When nurses help their expectant mothers assess the daily fetal movement counts, they should be aware that: a. Alcohol or cigarette smoke can irritate the fetus into greater activity. b. "Kick counts" should be taken every half hour and averaged every 6 hours, with every other 6-hour stretch off. c. The fetal alarm signal should go off when fetal movements stop entirely for 12 hours. d. Obese mothers familiar with their bodies can assess fetal movement as well as average-size women.

c. The fetal alarm signal should go off when fetal movements stop entirely for 12 hours.

14. With regard to amniocentesis, nurses should be aware that: a. Because of new imaging techniques, amniocentesis is now possible in the first trimester. b. Despite the use of ultrasound, complications still occur in the mother or infant in 5% to 10% of cases. c. The shake test, or bubble stability test, is a quick means of determining fetal maturity. d. The presence of meconium in the amniotic fluid is always cause for concern.

c. The shake test, or bubble stability test, is a quick means of determining fetal maturity.

1. A woman arrives at the clinic seeking confirmation that she is pregnant. The following information is obtained: She is 24 years old with a body mass index (BMI) of 17.5. She admits to having used cocaine "several times" during the past year and drinks alcohol occasionally. Her blood pressure (BP) is 108/70 mm Hg, her pulse rate is 72 beats/min, and her respiratory rate is 16 breaths/min. The family history is positive for diabetes mellitus and cancer. Her sister recently gave birth to an infant with a neural tube defect (NTD). Which characteristics place the woman in a high risk category? a. Blood pressure, age, BMI b. Drug/alcohol use, age, family history c. Family history, blood pressure, BMI d. Family history, BMI, drug/alcohol abuse

d. Family history, BMI, drug/alcohol abuse

25. The nurse recognizes that a nonstress test (NST) in which two or more fetal heart rate (FHR) accelerations of 15 beats/min or more occur with fetal movement in a 20-minute period is: a. Nonreactive b. Positive c. Negative d. Reactive

d. Reactive

11. In comparing the abdominal and transvaginal methods of ultrasound examination, nurses should explain to their clients that: a. Both require the woman to have a full bladder. b. The abdominal examination is more useful in the first trimester. c. Initially the transvaginal examination can be painful. d. The transvaginal examination allows pelvic anatomy to be evaluated in greater detail.

d. The transvaginal examination allows pelvic anatomy to be evaluated in greater detail.

6. A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? A. Biophysical profile B. Amniocentesis C. Maternal serum alpha-fetoprotein (MSAFP) D. Transvaginal ultrasound

d. Transvaginal ultrasound