bstrandable NCLEX OB/Peds 2 of 3
Ego Integrity vs. Despair
(Erikson) People in late adulthood either achieve a sense of integrity of the self by accepting the lives they have lived or yield to despair that their lives cannot be relived
Epiglottitis S/S
-excessive drooling is the universal sign -in addition, the child will have a sudden onset of dysphagia or difficulty swallowing, stridor, and high-grade fever. -the child may also be in the TRIPOD POSITION upon arrival
The total apgar score can range from
0 to 10
Petit mal
"Absence Seizure" Momentary LOC, appears like daydreaming -lasts 5-10 seconds
early crawling movements
1 M
head sags
1 M
A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1.Stop of Pitocin infusion 2.Perform a vaginal examination 3.Reposition the client 4.Check the client's blood pressure and heart rate 5.Administer oxygen by face mask at 8 to 10 L/min
1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord
Toddler age range
1-3
Rubella (German Measles) 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Rubella virus (viral) 2. Incubation period: 14 to 21 days 3. Communicable period: From 7 days before to about 5 days after rash appears. 4. Source: Nasopharyngeal secretions; virus is also present in blood, stool, urine. 5. Transmission: Airborne or direct contact w/infectious droplets. Indirectly via articles freshly contaminated. Also transplacental.
Chickenpox (Varicella) 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Varicella-zoster virus (viral) 2. Incubation period: 13 to 17 days 3. Communicable period: From 1 to 2 days before the onset of rash to 6 days after the first crop of vesicles, when crusts have formed. 4. Source: Respiratory tract secretions of infected persons; skin lesions. 5. Transmission: Direct contact, droplet, contaminated objects REMEMBER: Child is no longer contagious once lesions have dried and crusts have formed.
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: 1.An acceleration 2.An early elevation 3.A sonographic motion 4.A tachycardic heart rate
1. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute
The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: 1.Blowing 2.Slow chest 3.Shallow 4.Accelerated-decelerated
1. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.
Diphtheria 4 signs and symptoms and 2 important interventions
1. low-grade fever, malaise, sore throat 2. Foul-smelling, mucoprurulent nasal discharge 3. Dense pseudomembrane formation of the throat that may interfere with eating, drinking and breathing. 4. Lymphadenitis, neck edema, "bull neck" Interventions: Strict isolation for hospitalized child. Administer diphtheria antitoxin only AFTER a skin or conjunctival test rules out sensitivity to horse serum.
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A.The client begins to expel clear vaginal fluid B.The contractions are regular C.The membranes have ruptured D.The cervix is dilated completely
1.4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.
brings hands together
10 M
crawls well
10 M
pulls self to standing position with support
10 M
vocalizes one or two words
10 M
What is the second stage of labor?
10 cm to delivery
When does the anterior fontanelle close?
10-12 months (before 18 months)
At what point is fetal heart rate able to be auscultated during pregnancy?
10-12 weeks.
capable of helping
10-12Y
develops beginning of interest in opposite
10-12Y
increasingly responsible
10-12Y
loves conversation
10-12Y
more selective when choosing friends
10-12Y
raises pets
10-12Y
remainder of teeth
10-12Y
uses telephone
10-12Y
Correct Answer: A Your Response:
10. The nurse observes erythema, pain, and edema at a child's intravenous (IV) site with streaking along the vein. What should the nurse do first? A. Immediately stop the infusion. B. Check for a good blood return. C. Ask another nurse to check the IV site. D. Increase the IV drip for 1 minute and recheck.
On heart rate or cardiac status, a 2 means that the HR is above _______ BPM.
100
BP Girls 3 years
100-110/61-65
BP Boys 3 years
100-113/59-67
Pulse birth-1 week
100-160
Pulse 1 week-3 months
100-220
Correct Answer: D Your Response:
100. 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 won't 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."
ANS: C Murmurs are the sounds that are produced in the heart chambers or major arteries from the back-and-forth flow of blood. S1 is the closure of the tricuspid and mitral valves, and S2 is the closure of the pulmonic and aortic valves, and both are considered normal heart sounds. S3 is a normal heart sound sometimes heard in children. S4 is rarely heard as a normal heart sound. If heard, medical evaluation is required. Physiologic splitting is the distinction of the two sounds in S2, which widens on inspiration. It is a significant normal finding.
135. 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
ANS: D The correct order of abdominal examination is inspection, auscultation, and palpation. Palpation is always performed last because it may distort the normal abdominal sounds.
136. Examination of the abdomen is performed correctly by the nurse in this order: a. Inspection, palpation, and auscultation b. Palpation, inspection, and auscultation c. Palpation, auscultation, and inspection d. Inspection, auscultation, and palpation
ANS: A The tailor position stretches the muscle responsible for the cremasteric reflex. This prevents its contraction, which pulls the testes into the pelvic cavity. Undescended testes cannot be predictably palpated. Inguinal hernias are not detected by this method. This position is used for inhibiting the cremasteric reflex. Privacy should always be provided for children.
137. The nurse has a 2-year-old boy sit in "tailor" position during palpation for the testes. The rationale for this position is that: a. It prevents cremasteric reflex. b. Undescended testes can be palpated. c. This tests the child for an inguinal hernia. d. The child does not yet have a need for privacy.
ANS: D 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.
138. 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.
ANS: B The finger-to-nose-test is an indication of cerebellar function. This test checks balance and coordination. Each deep tendon reflex is tested separately. Each sense is tested separately. Although this test enables the nurse to evaluate the child's ability to follow directions, it is used primarily for cerebellar function.
139. 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.
Correct Answer: C Your Response:
14. A neonate had corrective surgery 3 days ago for esophageal atresia. The nurse notices that after the child receives his gastrostomy feeding, there is often a backup of formula feeding into the tube. As a result, the nurse should: A. Position the child in a supine position after feedings. B. Position the child on his or her left side after feedings. C. Leave the gastrostomy tube open and suspended after feedings. D. Leave the gastrostomy tube clamped after feedings.
Correct Answer: C
157. The parents of a young child ask the nurse for suggestions on how to discipline. When discussing the use of "time-outs," the nurse should include: A. Sending the child to his or her room if the child has one. B. Trying another approach if child cries, refuses, or is more disruptive. C. Selecting an area that is safe and nonstimulating such as a hallway. D. Teaching that the general rule for length of time is 1 hour per year of age.
Correct Answer: C
158. What is appropriate advice for parents who are preparing to tell their children about their decision to divorce? A. Avoid crying in front of children. B. Avoid discussing the reason for the divorce. C. Give reassurance that the divorce is not the children's fault. D. Give reassurance that the divorce will not affect most aspects of the children's lives.
Correct Answer: C
159. Which term refers to a shared cultural, social, and linguistic heritage? A. Beliefs B. Culture C. Ethnicity D. Socialization
ANS: B Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. Teaching sessions for this age group should be 10 to 15 minutes in length. Demonstrate the use of equipment and allow the child to play with miniature or actual equipment. Explain the procedure in simple terms and how it affects the child.
16 The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include to: a. Plan for a short teaching session of about 30 minutes. b. Tell the child that procedures are never a form of punishment. c. Keep equipment out of the child's view. d. Use correct scientific and medical terminology in explanations.
Resp 12+
16-18
Correct Answer: C
160. The most overwhelming adverse influence on health is: A. Race. B. Customs. C. Socioeconomic status. D. Genetic constitution.
Correct Answer: A
161. Which statement is true concerning folk remedies? A. They may be used to reinforce the treatment plan. B. They are incompatible with modern medical regimens. C. They are a leading cause of death in some cultural groups. D. They are not a part of the culture in large, developed countries.
Correct Answer: B
162. The nurse is caring for a dying boy whose religion is Islam (Muslim/Moslem). An important nursing consideration related to his impending death and religion is that: A. There are no special rites. B. There are specific practices to be followed. C. The family is expected to "wait" away from the dying person. D. Baptism should be performed if it has not been done previously.
Correct Answer:D
163. The nurse is planning care for a patient with an ethnic background different from that of the nurse. An appropriate goal is to: A. Strive to keep ethnic background from influencing health needs. B. Encourage continuation of ethnic practices in the hospital setting. C. Attempt in a nonjudgmental way to change ethnic beliefs. D. Adapt as necessary ethnic practices to health needs.
Correct Answer: B
164. A group of people with shared characteristics who interact with each other is known as: A. Culture. B. Community. C. Target population. D. Individual countries and states.
Correct Answer: A
165. The nurse is setting up a community safety program about car seats. What level of prevention is this? A. Primary B. Tertiary C. Secondary D. Environmental
ANS: B Epidemiology is the science of population health applied to the detection of morbidity and mortality in a population. It identifies the distribution and causes of diseases across a population. Nursing process is a systematic problem-solving approach for the delivery of nursing care. Morbidity and mortality statistics, along with natal rates, may provide an objective picture of a community's health status.
166. Which term best describes the identification of the distribution and causes of disease, injury, or illness? a. Nursing process c. Community-based statistics b. Epidemiologic process d. Mortality and morbidity statistics
ANS: C Incidence will provide the number of cases of a particular disease process. Mortality statistics specify the number of deaths from a given cause. Morbidity statistics specify the prevalence of specific illnesses in a population at a particular time.
167. One of the community nurses at the health department is trying to identify how many new cases of acquired immunodeficiency syndrome have occurred in her city this past year. The term that best describes this measurement is: a. mortality c. incidence b. morbidity d. prevalence
ANS: C The nursing process stages are similar, whether the client is one child or a population of children. The assessment phase of the nursing processes focuses on collecting subjective and objective data. Planning is the development of community-centered goals and objectives. Diagnosis is the identification of problems specific to the community.
168. The nurse is collecting subjective and objective information about the target population to diagnose problems based on community needs. Which step in the community nursing process is this? a. Planning c. Assessment b. Diagnosis d. Establishing objectives
ANS: A An agent is responsible for causing a disease or infectious illness. Lead paint is a physical agent. Host factors are those specific to an individual or group. These can be either genetic or lifestyle factors. Environmental factors provide a setting for the host and include climatic conditions related to home and school. A lifestyle factor consists of food selections or exercise patterns. Lifestyle is a component of the host factor.
169. A number of children in the same neighborhood have developed illness related to an exposure to lead paint. Which of the three factors that form the epidemiologic triangle is responsible for this condition? a. Agent c. Environmental factor b. Host factor d. Lifestyle factor
ANS: A It is appropriate for the child to leave her underpants on. This allows her some measure of control during the foot surgery. The mother should not be required to make the child more upset. Katie is too young to understand what hospital policy means.
17. Katie, 4 years old, is admitted to outpatient surgery for removal of a cyst on her foot. Her mother puts the hospital gown on her, but Katie is crying because she wants to leave on her underpants. The most appropriate nursing action is to: a. Allow her to wear her underpants. b. Discuss with her mother why this is important to Katie. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy.
ANS: C Males are at a much greater risk of having hemophilia A and B. Although age is one of the most important factors, it does not increase the risk for this disease. Race has long been associated with a number of other diseases and disabilities. Low socioeconomic status predisposes children to a variety of health problems.
170. Demography is the study of population characteristics. Which demographic characteristic would be associated with an increased risk for hemophilia? a. Age c. Gender b. Race and ethnicity d. Socioeconomic status
Correct Answer: A Your Response:
172. What has had the greatest impact on reducing infant mortality in the United States? A. Improvements in perinatal care B. Decreased incidence of congenital abnormalities C. Better maternal nutrition D. Improved funding for health care
Points Earned: 0/1 Correct Answer: D Your Response:
173. The role of the pediatric nurse is influenced by trends in health care. The greatest trend in health care is: A. Primary focus on treatment of disease or disability. B. National health care planning on a distributive or episodic basis. C. Accountability to professional codes and international standards. D. Shift of focus to prevention of illness and maintenance of health.
Points Earned: 0/1 Correct Answer: D Your Response:
174. Evidence-based practice, a current health care trend, is best described as: A. Gathering evidence of mortality and morbidity in children. B. Meeting physical and psychosocial needs of the child and family in all areas of practice. C. Using a professional code of ethics as a means for professional self-regulation. D. Questioning why something is effective and whether there is a better approach.
Points Earned: 0/1 Correct Answer: D Your Response:
175. The etiology component of the nursing diagnosis describes: A. Projected changes in an individual's health status, clinical conditions, or behavior. B. An individual's response to health pattern deficits in the child, family, or community. C. A cluster of cues and/or defining characteristics that are derived from patient assessment and indicate actual health problems. D. Physiologic, situational, and maturational factors that cause the problem or influence its development.
Points Earned: 0/1 Correct Answer: C Your Response:
176. When the nurse uses a standard nursing care plan as a guide in planning care for a hospitalized child, what should be eliminated? A. Expected outcome/goal B. Dependent nursing functions C. Problems not pertinent to the child or family D. Potential health problems of the child or family
ANS: D Analysis of these data provides the nurse with information about which groups of individuals are at risk for which health problems. Lifespan statistics are part of the mortality data. Treatment modalities and cost are not included in these data.
177. Information about morbidity and mortality gives the nurse data to identify: a. Lifespan statistics. b. Effectiveness of treatment. c. Cost-effective treatment for general population. d. High risk age groups for certain disorders or hazards.
ANS: A Although the death rate has decreased, the United States still ranks last among nations with the lowest infant death rates. The United States has the highest infant death rate of developed nations.
178. From a worldwide perspective, infant mortality in the United States: a. Is the highest of the other developed nations. b. Lags behind five other developed nations. c. Is the lowest infant death rate of developed nations. d. Lags behind 20 other developed nations.
ANS: A Congenital anomalies account for 20.6% of deaths in infants younger than 1 year. Sudden infant death syndrome accounts for 7.7% of deaths in this age group, while respiratory distress syndrome accounts for 3.6% of deaths in this age group. Infections specific to the perinatal period account for 2.9% of deaths in this age group.
179. The leading cause of death in infants younger than 1 year is/are: a. Congenital anomalies. b. Sudden infant death syndrome. c. Respiratory distress syndrome. d. Infections specific to the perinatal period.
If you are the nurse starting the IV on the client with Abruptia Placenta, what guage needle should you use?
18 (in preparation to give blood if necessary)
anterior fontanelle usually closed
18 M
builds 3 block tower
18 M
climbs stairs
18 M
oral vocab 10 words
18 M
scribbles
18 M
thumb sucking
18 M
walks backward
18 M
ANS: B Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child's favorite doll because the toddler may think the doll is really "feeling" the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it.
18. Using knowledge of child development, the best approach when preparing a toddler for a procedure is to: a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for the teaching session to last about 20 minutes. d. Show necessary equipment without allowing child to handle it.
ANS: C Unintentional injuries (accidents) are the leading cause of death after age 1 year through adolescence. Cancer is the leading cause of death in those younger than 1 year and is less significant in this age group. There have been major declines in deaths attributed infection and congenital abnormalities because of improved therapies.
180. The major cause of death for children older than 1 year is: a. Cancer. c. Unintentional injuries. b. Infection. d. Congenital abnormalities.
ANS: B In this age group, homicide and suicide account for 22.6% of deaths, suicide and cancer account for 14.4%, homicide and heart disease account for 14.5%, and drowning and cancer account for 2.8%.
181. In addition to injuries, the leading causes of death in adolescents ages 15 to 19 years are: a. Suicide, cancer. c. Homicide, heart disease. b. Suicide, homicide. d. Drowning, cancer.
ANS: C Motor vehicle-related fatalities is the leading cause of death in children, as either passengers or pedestrians. Poisoning is the ninth leading cause of death. Drowning is the second leading cause of death. Fire- and burn-related fatalities are the third leading cause of death.
182. The leading cause of death from unintentional injuries in children is: a. Poisoning. c. Motor vehicle-related fatalities. b. Drowning. d. Fire- and burn-related fatalities.
ANS: A Most deaths from unintentional injuries occur in males. The pattern of death caused by unintentional injuries is consistent in Western societies. Causes of unintentional deaths vary with age and gender.
183. Which of the following is descriptive of deaths caused by unintentional injuries? a. More deaths occur in males. b. More deaths occur in females. c. Pattern of deaths varies widely in Western societies. d. Pattern of deaths does not vary according to age and sex.
ANS: B The child's developmental stage determines the type of injury that is likely to occur. The child's physical health may facilitate his or her recovery from an injury. Educational level is related to developmental level, but it is not as important as the child's developmental level in determining the type of injury. The number of responsible adults in the home may affect the number of unintentional injuries, but the type of injury will be related to the child's developmental stage.
184. The type of injury a child is especially susceptible to at a specific age is most closely related to: a. Physical health of the child. b. Developmental level of the child. c. Educational level of the child. d. Number of responsible adults in the home.
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. 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.
101. 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 self. c. Explain the purpose of the interview. b. Make the family comfortable. d. Give an assurance of privacy.
What is the hightes that the temp will be in appendicitis?
102 F
ANS: C Closed-ended questions should be avoided when attempting to elicit parents' feelings. Open-ended questions require the parent to respond with more than a brief answer. Sympathy is having feelings or emotions in common with another person rather than understanding those feelings (empathy). Sympathy is not therapeutic in the helping relationship. Direct questions may obtain limited information. In addition, the parent may consider them threatening. Silence can be an effective interviewing tool. It allows sharing of feelings in which two or more people absorb the emotion in depth. Silence permits the interviewee to sort out thoughts and feelings and search for responses to questions.
102. What 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.
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. 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.
103. What is the single most important factor to consider when communicating with children? a. The child's physical condition b. The presence or absence of the child's parent c. The child's developmental level d. The child's nonverbal behaviors
BP Girls 6 years
104-114/67-75
ANS: B 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.
104. 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 child when parent is not present.
BP Boys 6 years
105-117/67-76
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. 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.
105. 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 the 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.
ANS: C 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.
106. Which age group is most concerned with body integrity? a. Toddler b. Preschooler c. School-age child d. Adolescent
ANS: B 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.
122. The earliest age at which a satisfactory radial pulse can be taken in children is: a. 1 year b. 2 years c. 3 years d. 6 years
ANS: C Petechiae, small distinct pinpoint hemorrhages, are difficult to see in dark skin unless they are in the mouth or conjunctiva.
123. 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
ANS: D 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.
124. 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.
BP Boys 16 years
125-138/79-87
ANS: A These symptoms indicate meningeal irritation and needs immediate evaluation. Continuing the assessment is not necessary. No indication of injury is present. This is not descriptive of head lag.
125. The nurse has just started assessing a young child 1who 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 assessment to determine cause of neck pain. c. Ask parent when neck was injured. d. Record "head lag" on assessment record and continue assessment of child.
ANS: D Ages 2 through 8 months are too early. The expected closure of the anterior fontanel occurs between ages 12 and 18 months; if it closes at these earlier ages, the child should be referred for further evaluation.
126. 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
ANS: A 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.
127. During a funduscopic examination of a school-age child, the nurse notes a brilliant, uniform red reflex in both eyes. The nurse should recognize that this is: a. A normal finding. b. An abnormal finding; child needs referral to ophthalmologist. c. A sign of possible visual defect; child needs vision screening. d. A sign of small hemorrhages, which usually resolve spontaneously.
ANS: B 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.
128. 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
ANS: D The Snellen letter chart, which consists of lines of letters of decreasing size, is the most frequently used test for visual acuity. Single cards (Denver—letter E; Allen—pictures) are used for children age 2 years and older who are unable to use the Snellen letter chart. The Ishihara vision test is used for color vision.
129. 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.
Correct Answer: D Your Response:
13. The nurse is caring for an infant with a tracheostomy when accidental decannulation occurs. The nurse is unable to reinsert the tube. What should be the next action by the nurse? A. Notifying the surgeon B. Performing oral intubation C. Trying to insert a larger-size tube D. Trying to insert smaller-size tube
ANS: C Visual fixation and following a target should be present by ages 3 to 4 months. Ages 1 to 2 months are is too young for this developmental milestone. If the infant is not able to fix and follow by 6 months of age, further ophthalmologic evaluation is needed.
130. 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
ANS: B 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.
131. The appropriate placement of a tongue blade for assessment of the mouth and throat is the: a. Center back area of tongue. b. Side of the tongue. c. Against the soft palate. d. On the lower jaw.
ANS: A Vesicular breath sounds are heard over the entire surface of lungs, with the exception of the upper intrascapular area and the area beneath the manubrium. Bronchial breath sounds are heard only over the trachea near the suprasternal notch. Adventitious breath sounds are not usually heard over the chest. These sounds occur in addition to normal or abnormal breath sounds. Bronchovesicular breath sounds are heard over the manubrium and in the upper intrascapular regions where trachea and bronchi bifurcate.
132. 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
ANS: C Wheezes are produced as air passes through narrowed passageways. The sound is similar when the narrowing is caused by exudates, inflammation, spasm, or tumor. Rubs are the sound created by the friction of one surface rubbing over another. Pleural friction rub is caused by inflammation of the pleural space. Rattles is the term formerly used for crackles. Crackles are the sounds made when air passes through fluid or moisture.
133. 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
ANS: D 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.
134. 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.
ANS: B The prevalence of a specific illness in the population at a particular time is the definition of morbidity statistics. The number of individuals who have died over a specific period refers to mortality statistics. Data regarding diseases occurring in greater than the expected number of cases in a community and occurring regularly within a geographic location may be extrapolated from analysis of the morbidity statistics.
185. Morbidity statistics describe: a. The number of individuals who have died over a specific period. b. The prevalence of a specific illness in the population at a particular time. c. Disease occurring in greater than the expected number of cases in a community. d. Disease occurring regularly within a geographic location.
ANS: B Morbidity is not distributed randomly in children. Increased morbidity is associated with certain groups of children, including children living in poverty and those who were low birth weight. Morbidity does vary with age. The types of illnesses in children are different for each age group. Morbidity can be decreased with interventions focused on groups with high morbidity and on decreasing unintentional injuries, which also affect morbidity.
186. What is descriptive of morbidity in childhood? a. Morbidity does not vary with age. b. Morbidity is not distributed randomly. c. Little can be done to improve morbidity. d. Unintentional injuries do not have an effect on morbidity.
ANS: C The key components of family-centered care are for the nurse to support, respect, encourage and embrace the family's strength by developing a partnership with the child's parents. Family-centered care recognizes the family as the constant in the child's life. The nurse should support the cultural diversity of the family, not reduce its effect. The family should be enabled and empowered to work with the health care system, and to be part of the decision-making process.
187. What is most descriptive of family-centered care? a. Reduces effect of cultural diversity on the family b. Encourages family dependence on health care system c. Recognizes that the family is the constant in a child's life d. Avoids expecting families to be part of the decision-making process
When does the posterior fontanelle close?
2-3 months
doll's reflex disappears
2-3M
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? 1.Three contractions occurring within a 10-minute period 2.A fetal heart rate of 90 beats per minute 3.Adequate resting tone of the uterus palpated between contractions 4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring
2. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? 1.Identifying the types of accelerations 2.Assessing the baseline fetal heart rate 3.Determining the frequency of the contractions 4.Determining the intensity of the contractions
2. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority.
A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? 1.Placing the client on complete bed rest 2.Continuous electronic fetal monitoring 3.An IV infusion of antibiotics 4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: 1.A form of biofeedback to enhance bearing down efforts during delivery 2.Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus 3.The application of pressure to the sacrum to relieve a backache 4.Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest
2. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.
A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? 1.Hypotonic contractions 2.Forceps delivery 3.Schultz delivery 4.Weak bearing down efforts
2. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.
Correct Answer: A Your Response:
2. It is time to give 3-year-old David his medication. Which approach is most likely to receive a positive response? A. "It's time for your medication now, David. Would you like water or apple juice afterward?" B. "Wouldn't you like to take your medicine, David?" C. "You must take your medicine, David, because the doctor says it will make you better." D. "See how nicely John took his medicine? Now take yours."
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes
2. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.
A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver
2. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor.
An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: 1.Complete bed rest for the remainder of the pregnancy 2.Delivery of the fetus 3.Strict monitoring of intake and output 4.The need for weekly monitoring of coagulation studies until the time of delivery
2. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.
During the period of induction of labor, a client should be observed carefully for signs of: 1.Severe pain 2.Uterine tetany 3.Hypoglycemia 4.Umbilical cord prolapse
2. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? 1.Early decelerations 2.Variable decelerations 3.Late decelerations 4.Short-term variability
2. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: 1.Stop the oxytocin infusion 2.Change the client's position 3.Prepare for immediate delivery 4.Take the client's blood pressure
2. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.
How much should 3-6 years olds grow per year?
2.5-3 inches per year
ANS: C The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know that it is all right to cry. There is no reason for him to be quieter. He is too upset and needs to be able to express his feelings.
20. The emergency department nurse is cleaning multiple facial abrasions on 9-year-old Mike. His mother is present. He is crying and screaming loudly. The nurse should: a. Ask him to be quieter. b. Have his mother tell him to relax. c. Tell him it is okay to cry and scream. d. Suggest that he talk to his mother instead of crying.
A CD4 count of under _______ is associated with the onset of opportunistic infections.
200
Resp 2-6 years
21-24
binocular vision
3 M
can bring objects to mouth at will
3 M
head held erect, steady
3 M
laughs audibly
3 M
smiles in mother's presence
3 M
What should the fundal height be three days after a vaginal delivery?
3 finger-breadths below the umbilicus
How much do toddlers grow each year?
3 inches
Preschool age range
3-5
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: 1.Not yet engaged 2.Entering the pelvic inlet 3.Below the ischial spines 4.Visible at the vaginal opening
3. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: 1.Above the umbilicus at the midline 2.Above the umbilicus on the left side 3.Below the umbilicus on the right side 4.Below the umbilicus near the left groin
3. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: 1.Over the fetus that is most anterior to the mothers abdomen 2.Over the fetus that is most posterior to the mothers abdomen 3.So that each fetal heart rate is monitored separately 4.So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus
3. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.
A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? 1.Absence of abdominal pain 2.A soft abdomen 3.Uterine tenderness/pain 4.Painless, bright red vaginal bleeding
3. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding.
ANS: D When a child is hospitalized, the altered family role, physical disability, loss of peer acceptance, lack of productivity, and inability to cope with stress usurps individual power and identity. This is especially detrimental to school-age children, who are striving for independence and productivity and are now experiencing events that lessen their control and power. Infants, toddlers, and preschoolers, although affected by loss of power, are not as significantly affected as are school-age children.
57. Because of their striving for independence and productivity, which age group of children is particularly vulnerable to events that may lessen their feeling of control and power? a. Infants b. Toddlers c. Preschoolers d. School-age children
ANS: A This school-age child is attempting to maintain control. The nurse should provide the girl with structured choices about when the IV will be inserted. This can be characteristic behavior when an individual needs to maintain some control over a situation. The child is trying to have some control in the hospital experience.
58. A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, "Wait a minute," and, "I'm not ready." The nurse should recognize that: a. This is normal behavior for a school-age child. b. This behavior is usually not seen past the preschool years. c. The child thinks the nurse is punishing her. d. The child has successfully manipulated the nurse in the past.
ANS: B Siblings experience loneliness, fear, worry, anger, resentment, jealousy, and guilt. The siblings experience stress equal to that of the hospitalized child. These are not uncommon responses by normal siblings. There is no evidence that the family has maladaptive coping.
59. Amy, age 6 years, needs to be hospitalized again because of a chronic illness. The clinic nurse overhears her school-age siblings tell her, "We are sick of Mom always sitting with you in the hospital and playing with you. It isn't fair that you get everything and we have to stay with the neighbors." The nurse's best assessment of this situation is that: a. The siblings are immature and probably spoiled. b. Jealousy and resentment are common reactions to the illness or hospitalization of a sibling. c. The family has ineffective coping mechanisms to deal with chronic illness. d. The siblings need to better understand their sister's illness and needs.
2100 word vocab
5Y
beginnings of cooperative play
5Y
dresses without help
5Y
gender specific behavior
5Y
jumps rope
5Y
runs well
5Y
skips on alternate feet
5Y
ties shoes
5Y
tolerates increasing periods of separation from parents
5Y
average weight gain of 4 oz per week
6 M
can turn from back to stomach
6 M
early ability to distinguish and recognize strangers
6 M
lower central incisors come in
6 M
teething may begin
6 M
Influenza
6 months initiate, annually
H1N1 Vaccine: When are children old enough to receive it?
6 months. Children younger than six months are not old enough, but family members and caregivers should be vaccinated.
School age range
6-12
responds to their own name
6-8M
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion
3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? 1.Prepare the client for an ultrasound 2.Obtain equipment for external electronic fetal heart monitoring 3.Obtain equipment for a manual pelvic examination 4.Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia
A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? 1.Keeping the significant other informed of the progress of the labor 2.Providing comfort measures 3.Monitoring fetal heart rate 4.Changing the client's position frequently
3. The priority is to monitor the fetal heart rate.
A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? 1.Medication that will provide sedation 2.Increased hydration 3.Oxytocin (Pitocin) infusion 4.Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.
The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: 1.Until the time it is completely over 2.To the end of a second contraction 3.To the beginning of the next contraction 4.Until the time that the uterus becomes very firm
3. This is the way to determine the frequency of the contractions
Correct Answer: A Your Response:
3. When should clear liquids be stopped before scheduled surgery? A. 2 hours before surgery B. 6 hours before surgery C. The night before surgery, at 8 PM D. The night before surgery, at midnight
The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: 1.Clear and dark amber in color 2.Milky, greenish yellow, containing shreds of mucus 3.Clear, almost colorless, and containing little white specks 4.Cloudy, greenish-yellow, and containing little white specks
3. by 36 weeks' gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
Resp newborn-1 year
30
builds 7 to 8 block tower
30 M
has sphincter control for toilet training
30 M
stands on one foot
30 M
walks on tiptoe
30 M
What is the normal range for newborn respirations?
30-60 breaths/min
Resp Newborn
30-60 w some apnea (<15s)
ANS: B Both the mother's preference for assisting, observing, or waiting outside the room and the child's preference for parental presence should be assessed. The child's choice should be respected. This will most likely help the child through the procedure. If the mother and child are agreeable, the mother is welcome to stay. Her familiarity with the procedure should be assessed, and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care
30. A venipuncture will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. The nurse should recognize that this: a. Is unsafe. b. May help the child relax. c. Is against hospital policy. d. Is unnecessary because of the child's age.
state first and last name
30M
ANS: C Restrain the child only as needed to perform the procedure safely; use therapeutic hugging. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Keep all equipment out of sight until used.
34. A nurse must do a venipuncture on a 6-year-old child. An important consideration in providing atraumatic care is to: a. Use an 18-gauge needle if possible. b. If not successful after four attempts, have another nurse try. c. Restrain the child only as needed to perform venipuncture safely. d. Show the child equipment to be used before procedure.
What is the age range for middle adulthood?
35 to 64 years of age
ANS: C Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will make the medication more palatable to the child. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat in future.
35. An appropriate method for administering oral medications that are bitter to an infant or small child would be to mix them with: a. A bottle of formula or milk. b. Any food the child is going to eat. c. A small amount (1 teaspoon) of a sweet-tasting substance such as jam or ice cream. d. Large amounts of water to dilute medication sufficiently.
absent tonic neck reflex
4 M
appearance of thumb apposition
4 M
drooling
4 M
evidence of pleasure in social contact
4 M
moro reflex absent after 3-4 M
4 M
How long will it take for the person to see results when acne is being treated?
4 to 6 weeks
Until what age should toddlers remain in a car seat?
4 years
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? 1.Encourage the client's coach to continue to encourage breathing exercises 2.Encourage the client to continue pushing with each contraction 3.Continue monitoring the fetal heart rate 4.Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified.
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: 1.Breech 2.Transverse 3.Occiput anterior 4.Occiput posterior
4. A persistent occiput-posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.
At 38 weeks' gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: 1.Discontinue the catheter, if the reading is not above 80% 2.Discontinue the catheter, if the reading does not go below 30% 3.Advance the catheter until the reading is above 90% and continue monitoring 4.Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
4. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.
A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? 1.A loud mouth 2.Low self-esteem 3.Hemorrhage 4.Postpartum infections
4. Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Having a loud mouth is only related to the person typing up this test.
A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: 1.Hematoma 2.Placenta previa 3.Uterine atony 4.Placental separation
4. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? 1.Disseminated intravascular coagulation 2.Chronic hypertension 3.Infection 4.Hemorrhage
4. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? 1.The umbilical cord shortens in length and changes in color 2.A soft and boggy uterus 3.Maternal complaints of severe uterine cramping 4.Changes in the shape of the uterus
4. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping. I am going to look more into this answer. According to our book on page 584, this is not one of our options.
Correct Answer: D Your Response:
4. The nurse is doing preoperative teaching with a child and his parents. The parents say that he is "dreading the shot" for premedication. The nurse's response should be based on the knowledge that: A. Preanesthetic medication can only be given intramuscularly. B. In children the intramuscular route is safer than the intravenous (IV) route. C. The child will have no memory of the injection because of amnesia. D. Preanesthetic medication should be "atraumatic," using oral, existing intravenous, or rectal routes.
. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: 1.Noting if the heart rate is greater than 140 BPM 2.Placing the diaphragm of the Doppler on the mother abdomen 3.Performing Leopold's maneuvers first to determine the location of the fetal heart 4.Palpating the maternal radial pulse while listening to the fetal heart rate
4. The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: 1.Trendelenburg's position with the legs in stirrups 2.Semi-Fowler position with a pillow under the knees 3.Prone position with the legs separated and elevated 4.Supine position with a wedge under the right hip
4. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus.
How much weight should a school aged child gain per year? (6-12 yr)
4.4-8lbs annually
How much weight should 3-6 year olds gain per year?
4.5-6.5 lbs annually.
What is normal blood glucose in the term neonate?
40-80
ANS: A If a toddler is not prepared for hospitalization, a typical preschooler fantasy is to attribute the hospitalization to punishment for real or imagined misdeeds. Threat to child's self-image and loss of companionship with friends are reactions typical of school-age children. Regression is a response characteristic of toddlers when threatened with loss of control.
56. When a preschool child is hospitalized without adequate preparation, the nurse should recognize that the child may likely see hospitalization as: a. Punishment. b. Threat to child's self-image. c. An opportunity for regression. d. Loss of companionship with friends.
ANS: C Loss of peer-group contact may pose a severe emotional threat to an adolescent because of loss of group status; friends visiting are an important aspect of hospitalization for an adolescent and would be very reassuring. Adolescents may welcome the opportunity to be away from their parents. The separation from siblings may produce reactions from difficulty coping to a welcome relief.
67. The nurse is caring for an adolescent who had an external fixator placed after suffering a fracture of the wrist during a bicycle accident. Which statement by the adolescent would be expected about separation anxiety? a. "I wish my parents could spend the night with me while I am in the hospital." b. "I think I would like for my siblings to visit me but not my friends." c. "I hope my friends don't forget about visiting me." d. "I will be embarrassed if my friends come to the hospital to visit."
ANS: A, C, E Intensive care units, especially when the family is unprepared for the admission, are a strange and unfamiliar place. There are many pieces of unfamiliar equipment, and the sights and sounds are much different from a general hospital unit. Also, with the child's condition being more precarious, it may be difficult to keep the parents updated and knowledgeable about what is happening. Lights are usually on around the clock, seriously disrupting the diurnal rhythm. There is usually little privacy available for families in intensive care units.
68. Ryan has just been unexpectedly admitted to the intensive care unit after abdominal surgery. The nursing staff has completed the admission process, and Ryan's condition is beginning to stabilize. When speaking with the parents, the nurses should expect which stressors to be evident? Choose all that apply. a. Unfamiliar environment b. Usual day-night routine c. Strange smells d. Provision of privacy e. Inadequate knowledge of condition and routine
Correct Answer: C Your Response:
69. The nurse is using the C.R.I.E.S. pain assessment tool on a preterm infant in the neonatal intensive care unit. A component of this tool is: A. Color. B. Reflex. C. Oxygen saturation. D. Posture of arms and legs.
Correct Answer: B Your Response:
73. An important consideration when using the FACES Pain Rating Scale with children is: A. Children color the face with the color they choose to best describe their pain. B. The scale can be used with most children as young as 3 years of age. C. The scale is not appropriate for use with adolescents. D. The scale is useful in pain assessment but is not as accurate when assessing physiologic responses.
Correct Answer: A Your Response:
74. Nonpharmacologic strategies for pain management: A. May reduce pain perception. B. Make pharmacologic strategies unnecessary. C. Usually take too long to implement. D. Trick children into believing that they do not have pain.
Correct Answer: A Your Response:
75. The nurses caring for a child are concerned about the child's frequent requests for pain medication. During a team conference a nurse suggests that they consider administering a placebo instead of the usual pain medication. This decision should be based on knowledge that: A. This practice is unjustified and unethical. B. This practice is effective in determining whether a child's pain is real. C. The absence of a response to a placebo means the child's pain has an organic basis. D. A positive response to a placebo will not occur if the child's pain has an organic basis.
Correct Answer: B Your Response:
76. A child who has been receiving morphine intravenously will now start receiving it orally. The nurse should anticipate that, to achieve equianalgesia (equal analgesic effect), the oral dose will be: A. The same as the intravenous (IV) dose. B. Greater than the IV dose. C. One half of the IV dose. D. One fourth of the IV dose.
Correct Answer: B Your Response:
77. Transdermal fentanyl (Duragesic) is being used for an adolescent with cancer who is in hospice care. The adolescent has been comfortable for several hours but now complains of severe pain. The most appropriate nursing action is to: A. Administer meperidine (Demerol) intramuscularly (IM). B. Administer morphine sulfate immediate release (MSIR) intravenously (IV). C. Use a nonpharmacologic strategy. D. Place another fentanyl patch on the adolescent.
Correct Answer: C Your Response:
78. The nurse is caring postoperatively for an 8-year-old child with multiple fractures and other trauma resulting from a motor vehicle injury. The child is experiencing severe pain. An important consideration in managing the child's pain is to: A. Give only an opioid analgesic at this time. B. Increase the dosage of analgesic until the child is adequately sedated. C. Plan a preventive schedule of pain medication around the clock. D. Give the child a clock and explain when he or she can have pain medications.
ANS: D The child is displaying a local sign of pain. Rolling the head from side to side and pulling at ears indicate pain in the ear. The child's behavior indicates the location of the pain. The behavior does not provide information about the type, severity, or duration.
79. Kyle, age 6 months, is brought to the clinic. His parent says, "I think he hurts. He cries and rolls his head from side to side a lot." This most likely suggests which feature of pain? a. Type b. Severity c. Duration d. Location
increased self reliance for basic activities
7Y
team games/ sports/ organizations
7Y
temporal perception improving
7Y
anxiety with strangers
8 M
Correct Answer: D Your Response:
8. The nurse is preparing a plan to teach a mother how to administer 1½ teaspoons of medicine to her 6-month-old child. The nurse should recommend using: A. A household measuring spoon. B. A regular silverware teaspoon. C. A paper cup measure in 5-ml increments. D. A plastic syringe (without needle) calibrated in milliliters.
Pulse 3 months-2 years
80-150
ANS: D Physiologic manifestations of pain may vary considerably, not providing a consistent measure of pain. Heart rate may increase or decrease. The same signs that may suggest fear, anxiety, or anger also indicate pain. In chronic pain the body adapts, and these signs decrease or stabilize. These are of limited value and must be viewed in the context of a pain-rating scale, behavioral assessment, and parental report. When the child states that pain exists, it does. That is the truth.
80. Physiologic measurements in children's pain assessment are: a. The best indicator of pain in children of all ages. b. Essential to determine whether a child is telling the truth about pain. c. Of most value when children also report having pain. d. Of limited value as sole indicator of pain.
What is the normal newborn blood pressure?
80/50, but not usually measured.
ANS: A Nonpharmacologic techniques provide coping strategies that may help reduce pain perception, make the pain more tolerable, decrease anxiety, and enhance the effectiveness of analgesics. Nonpharmacologic techniques should be learned before the pain occurs. With severe pain it is best to use both pharmacologic and nonpharmacologic measures for pain control. The nonpharmacologic strategy should be matched with the child's pain severity and taught to the child before the onset of the painful experience. Some of the techniques may facilitate the child's experience with mild pain, but the child will still know that discomfort is present.
81. Nonpharmacologic strategies for pain management: a. May reduce pain perception. b. Make pharmacologic strategies unnecessary. c. Usually take too long to implement. d. Trick children into believing they do not have pain.
ANS: B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in parenteral form in the United States. Meperidine is not used for continuous and extended pain relief.
82. Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine b. Morphine c. Methadone d. Meperidine
ANS: C EMLA is an effective analgesic agent when applied to the skin 60 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin. The gel can be placed on the wound for suturing. Transdermal fentanyl patches are useful for continuous pain control, not rapid pain control. For maximal effectiveness EMLA must be applied approximately 60 minutes in advance.
83. A lumbar puncture is needed on a school-age child. The most appropriate action to provide analgesia during this procedure is to apply: a. Tetracaine-adrenaline-cocaine (TAC) 15 minutes before procedure. b. Transdermal fentanyl (Duragesic) patch immediately before procedure. c. Eutectic mixture of local anesthetics (EMLA) 1 hour before procedure. d. EMLA 30 minutes before procedure.
ANS: A The management of opioid-induced respiratory depression includes lowering the rate of infusion and stimulating the child. If the respiratory rate is depressed and the child cannot be aroused, IV naloxone should be administered. The child will be in pain because of the reversal of the morphine. The morphine should be discontinued, but naloxone is indicated if the child is unresponsive.
84. The nurse is caring for a child receiving intravenous (IV) morphine for severe postoperative pain. The nurse observes a slower respiratory rate, and the child cannot be aroused. The most appropriate management of this child is for the nurse to: a. Administer naloxone (Narcan). b. Discontinue IV infusion. c. Discontinue morphine until child is fully awake. d. Stimulate child by calling name, shaking gently, and asking to breathe deeply.
ANS: Kangaroo Infants who spent 1 to 3 hours in kangaroo care showed increased frequency in quiet sleep, longer duration of quiet sleep and decreased crying in the neonatal intensive care unit. Significant differences were found in pain responses during heel lancing between infants who were kangaroo held and those that were not.
85. Skin-to-skin holding of infants dressed only in diapers next to their mother's or father's chest is commonly known as _________________ care.
Correct Answer: C Your Response:
86. 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 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.
Correct Answer: C Your Response:
87. The nurse is interviewing the mother of Adam, age 9 years. 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?"
Correct Answer: A Your Response:
88. 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.
Correct Answer: D Your Response:
89. What assessment tool would help the nurse assess a family member's satisfaction with the family's functional state? A. Genogram B. Sociogram C. Family ECOMAP D. Family Apgar
eye development generally complete
8Y
friends sought out actively
8Y
movements more graceful
8Y
writing replaces printing
8Y
elevates self to sitting position
9 M
expressions like dada may be heard
9 M
responds to parental anger
9 M
rudimentary imitative expression
9 M
takes deliberate steps when standing
9-10M
Correct Answer: C Your Response:
9. Several types of long-term central venous access devices are used. A benefit of using an implanted port (e.g., Port-a-cath) is that it: A. Is easy to use for self-administered infusions. B. Does not need to pierce the skin for access. C. Does not need to limit regular physical activity, including swimming. D. Cannot dislodge from the port, even if child plays with port site.
Correct Answer: D Your Response:
90. 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.
Correct Answer: B Your Response:
91. 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
Correct Answer: D Your Response:
92. 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.
Correct Answer: D Your Response:
93. 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.
BP Boys 1 year
94-106/50-59
Correct Answer: D Your Response:
94. 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.
Correct Answer: B Your Response:
95. 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.
Correct Answer: A Your Response:
96. 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
BP Girls 1 year
97-107/53-60
Correct Answer: A Your Response:
97. 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 & 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 tongue blade
Temp Birth-1 year
97.7-98.9
What is the normal newborn temperature?
97.7-99.4
Temp 12 +
97.8-98.0
Correct Answer: D Your Response:
98. When assessing a preschooler's chest, the nurse would expect: A. Respiratory movements to be chiefly thoracic. B. Anteroposterior diameter to be equal to the transverse diameter. C. Intercostal retractions on respiratory movement. D. Movement of the chest wall to be symmetric bilaterally and coordinated with breathing.
Temp 1-12 years
98.1-99.9
Correct Answer: D Your Response:
99. 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
better behaved
9Y
conflict between needs for independence and dependence
9Y
conflicts between adult authorities and peer groups
9Y
likes school
9Y
skillful manual work possible
9Y
What is considered normal maternal pulse during labor?
<100 bpm
What is considered a prolonged latent phase in a multipara?
> 14 hours
What is considered a prolonged latent phase in a nullipara?
> 20 hours
How are pinworms diagnosed? 1.) seeing the worm in the stool 2.) a blood antigen level 3.) A "Scotch tape test" in the early morning 4.) a stool laboratory examination obtained at the hour of sleep
A "Scotch tape test" in the early morning
How is fetal bradycardia defined?
A FHR below 110 bpm for 10 minutes.
A patient reports for a preoperative appointment in preparation for surgery that will change his body from a female to male. The patient has expressed to the nurse and physician that he should been born a man. What sexual orientation is the patient demonstrating?
A: bisexual B: transsexual C: homosexual D: transvestite B: transsexual rationale: A transsexual is a person of certain biological gender who has the feelings of the opposite sex, and the person is trapped within the body of the wrong sex. For many transsexuals, the solution is to change their bodies. A homosexual is one who experiences sexual fulfillment with a person of the same gender. A bisexual is a person who finds pleasure with both the opposite sex and same-sex partners. A transvestite is an individual who desires to take on the role or where the clothes of the opposite sex.
A nurse is conducting a healthy living workshop with a group of female college students. Which of the following methods of contraception should the nurse recommend as a means of preventing pregnancy and sexually transmitted infections?
A: condoms B: Intrauterine devices (IUD) C: Coitus interruptus. D: oral contraceptives A: condoms rationale Coitus interruptus, oral contraceptives, and IUD provide no protection against STIs, while condoms provide significant (but imperfect) protection against both pregnancy and STIs.
During a routine physical exam, a male patient forms the nursethat he frequently participates in anal intercourse with his new girlfriend. The nurse discusses this practice with the patient by informing the patient that:
A: condoms are recommended for anal intercourse. B: anal intercourse and be avoided C: lubricants should be avoided during anal intercourse D: the rectal mucosa is thick and Withstand vigorous activity. A: condoms are recommended for anal intercourse. Rationale Condoms are recommended for anal and vaginal intercourse to prevent sexually transmitted diseases. Care should be used to avoid injury to the delicate rectal mucosa, and lubrication is necessary for comfort.
A female patient experienced a pelvic fracture in a motor vehicle accident several months earlier and her recovery has been slow. Among the challenges presented by event is the fact that sexual activity causes a dull ache in her pelvis.What diagnosis is most important for this patient?
A: disturbed body image B: sexual dysfunction: Dyspareunia C: alteration in comfort: Pain D: altered sexuality patterns: change in sexual expression C: alteration in comfort: pain rationale The patient's change in sexual behavior is directly attributable to the pain of her injury. There is no evidence of alterations and her sexual expression or a disturbed body image. Dyspareunia involves genital, rather than skeletal, pain.
A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement? A. A thorough physical to include gynecological examination B. Referral to a sex therapist C. Assessment of sexual history and previous satisfaction with sexual relationships D. Referral to the recreational therapist for relaxation therapy
ANS: A The nurse should expect the physician to implement a thorough physical to include a gynecological examination to assess for any physiological causes of the client's symptoms. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse.
In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client? A. Self-assess personal attitudes toward homosexuality. B. Review client's possible childhood sexual abuse history. C. Encourage discussion of aversion to heterosexual relationships. D. Explore client's family history of homosexuality.
ANS: A The nurse should initially self-assess personal attitudes toward homosexuality. The nurse must be able to recognize the potential for negative feelings compromising client care. Unconditional acceptance of each individual is an essential component of compassionate nursing.
A client is diagnosed with sexual aversion disorder. Which symptom of this disorder should the nurse correctly pair with an appropriate therapeutic intervention? A. Avoidance of all genital sexual contact treated by systematic desensitization B. Avoidance of all genital sexual contact treated by medicating with tadalafil (Cialis) C. Anorgasmia treated by vardenafil (Levitra) D. Anorgasmia treated by sensate focus exercises
ANS: A The nurse should recognize that this sexual aversion disorder is characterized by an avoidance of genital sexual contact. Sexual aversion implies anxiety, fear, or disgust in sexual situations. Sexual aversion can be treated by systematic desensitization.
Which of the following characteristics should a nurse identify as "normal" in the development of human sexuality for an 11-year-old child? (Select all that apply.) A. The child experiments with masturbation. B. The child may experience homosexual play. C. The child shows little interest in the opposite sex. D. The child shows little concern about physical attractiveness. E. The child is unlikely to want to undress in front of others.
ANS: A, B, E The nurse should identify that experimenting with masturbation and homosexual play and not wanting to undress in front of others are characteristics that are normal in the development of human sexuality in an 11-year-old child. Interest in the opposite sex usually increases during this age, and children often become self-conscious about their bodies.
A 49-year-old woman has sought care from her primary care provider because of "intimacy problems". Upon questioning, I the woman reveals that she is experiencing sexual desire, but the intercourse causes her significant pain. In the absence of sexual activity, the woman states that she does not have any significant vaginal discomfort. What should the clinician recognize that this patient is most likely experiencing?
A: Dyspareunia B: a sexually transmitted infection (STI) C: Vaginismus D: Vulvodynia A: Dyspareunia rationale Dyspareunia is painful intercourse. Vaginismus is characterized by difficult penetration rather than acute pain during intercourse, vulvodynia is associated with pain that is not limited to intercourse. And STI may or may not be contributing to the woman's problem, though most cases of dyspareunia are related to infections.
What is associated with the resolution phase of the male sexual response cycle?
A: Increased blood flow to the penis B: feelings of relaxation and fulfillment C: the ability to begin the excitement phase again D: intense physical pleasure B: Feelings of relaxation and fulfillment rationale: The resolution phase of the sexual response cycle is associated with feelings of relaxation, fatigue, and fulfillment. The most intense pleasure of a physical nature takes place during orgasm and the male experiences a refactory period during which he is incapable sexual response. Blood flow to the penis returns to normal levels during the resolution phase.
A 50-year-old man has a long history of type I diabetes, which poorly controlled. What does diabetes greatly increase the man's risk of experiencing?
A: Retarded ejaculation B: Premature ejaculation C: Erectile dysfunction D; Sexually-transmitted infections C; Erectile dysfunction rationale diabetes mellitus is significant risk factor for erectile dysfunction. Retarded or premature ejaculation is less likely, since these problems do not have vascular etiology. Diabetes does not behave an appreciably increased risk of developing STIs, though persons with diabetes do have an increased susceptibility to infections of all kinds.
A school nurse is providing a class on sexually-transmitted infections (STIs). Which statement is correct regarding STI's?
A: STI's are more prevalent among teenagers and young adults B: STI disproportionately affect people with a lower social economic status and education. C: the incidence of STI is decreasing due to limited sex partners D: the signs and symptoms of STI are obvious. A:STI's are more prevalent among teenagers and adults. Rationale STIs are more prevalent among teenagers and young adults, and nearly 2/3 of all STIs occur people younger than 25 years age. The incident of STI is increasing due to multiple sex partners and sexual activity at a younger age. STI affect men and women of all backgrounds and economic levels.
After receiving information on various forms of birth control, a young couple decides to use a barrier methods because they would like to try and conceive in a year or two. Which barrier method uses a rubber barrier to hold spermicide against the cervix?
A: a cervical cap B: a diaphragm C: a condom D: the vaginal sponge B: a diaphragm rationale a diaphragm in the dome shaped device made from latex rubber that mechanically prevents semen from coming in contact with the cervix, and it holds a spermicidal jelly in place against the cervix. A kind of rolls over an erect penis collects the semen after ejaculation. A cervical cap is placed over the cervix and may be left in place for up to three days. A vaginal sponge contains spermicide and of a reservoir to hold the semen.
The nurse is justified in assessing for sexual dysfunction in patients who are receiving:
A: antibiotic B: antihypertensives C: nonsteroidal anti-drugs D: bronchodilators B: antihypertensives rationale antihypertensives are among the drug implicated in sexual dysfunction. Antibiotics, bronchodilators, and NSAIDs do not typically have this effect.
AGN S/S
Oliguria Hematuria Proteinuria Edema/HTN
What vessels should be found in the umbilical cord?
One vein and two arteries
What are nursing implications with indomethacin?
Only give for 48 hours or less, do not use for women with bleeding potential, and give with food.
When should breastfeeding be discontinued in the patient with mastitis?
Only if pus present or antibiotics are contraindicated for neonate. However, the mother may throw away expressed milk to help condition and resume breastfeeding after the infection has cleared.
MD -onset age?
Onset between ages 2-6
What are FHR accelerations?
An increase in FHR in response to stimulus (contractions, etc.). Indicates a healthy fetus.
What immediate intervention should occur if meconium passage occurred in utero?
Arrange for immediate ET observation.
A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis should be prioritized for this client? A. Risk for situational low self-esteem AEB inability to achieve an erection B. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm C. Social isolation R/T low self-esteem AEB refusing to engage in dating activities D. Disturbed body image R/T penile flaccidity AEB client statements
ANS: B Based on the client's symptoms, the nurse should prioritize the nursing diagnosis of sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the client's mood and level of energy because depression and fatigue can decrease desire for participation in sexual activity.
A 52-year-old client states, "My husband is upset because I don't enjoy sex as much as I used to." Which priority client data should a nurse initially collect? A. History of hysterectomy B. Date of last menstrual cycle C. Use of birth control methods D. History of thought disorder
ANS: B The nurse should assess the client's last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms including a decrease in biological drives and sexual activity.
4. Which description of postpartum restoration or healing times is accurate? A. The cervix shortens, becomes firm, and returns to form within a month postpartum. B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth. C. Most episiotomies heal within a week. D. Hemorrhoids usually decrease in size within 2 weeks of childbirth.
B. The vagina gradually returns to prepregnancy size by 6 to 10 weeks after childbirth. The cervix regains its form within days; the cervical os may take longer to return to form. The vagina returns to prepregnancy size by 6 to 10 weeks; however, lubrication may take longer to return to prepregnancy level. Most episiotomies take 2 to 3 weeks to heal. Hemorrhoids can take 6 weeks to decrease in size.
6. With regard to afterbirth pains, nurses should be aware that these pains are: A. Caused by mild, continuous contractions for the duration of the postpartum period. B. More common in first-time mothers. C. More noticeable in births in which the uterus was overdistended. D. Alleviated somewhat when the mother breastfeeds.
C. More noticeable in births in which the uterus was overdistended. The cramping that causes afterbirth pains arises from periodic, vigorous contractions and relaxations, which persist throughout the first part of the postpartum period. Afterbirth pains are more common in multiparous women because first-time mothers have better uterine tone. A large baby or multiple babies overdistend the uterus and this accounts for afterbirth pains. Breastfeeding intensifies afterbirth pain because it stimulates contractions.
7. Postbirth uterine/vaginal discharge, called lochia: A. Is similar to a light menstrual period for the first 6 to 12 hours. B. Is usually greater after cesarean births. C. Will usually decrease with ambulation and breastfeeding. D. Should smell like normal menstrual flow unless an infection is present.
D. Should smell like normal menstrual flow unless an infection is present. Lochia flow should approximate a heavy menstrual period for the first 2 hours and then steadily decrease. Less lochia usually is seen after cesarean births. Lochia usually increases with ambulation and breastfeeding. An offensive odor usually indicates an infection.
14. Which measure would be least effective in preventing postpartum hemorrhage? A. Administer Methergine, 0.2 mg every 6 hours for four doses, as ordered. B. Encourage the woman to void every 2 hours. C. Massage the fundus every hour for the first 24 hours following birth. D. Teach the woman the importance of rest and nutrition to enhance healing.
C. Massage the fundus every hour for the first 24 hours following birth. Administration of Methergine can help prevent postpartum hemorrhage. Voiding frequently can help the uterus contract, thus preventing postpartum hemorrhage. The fundus should be massaged only when boggy or soft. Massaging a firm fundus could cause it to relax. Rest and nutrition are helpful for enhancing healing and preventing hemorrhage.
Where does the pain of appendicitis finally end up?
RLQ
What insulin should be used during labor?
Regular insulin
How do you prevent flexion contracture of the knee after BKA?
Remide the patient to straighten their knee constantly while standing
Newborn Vital signs -Resp -HR -BP
Resp. 40-60. HR 110-160. BP 65-85/45-55
What are signs of mag toxicity and what should be done?
Respirations < 12/min, urine output < 100 mL/4 hr, absent DTRs, Mag serum levels > 8mg/dL; Hold dose and notify provider.
RSV
Respiratory Synctial Virus
What blood gas issues can be caused by hyperventiliaton?
Respiratory alkalosis.
Vesicoureteral Reflex
Result of valvular malfunction and backflow of urine into the ureters (and higher) from the bladder (severe cases are associated with hydronephrosis
What is the most common cause of uterine atony after the first postpartum day?
Retained placental fragments
What complications can result from O2 toxicity?
Retinopathy of prematurity and bronchopulmonary dysplasia.
17. The _________________________ test is used to detect the amount of fetal blood in the maternal circulation.
The correct response is "Kleihauer-Betke"
What is considered the newborn transitional period of life?
The first 6-8 hours.
What is the baseline FHR?
The heart rate between contractions, monitored over a 10-minute period.
What is measured in intraunterine monitoring that cannot be measured externally?
The intensity of contractions, measured by the increased IUP in mmHg (30-70 mmHg)
Prevention of rheumatic fever can best be accomplished by: 1.) keeping children with fever home 2.) sending children with sore throats home from school 3.) having sore throats cultured as soon as possible 4.) treating all colds with antibiotics
having sore throats cultured as soon as possible
3 months old motor skills
head and shoulders lift with no more grasp reflex and hands held open
2 months old motor skills
head lift with hands held open
What are the top 2 side effects of nitro?
headache and hypotension
Never apply __________ to the area of the appendix.
heat (it causes rupture)
An elderly client is a (high/low) risk for accidental poisoning? What about a school age child?
high - due to poor eyesight, high
The pathologic disturbance of pyloric stenosis results from: 1.) edema of the pyloric muscle 2.) ischemia of the pyloric muscle 3.) hypertrophy of the pyloric muscle 4.) neoplastic obstruction
hypertrophy of the pyloric muscle
When will phantom limb sensation subside?
in a few months
A 10 on the apgar means the baby is
in terrific health
Kernig sign
inability to fully extend the knees with hips flexed.
IPV
inactivated poliovirus vaccine
The administration of prednisone to children with nephrosis creates the problem of: 1.) intolerance of foods 2.) increased risk of infection 3.) increased periorbital edema 4.) weight loss
increased risk of infection
what stage are school age in according to Erikson
industry v. inferiority
What psychosocial stage for 6-12 years?
industry vs. inferiority
Cleft Lip fx age/weight
infant weighs 10 lbs
When is trust vs. mistrust
infant-first year of life
An aneurysm can result from an _____________ and from ____________.
infection, syphilis
Peritonitis
inflammation of the peritoneum
Bacterial Meningitis
inflammation of the protective membranes covering the brain and spinal cord caused by various types of bacteria
Apendicitis is an _________ of the appendix due to __________.
inflammation, obstruction
Priority teaching for a parent of a child who ingested a foreign body includes: 1.) encouraging the use of a mild laxative every night 2.) slicing each stool passed to observe for the foreign body 3.) encouraging a daily enema until the foreign body is passed 4.) keeping the child NPO until the foreign body is passed
slicing each stool passed to observe for the foreign body
When the patient experiences apprehension and urticaria while receiving a blood transfusion, the nurse: 1.) slows the transfusion and takes the patient's vital signs 2.) observes the child for further transfusion reactions 3.) stops the transfusion, allows normal saline solution to run slowly, and notifies the charge nurse 4.) stops what he or she is doing and obtains the patient's history
stops the transfusion, allows normal saline solutions to run slowly, and notifies the charge nurse
The nurse understands that genitourinary surgery affects growth and development. When caring for a 4-year-old child postoperatively, a priority nursing responsibility would include: 1.) strategies that preserve the child's body image 2.) assurances that appearance and sexual function will not be affected 3.) providing age-appropriate toys such as tricycles 4.) preventing embarrassment by limiting visitation of family and frients
strategies that preserve the child's body image
By what route do you take nitro?
sublingual
Chorea
sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face
What is the only treatment recommended for appendicitis?
surgery - appendectomy
Tonsilectomy warning sign
swallowing repeatedly can signify bleeding
Dunlop's Traction -part of body
temporary skin traction used for Fx of the upper arm and for shoulder dislocations.
Which aneurysm is most likely to have no symptoms?
the abdominal is most often "silent"
What artery is widened in a thoracic aneurysm?
the aorta
How do you tell if a client has angina or an MI?
the pain of the two is similar, the way to tell the difference is if nitro and rest relieve the pain. For angina, nitro and rest relieve the pain, for MI, nitro and rest do not relieve the pain
Clonic Phase
the phase of a grand mal seizure in which the patient shows rhythmic jerking movements
An aneurysm will most affect which of the following, the blood pressure or the pusle?
the pulse (many times the aneurysm will rupture and much blood will be lost before the blood pressure starts to change.
What is an important aspect of a teaching plan for the parent of a child with hypopituitarism? 1.) the child should be enrolled in a special education program at school 2.) the routine administration of growth hormone should be carried out at bedtime 3.) all family members should have an endocrine workup 4.) the routine medication should be administered before the school day starts
the routine administration of growth hormone should be carried out at bedtime
When taking a child to the ER after accidental poisoning has occurred what must accompany the child to the ER?
the suspected poison
How often should the client with acne wash his face each day?
twice a day
Russell's traction -part of body
uses a knee sling to provide support of the affected leg. It is commonly used to treat fractures of the end of the tibia in the leg.
2 years motor skills
walks up and down stairs; builds block tower of 6-7 blocks
11 months old motor skills
walks while holding onto something; can put objects in a container
Motor skills 15 months
walks without help, creeps up and down stairs, builds block towers
What precaution must the nurse take when administering topical nitro paste?
wear gloves, nurse may get a dose of the med
Preschool favorite word
why?
An aneurysim is an abnormal _______________ of the wall of a(n) artery.
widening (it is also weakening)
Does stress make acne worse?
yes
Cleft Palate age
~1 year
Muscular Dystrophy
any of several hereditary diseases of the muscular system characterized by weakness and wasting of skeletal muscles
Motor skills at 18 months
assumes standing position; manages a spoon, turns pages of book
When is apgar scoring performed on infants?
at one minute and again at 5 minutes after the birth
what stage are toddlers in according to Erikson
autonomy versus shame and doubt
What is Erikson's psychosocial stage for a toddler (1-3 years)
autonomy vs. shame and doubt
What is the most common side effect of accutane and Tetracycline?
birth defects
When the AIDS patient has a low platelet count, what is indicated?
bleeding precautions; No IM's, no rectal temperatures, other bleeding precautions
AIDS is trasmissible through what four routs?
blood, sexual contact, breast feeding, across placenta in utero
90/90 traction -part of body
boot cast and pins surgically through distal part of femur and hip and knee
After appendectomy, document in the nurses notes the return of __________
bowel sounds (peristalsis)
Order of pubescent changes for girls
breasts bud, pubic hair appears, onset of menarche
If a child swallows a potentially poisonous substance, what should be done first?
call medical help
Daily weights are obtained in children with nephrosis to monitor: 1.) weight loss from a low-protein diet 2.) accuracy of fluid balance sheets 3.) changes in the amount of edema 4.) percentile on the growth grid
changes in the amount of edema
If you care for a client who is post-op for a repair of a femoral popliteal resection what assessment must you make every hour for the first 24 hours?
check the distal extremity (far from center) for color, temperature, pain and PULSE, also document
Respiratory Synctial Virus
common respiratory virus that affects children.
Appropriate play for school aged children?
competitive and cooperative play. Peers of same gender.
Which menu selections are best for a child diagnosed with celiac disease? 1.) pizza and chocolate cake 2.) spaghetti and blueberry muffin 3.) chicken sandwich on whole-wheat bread 4.) corn tortilla and fresh fruit
corn tortilla and fresh fruit
A priority goal in the approach to a child with anorexia nervosa is to" 1.) encourage weight gain 2.) prevent depression 3.) limit exercise 4.) correct malnutrition
correct malnutrition
Describe the pain of angina pectoris
crushing substernal chest pain that may radiate
Which vaccines would the nurse expect to be prescribed for a 2-month-old during well checkup?
d-tap, HepB HIB IPV PCV
How often should a stump be washed?
daily
Define Leukopenia
decrease in wbc, indicated viral infection
If an aneurysm is ruptured how would you know it?
decreased LOC (restlessness), tachycardia, hypotension - all signs of shock
"Time is too short to start another life, though I wish I could," is an example of ___________.
despair
What is the action of nitro?
dilates coronary arteries to increase blood supply (O2 supply) and reduces preload.
When a stump is wrapped, the bandage should be tightest _____________ and loosest _____________.
distally (far from the center), proximally (neareast to the point)
Babies weight -two
doubles by 6 months triples by 12 months
Children at highest risk for seizure activity after ingestion are those who have swallowed _____________ and ______________.
drugs, insecticides
What are the three adult stages of development called
early adulthood, middle adulthood and later adulthood
If after a right BKA, the client c/o pain in his right tow, he is experiencing _____________.
phantom limb sensation (which is normal)
Babies ability -three
plays peak-a-boo by 6 months Sits upright w/o support by 8 months Fine pincer grasp by 10-12 months (pick up Cheerios)
PCV
pneumococcal conjugate vaccine
The nurse teaches the diabetic child to rotate sites of insulin injection in order to: 1.) prevent subcutaneous deposit of the drug 2.) prevent lipoatrophy of subcutaneous fat 3.) decrease the pain of the injection 4.) increase absorption of insulin
prevent lipoatrophy of subcutaneous fat
If the patient had an AKA they should lie ____________ several times per day.
prone (to prevent flexion contracture
If the AIDS patient has leukopenia they will be on _____________ ________________.
protective (reverse) isolation
How often should you measure the vital signs, vaginal bleeding, fetal heart rate during Abruptio Placenta>?
Q5-15 minutes for bleeding and maternal VS, continuous fetal monitoring, deliver at earliest sign of fetal distress
Epiglottitis
severe, life threatening infection of the epiglottis and supraglottic stuructures that occurs most commonly in children between 2 and 12 years of age.
12 months old motor skills
sits from standing; attempts to create a 2 block tower but fails.
8 months old motor skills
sits unsupported, has pincer grasp
Kaposi's sarcoma is a cancer of the ___________.
skin
Motor skills 4 years
skips and hops on one foot, throws a ball overhead
A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? 1.Fetal heart rate of 180 beats per minute 2.White blood cell count of 12,000 3.Maternal pulse rate of 85 beats per minute 4.Hemoglobin of 11.0 g/dL
1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.
Scarlet Fever 7 signs and symptoms
1. Abrupt high fever, flushed cheeks, vomiting, headache, enlarged lymph nodes in neck, malaise, ab. pain 2. Red, fine, sandpaper-like rash develops in the axilla, groin, and neck that spreads to cover the entire body except face. 3. Rash blanches with pressure, except in areas of deep creases and folds of joints. 4. Desquamanation of skin on palms and soles appears by weeks 1-3 5. Tongue is initially coated by white, furry covering with red papillae; by fifth day, white coat sloughs off leaving red, swollen tongue (White strawberry tongue -> Red strawberry tongue) 6. Tonsils are reddened and covered with exudate. 7. Pharynx is edematous and beefy red Remember: Key is the strawberry tongue
A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? 1.Document the findings and tell the mother that the monitor indicates fetal well-being 2.Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. 3.Notify the physician or nurse mid-wife of the findings. 4.Reposition the mother and check the monitor for changes in the fetal tracing
1. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.
Pertussis (Whooping Cough) 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Bordetella pertussis (Gram negative bacteria) 2. Incubation period: 5-21 days (usually 10) 3. Communicable period: greatest during the catarrhal stage 4. Source: Discharge from resp. tract of infected person 5. Transmission: Direct contact or droplet spread
Diphtheria 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Corynebacterium diptheriae 2. Incubation period: 2 to 5 days 3. Communicable period: Variable. Until virulent bacteria are no longer present (three consecutively negative cultures of pharyngeal secretions); usually 2 weeks, can be 4 weeks. 4. Source: Discharge from mucous membranes of nose and nasopharynx, skin and other lesions. 5. Transmission: Direct contact with infected person, carrier, or contaminated articles
Infectious Mononucleosis 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Epstein-Barr virus (viral) 2. Incubation period: 4 to 6 weeks 3. Communicable period: Unknown 4. Source: Oral secretions 5. Transmission: Direct intimate contact
Scarlet Fever 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Group A beta-hemolytic streprococci (Gram positive bacteria) 2. Incubation period: 1 to 7 days 3. Communicable period: About 10 days during the incubation period and clinical illness; during the first 2 weeks of the carrier stage, although may persist for months. 4. Source: Nasophayngeal secretions of infected person and carriers. 5. Transmission: Direct contact or droplet spread; indirectly by contact with contaminated articles.
Erythema Infectiosum (Fifth Disease) 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Human Parvovirus B19 (viral) 2. Incubation period: 4 - 14 days, may be 20 days 3. Communicable period: Uncertain, but before onset of symptoms in most children. 4. Source: Infected persons 5. Transmission: Unknown mode of transmission, possibly resp. secretions and blood.
Roseola (Exanthema Subitum) 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Human herpesvirus type 6 (viral) 2. Incubation period: 5-15 days 3. Communicable period: unknown, but thought to be from febrile stage to time rash appears 4. Source: unknown 5. Transmission: unknown
Rubeola (Measles) 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Paramyxovirus (viral) 2. Incubation period: 10-20 days 3. Communicable period: from 4 days before to 5 days after rash appears. 4. Source: Respiratory tract secretions, blood, or urine 5. Transmission: Airborne particles or direct contact with infectious droplets; transplacental
Mumps 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Paramyxovirus (viral) 2. Incubation period: 14-21 days 3. Communicable period: Immediately before and after parotid gland swelling begins. 4. Source: Saliva of infected persons. 5. Transmission: Direct contact or droplet spread
Rocky Mountain Spotted Fever 1. Agent? 2. Incubation period? 3. Communicable period? 4. Source? 5. Transmission?
1. Agent: Rickettsia rickettsii (Gram negative bacteria) 2. Incubation period: 2 to 14 days 3. Communicable period: NOT CONTAGIOUS 4. Source: Tick bite from mammal, usually wild rodents and dogs. 5. Transmission: Tick bite
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? 1.Swelling of the calf in one leg 2.Prolonged clotting times 3.Decreased platelet count 4.Petechiae, oozing from injection sites, and hematuria
1. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophebitis.
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: 1.Auscultating the fetal heart 2.Taking an obstetric history 3.Asking the client when she last ate 4.Ascertaining whether the membranes were ruptured
1. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.
Mumps 5 signs and symptoms
1. Fever 2. Headache and malaise 3. Anorexia 4. Jaw or ear pain aggravated by chewing, followed by parotid gland swelling. 5. Orchitis (inflamed testes) may occur Remember: Key is parotid gland swelling.
Rubeola (Measles) 5 Signs and symptoms
1. Fever 2. Malaise 3. The three "C's" - coryza, cough, conjunctivitis 4. Red, erythematous maculopapular eruption starting on face and spreading down towards feet; blanches with pressure and gradually turns brownish color (1 week) 5. Koplik's spots: small red spots with a bluish white center and red base, located on buccal mucosa Remember: Three "Cs" & Koplik's spots are the key for identifying measles.
Rocky Mountain Spotted Fever 2 signs and symptoms
1. Fever, malaise, anorexia, vomiting, headache, myalgia 2. Maculopapular OR petechial rash primarily on the extremities (ankles and wrists), but may spread to other areas, characteristically on the palms and soles. Key: Rash on ankles, wrists, palms and soles. Remember it is not communicable. Provide parents teaching about preventing tick bites.
Infectious Mononucleosis 3 signs and symptoms and 1 important complication to teach parents to monitor for.
1. Fever, malaise, headache, fatigue, nausea, abdominal pain, sore throat, enlarged red tonsils. 2. Lymphadenopathy and hepatosplenomegaly 3. Discrete macular rash most prominent over the trunk may occur. TEACH PARENTS TO MONITOR FOR SPLENIC RUPTURE: Marked by abdominal pain, left upper quadrant pain, referred left-shoulder pain.
Contraindications for HPV vaccine?
1. Individuals with a reaction to a previous injection. 2. PREGNANT WOMEN should not receive HPV vaccine.
Chickenpox (Varicella) 3 signs and symptoms
1. Slight fever, malaise, and anorexia are followed by a macular rash that first appears on the trunk and scalp and move to the face and extremities. 2. Lesions become pustules, begin to dry, and develop a crust. 3. Lesions may appear on mucous membranes of mouth, genital area, or rectum.
A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is: 1.1 cm above the ischial spine 2.1 fingerbreadth below the symphysis pubis 3.1 inch below the coccyx 4.1 inch below the iliac crest
1. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.
Roseola (Exanthema Subitum) 2 Signs and symptoms?
1. Sudden high (>38.8 C / >102 F) fever of 3 to 5 day's duration in a child that appears well, followed by a rash (rose-pink macules that blanch with pressure. 2. Rash appears several hours to 2 days after fever subsides and lasts 1 to 2 days. Disease is self-limiting and treatment is supportive. Remember: fever first, then rash.
Pertussis (Whooping Cough) 3 signs and symptoms
1. Symptoms of respiratory infection followed by increased severity of cough, with a loud, whooping INSPIRATION. 2. May experience cyanosis, resp. distress, and tongue protrusion. 3. Listlessness, irritability, anorexia. Remember: Key is whooping inspirations. Child will be receiving antimicrobials. Institute airborne precautions and isolate child.
Correct Answer: D Your Response:
1. The nurse needs to take the blood pressure of a preschool boy for the first time. Which action would be best in gaining his cooperation? A. Taking his blood pressure when a parent is there to comfort him B. Telling him that this procedure will help him get well faster. C. Explaining to him how the blood flows through the arm and why the blood pressure is important D. Permitting him to handle equipment and see the dial move before putting the cuff in place
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician
1. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
Rubella (German Measles) 4 signs and symptoms and 1 very important intervention to remember
1. low-grade fever 2. Malaise 3. Pinkish red maculopapular rash the begins on face and spreads to the entire body within 1 to 3 days. 4. Petechial, red, pinpoint spots may appear on the soft palate. Key for identification is rash covering entire body and spots on soft palate. REMEMBER: ISOLATE CHILD FROM PREGNANT WOMEN.
ANS: C 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 for requests for information about procedures and health information. By not responding the nurse may be limiting communication with the child. The child is not exhibiting anxiety, just requesting clarification of what will be occurring. The nurse must explain how the blood pressure cuff works so the child can then observe during the procedure.
107. An 8-year-old girl asks the nurse how the blood pressure apparatus works. The most appropriate nursing action is to: a. Ask her why she wants to know. b. Determine why she is so anxious. c. Explain in simple terms how it works. d. Tell her she will see how it works as it is used.
ANS: B 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.
108. 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.
ANS: D 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, since 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.
109. The nurse is having difficulty communicating with a hospitalized 6-year-old child. What technique might 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 if the child is always uncommunicative. d. Ask the child to draw a picture.
erect standing posture with support
11 M
Correct Answer: A Your Response:
11. The best explanation for why pulse oximetry is used on young children is that it: A. Is noninvasive. B. Is better than capnography. C. Is more accurate than arterial blood gases. D. Provides intermittent measurements of O2.
BP Boys 10 years
110-123/73-82
What is the normal fetal heart rate?
110-160 bpm
What is the normal newborn heart rate?
110-160; 100-180 if sleeping or crying
ANS: B The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. Because the adolescent is the focus of the history, this is an appropriate way to determine the chief complaint. A listing of symptoms will make it difficult to determine the chief complaint. The adolescent should be prompted to tell which symptom caused him 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.
110. The nurse is taking a health history on an adolescent. What best describes how the chief complaint should be determined? a. Ask for detailed listing of symptoms. b. Ask adolescent, "Why did you come here today?" c. Use what adolescent says to determine, in correct medical terminology, what the problem is. d. Interview parent away from adolescent to determine chief complaint.
ANS: C The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. The focus of the present illness is on all factors relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present. Past history refers to information that relates to previous aspects of the child's health, not to the current problem. The chief complaint is the specific reason for the child's visit to the clinic, office, or hospital. It does not contain the narrative portion describing the onset and progression. The review of systems is a specific review of each body system.
111. 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
BP Girls 10 years
112-122/73-80
ANS: A The birth history refers to information that relates to previous aspects of the child's health, not to the current problem. The mother's difficult delivery and prematurity are important parts of the past history of an infant. The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Unless 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.
112. 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
ANS: C Head circumference begins larger than chest circumference. Between ages 1 and 2 years, they become approximately equal. Head circumference is larger than chest circumference at ages 1 month and 6 to 9 months. Chest circumference is larger than head circumference at age 2.5 to 3 years.
121. 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
BP Girls 16 years
122-132/79-86
ANS: C 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.
113. 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.
ANS: B 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.
114. The nurse is taking a sexual history on an adolescent girl. The best way to determine whether she is sexually active is to: a. Ask her, "Are you sexually active?" b. Ask her, "Are you having sex with anyone?" c. Ask her, "Are you having sex with a boyfriend?" d. Ask both the girl and her parent if she is sexually active.
ANS: C The diet that contains vegetable, legumes, and starches may provide sufficient essential amino acids, even though the actual amount of meat or dairy protein is low. Many cultures use diets that contain this combination of foods. It does not indicate poverty. Combinations of foods contain the essential amino acids necessary for growth. A dietary assessment should be done, but many vegetarian diets are sufficient for growth.
115. When doing a nutritional assessment on an Hispanic family, the nurse learns that their diet consists mainly of vegetables, legumes, and starches. The nurse should recognize that this diet: a. Indicates that they live in poverty. b. Is lacking in protein. c. May provide sufficient amino acids. d. Should be enriched with meat and milk.
ANS: D Upper arm circumference is correlated with measurements of total muscle mass. Muscle serves as the body's major protein reserve and is considered an index of the body's protein stores. Height is reflective of past nutritional status. Weight is indicative of current nutritional status. Skin-fold thickness is a measurement of the body's fat content.
116. 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
ANS: C Parents can remove clothing, and the child can remain on the parent's lap. The nurse should use minimal physical contact initially to gain the child's cooperation. The head-to-toe assessment can be done in older children but usually must be adapted in younger children. Traumatic procedures should always be performed last. These will most likely upset the child and inhibit cooperation. The nurse should introduce the equipment slowly. The child can inspect the equipment, but demonstrations are usually too complex for this age group.
117. 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.
ANS: C 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.
118. 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
ANS: D 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.
119. 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.
pick up bite size pieces of ceral
11M
birth weight usually trippled
12 M
eats with fingers
12 M
needs help while walking
12 M
sits from standing position without assistance
12 M
usually says two words in addition to mama and dada
12 M
What is the normal leukocytosis of pregnancy?
12,000 to 15,000
What is considered normal WBC level after labor?
12,000 to 25,000
MMR
12-15 months, 4-6 years
Varicella
12-15 months, 4-6 years
How long should the stump be elevated to prevent post op swelling?
12-24 hours
Correct Answer: B Your Response:
12. When is bronchial (postural) drainage generally performed? A. Immediately before all aerosol therapy B. Before meals and at bedtime C. Immediately on arising and at bedtime D. Thirty minutes after meals and at bedtime
ANS: B 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.
120. Which tool measures body fat most accurately? a. Stadiometer b. Calipers c. Cloth tape measure d. Paper or metal tape measure
ANS: B, C Research has demonstrated that cuff selection with a bladder width that is 40% of the arm circumference will usually have a bladder length that is 80% to 100% of the upper arm circumference. This size cuff will most accurately reflect measured radial artery pressure. The name of the cuff is a representative size that may not be suitable for any individual child. Choosing a cuff by limb circumference more accurately reflects arterial pressure than choosing a cuff by length.
140. 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? Choose 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.
ANS: A, C, E, F 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.
141. Which data would be included in a health history? Choose all that apply. a. Review of systems b. Physical assessment c. Sexual history d. Growth measurements e. Nutritional assessment f. Family medical history
ANS: C Family stress theory explains the reaction of families to stressful events. In addition, crisis intervention strategies are used to help family members cope with the challenging event. In the family systems theory, the focus is on the interaction of family members within the larger environment. In the developmental theory the nurse provides anticipatory guidance to help family members cope with the challenging event. Family assessment is not a theory. An assessment is necessary to discover the family's dynamics, strengths and weaknesses.
142. Which family theory explains how families react to stressful events and suggests factors that promote adaptation to these events? a. Family systems theory c. Family stress theory b. Developmental theory d. Family assessment
ANS: A A consanguineous family is one of the most common types and consists of members who have a blood relationship. The affinal family is one made up of marital relationships. Although the parents are married, they may each bring children from a previous relationship. The family of origin is the family unit that a person is born into. Considerable controversy has been generated about the newer concepts of families (i.e., communal, single-parent or homosexual families). To accommodate these other varieties of family styles, the descriptive term household is frequently used.
143. What type of family is one in which all members are related by blood? a. Consanguineous c. Family of origin b. Affinal d. Household
ANS: B Firstborn children, like only children, tend to be more achievement oriented. Later-born children are praised less often, are more popular with their peer group, and identify with their peer group more than with their parents.
144. Studies about the ordinal position of children suggest that firstborn children tend to: a. Be praised less often. b. Be more achievement oriented. c. Be more popular with the peer group. d. Identify with peer group more than parents.
ANS: B Later-born children are obliged to interact with older siblings from birth and seem to be more outgoing and make friends more easily than firstborns. Characteristics of firstborn children and only children include only children are more dependent than firstborn children, both types of children identify more with their parents than with their peers, and both types of children are subject to greater parental expectations.
145. Birth position of children affects their personalities. What is considered to be a characteristic of children who are the youngest in their family? a. More dependent than firstborn children. b. More outgoing than firstborn children. c. Identify more with parents than with peers. d. Are subject to greater parental expectations.
ANS: D Monozygotic twins occur with the same frequency uniformly in all populations. The tendency toward monozygotic twins is unaffected by heredity. Monozygotic twins are not affected by maternal age, but higher-order births are. The frequency is uniform among races.
146. What applies to the rate of frequency of monozygotic (identical) twins being born? a. The rate is affected by heredity. c. It varies among races. b. The rate is affected by maternal age. d. It occurs uniformly in all populations.
ANS: A Twins work out a relationship that is reasonably satisfactory to both. They develop a remarkable capacity for cooperative play and considerable loyalty and generosity toward each other. Parents should foster individual differences and allow the children to follow their natural inclinations. Individuation does occur. In twinship one member of the pair is more dominant, outgoing, and assertive than the other. Early separation may produce unnecessary stresses for the children. There is no evidence that pathologic bonding occurs.
147. Nicole and Kelly, age 5 years, are identical twins. Their parents tell the nurse that the girls always want to be together. The nurse's suggestions should be based on knowing that: a. Some twins thrive best when they are constantly together. b. Individuation cannot occur if twins are together too much. c. Separating twins at an early age helps them develop mentally. d. When twins are constantly together, pathologic bonding occurs.
ANS: A If parents are supportive of each other, they can serve as positive influences on establishing satisfying parental roles. When marital tensions alter caregiving routines and interfere with the enjoyment of the infant, the marital relationship has a negative effect. Infants with special care needs can be a significant source of added stress. Older parents are usually more able to cope with the greater financial responsibilities, changes in sleeping habits, and reduced time for each other and other children. Parents who have previous experience with parenting appear more relaxed, have less conflict in disciplinary relationships, and are more aware of normal growth and development.
148. The nurse is teaching a group of new parents about the experience of role transition. Which statement by a parent indicates a correct understanding of the teaching? a. "My marital relationship can have a positive or negative effect on the role transition." b. "If an infant has special care needs, the parents' sense of confidence in their new role is strengthened." c. "Young parents can adjust to the new role easier than older parents." d. "A parent's previous experience with children makes the role transition more difficult."
Correct Answer: B
156. Studies of families with only one child indicate that only children: A. Tend to be selfish. B. Are similar to firstborn children. C. Are less stimulated toward achievement. D. Grow up lonely and dependent on other adults.
ANS: A Permissive parents avoid imposing their own standards of conduct and allow their children to regulate their own activity as much as possible. The parents exert little or no control over their children's actions. Dictatorial or authoritarian parents attempt to control their children's behavior and attitudes through unquestioned mandates. They establish rules and regulations or standards of conduct that they expect to be followed rigidly and unquestioningly. Democratic parents combine permissive and dictatorial styles. They direct their children's behavior and attitudes by emphasizing the reasons for rules and negatively reinforcing deviations. They respect the child's individual nature.
149. When assessing a family, the nurse determines that the parents exert little or no control over their children. This style of parenting is called: a. Permissive. c. Democratic. b. Dictatorial. d. Authoritarian.
The diagnosis is made when there is a weight loss of _______% or more of body weight.
15 (weigh < 85% of normal body weight), hospitalize if 30% weight loss
builds 2 blocker tower
15 M
grasps spoon
15 M
names commonplace objects
15 M
throws objects
15 M
walks alone
15 M
Apendicitis occurs most in what age group?
15 to 35
ANS: C The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed.
15. What should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered "informed."
ANS: D Through the use of physical punishment, children learn what they should not do. When parents are not around, it is more likely that children will misbehave because they have not learned to behave well for their own sake but rather out of fear of punishment. Spanking can cause severe physical and psychologic injury and interfere with effective parent-child interaction. Children do become accustomed to spanking, requiring more severe corporal punishment each time. The use of corporal punishment may interfere with the child's development of moral reasoning.
150. What is most characteristic of the physical punishment of children, such as spanking? a. Psychologic impact is usually minimal. b. Children rarely become accustomed to spanking. c. Children's development of reasoning increases. d. Misbehavior is likely to occur when parents are not present.
ANS: A It is important for the parents not to withhold information about the adoption from the child. It is an essential component of the child's identity. There is no recommended best time to tell children. It is believed that children should be told young enough so they do not remember a time when they did not know. It should be done before the children enter school to keep third parties from telling the children before the parents have had the opportunity.
151. A 3-year-old girl was adopted immediately after birth. The parents have just asked the nurse how they should tell the child that she is adopted. Which guideline concerning adoption should the nurse use in planning her response? a. Telling the child is an important aspect of their parental responsibilities. b. The best time to tell the child is between ages 7 and 10 years. c. It is not necessary to tell the child who was adopted so young. d. It is best to wait until the child asks about it.
ANS: B Parental divorce affects school-age children in many ways. In addition to difficulties in school, they often have profound sadness, depression, fear, insecurity, frequent crying, loss of appetite, and sleep disorders. Uncommon responses to parental divorce include indications of maladjustment, the suggestion of lack of adequate parenting, and the need for referral.
152. A parent of a school-age child tells the school nurse that the parent is going through a divorce. The child has not been doing well in school and sometimes has trouble sleeping. The nurse should recognize this as: a. Indicative of maladjustment. b. Common reaction to divorce. c. Suggestive of lack of adequate parenting. d. Unusual response that indicates need for referral.
ANS: D "Let's talk about the child-care options that will be best for Eric" is an open-ended statement that will assist the mother in exploring her concerns about what is best for both her and Eric. "I'm sure he'll be fine if you get a good babysitter," "You will need to stay home until Eric starts school," and "You should go back to work so Eric will get used to being with others" are directive statements and do not address the effect of her working on Eric.
153. A mother brings 6-month-old Eric to the clinic for a well-baby checkup. She comments, "I want to go back to work, but I don't want Eric to suffer because I'll have less time with him." The nurse's most appropriate answer is: a. "I'm sure he'll be fine if you get a good babysitter." b. "You will need to stay home until Eric starts school." c. "You should go back to work so Eric will get used to being with others." d. "Let's talk about the child-care options that will be best for Eric."
ANS: A, D Internal resources include both adaptability and integration. Adaptation is learning to be patient, becoming better organized and more flexible. Integration refers to the couples attempt to continue some activities they engaged in before they became parents. The second resource for dealing with stress is the use of coping strategies. These include the use of social support systems such as friends, family and neighbors and community resources.
154. A young couple who has just delivered their first child adapts to the stress of new parenthood by using two types of family resources. These include (choose all that apply): a. Internal resources. b. Adaptation. c. Integration. d. Coping strategies. e. Community resources.
Correct Answer: D
155. What is descriptive of the family system theory? A. Family is viewed as the sum of individual members. B. Change in one family member cannot create a change in other members. C. Individual family members are readily identified as the source of a problem. D. When the family system is disrupted, change can occur at any point in the system.
ANS: B Preparing the child for any unfamiliar treatments, controlling pain, allowing privacy, providing play activities for expression of fear and aggression, providing choices, and respecting cultural differences are components of atraumatic care. In providing atraumatic care, the separation of child from parents during hospitalization is minimized. The nurse should promote a sense of control for the child. Preventing and minimizing bodily injury and pain are major components of atraumatic care.
188. The nurse is preparing staff in-service education about atraumatic care for pediatric patients. Which intervention should the nurse include? a. Prepare the child for separation from parents during hospitalization by reviewing a video. b. Prepare the child before any unfamiliar treatment or procedure by demonstrating on a stuffed animal. c. Help the child accept the loss of control associated with hospitalization. d. Help the child accept pain that is connected with a treatment or procedure.
ANS: A Many of the nurse's actions may serve the needs of the nurse rather than those of the child and the family. It would be therapeutic for the patient and family to have the same nurse provide care over an extended period of time. By withdrawing somewhat, nurses can protect themselves while providing therapeutic care. The nurse's role is to transition the child and family to self-care.
189. What most suggests that a nurse has a nontherapeutic relationship with a patient and family? a. The boundaries between staff and patients are blurred. b. Staff assignments allow the nurse to care for same patient and family over an extended time. c. Nurse is able to withdraw emotionally when emotional overload occurs but still remains committed. d. Nurse uses teaching skills to instruct patient and family rather than doing everything for them.
What is the age range for early adulthood?
19 to 35 years of age
Resp 6-12 years
19-21
ANS: A The parents' preferences for assisting, observing, or waiting outside the room should be assessed, as well as the child's preference for parental presence. The child's choice should be respected. If the mother and child are agreeable, the mother is welcome to stay. An appropriate substitute for the mother is necessary only if the mother does not wish to stay. Support is offered to the child regardless of parental presence.
19. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse that she wants her mother with her "like before." The most appropriate nursing action is to: a. Grant her request. b. Explain why this is not possible. c. Identify an appropriate substitute for her mother. d. Offer to provide support to her during the procedure.
ANS: B Critical thinking is a complex, developmental process based on rational and deliberate thought. When thinking is clear, precise, accurate, relevant, consistent, and fair, a logical connection develops between the elements of thought and the problem at hand.
190. What is most descriptive of critical thinking? a. A simple developmental process b. Purposeful and goal directed c. Based on deliberate and irrational thought d. Assists individuals in guessing what is most appropriate
ANS: A, B, C, E, F The accepted model is assessment, diagnosis, planning, implementation and evaluation. The diagnosis phase is separated into two steps: nursing diagnosis and outcome identification. Although important, identification is not a stand-alone step in the nursing process.
191. The nursing process is a method of problem identification and problem solving that describes what the nurse actually does. The five steps include (choose all that apply): a. Assessment b. Diagnosis c. Planning d. Identification e. Implementation f. Evaluation
ANS: Evidence-Based Practice Evidence-based nursing practice combines knowledge with clinical experience and intuition. It provides a rational approach to decision making.
192. EBP, __________________ _____________ _______________, is the collection, interpretation and integration of valid, important and applicable patient-reported, nurse-observed and research-derived information.
If an AIDS patient's blood contaminates a counter top, with what di you clean?
1:10 solution of bleach and water
What tissue to tears extend to?
1st degree - epidermis 2nd degree - dermis, muscle and fascia 3rd degree - extends into anal sphincter 4th degree - extends into rectal mucosa
The maximum score and infant can receive on any one of the criteria is
2
Social smile first appears
2 M
able to turn from side to back
2 M
closing of posterior fontanelle
2 M
diminished moro reflex
2 M
diminished tonic neck
2 M
eyes begin to follow a moving object
2 M
Hep A
2 doses between 12-23 months
Height for school age per year?
2 inches per year
DTap
2 months, 4 months, 6 months, 15-18 months, 4-6 years
What are the urinaysis findings on AGN?
2 to 3 weeks after initial infection
At what age are accidental poisonings most common?
2 years old
Rotavirus
2, 4, 6 months
Inactivated polio
2, 4, 6 months, 4-6 years
Hib
2, 4, 6, 12-15 months
Pneumococcal
2, 4, 6, 12-15 months
ANS: C Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia. Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased, not decreased, blood pressure is characteristic of malignant hyperthermia.
21. In some genetically susceptible children anesthetic agents can trigger malignant hyperthermia. The nurse should be alert in observing that, in addition to an increased temperature, an early sign of this disorder is: a. Apnea. b. Bradycardia. c. Muscle rigidity. d. Decreased blood pressure.
ANS: C A draw sheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms. Pressure-reduction devices should be used to redistribute weight. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices should be used instead. The skin should be cleansed with mild nonalkaline soap or soap-free cleaning agents for routine bathing.
22. The nurse is caring for an unconscious child. Skin care should include: a. Avoiding use of pressure reduction on the bed. b. Massaging reddened bony prominences to prevent deep tissue damage. c. Using draw sheet to move child in bed to reduce friction and shearing injuries. d. Avoiding rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.
ANS: D Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, and macaroni and cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the behavior as a control mechanism. Large quantities of fluid may decrease the child's hunger and further inhibit food intake.
23. An appropriate intervention to encourage food and fluid intake in a hospitalized child is to: a. Force child to eat and drink to combat caloric losses. b. Discourage participation in noneating activities until caloric intake is sufficient. c. Administer large quantities of flavored fluids at frequent intervals and during meals. d. Give high-quality foods and snacks whenever child expresses hunger.
300 word vocab
24 M
builds 5 to 6 block tower
24 M
early efforts at jumping
24 M
obeys easy commands
24 M
ANS: A Most fevers are of brief duration, have limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection.
24. Kimberly, age 3 years, has a fever associated with a viral illness. Her mother calls the nurse, reporting a fever of 102° F even though she had acetaminophen 2 hours ago. The nurse's action should be based on knowing that: a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102° F indicates greater severity of illness. d. Fever over 102° F indicates a probable bacterial infection.
Resp 1-2 years
25-30
What should the total weight gain be in a "normal" weight woman during pregnancy?
25-35 lbs.
ANS: C Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the body's way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever. Ice water and isopropyl alcohol are inappropriate, potentially dangerous solutions. Fans should not be used because of the risk of the child developing vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to the skin surface, and the blood remains primarily in the viscera to become heated. The child is placed in a tub of tepid water for 20 to 30 minutes.
25. Tepid water or sponge baths are indicated for hyperthermia in children. The nurse should: a. Add isopropyl alcohol to the water. b. Direct a fan on the child in the bath. c. Stop the bath if the child begins to chill. d. Continue the bath for 5 minutes.
ANS: D The child must be correctly identified before the administration of any medication. Children are not totally reliable in giving correct names on request; identification bracelets should always be checked. Asking the group to identify the child, calling out the child's name, and asking each child to give their name are not acceptable ways to identify a child. Older children may exchange places, give an erroneous name, or choose not to respond to their name as a form of a joke.
26. The nurse approaches a group of school-age patients to administer medication to Sam Hart. To identify the correct child, the nurse should: a. Ask the group, "Who is Sam Hart?" b. Call out to the group, "Sam Hart?" c. Ask each child, "What's your name?" d. Check the patient's identification name band.
ANS: A When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of after use and hands should be thoroughly washed again before new gloves are applied.
27. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should: a. Wash hands thoroughly. b. Check the gloves for leaks. c. Rinse gloves in disinfectant solution. d. Apply new gloves before touching the next patient.
ANS: A All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently these containers should be installed in the patient's room. The uncapped needle should not be transported to an area distant from use.
28. The nurse gives an injection in a patient's room. What should the nurse do with the needle for disposal? a. Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room. b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patient's room. c. Cap needle immediately after giving injection and dispose of in proper container. d. Cap needle, break from syringe, and dispose of in proper container.
ANS: D The nurse should remove the restraints whenever possible. When parents and/or staff are present, the restraints can be removed, and the intravenous site protected. Restraints must be checked and documented every 1 to 2 hours and should be removed for range of motion on a periodic basis. The child should not be securely restrained in the supine position because of risks of aspiration.
29. An 8-month-old infant is restrained to prevent interference with the intravenous infusion. The nurse should: a. Remove the restraints once a day to allow movement. b. Keep the restraints on constantly. c. Keep the restraints secure so infant remains supine. d. Remove restraints whenever possible.
How many nitro tabs can you take before you call the doctor?
3
ANS: C To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child's skin. Taping a small medicine cup to the inside of the diaper is not feasible; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.
31. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. The most appropriate way to collect small amounts of urine for these tests is to: a. Apply a urine-collection bag to perineal area. b. Tape a small medicine cup to the inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe. d. Aspirate urine from a superabsorbent disposable diaper with a syringe.
What are normal hematocrit values at 28-32 weeks gestation?
32%-42%
ANS: B The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparing the child and parents, selecting the correct catheter, and using appropriate insertion technique. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. Catheterization is a sterile procedure, and Standard Precautions for body-substance protection should be followed. Water-soluble lubricants do not provide appropriate local anesthesia. Catheterization should be delayed only 2 to 3 minutes. This provides sufficient local anesthesia for the procedure.
32. An important nursing consideration when performing a bladder catheterization on a young boy is to: a. Use clean technique, not Standard Precautions. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.
ANS: C The Allen test assesses the circulation of the radial, ulnar, or brachial arteries before arterial puncture.
33. The Allen test is performed as a precautionary measure before which procedure? a. Heel stick b. Venipuncture c. Arterial puncture d. Lumbar puncture
9 months old motor skills
pulls to a standing position, has a crude pincer grasp
ANS: A Administer the medication with a syringe without needle placed alongside of the infant's tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. Holding the child's nasal passages increases the risk of aspiration.
36. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administering the medication with a syringe (without needle) placed along the side of the infant's tongue b. Administering the medication as rapidly as possible with the infant securely restrained c. Mixing the medication with the infant's regular formula or juice and administer by bottle d. Keeping the child upright with the nasal passages blocked for a minute after administration
ANS: B The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before skin is penetrated. Place the child in a lying or sitting position.
37. Guidelines for intramuscular administration of medication in school-age children include to: a. Inject medication as rapidly as possible. b. Insert the needle quickly, using a dartlike motion. c. Penetrate the skin immediately after cleansing the site, before skin has dried. d. Have the child stand, if possible, and if he or she is cooperative.
ANS: A The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball.
38. When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down b. Carefully under the eye lid while it is gently pulled upward c. On the sclera while the child looks to the side d. Anywhere as long as drops contact the eye's surface
ANS: B In situations in which rapid establishment of systemic access is vital and venous access is hampered such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe lifesaving alternative. The procedure is painful, and local anesthesia and systemic analgesia are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time consuming, and intraosseous infusion is used in an emergency situation.
39. A 2-year-old child comes to the emergency department with dehydration and hypovolemic shock. What best explains why an intraosseous infusion is started? a. It is less painful for small children. b. Rapid venous access is not possible. c. Antibiotics must be started immediately. d. Long-term central venous access is not possible.
900 word vocab
3Y
builds bridge w/ 3 cubes
3Y
copies a circle
3Y
learns from experience
3Y
less negativistic than toddler, decreased tantrums
3Y
may invent imaginary friend
3Y
rides tricycle
3Y
undressed without help
3Y
uses sentences
3Y
walks backward and downstairs without assistance
3Y
ANS: D The nursing responsibility for intravenous therapy is to calculate the amount to be infused in a given length of time, set the infusion rate, and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. A minidropper (60 drops per milliliter) is the recommended intravenous tubing in pediatrics. The intravenous site should be protected. This may require soft restraints on the child. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. Frequent change exposes the child to significant trauma.
40. When caring for a child with an intravenous infusion, the nurse should: a. Use a macrodropper to facilitate reaching the prescribed flow rate. b. Avoid restraining the child to prevent undue emotional stress. c. Change the insertion site every 24 hours. d. Observe the insertion site frequently for signs of infiltration.
ANS: D It is important to make certain that sensor connectors and oximeters are compatible. Wiring that is incompatible can generate considerable heat at the tip of the sensor, causing second- and third-degree burns under the sensor. Incompatibility would cause a local irritation or burn. A low voltage is used, which should not present risk of electrocution. Pressure necrosis can occur from the sensor being attached too tightly, but this is not a problem of incompatibility.
41. It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible can cause: a. Hyperthermia. b. Electrocution. c. Pressure necrosis. d. Burns under sensors.
ANS: A For postural drainage and percussion, the child should be dressed in a light shirt to protect the skin and placed in the appropriate postural drainage positions. The chest wall is struck with a cupped-hand, not a flat-hand position. The procedure should be done over the rib cage only. Positioning precedes the percussion.
42. The nurse is teaching a mother how to perform chest physiotherapy and postural drainage on her 3-year-old child, who has cystic fibrosis. To perform percussion the nurse should instruct her to: a. Cover the skin with a shirt or gown before percussing. b. Strike the chest wall with a flat-hand position. c. Percuss over the entire trunk anteriorly and posteriorly. d. Percuss before positioning for postural drainage.
ANS: C Suctioning should require not longer than 5 seconds per pass. Otherwise the airway may be occluded for too long. If the child is able to cough up secretions, suctioning may not be indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it is too large, it might block the child's airway. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear.
43. The nurse must suction a child with a tracheostomy. Interventions should include: a. Encouraging the child to cough to raise the secretions before suctioning. b. Selecting a catheter with a diameter three fourths as large as the diameter of the tracheostomy tube. c. Ensuring that each pass of the suction catheter take no longer than 5 seconds. d. Allowing the child to rest after every five times the suction catheter is passed.
ANS: B The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia. Any changes from the prescribed flow rate may lead to hyperglycemia or hypoglycemia.
44. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours the nurse observes the solution and notes that 200 ml/8 hr is being infused rather than the ordered amount of 300 ml/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours? a. 200 ml b. 300 ml c. 350 ml d. 400 ml
ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Fleet enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the Fleet enema can result in diarrhea, which can lead to metabolic acidosis.
45. In preparing to give "enemas until clear" to a young child, the nurse should select: a. Tap water. b. Normal saline. c. Oil retention. d. Fleet solution.
ANS: A, B, E Less painful, free of important nerves and vascular structures, and easily identifiable are advantages of the ventrogluteal muscle. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. Cannot be used when a child is 20 pounds or more and increased subcutaneous fat are not advantages of the ventrogluteal muscle as an injection site in young children.
46. The advantages of the ventrogluteal muscle as an injection site in young children include (choose all that apply): a. Less painful than vastus lateralis b. Free of important nerves and vascular structures c. Cannot be used when child reaches a weight of 20 pounds d. Increased subcutaneous fat, which increases drug absorption e. Easily identified by major landmarks
When administering digoxin (Lanoxin) to an infant, the medication should be withheld and the physician notified if the: 1.) pulse rate is below 60 beats/min 2.) infant is dyspneic 3.) pulse rate is below 100 beats/min 4.) respiratory rate is above 40 breaths/min
pulse rate is below 100 beats/min
1. ANS: D 2. ANS: F 3. ANS: A 4. ANS: E 5. ANS: C 6. ANS: B
47. MATCHING The nurse is preparing to insert a nasogastric tube into a 4-year-old child for intermittent suctioning after abdominal surgery. Place in correct sequence the steps for inserting a nasogastric tube. a. Lubricate the nasogastric tube with water-soluble lubricant. b. Tape the nasogastric tube securely to the child's face. c. Check the placement of the tube by aspirating stomach contents. d. Place the child in the supine position with head slightly hyperflexed. e. Insert the nasogastric tube through the nares. f. Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid process and the umbilicus. 1. Place the child in the supine position with head slightly hyperflexed. 2. Measure the tube from the tip of the nose to the ear lobe to midpoint between the xiphoid process and the umbilicus. 3. Lubricate the nasogastric tube with water-soluble lubricant. 4. Insert the nasogastric tube through the nares. 5. Check the placement of the tube by aspirating stomach contents. 6. Tape the nasogastric tube securely to the child's face.
When is the risk of seizures usually gone in the preeclamptic patient?
48 hours after birth
Correct Answer: B Your Response:
48. Which behavior would most likely be manifested in a young child experiencing the protest phase of separation anxiety? A. Inactivity B. Clings to parent C. Depressed, sad D. Regression to earlier behavior
Correct Answer: D Your Response:
49. The most consistent indicator of pain in infants is: A. Increased respirations. B. Increased heart rate. C. Squirming and jerking. D. Facial expression of discomfort.
drooling begins
4M
1500 word vocab
4Y
brushes teeth
4Y
climbs and jumps well
4Y
laces shoes
4Y
skips and hops on one foot
4Y
throws overhead
4Y
Birth weight usually doubled
5 M
takes objects presented to him/her
5 M
How many minutes should lapse between the nitro pills you take?
5 minutes - take one nitro tab every 5 minutes 3 times, if no relief, call MD
Preschool speech
5-8 words
Correct Answer: A Your Response:
5. Maria, age 10, requires daily medications for a chronic illness. Her mother tells the nurse that she is always nagging her to take her medicine before school. What is the most appropriate nursing action to promote Maria's compliance? A. Establishing a contract with her, including rewards B. Suggesting time-outs when she forgets her medicine C. Discussing with her mother the damaging effects of nagging D. Asking Maria to bring her medicine containers to each appointment so they can be counted
Pulse 12 +
50-90
Correct Answer: C Your Response:
50. The psychosexual conflicts of preschool children make them extremely vulnerable to: A. Separation anxiety. B. Loss of control. C. Bodily injury and pain. D. Loss of identity.
A CD4 count of under __________ is associated with the onset of AIDS-related symptoms.
500
Correct Answer: B Your Response:
51. The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, O.K.?" The nurse should: A. Start the IV line because allowing the child to manipulate the nurse is bad. B. Start the IV line because unlimited procrastination results in heightened anxiety. C. Postpone starting the IV line until the child is ready so that the child experiences a sense of control. D. Postpone starting the IV line until the child is ready so the child's anxiety is reduced.
Correct Answer: C Your Response:
52. A 4-year-old child will be having cardiac surgery next week. The child's parents call the hospital, asking about how to prepare her for this. The nurse's reply should be based on knowledge that: A. Preparation at this age will only increase the child's stress. B. Preparation needs to be at least 2 to 3 weeks before hospitalization. C. Children who are prepared experience less fear and stress during hospitalization. D. Children who are prepared experience overwhelming fear by the time hospitalization occurs.
Correct Answer: A Your Response:
53. A mother tells the nurse that she will visit her 2-year-old son tomorrow about noon. During the child's bath, he asks for Mommy. The nurse's best reply is: A. "Mommy will be here after lunch." B. "Mommy always comes back to see you." C. "Your Mommy told me yesterday that she would be here today about noon." D. "Mommy had to go home for a while, but she will be here today."
Correct Answer: D Your Response:
54. The nurse working in an outpatient surgery center for children should understand that: A. Children's anxiety is minimal in such a center. B. Waiting is not stressful for parents in such a center. C. Accurate and complete discharge teaching is the responsibility of the surgeon. D. Families need to be prepared for what to expect after discharge.
ANS: A The major stress for children from infancy through the preschool years is separation anxiety, also called anaclitic depression. This is a major stressor of hospitalization. Loss of control, fear of bodily injury, and fear of pain are all stressors associated with hospitalization. However, separation from family is a primary stressor in this age group. PTS: 1 DIF: Cognitive Level: Comprehension REF: 1221 OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment
55. What represents the major stressor of hospitalization for children from middle infancy throughout the preschool years? a. Separation anxiety b. Loss of control c. Fear of bodily injury d. Fear of pain
Correct Answer: A Your Response:
6. Allison, age 7 years, has a fever associated with a viral illness. She is being cared for at home. The nurse should recognize that the principal reason for treating fever in this child is: A. Relief of discomfort. B. Reassurance that illness is temporary. C. Prevention of secondary bacterial infection. D. Prevention of life-threatening complications.
What respiratory rate in the newborn indicates that the newborn should not be fed?
60 breaths/min or more
ANS: B A toddler experiences separation anxiety secondary to being separated from the parents. To avoid this, the parents should be encouraged to room in as much as possible. Maintaining routines and ensuring privacy are helpful interventions, but they would not substitute for the parents. Contact with same-aged children would not substitute for having the parents present.
60. An appropriate nursing intervention to minimize separation anxiety in a hospitalized toddler is to: a. Provide for privacy. b. Encourage parents to room in. c. Explain procedures and routines. d. Encourage contact with children the same age.
ANS: A Crying is an appropriate behavior for the upset preschooler. The nurse provides support through physical presence. Giving the child time to gain control is appropriate, but the child must know that crying is acceptable. The preschooler does not engage in competitive behaviors.
61. Four-year-old Brian appears to be upset by hospitalization. An appropriate intervention is to: a. Let him know that it is all right to cry. b. Give him time to gain control of himself. c. Show him how other children are cooperating. d. Tell him what a big boy he is to be so quiet.
ANS: A School-age children need to have control of their environment. The nurse should offer explanations or prepare the child for experiences that are unavoidable. The nurse should refer to the child by the preferred name. Telling the child about all of the limitations of visiting does not help her adjust to the hospital. At the age of 8 years the child and parent should be oriented to the environment.
62. Natasha, age 8 years, is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. What will help her most in her adjustment to the hospital? a. Explain hospital schedules such as mealtimes. b. Use terms such as "honey" and "dear" to show a caring attitude. c. Explain when parents can visit and why siblings cannot come to see her. d. Orient her parents, because she is young, to her room and hospital facility.
ANS: A Children at this age group still fear that their insides may leak out at the injection site. Provide the Band-Aid. No explanation should be required.
63. Samantha, age 5 years, tells the nurse that she "needs a Band-Aid" where she had an injection. The best nursing action is to: a. Apply a Band-Aid. b. Ask her why she wants a Band-Aid. c. Explain why a Band-Aid is not needed. d. Show her that the bleeding has already stopped.
What is the age range for late adulthood?
64 years of age to death
ANS: C Parents should bring favorite items from home to be with the child. Young children associate inanimate objects with significant people; they gain comfort and reassurance from these items. New toys will not serve the purpose of familiar toys and objects from home. The parents may experience some guilt as a response to the hospitalization, but there is no evidence that it is maladaptive.
64. Kimberly, age 3 years, is being admitted for about 1 week of hospitalization. Her parents tell the nurse that they are going to buy her "a lot of new toys because she will be in the hospital." The nurse's reply should be based on an understanding that: a. New toys make hospitalization easier. b. New toys are usually better than older ones for children of this age. c. At this age children often need the comfort and reassurance of familiar toys from home. d. Buying new toys for a hospitalized child is a maladaptive way to cope with parental guilt.
ANS: A Guilt is a common response of parents when a child is hospitalized. They may blame themselves for the child's illness or for not recognizing it soon enough. The nurse should clarify the nature of the problem and reassure parents that the child is being cared for. Croup is a potentially very serious illness. The nurse should not minimize the parents' feelings. Encouraging the parent to maintain a sense of control would be difficult for the parents while their child is seriously ill. No further assessment is indicated at this time—guilt is a common response for parents.
65. Matthew, age 18 months, has just been admitted with croup. His parent is tearful and tells the nurse, "This is all my fault. I should have taken him to the doctor sooner so he wouldn't have to be here." What is appropriate in the care plan for this parent who is experiencing guilt? a. Clarify the misconception about the illness. b. Explain to the parent that the illness is not serious. c. Encourage the parent to maintain a sense of control. d. Assess further why the parent has excessive guilt feelings.
ANS: D This is a necessary part of preoperative preparation that will help reduce the anxiety associated with surgery. If the child wakes and is not prepared for the inability to speak, she will be even more anxious. It is a joint responsibility of nursing, medical staff, and child life personnel. This is a necessary component of preparation that will help reduce the anxiety associated with surgery.
66. The nurse is doing a prehospitalization orientation for Diana, age 7, who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that she will not be able to talk because of an endotracheal tube but that she will be able to talk when it is removed. This explanation is: a. Unnecessary. b. The surgeon's responsibility. c. Too stressful for a young child. d. An appropriate part of the child's preparation.
appearance of first permanent teeth
6Y
begins losing temporary teeth
6Y
extreme sensitivity to criticism
6Y
self centered, show off rude
6Y
tie knots
6Y
fear of strangers begins to appear
7 M
grasps toy with hand
7 M
lability of mood (abrupt mood shifts)
7 M
sits for short periods using hands for support
7 M
What is considered a "good" APGAR score?
7-10
Correct Answer: C Your Response:
7. Standard Precautions for infection control include: A. Gloves are worn any time a patient is touched. B. Needles are capped immediately after use and disposed of in a special container. C. Gloves are worn to change diapers when there are loose or explosive stools. D. Masks are needed only when caring for patients with airborne infections.
Pulse 2-12 years
70-110
What is the euglycemia goal for the diabetic patient in labor?
70-90 mg/dL
Correct Answer: D Your Response:
70. A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on knowledge that: A. Children tend to be overmedicated for pain. B. Giving large doses of opioids causes euthanasia. C. Narcotic addiction is common in terminally ill children. D. Large doses of opioids are justified when there are no other treatment options.
Correct Answer: D Your Response:
71. The most consistent indicator of pain in infants is: A. Increased respirations. B. Increased heart rate. C. Clenching the teeth and lips. D. Facial expression of discomfort.
Correct Answer: D Your Response:
72. The nurse is starting an intravenous (IV) line on a school-age child with cancer. The child says, "I have had a million IVs. They hurt." The nurse's response should be based on the knowledge that: A. Children tolerate pain better than adults. B. Children become accustomed to painful procedures. C. Children often lie about experiencing pain. D. Children often demonstrate increased behavioral signs of discomfort with repeated painful procedures.
What are FHR decelerations?
A decrease in FHR that can be early or late when compared to uterine contractions.
What does the physician hope to achieve with NRTI's and PI's for HIV?
A delayed onset of AIDS for as long as possible (usually can delay onset for 10-15 years)
Sickle Cell Anemia
A human genetic disease of red blood cells caused by the substitution of a single amino acid in the hemoglobin protein; it is the most common inherited disease among African Americans.
What is the Silverman-Anderson Index?
A measure of respiratory distress where 10 is severe and 1 is okay.
What is a reactive fetal nonstress test?
A normal result indicating good fetal health where the fetus responds to its own movements with an acceleration of 15 bpm lasting for 15 seconds after the movement, twice within a 20 minute period.
Name ways to toughen a stump so it will not breakdown due to the wear of the prosthetic leg?
push the stump against the wall, hitting it with a pillow
What is the apgar scale?
quick objective way to evaluate the vital functions of the newborn
Brudzinski sign
A positive sign of meningitis, in which there is an involuntary flexion of the arm, hip, and knee when the patient's neck is passively flexed.
Should a newborn have a positive or negative Babinski?
A positive unti 12-18 months of age
Adolescence growth
rapid growth second only to the first year of life
Tonic phase
A state of muscle contraction in which there is excessive muscle tone; rigid & stiff
16. Discharge instruction, or teaching the woman what she needs to know to care for herself and her newborn, officially begins: A. At the time of admission to the nurse's unit. B. When the infant is presented to the mother at birth. C. During the first visit with the physician in the unit. D. When the take-home information packet is given to the couple.
A. At the time of admission to the nurse's unit. Discharge planning, the teaching of maternal and newborn care, begins on the woman's admission to the unit, continues throughout her stay, and actually never ends as long as she has contact with medical personnel.
19. Parents can facilitate the adjustment of their other children to a new baby by: A. Having the children choose or make a gift to give to the new baby on its arrival home. B. Emphasizing activities that keep the new baby and other children together. C. Having the mother carry the new baby into the home so she can show him or her to the other children. D. Reducing stress on other children by limiting their involvement in the care of the new baby.
A. Having the children choose or make a gift to give to the new baby on its arrival home. Having the sibling make or choose a gift for the new baby helps to make the child feel a part of the process. Special time should be set aside just for the other children, time without interruption from the newborn. Someone other than the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively involved in the care of the baby according to their ability but without overwhelming them.
15. While admitting the pregnant woman, the nurse should be aware that postpartum hospital stays that are becoming shorter are primarily the result of the influence of: A. Health maintenance organizations (HMOs) and private insurers. B. Consumer demand. C. Hospitals. D. The federal government.
A. Health maintenance organizations (HMOs) and private insurers. The trend for shortened hospital stays is based largely on efforts to reduce health care costs. Secondarily consumers have demanded less medical intervention and more family-centered experiences. Hospitals are obligated to follow standards of care and federal statutes regarding discharge policies. The Newborns' and Mothers' Health Protection Act provided minimum federal standards for health plan coverage for mothers and their newborns. Under this act, couples were allowed to stay in the hospital for longer periods.
26. What concerns about parenthood are often expressed by visually impaired mothers? Choose all that apply. A. Infant safety B. Transportation C. The ability to care for the infant D. Missing out visually E. Needing extra time for parenting activities to accommodate the visual limitations
A. Infant safety B. Transportation D. Missing out visually E. Needing extra time for parenting activities to accommodate the visual limitations
22. When the infant's behaviors and characteristics call forth a corresponding set of maternal behaviors and characteristics, this is called: A. Mutuality. B. Bonding. C. Claiming. D. Acquaintance.
A. Mutuality. Mutuality extends the concept of attachment to include this shared set of behaviors. Bonding is the process over time of parents forming an emotional attachment to their infant. Mutuality refers to a shared set of behaviors that is a part of the bonding process. Claiming is the process by which parents identify their new baby in terms of likeness to other family members and their differences and uniqueness. Mutuality refers to a shared set of behaviors that is part of the bonding process. Like mutuality, acquaintance is part of attachment. It describes how parents get to know their baby during the immediate postpartum period through eye contact, touching, and talking.
1. As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is 1 day postpartum. An expected finding would be: A. Presence of soft, nontender colostrum. B. Leakage of milk at let-down C. Swollen, warm, and tender on palpation. D. A few blisters and a bruise on each areola.
A. Presence of soft, nontender colostrum. Breasts are essentially unchanged for the first 2 to 3 days after birth. Colostrum is present and may leak from the nipples. Leakage of milk occurs around day 2 or 3. Engorgement occurs at day 2 or 3 postpartum. A few blisters and a bruise indicate problems with the breastfeeding techniques being used.
8. Although all other joints return to their normal prepregnancy state, those in the parous woman's feet do not. The new mother may notice a permanent increase in her shoe size. A. True B. False
A. True This is an accurate statement.
5. The breasts of a bottle-feeding woman are engorged. The nurse should tell her to: A. Wear a snug, supportive bra. B. Allow warm water to soothe the breasts during a shower. C. Express milk from breasts occasionally to relieve discomfort. D. Place absorbent pads with plastic liners into her bra to absorb leakage.
A. Wear a snug, supportive bra. A snug, supportive bra limits milk production and reduces discomfort by supporting the tender breasts and limiting their movement. Cold packs reduce tenderness, whereas warmth would increase circulation, thereby increasing discomfort. Expressing milk results in continued milk production. Plastic liners keep the nipples and areola moist, leading to excoriation and cracking.
What are the uterus and vagina connected by?
A: Cervix B: Fallopian tubes C: Clitoris D: ovaries A: Cervix rationale the cervix is the structure at the lower portion of the uterus that connects the uterus and vagina.
A female patient informs the nurse that her husband is concerned about her sexual response. The patient reports that during stimulation her husband has noticed her clitoris disappears, and he wonders if she is enjoying the experience despite her positive responses to his stimulation. The nurse explains that building excitement and retraction of the clitoris are normal characteristics of which stage of the sexual response cycle?
A: excitement phase B: resolution phase C: orgasm D: plateau phase D: plateau phase rationale during the plateau phase, the intensity of excitement increases but not enough to cause orgasm. The female clitoris reacts and disappears under the clitoral hood. This phase may last for 15 to 20 minutes. The excitement phase is initiated by erotic stimulation and arousal, and physiologic changes begin. Orgasm defines the climax and sexual explosion of the tension that has been building during the preceding phases. The resolution phase is the return to normal body function.
A male patient informs the urology nurse that he is embarrassed because his wife rarely has time to reach sexual satisfaction because the experiences an orgasm as soon as he enters the vagina . What is the condition best known as?
A: impotence B: erectile failure C: retarded ejaculation D: premature ejaculation Premature ejaculation rationale premature ejaculation is a condition in which a man reaches ejaculation or orgasm before or soon after entering the vagina. Erectile failure, also known as impotence, is the inability of a man to maintain an erection to the extent that he cannot have satisfactory intercourse. Retarded ejaculation refers to a man's inability to ejaculate into the vagina or delayed intravaginal ejaculation.
During the menstrual cycle, when does ovulation typically take place?
A: on day one of a new cycle B: on day 14 C: from days 15 to 28 D; when sperm is present B: on day 14 rationale ovulation generally occurs on day 14 when the mature ova ruptures from the follicle and the surface of the ovary and is swept into the fallopian tube. Monday 15 to day 28, the phase and ovaries is called the luteal phase.
An elderly couple who have just relocated to a long-term care facility have been unable to obtain a shared room. A staff member at the facility states that this should not be a concern and implies that sexual activity between the couple likely ceased many years ago. How should the nurse to best respond to this individual's assertion?
A: resource as shown the nature of sexual activity changes with age but that it actually becomes more frequent. B: that's true, but it's important for us to give them the teaching they need in order to resume this part of their relationship. C: it's true that they probably stopped having sexual activity, but it's important for them to have companionship. D: actually it's not ture that older people always stop having sexual activity when they get older. D: actually it is not ture that older people always stop having sexual activity when they get older. Rationale Sexual activity need not be hindered by age. There's no evidence, however, that it becomes increasingly frequent and late adulthood.
Which of the following statements best describes the relationship between biologic sex and gender identity?
A: sex is chromosomally determined, while gender is a psychosocial construct. B: Biologics sex and gender identity are considered synonymous in nursing practice C: Biologics facts and gender identity are both modifiable by surgery and medical interventions. D: Biologic sex is genetically determined but gender identity is chosen during adolescence. A: sex is chromosomally determined, while gender is a psychosocial construct. Rationale biologic sex is the term used to denote chromosomal sexual development. Gender identity is the inner sense a person has of being male or female. As such, Biologic sex is amenable to medical intervention, but surgery and hormone therapy will not change individuals inner sense of being male or female. Gender identity is not commonly thought to be chosen or objectively selecting during adolescence.
Which of the following assessment questions is most likely to yield clinically meaningful data about a female patients sexual identity?
A: you ever had any sexually-transmitted diseases in the past? B: how do you feel about yourself as a woman? C: do you find that your health allows you to enjoy a meaningful sex life? D: are you satisfied with the quality of your relationships right now? B: how do you feel about yourself as a woman? Rationale Sexual identity is a broad concept that includes, but supersedes, sexual functioning. However, it is more specific than simply asking about the quality of relationships. Asking an open-ended question about how the patient feels about herself as a woman is likely to elicit important insights. Assessing the patient's history of STIs does not directly address her sexual identity.
The nurse should inform a young female client that the barrier method providing the best protection against STIs is:
A; Spermicides B: Condoms C: A cervical cap D: A diaphragm B: condoms rationale condoms provide effective (though imperfect) protection against STIs. Spermicides, diaphragms, and cervical cap donot provide effective protection against STIs.
A mother expressed concern because her three-year-old son is fondling his penis. The mother does not know the best approach for the child's behavior. What is the nurses response to the mother?
AA: "this is a strong sign that he is ready for toilet training" B: "you should just discourage this behavior now before it worsens as he gets older" C: "this this normal behavior for a child of his age" D: "we should obtain a urine sample to assess for an infection" C: "this is normal behavior for a child of the age" rationale children ages 1 to 3 enjoyed fondling their genitals. Punishment for genital fondling may lead to guilt and shame regarding sexual behavior later in life.
During hospitalization for a suicide attempt, the patient informs the nurse that she does not want to return to work because her boss expects sexual favors each week before he gives her a paycheck. The patient finorms the nurse that she needs job but is embarrassed that she performs these favors. The nurse informs the patient that is his illegal behavior and is called:
AA: environmental harassment B: fetishism C: quid pro quo harassment D: hostile environment harassment C: quid pro quo harassment rationale quid pro quo means that something is given or withheld in exchange for something else. It generally occurs with a person in a position of authority offers either direct or indirect reward or punishment based on the granting of sexual favors. Environmental harassment and hostile environment harassment are the situation and occur when workplace behaviors of a sexual nature create a hostile, intimidating environment that interferes with a person's work performance. Fetishism is sexual arousal with the aid of an inanimate object not generally associated with sexual activity.
A nurse is counseling a client diagnosed with transgenderism. Which characteristic would differentiate this disorder from transvestic fetishism? A. Clients diagnosed with transvestic fetishism are dissatisfied with their gender, whereas clients diagnosed with transgenderism are not. B. Clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. C. Clients diagnosed with transgenderism never engage in cross-dressing, whereas clients diagnosed with transvestic fetishism do. D. Clients diagnosed with transvestic fetishism never engage in cross-dressing, whereas clients diagnosed with transgenderism do.
ANS: B The nurse should identify that clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. Both clients diagnosed with transgenderism and transvestic fetishism may participate in cross-dressing.
A nurse is assessing a client diagnosed with pedophilia. What would differentiate this sexual disorder from a sexual dysfunction? A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.
ANS: B The nurse should identify that pedophilia is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Sexual dysfunction involves impairment in normal sexual response. Pedophilia involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.
A nursing instructor is teaching about the various categories of paraphilia. Which of the following categories are correctly matched with expected behaviors? (Select all that apply.) A. Exhibitionism: Mary models lingerie for a company that specializes in home parties. B. Voyeurism: John is arrested for peering in a neighbor's bathroom window. C. Frotteurism: Peter enjoys subway rush-hour female contact that results in arousal. D. Pedophilia: George can experience an orgasm by holding and feeling shoes. E. Fetishism: Henry masturbates into his wife's silk panties.
ANS: B, C, E Categories of paraphilia include voyeurism (observing unsuspecting people who are naked, dressing, or engaged in sexual activity), frotteurism (touching or rubbing against a nonconsenting person), fetishism (using nonliving objects in sexual ways), and pedophilia (recurrent sexual urges involving sexual activity with a prepubescent child). Exhibitionism is a paraphilia but involves the urge to show one's genitals to unsuspecting strangers.
A nurse is working with a client diagnosed with pedophilia. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization? A. The client will verbalize an understanding of the importance of follow-up care. B. The client will implement several relapse-prevention strategies. C. The client will identify triggers that lead to inappropriate behaviors. D. The client will attend aversion therapy groups.
ANS: C During the first week of hospitalization, identifying triggers that lead to inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilia. Pedophilia involves intense sexual urges, behaviors, or fantasies involving sexual activity with a prepubescent child.
A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurse's first priority? A. Discuss with the client the inappropriateness of her attire. B. Avoid addressing her attention-seeking behavior. C. Lead the client back to her room and assist her to choose appropriate clothing. D. Restrict client to room until visiting hours are over.
ANS: C The most appropriate intervention by the nurse is to lead the client back to her room and assist her to choose appropriate clothing. The client could be exhibiting signs of exhibitionism which is characterized by urges to expose oneself to unsuspecting strangers.
A client is diagnosed with female sexual aversion disorder. In addition to systematic desensitization techniques, which medication therapy could accompany this intervention? A. Quetiapine (Seroquel) B. Phenelzine (Nardil) C. Amoxapine (Asendin) D. Carbamazepine (Tegretol)
ANS: C The nurse should identify that medication therapy of amoxapine could complement systematic desensitization techniques. Amoxapine is a heterocyclic antidepressant that can assist in reduction of anxiety.
When planning care for a client diagnosed with female sexual arousal disorder, what should a nurse document as an expected outcome of senate focus exercises? A. To initiate immediate orgasm B. To reduce anxiety by eliminating physical touch C. To focus on touching breasts and genitals D. To reduce goal-oriented demands of intercourse
ANS: D The expected outcome of senate focus exercises is to reduce goal-oriented demands of intercourse. Senate focus exercises consist of touching and being touched by another with attention focused on the physical sensations encountered. Erotic contact is gradually increased, leading to the possibility of sexual intercourse. The reduction in demands reduces performance pressures and anxiety associated with possible failure.
A psychiatric nursing instructor is teaching about the psychological effects of the diagnosis of a sexually transmitted disease (STD). Which student statement indicates that further instruction is needed? A. "STDs carry strong connotations of illicit sex and considerable social stigma." B. "STDs can cause insanity." C. "The diagnosis of HIV can generate hopelessness and helplessness." D. "Antibiotics administered in the early stages can cure all STDs."
ANS: D The instructor should identify the need for further instruction if a student states that antibiotics can cure all STDs. STDs refer to infections that are contracted primarily through sexual activities or intimate contact. An example of an incurable STD is HIV. STDs are at epidemic levels in the United States.
What is the most common NRTI used?
AZT (zidovudine)
7 months old motor skills
Able to fully bear weight, can move objects between hands
How many calories/day does an infant need for the first six months?
About 50 calories/lb or 108 calories/kg of body weight.
What is the fourth stage?
About two hours after the delivery of the placenta
What does AKA mean?
Above the knee amputation
What is the most common retinoid given to people with acne?
Accutane
AGN
Acute Glomerulonephritis This is a sudden inflammation of the Glomerulus, inflamed because of an antigen, antibody reaction to STREP, that damages the glomerulus. Causes the Glomerulus membrane to thicken so it doesn't filter. Will show high protein and RBC's in the urine.
Atrial Septal defect
Acyanotic Malfunctioning foramen ovale causes shunting of oxygenated blood from L to R atrium, increased RV output and work load, may develop pulm hypertension in adulthood May be asymptomatic or may hear soft blowing, systolic murmur, have frequent episodes of pulm inflammatory diseases, poor exercise intolerance May require open heart surg with direct closure or suturing with plastic prosthesis.
Coarction of aorta
Acyanotic preductal constriction of aorta between subclavian artery and ductus arteriosis. Postductal constriction of aorta directly beyond ductus. Leads to obstructions of blood flow through the constricted segments, weak or absent pulsations in lower extremities, heart failure, may notice fatigue, headaches, leg cramps, epistaxis. Surgical resection of coarctate area with direct anastamosis or use of a graft. Must be done within 2 years of age to prevent hypertension
Patent ductus arteriosis
Acyanotic congenital defect vascular channel between the left main pulmonary artery and the descending aorta as a result of failure of the fetal ductus arteriosis to close. shunt of oxygenated blood from aorta into pulm artery. increased LV output and work load. Usually asymptomatic but may hear a machinery murmur and witness a widening pulse pressure. Administer indocin or undergo ligation of patent ductus
Ventricular septal defect
Acyanotic defect Shunt of oxygenated blood from L to R ventricle, leads to R ventricular hypertrophy, needs surgical repair, and bidirectional shunting may occur. May be asymptomatic, heart murmur heard in first week of life, growth failure, feeding problems, FTT, respiratory infections Some may close spontaneously, others require open heart surgery
A major mental/emotional nursing diagnosis seen in anorexia nervosa is ___________.
Altered body image
What would the fundal height be at 20 weeks?
At the umbilicus
What are late decelerations?
An ominous and potentially disastrous non-reassuring sign. Indicates uteroplacental insufficiency. Uniform shape of deceleration that occurs toward the end of contractions and recovery occurs after end of contraction. Decel's don't go past 100 bpm
Give 6 symptoms of HIV disease.
Anorexia, fatigue, weakness, night sweats, fever, diarrhea
What class of drugs is the client with an aneurysm most likely to be on?
Antihypertensives
What five things does APGAR assess?
Appearance, Pulse, Grimace, Activity, Respiration
When is amniocentesis done?
As early as 14-16 weeks
What play stage is associated with Preschool aged children?
Associative play- playing ball, puzzles, playing pretend/dress-up, role-play, painting, seweing cards and beads, reading books
When is PKU testing done usually?
At 2-3 days of life
PKU Diet
Avoid meat, milk, dairy, eegs Eat fruits, juices, cereal, bread, starches
What precautions should be done when performing heel stick?
Avoid the plantar artery in the middle of the heel and wipe away the first drop with sterile gauze.
What may indicate a need for insulin in a diabetic child? 1.) diaphoresis and tremors 2.) red lips and fruity odor to the breath 3.) confusion and lethargy 4.) headache and pallor
red lips and fruity odor to the breath
20. Many first-time parents do not plan on their parents' help immediately after the newborn arrives. What statement by the nurse is the most appropriate when counseling new parents about the involvement of grandparents? A. "You should tell your parents to leave you alone." B. "Grandparents can help you with parenting skills and also help preserve family traditions." C. "Grandparent involvement can be very disruptive to the family." D. "They are getting old. You should let them be involved while they can."
B. "Grandparents can help you with parenting skills and also help preserve family traditions." Intergenerational help may be perceived as interference, but a statement of this sort is not therapeutic to the adaptation of the family. Stating that grandparents can help with parenting skills and also help preserve family traditions is the most appropriate response. Stating that grandparent involvement can be disruptive is invalid; it also is not an appropriate nursing response. Regardless of age, grandparents can help with parenting skills and can preserve family traditions. Stating that the grandparents are old is not the most appropriate statement, and it does not demonstrate sensitivity on the part of the nurse.
3. Which statement by a newly delivered woman indicates that she knows what to expect about her menstrual activity after childbirth? A. "My first menstrual cycle will be lighter than normal and then will get heavier every month thereafter." B. "My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles." C. "I will not have a menstrual cycle for 6 months after childbirth." D. "My first menstrual cycle will be heavier than normal and then will be light for several months after."
B. "My first menstrual cycle will be heavier than normal, and my period will return to my prepregnant volume within three or four cycles." She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles. Saying the first menstrual cycle will be heavier than normal and the subsequent three or four cycles will return to prepregnant volume is an accurate statement and indicates her understanding of her expected menstrual activity. Most women experience a heavier than normal flow during the first menstrual cycle, which occurs by 3 months after childbirth. She can expect her first menstrual cycle to be heavier than normal, and the volume of her subsequent cycles to return to prepregnant levels within three or four cycles.
2. A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is: A. Urinary tract infection. B. Excessive uterine bleeding. C. A ruptured bladder. D. Bladder wall atony.
B. Excessive uterine bleeding. A urinary tract infection may result from overdistention of the bladder, but it is not the most serious consequence. Excessive bleeding can occur immediately after birth if the bladder becomes distended because it pushes the uterus up and to the side and prevents it from contracting firmly. A ruptured bladder may result from a severely overdistended bladder. However, vaginal bleeding most likely would occur before the bladder reaches this level of overdistention. Bladder distention may result from bladder wall atony. The most serious concern associated with bladder distention is excessive uterine bleeding.
9. Changes in the maternal immune system during the postpartum period account for the profuse diaphoresis that new mothers experience. A. True B. False
B. False No significant changes in the maternal immune system occur during the postpartum period.
12. The nurse examines a woman 1 hour after birth. The woman's fundus is boggy, midline, and 1 cm below the umbilicus. Her lochial flow is profuse, with two plum-sized clots. The nurse's initial action would be to: A. Place her on a bedpan to empty her bladder. B. Massage her fundus. C. Call the physician. D. Administer Methergine, 0.2 mg IM, which has been ordered prn.
B. Massage her fundus. There is no indication of a distended bladder; thus having the woman urinate will not alleviate the problem. A boggy or soft fundus indicates that uterine atony is present. This is confirmed by the profuse lochia and passage of clots. The first action would be to massage the fundus until firm. The physician can be called after massaging the fundus, especially if the fundus does not become or remain firm with massage. Methergine can be administered after massaging the fundus, especially if the fundus does not become or remain firm with massage.
23. A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. Recognizing the needs of women during this stage, the nurse should: A. Foster an active role in the baby's care. B. Provide time for the mother to reflect on the events of and her behavior during childbirth. C. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. D. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs.
B. Provide time for the mother to reflect on the events of and her behavior during childbirth. Once the mother's needs are met, she would be more able to take an active role, not only in her own care but also the care of her newborn. Women express a need to review their childbirth experience and evaluate their performance. Short teaching sessions, using written materials to reinforce the content presented, are a more effective approach. The focus of the taking-in stage is nurturing the new mother by meeting her dependency needs for rest, comfort, hygiene, and nutrition.
21. The nurse observes that a 15-year-old mother seems to ignore her newborn. A strategy that the nurse can use to facilitate mother-infant attachment in this mother is to: A. Tell the mother she must pay attention to her infant. B. Show the mother how the infant initiates interaction and pays attention to her. C. Demonstrate for the mother different positions for holding her infant while feeding. D. Arrange for the mother to watch a video on parent-infant interaction.
B. Show the mother how the infant initiates interaction and pays attention to her. Telling the mother she has to pay attention to the baby may be perceived as derogatory and is not appropriate. Pointing out the responsiveness of the infant is a positive strategy for facilitating parent-infant attachment. Educating the young mother in infant care is important, but pointing out the responsiveness of her baby is a better tool for facilitating mother-infant attachment. Videos are an educational tool that can demonstrate parent-infant attachment, but encouraging the mother to recognize the infant's responsiveness is more appropriate.
Motor skills 3 years old
rides a tricycle, jumps off of bottom step, stands on one foot for a while
Preschool ability
rides tricycle at 3
How is fetal tachycardia defined?
Baseline of greater than 160 bpm for 10 minutes.
After surgery for pyloric stenosis, the nurse could anticipate that the infant will: 1.) have nasogastric suction for 24 hours 2.) be fed clear liquids within 6 hours 3.) remain NPO for 24 to 48 hours 4.) be fed formula within 4 hours
Be fed clear liquids within 6 hours
Why is hCG taken for a year after hydatidiform mole?
Because hCG levels that do not diminish can lead to choriocarcinoma. Pregnancy must also be avoided for a year.
What is the most important intervention in treating AGN?
Bedrest - they can walk if hematuria, edema and hypertension are gone.
What instructions should be given to the woman with a threatened abortion?
Bedrest for 24-48 hours, no sex for 2 weeks.
What activity order is the client with an aneurysm supposed to have?
Bedrest. do not get these people up
What is the first sign of appendicitis?
right upper quadrant pain
How are SGA and LGA defined?
Below the 10th percentile or above the 90th percentile.
What does BKA mean?
Below the knee amputation
When is chorionic villus sampling done?
Between 8 and 12 weeks' gestation.
When do most miscarriages occur?
Between 8 and 13 weeks.
Hep B
Birth, 1-2 months, 6-18 months
When is the sensorimotor stage? What are the 3 components that make it up?
Birth-24 months of age; separation, object permanence, and mental representation (recognition of symbols)
What are comedones?
Blackheads and white heads
How do you assess for jaundice in the infant?
Blanche forehead with thumb. If jaundiced, skin will turn yellow before normal skin color reappears. In dark-skinned infants, observe conjunctival sac and oral mucosa.
What should be assessed before giving methergine?
Blood pressure - withhold if over 140/90 and notify physician. Use with caution in pts with preeclampsia
10. When palpating the fundus of a woman 18 hours after birth, the nurse notes that it is firm, 2 fingerbreadths above the umbilicus, and deviated to the left of midline. The nurse should: A. Massage the fundus. B. Administer Methergine, 0.2 mg PO, that has been ordered prn. C. Assist the woman to empty her bladder D. Recognize this as an expected finding during the first 24 hours following birth
C. Assist the woman to empty her bladder A firm fundus should not be massaged because massage could overstimulate the fundus and cause it to relax. Methergine is not indicated in this case because it is an oxytocic and the fundus is already firm. The findings indicate a full bladder, which pushes the uterus up and to the right or left of midline. The recommended action would be to empty the bladder. If the bladder remains distended, uterine atony could occur, resulting in a profuse flow. A Firm fundus that is 2 fingerbreadths above the umbilicus and deviated to the left of midline is not a normal finding, and an action is required.
The pulse rate of anorexics is tachycardic or bradycardic?
Bradycardic
What is cephalhematoma?
Bruising under the periosteum that does not cross suture lines and usually manifests a few hours after birth. Can cause hyperbilirubinemia.
How can AGN be prevented?
By having all sore throats cultured for strep and treating any strep infections
25. During a phone follow-up conversation with a woman who is 4 days' postpartum, the woman tells the nurse, "I don't know what's wrong. I love my son, but I feel so let down. I seem to cry for no reason!" The nurse would recognize that the woman is experiencing: A. Taking-in. B. Postpartum depression (PPD). C. Postpartum (PP) blues. D. Attachment difficulty.
C. Postpartum (PP) blues. The taking-in phase is the period after birth when the mother focuses on her own psychologic needs. Typically this period lasts 24 hours. PPD is an intense, pervasive sadness marked by severe, labile mood swings; it is more serious and persistent than the PP blues. During the PP blues, women are emotionally labile, often crying easily and for no apparent reason. This lability seems to peak around the fifth PP day. Crying is not a maladaptive attachment response; it indicates PP blues.
18. When making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: A. Express a strong need to review events and her behavior during the process of labor and birth. B. Exhibit a reduced attention span, limiting readiness to learn. C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. D. Have reestablished her role as a spouse/partner.
C. Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. Expressing a strong need to review events is characteristic of the taking-in stage, which lasts for the first few days after birth. Exhibiting a reduced attention span is characteristic of the taking-in stage, which lasts for the first few days after birth. One week after birth, the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth. Reestablishing her role as spouse/partner reflects the letting-go stage, which indicates that psychosocial recovery is complete.
Which test is the best indicator of the progress of HIV disease?
CD4 count
What type of oral/esophageal infections do AIDS patients get?
Candida
Name the 5 criteria that are recorded on an apgar scale
Cardiac status, respiratory effort, muscle tone, neuromuscular irritability, and color
11. Which finding would be a source of concern if noted during the assessment of a woman who is 12 hours' postpartum? A. Postural hypotension B. Temperature of 100.4° F C. Bradycardia—pulse rate of 55 beats/min D. Pain in left calf with dorsiflexion of left foot
D. Pain in left calf with dorsiflexion of left foot Postural hypotension is an expected finding related to circulatory changes after birth. A temperature of 100.4° F in the first 24 hours most likely indicates dehydration, which is easily corrected by increasing oral fluid intake. A heart rate of 55 beats/min is an expected finding in the initial postpartum period. Findings of pain in the left calf with dorsiflexion of the left foot indicate a positive Homan's sign and are suggestive of thrombophlebitis and should be investigated.
What three risk factors can lead to respiratory depression (depression) in the newborn?
Cesarean delivery, mag given to mother in labor, and/or ashyxia or fetal distress during labor
What are the nursing actions associated with variable decelerations?
Change position, stimulate fetus if indicated, d/c oxytocin, give O2 at 10L by tight face mask, SVE for cord prolapse, and the report findings to physician and document.
What are nursing implications with Procardia (nifedipine)?
Check bp for hypotension immediately before given, do not use with Mag, and dangle before rising.
The post op thoracic aneurysm is most likely to have which type of tube?
Chest tube, because the chest was opened
Rheumatic Fever S/S
Chorea muscle twitch carditis chest pain SOB sub q nodles
Sickle Cell Anemia Symptoms
Chronic fatigue, dyspnea, joint pain, swelling chest pain
When assessing an 8-year-old child with obsessive compulsive disorder, the nurse would expect to find: 1.) an intelligence deficit 2.) ritualistic behavior 3.) antisocial behavior 4.) combative behavior
ritualistic behavior
What is the first test for HIV antibodies?
ELISA
What are variable decelerations?
Common pattern with rapid decelerations that is variable in duration, depth, and fall, and timing relative to the contraction cycle.
What stage of Piaget in school aged children?
Concrete operations- weight/vol unchanging, understands analogies, understands time, classifies more complex info, understands various emotions, self-motivated, able to solve problems
How do you calculate 1 mL of urine when weighting diaper?
Each gram of weight of the urine is calculated as 1 mL of urine.
6 months old motor skills
rolls back to front, can hold a bottle
Transposition of great vessels
Cyanotic Aorta originates from the RV and the pulmonary artery from the LV. two separate circulations without mixture of oxygenated/unoxygenated blood. Usually deep cyanosis shortly after birth or closing of ductus, clubbed fingers/toes, poor growth and development, heart failure. TX with prostaglandins to keep ductus arteriosis open until surgery, then repair by switching the great vessels.
Tetralogy of Fallot
Cyanotic Combo of four defects: pulm stenosis, VSD, overriding aorta, hypertrophy of RV. Obstruction of outflow of blood from the RV into the pulmonary circuit and increased pressure in the right ventricle leads to R-L shunting of oxygenated blood through the VSD directly into the aorta Severity of defect depends on degree of pulm stenosis and size of vsd. Results in acute cyanosis @ birth, cyanosis increases with activity, clubbing of fingers and toes, systolic murmur, acute episodes of cyanosis, squatting, growth retardation. Surgical tx: blalock-taussing procedures, or repair of openings.
CF
Cystic Fibrosis, the most common congenital disease the child's lungs and intestines and pancreas become clogged with thick mucus; caused by defect in a single gene; there is no cure
24. Nursing activities that promote parent-infant attachment are many and varied. One activity that should not be overlooked is the management of the environment. While providing routine mother-baby care, the nurse should ensure that: A. The baby is able to return to the nursery at night so that the new mother can sleep. B. Routine times for care are established to reassure the parents. C. The father should be encouraged to go home at night to prepare for mother-baby discharge. D. An environment that fosters as much privacy as possible should be created.
D. An environment that fosters as much privacy as possible should be created. Once the baby has demonstrated adjustment to extrauterine life (either in the mother's room or the transitional nursery), all care should be provided in one location. This important principle of family-centered maternity care fosters attachment by giving parents the opportunity to learn about their infant 24 hours a day. One nurse should provide care to both mother and baby in this couplet care or rooming-in model. It is not necessary for the baby to return to the nursery at night. In fact, the mother will sleep better with the infant close by. Care should be individualized to meet the parents' needs, not the routines of the staff. Teaching goals should be developed in collaboration with the parents. The father or other significant other should be permitted to sleep in the room with the mother. The maternity unit should develop policies that allow for the presence of significant others as much as the new mother desires. Care providers need to knock before gaining entry. Nursing care activities should be grouped.
MMR and allergies?
Expect to hold for Egg/neomycin Allergy
4 months old motor skills
rolls back to side, puts objects in mouth
13. Perineal care is an important infection control measure. When evaluating a postpartum woman's perineal care technique, the nurse would recognize the need for further instruction if the woman: A. Uses soap and warm water to wash the vulva and perineum. B. Washes from symphysis pubis back to episiotomy. C. Changes her perineal pad every 2 to 3 hours. D. Uses the peribottle to rinse upward into her vagina.
D. Uses the peribottle to rinse upward into her vagina. Washing the vulva and perineum with soap and water is an appropriate measure. Washing from symphysis pubis back toward episiotomy is an appropriate measure. Changing the perineal pad every 2 to 3 hours in an appropriate measure. The peribottle should be used in a backward direction over the perineum. The flow should never be directed upward into the vagina because debris would be forced upward into the uterus through the still-open cervix.
AGN Tx
Daily Weights/ Strict I & O restriction of salt, maintenance of fluid and electrolyte balance, antipyretics(fever) diuretics(edema)
How do you assess fluid excess in the child with AGN?
Daily weight
How is placentae abruptio different from previa?
Dark red vaginal bleeding, rigid uterus, and severe pain.
What are early decelerations?
Decelerations that begin with the beginning of contractions or with contractions that symbolize a benign pattern caused by head compression. Slowly decelerates and returns to baseline.
What lab findings are present in AIDS?
Decreased RBC's, WBC's and platelets
What causes angina pectoris?
Decreased blood supply to myocardium, resulting in ischemia and pain
MD S/S
Delayed Walking Frequent Falls Easily tires when walking Trouble climbing stairs
What is the third stage of labor?
Deliver of the fetus to delivery of the placenta
What complications can occur from hypothermia?
Depletion of glucose and the use of brown fat -- ketoacidosis.
PKU Screening -When is best
Done at birth (after breast feeding or formula to allow body to fail at processing) Also done at 3 weeks
Weight changes in first year?
Doubles within first 6 months, triples in one year
To prevent post-op swelling, the stump should be __________.
elevated
What are the causes of fetal tachycardia?
Early sign of fetal hypoxia, fetal anemia, dehydration, maternal infection/fever, maternal hyperthyroid disease, and medication-induced tachycardia.
What is caput succedaneum?
Edema under the scalp that crosses suture lines and is usually present at birth.
"If I had to do it over again, I'd life my life just about the same," is an example of ____ ____________
Ego Integrity
What is the developmental task for later adulthood?
Ego Integrity vs. Despair
Intimacy vs. Isolation
Erikson's stage in which individuals form deeply personal relationships, marry, begin families
Generativity vs. Stagnation
Erikson's stage of social development in which middle-aged people begin to devote themselves more to fulfilling one's potential and doing public service
How is chlamydia treated in pregnancy?
Erythromycin and treat for gonorrhea, too (penicillin and/or erythromycin and ceftriaxone)
What is the pattern of check-ups in a low-risk pregnancy?
Every 4 weeks until week 28. Every two weeks from 28 to 36 weeks. Every week from week 36 to delivery.
Bacterial Epiglottitis Symptom
Excessive drooling due to painful swallowing
What are severe variable decelerations?
FHR below 70 bpm lasing longer than 30 seconds, with a slow return to baseline and decreasing or absent variablity.
What is the most important indicator of fetal autonomic nervous system integrity and health?
FHR variability
Patent Ductus Arteriosus
Failure of the ductus arteriosus to close after birth, allowing blood to flow from the aorta into the pulmonary (lung) artery
Everyone with angina needs bypass surgery? t/f
False
5 months old motor skills
rolls front to back, has palmar grasp
Erythema Infectiosum (Fifth Disease) Signs and symptoms
Fifth Disease is marked by a rash that appears in three stages. Just prior to the rash appearance the child may experience mild fever, malaise, headache or runny nose. Stage 1: Erythema on face, chiefly on cheeks. "Slapped cheek" appearance. Disappears by 1 - 4 days. Stage 2: About 1 day after rash appears on face, maculopapular red spots appear, symmetrically distributed on the extremities; the rash progresses from proximal to distal surfaces and may last a week or more. Stage 3: The rash subsides, but may reappear if skin becomes irritated by sun, heat, cold, exercise, or friction. REMEMBER: Pregnant women need to avoid infected persons. Key to identification is "slapped cheek" appearance. Child is not usually hospitalized as disease is self-limiting.
Tonsilectomy risk for bleeding times
First 24 hrs 5-10 days post-op (scabs fall off)
What is the first stage of labor?
First stage: From beginning of regular contractions or rupture of membranes to 10 cm dilation with 100% effacement
How is anemia defined through the pregnancy?
First trimester: Hgb < 11; Hct < 37% Second: Hgb < 10.5; Hct < 35% Third: Hgb < 10 ; Hct < 32%
What is the #1 contracture problem after BKA?
Flexion of the knee
Piaget stage for adolescents?
Formal operations: capable of thinking at adult level, abstract thinking, imaginative/idealistic, deductive reasoning
How much should toddlers weight at 30 months?
Four times their birth weight
How do you calculate the frequency of contractions?
From the beginning of one contraction to the beginning of the next
Nephrotic Syndrome Dx
Frothy urine Massive proteinuria Edema Anorexia
What is the most common cause of uterine atony?
Full bladder - if patient has soft fundus displaced to the right of the umbilicus, massage uterus and then have patient empty bladder.
What type of play do toddlers engage in?
Gender appropriate, parallel play
Seizures -two
Generalized tonic/clonic Petit mal
What is the developmental task for middle adulthood?
Generativity vs. stagnation.
If an aneurysm ruptures what is the #1 priority?
Get them to the operating room ASAP
Name two reasons that anesthesia and analgesia should be given in the midactive phase of stage I labor.
Given too early can retard labor; given too late can cause fetal distress
What organism causes acute glomerular nephritis?
Group A beta hemolytic strep
Name three signs of placental separation.
Gush of blood, lengthening of cord and globular shape of uterus.
What virus causes AIDS?
HIV - Human immunodeficiency virus
Human Papillomavirus Vaccine How many injections comprise the full course of vaccination and at what age should girls receive it? What age should boys receive it?
HPV vaccine is administered in three injections over six months. First dose, then the second dose 2 months later, followed by the final dose 6 months after the first. Girls can receive it around age 11 to 12. Boys can receive it from age 9 to 18. Guards against cervical cancer and genital warts in females and genital warts in males.
When should compressions be done in a newborn?
HR < 60 bpm; do 90 compressions and 30 breaths.
Name two nursing interventions to be done prior to a first trimester ultrasound.
Have client fill bladder and lie supine with uterine wedge.
1 month old Motor skills
Head lag with grasp reflex
What anticoagulant can be used in pregnancy?
Heparin
What are the 3 causative factors in acne vulgaris?
Heredity, Bacterial, Hormonal
What do high or low AFP levels mean?
High could:NTD (neural tube defect) low: could be trisomy 21.
Is there a higher or lower incidence of fetal death with Abruptio Placenta compared to Placenta Previa?
Highter
What are nursing implications with Mag sulfate?
Hold if respirations are < 12/min or urine output is < 100 mL/4hrs; keep calcium gluconate handy
Name the 5 risk groups for AIDS
Homosexual/bisexual men, IV drug users, hemophiliacs, heterosexual partners of infected people, newborn children of infected women
Sickle Cell Tx
Hydration, Oxygenation, Pain management (morphine, ect..), blood transfusions, bone marrow transplant- life threatening, eg. strokes
Will the client have hypo or hyper tension with AGN? Why?
Hypertension, because of fluid retention
What two diseases can cause jitteriness in the newborn?
Hypoglycemia and hypocalcemia
Erikson's stage for adolescents
Identity vs. role confusion. Sense of personality developed that is influenced by expectations of parents
When are antihypertensives given to the preeclamptic patient?
If the diastolic is greater than 110 mm Hg, and then hydralazine is given.
When do you need a gown with AIDS?
If you are going to get contaminated with secretions
Describe height changes in first year
Increases 50% in the first year
Erikson's stage for 3-6 years?
Initiative vs. guilt. May feel remorse when cannot complete an assigned task
What is the developmental task for early adulthood?
Intimacy vs. Isolation
RSV Tx
Isolation (contact) Antiviral agent (ribavirin aerosols)
What happens to the kidney in AGN?
It becomes clogged with antigen-antibody complexes which then cause inflammation and loss of function.
What causes physiologic jaundice of the newborn?
It begins 2-3 days after birth because the newborn liver can't keep up with the RBC destruction and to bind bilirubin. Unconjugated bilirubin is the culprit.
What is an advantage CVS has over amniocentesis?
It can be done earlier (8-12 weeks gestation) with results back within a week, allowing for a first trimester termination, if warranted.
How is pathologic jaundice different from physiologic jaundice?
It occurs before 24 hours of age or persists for longer than 7 days.
How is Flagyl used during pregnancy?
Its use is contraindicated in the first trimester and its use in the second trimester is contraversial.
What is the #1 cancer that AIDS patients get?
Kaposi's sarcoma
An infant with tetralogy of Fallot is experiencing a tet attack involving cyanosis and dyspnea. Which position should the infant be placed in? 1.) Fowler's 2.) Knee-chest 3.) Trendelenburg's 4.) Prone
Knee-chest
What are the three phases of the first stage of labor?
Latent - from beginning to 3-4 cm; Active - from 4-7 cm cervical dilation; Transition - from 8-10 cm dilation
Reye's S/S
Lethargy progressing to coma vomiting hypoglycemia
What should patients be taught are signs that the doctor should be called after discharge?
Lethargy, temp > 100, vomiting, green stools, or refusal of two feeds in a row.
What is the name for an elevated WBC?
Leukocytosis
What types of chemicals cause burns to oral mucosa when ingested?
Lye, caustic cleaners
What will prevent hip flexion contracture after AKA?
Lying prone several times a day
What is the main drug given for preeclampsia in the hospital?
Mag sulfate
Reye's Tx
Mannitol for ICP control
What immediate nursing interventions should be taken when a postpartum hemorrhage is detected?
Massage fundus, notify HCP if fundus doesn't get firm with massage, count pads, assess vital signs, increase IV fluids, and administer oxytocin as prescribed.
What are nursing implications with Yutopar (Ritodrine) and terbutaline?
Maternal pulse should not exceed 140 bpm, fetal heart rate should not exceed 180 bpm, and keep antidote (beta-blocking agent) available.
What is the name of the RLQ abd pain where appendicitis pain finally localizes?
McBirney's point
What is the most common dietary restriction for AGN?
Moderate sodium restriction. Fluid restriction is #2 if edema is severe.
How should suctioning be done in the newborn?
Mouth first and then nose (to prevent aspiration in the mouth)
Abruptio Placenta usually occurs in (prima/multi) gravida over the age of ____________.
Multi, 35 (HTN, trauma, cocaine)
MD Dx
Muscle biopsy
What follows the RUQ abd pain of appendicitis?
N/V
What are complications with neonatal hypoxia?
NEC, PDA, or intraventricular hemorrhage.
The post op abdominal aneurysm repair client is most likely to have which type of tube?
NG tube for decompression of bowel
Dietary indiscretions and uncleanliness are causes of acne?
NO
Which 2 classes of drugs are given in combination for HIV sero-positivity?
NRTI's (nucleoside reverse transcriptease inhibitors) and PI's (protease inhibitors)
What is one of the first signs of hypotension occurring immediately after administration of regional block?
Nausea
Bacterial Meningitis S/S
Neck Stiffness!!! Kernig sign + Brudzinski sign
Name two tests that show the membranes have ruptured.
Nitrazine paper turns dark blue or black; ferning under microscope
What drug treates angina pectoris?
Nitroglycerine
Toddler behavior/concepts
No concept of time Frequent Tantrums
Is the newborn's head smaller than its chest?
No, it should be 2cm larger unless severe molding has occurred.
What is a characteristic manifestation of Hodgkin's Disease? 1.) petechiae 2.) erythematous rash 3.) enlarged lymph nodes 4.) pallor
enlarged lymph nodes
Can oral hypoglycemics be taken during pregnancy?
Nope.
What can cause problems postpartum in the cardiac patient?
Normal postpartum diuresis can increase CO.
When do you need a mask with AIDS?
Not usually unless they have an infection caused by an airborne bug
Is dietary protein limited in AGN?
Not usually, however if there is severe azotemia then it may be restricted
What interventions should be started with placentae abruptio?
Notify MD! Do not manipulate abdomen or vagina, give O2 by facemask, monitor for DIC signs, type and cross-match, side-lying position, and prepare for emergency C-section.
Piaget stage of development for 3-6 years old? Misconceptions occurring at this age?
Still in preoperational. Misconceptions occur: artificialism (everything comes from humans), animism (inanimate objects are alive), Imminent justice (universal code exists that determines law and order), intuitive thought (awareness of cause and effect relationships), Time (begin to understand the concept of time), Language (enjoy talking, can identify colors and speak in sentences. Vocab jumps)
Name three uterine stimulants given for uterine atony.
Oxytocin, methergine, and hemabate.
What is the causative organism of acne?
P. acnes (propionibacterium acnes)
How is previa different from abruption?
Painless, bright red bleeding, soft uterus, with FHR usually normal.
Who should not get hemabate?
Patients with asthma
How is gonorrhea treated in pregnancy?
Penicillin and/or erythromycin and ceftriaxone and treat for chlamydia (erythromycin)
What is present when rebound tenderness is present?
Peritoneal inflammation
What is the most common complication of appendicitis?
Peritonitis
CF diagnosis
Pilocarpine sweat test -> normal = 10, severe variant >60, mild=40-60 -> genetic diagnosis
The typical pneumonia of AIDS is caused by ___________ ____________.
Pneumocystic carinii
What HPV drug is contraindicated in pregnancy and what drug is recommended?
Podophyllin is contraindicated; The one with the initials is still used (TCC/BCA, idk, lol)
How should cord prolapse be managed?
Position mother to relieve pressure on the cord (knee-chest) or push presenting part off of cord until delivery is accomplished.
Congenital Dislocated hip
Positive Ortolani sign Unequal fold of skin on buttock Limited abduction of hip
What conditions might cause uteroplacental insufficiency and late decelerations?
Preeclampsia, DM, cardiac disease, and placentae abruptio.
Name three conditions that DM patients are likely to develop in pregnancy.
Preeclampsia, hydramnios, and infection
How often are vital sign measurements taken in AGN?
Q4 hours with blood pressure
Pyloric Stenosis feature
Projectile vomit around 14 days after birth
What are the first signs of AGN?
Puffiness of face, dark urine
What occurs to the maternal pulse after delivery?
Pulse may decrease to 50 bpm; normal puerperal bradycardia
Order of pubescent changes in boys
enlargement of testicles with looseness of scrotum, appearance of pubic hair, growth of genitalia, growth of axillary hair, downy hair on upper lip, change in voice
What is the BIG danger with aneurysms of any type?
Rupture, leads to shock and death
Where do you hear S1? Where do you hear S2?
S1- Apex, S2- Base
What interventions are used during the labor of a cardiac patient?
Semi- or high- Fowler position, prevent valsalva, side-lying position for regional anesthesia, and avoid stirrups.
In Abruptio Placenta, the placenta _______________ from the uterine wall ____________.
Separates, prematurely
MD Lab
Serum creatine phosphokinase (CK) levels are extremely high in the first 2 years of life before onset
What are symptoms of uterine rupture?
Sharp pains accompanied by abrupt cessation of contractions.
A child with suspected bulimia should be assesed for: 1.) abnormal weight gain 2.) abnormal weight loss 3.) erosion of tooth enamel 4.) amenorrhea
erosion of tooth enamel
What interventions should be started with previa?
Side-lying position, bed rest, bp and pulse every 15 minutes, start IV, type and screen, monitor blood loss, prepare for u/s and possible c/s.
The adolescent with anorexia nervosa has a body self-image characteristically expressed by: 1.) wearing tight clothing to emphasize thinness 2.) increasing elation as weight is lost 3.) feeling "fat" even when appearing thin 4.) efforts to achieve specific figure measurements
feeling "fat" even when appearing thin
How should an IV bolus be administered during labor?
Slowly, beginning at the start of a contraction, so that less gets to the fetus.
Without leukopenia the AIDS patient will be on ____________ precautions.
Standard precautions or blood and body fluid precautions
What interventions should be done in patient having miscarriage?
Start IV of at least 18 gauge, give RhoGAM if indicated, and teach client to notify nurse with temp > 100.4, foul-smelling discharge, or bright-red bleeding with tissue larger than a dime.
Anorexics are usually __________ under the age of _____.
females, 25
What are signs of endometritis?
Subinvolution, lochia returning to rubra with possible foul smell, temper of 100.4 or higher, and unusual fundal tenderness.
What are causes of fetal bradycardia?
fetal hypoxia (late manifestation), medications, maternal hypotension, fetal heart block, prolonged umbilical cord compression.
When do you need goggles with AIDS?
Suctioning, central line start, arterial procedures
How is toxoplasmosis treated during pregnancy?
Sulfa drugs; maybe therapeutic abortion if discovered before 20 weeks.
Reye's Syndrome
Syndrome which is an acute encephalopathy (inflammation of the brain). Usually follows a viral illness & linked to intake of aspirin. Use acetaminophen (not aspirin) to reduce fever with child with a communicable disease (virus) to prevent this.
The AIDS virus invades helper ____________.
T-lymphocytes (or CD4 cells)
What instructions do you give to a client taking tetracycline?
Take it on an empty stomach and avoid the sunlight (photosensitivity)
Intussesception
Telescoping of one part of intestine
Acrocyanosis
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
What drugs should cardiac patients NOT get for preterm labor?
Terbutaline or Yutopar (ritodrine HCl) because of the risk of myocardial ischemia.
What is the antibiotic most commonly given to clients with acne?
Tetracycline
Otitis Media S/S
fever pulling at ear discharge from ear
The #1 contracture problem in AKA is ____________ of the _____________
flexion, hip
Bryant's traction -age -part of body
for small children with fracture of the femur uses the weight of the child's lower body to pull the bone fragments of the fractured leg into alignment. To accomplish this, the child's buttocks should just clear the mattress and the legs should be at a 90-degree angle to the trunk.
To lessen pain place the client in ___________ position.
fowlers (a sitting position) (also use post op)
What is variability?
The normal irregularity of the cardiac rhythm.
What is the most challenging aspect of combination of drug therapy for HIV disease?
The number of pills that must be taken in 24 hours can be overwhelming. The frequency also makes it hard to remember-an alarm wristwatch is used.
School age growth
gains 4-6lbs per year grows 2 inches
PKU
genetic disorder in which the body cannot metabolize their amino acid phenylalanine
10 months old motor skills
goes from prone to sitting by themselves, grasps a rattle
On the HR criteria an infant scores a "1" if their HR is _________ than 0 and ____________ 100
greater, less than
HIB
haemophilus Influenza B for glottitis and meningitis
How is the bleeding of Abruptio Placenta different from that in placenta previa?
pain and less voluminous in abruptio
What is fetal presentation?
The part of the fetus that is presenting int the inlet. Usually, the vertex, acromion, or breech.
Which vital signs are most important to measure in clients with aneurysm?
The pulse and blood pressure
What is the fetal attitude?
The relationship of the fetal parts to one another. The fetal attitude can be flexion or extension.
What is fetal position?
The relationship of the point of reference on the fetal presenting part to the mother's pelvis. LOA is left occiput anterior. Left is the mother's left pelvis.
What is the fetal lie?
The relationship of the spine of the mother to the spine of the fetus. It can be longitudinal, transverse (perpendicular), or oblique.
What structures are involved in acne vulgaris?
The sebaceous glands
What is the best indicator of renal function?
The serum creatinine
Before the client with suspected appendicitis sees the physician what should be avoided?
pain meds, enemas, laxatives, food! NPO
What is the dangerous bilirubin type?
The unconjugated, indirect type.
What muscle should be used in newborn injections?
The vastus lateralis muscle of the thigh.
What do NRTI's and PI's do?
They prevent viral replication
What type of contraceptive should diabetics use?
They should avoid estrogen. They should also avoid IUDs due to the increased risk for infection.
In what trimester does Abruptio Placenta most commonly occur?
Third
Where is the fetal heart rate best heard?
Through the fetal back in vertex, OA positions
Toddler ability -three
Throw ball overhand at 18 months 2-3 word sentences at 2rs Toilet training 2 yrs old
When is the preoperational stage?
Toddlers, Includes object permanence, have memories, domestic mimicry, imitation but not understanding of viewpoints, egocentric
What is TTN?
Transient tachypnea of the newborn; commonly seen in c/s babies
T/F: AIDS patients get lymphomas?
True
ANS: F This is an example of a secondary intervention. Secondary prevention includes tuberculosis and lead screening as well as mental health counseling for stressful events. Primary prevention focuses on health promotion and disease prevention (i.e., well-baby clinics and immunizations).
True or False 171. A local community has recently experienced severe flooding with loss of homes and injuries. Counseling has been provided to assist families in coping with the sequelae of this natural disaster. This is an example of primary prevention.
What are nursing actions for late decelerations?
Turn client to left side, d/c oxytocin, give O2 10L by tight face mask, assist with fetal blood sampling if indicated, maintain IV, elevate legs to increase venous return (if possible), correct any hypotension by increasing IV or with meds, assess FHR variability, notify MD, and document pattern and response to each nursing action.
What are the nursing actions for severe variable decelerations?
Turn client to left side, d/c oxytocin, give O2 10L by tight face mask, assist with fetal blood sampling if indicated, maintain IV, elevate legs to increase venous return (if possible), correct any hypotension by increasing IV or with meds, assess FHR variability, notify MD, and document pattern and response to each nursing action.
When can a rear-facing car seat be used until?
Until the toddler weights 20lbs
FeSO4 drops administration -with what drink
Use Straw to prevent teeth staining Give with Orange Juice... not Milk
Buck's traction -part of body
Used for fractures of the FEMUR, HIP, or KNEE contractures. How is by pulling the hip and femur into extension.
How is an infant delivered when Abruptio Placenta is present?
Usually C-section
The nurse is assessing a child admitted with possible Kawasaki's disease. A characteristic sign or symptom that the nurse should observe and document would be: 1.) cardiac dysrhythmia 2.) decreased urine output 3.) peeling skin on fingers 4.) decreased level of consciousness
peeling skin on fingers
Accutane is an analog of which vitamin?
Vitamin A
Name 3 drugs given for acne?
Vitamin A, Antibiotics, Retinoids
What blood count is elevated in appendicitis?
WBC
What test confirms the ELISA?
Western Blot
Postictal phase
period following the cessation of seizure activity; patient is confused, needs close monitoring
When can preterm labor be arrested?
When cervix is < 4cm dilated, <50% effacement, and membranes are intact and not bulging out of the cervical os.
Atrial Septal Defect
an abnormal opening between the left and right atria of the heart
How is IUGR diagnosed?
With serial ultrasounds
The best goal to evaluate the progress of the client with anorexia nervosa?
an adequate weight gain
NRTI (nucleoside reverse transcriptease inhibitors)
an antiviral drug used against HIV (is incorporated into the DNA of the virus and stops the building process; results in incomplete DNA that cannot create a new virus; often used in combination with other drugs)
When does normal cardiac output return?
Within 2 to 3 weeks postpartum
How soon after delivery should the client void?
Within four hours of delivery.
Can insulin be used in breastfeeding?
Yes
Does AIDS require a single room?
Yes - if WBC counts are low
HIV is present in all body fluids?
Yes, but not transmitted by all, only blood, semen and breast milk
Is there anything that can be done for the client with a ruptured aneurysm before they get to the operating room?
Yes, if available you can get them into antishock trousers but not if this causes a delay in getting them to the operating room
Do people recover from AGN?
Yes, the vast majority of all clients recover completely from it
Can AIDS patients leave the floor?
Yes, unless WBC's are very low
Can impaired skin integrity ever be an appropriate nursing diagnosis when poisoning has occurred?
Yes, when lye or caustic agents have been ingested
Ventricular Septal defect
a common congenital heart defect an abnormal opening in the septum dividing the ventricles allows blood to pass directly from the left to the right ventricle; large openings may cause congestive heart failure
The most common symptom of abdominal aneurysm is:
a pulsating mass above the umbilicus
Rheumatic Fever
a severe disease chiefly of children and characterized by painful inflammation of the joints and frequently damage to the heart valves
An important approach to the care for a 7-year-old child diagnosed with attention deficit hyperactivity disorder is to encourage: 1.) a diet high in processed foods 2.) regular use of sedatives 3.) strict discipline 4.) a structured, one-on-one environment
a structured one-on-one environment
Nephrotic Syndrome
a syndrome characterized by edema and large amounts of protein in the urine and usually increased blood cholesterol
Ortolani sign
abducting the thighs and applying gentle pressure forward over the greater trochanter produces a 'clunk"
School age ability -important?
able to tell time socialization with peers important
Which principle should the nurse teach the parent concerning administering liquid iron preparations to the child with iron-deficiency anemia? 1.) allow the preparation to mix with saliva and bathe the teeth before swallowing 2.) warm the medication before administering 3) administer between meals 4.) administer in the bottle of formula
administer between meals
Grand mal seizure
also called tonic-clonic seizures; characterized by a sudden loss consciousness, falling down, and involuntary muscle contractions. Often preceded by an aura, a peculiar sensation such as visual disturbance, numbness, or dizziness, which appears just before more definite symptoms
List the most common gynecologic symptom of anorexia nervosa?
amenorrhea
what stage are preschoolers in according to Erikson
initiative versus guilt
A child who has diabetes mellitus asks why he cannot take insulin orally instead of by subcutaneous injection. The best response of the nurse would be that: 1.)pills are only for adults 2.) insulin is destroyed by digestive enzymes 3.) insulin can cause a stomach ulcer 4.) insulin interacts with food in the stomach
insulin is destroyed by digestive enzymes
What is the top priority in the care of the client with anorexia nervosa?
intake of enough food to keep them alive, have them gain weight
A 0 on the apgar means the baby
is stillborn
2.5 years motor skills
jumps in place with both feet, stands on one foot momentarily; draws circles, has good hand-finger coordination
Motor skills 5 years old
jumps rope, walks backward with heel to toe, moves up and down stairs easily
Pavlik Harness
keep femur in acetabulum (4-5mon) wear 24 hrs a day adjust every 2 weeks because of rapid growth
A child who has had heart surgery returns to the pediatric unit with a chest tube and drainage bottles in place. What is a priority nursing responsiblity when caring for a child with chest tubes? 1.) empty the chest tube drainage bottles each shift 2.) clamp the chest tubes when turning the patient 3.) place the drainage bottles ont he bed when moving the bed 4.) keep the drainage bottle below the chest level at all times
keep the drainage bottle below the chest level at all times
Kussmaul's respirations are seen in diabetic children with: 1.) neuropathy 2.) ketoacidosis 3.) hypoglycemia 4.) retinopathy
ketoacidosis
What is found over the body of the client with anorexia nervosa?
lanugo
Clients with AIDS (gain/lose) weight?
lose
The nurse is caring for a child diagnosed with nephrosis. Symptoms that are characteristic of nephrosis include (select all that apply) 1.) massive proteinuria 2.) edema 3.) a positive antistreptolysin titer 4.) bacteriuria
massive proteinuria edema
A child who is in a vasoocclusive crisis caused by sickle cell anemia is experiencing acute pain. The nurse understands that Demerol (Meperidine) is not an appropriate pain medication to administer to this child because it: 1.) is very addictive 2.) is not strong enough 3.) may induce seizures 4.) cannot be given by mouth
may induce seziures
Duchenne MD
most common type of MS affecting only males
PI's (Protease inhibitors)
most potent of antiviral meds, inhibit cell protein synthesis that interferes with viral replication, does not cure but slows progression of AIDS and prolongs life, used prophylactically, used in AIDS to decrease viral load and opportunistic infections
Abduction
movement away from the body
Adduction
movement of a limb toward the body
Thalassemia major (Cooley's anemia) is treated primarily with: 1.) a diet high in iron 2.) multiple blood transfusions 3.) bed rest until the sedimentation rate is normal 4.) oxygen therapy
multiple blood transfusions
Coarctation of the aorta
narrowing of the descending portion of the aorta, resulting in a limited flow of blood to the lower part of the body
Define azotemia?
nitrogenous wastes in the blood (increased creatinine, BUN)
Are all articles used by AIDS patients double-bagged?
no - only those contaminated with secretions
If the client with aneurysm is physically unstable, should you encourage turning, coughing and deep breathing?
no, bedrest until the client is stable!
Reye's Syndrome
often, BUT NOT ALWAYS associated with ASA use -Rapidly progressing encephalopathy
A priority nursing responsibility in the care of a child with Wilms' tumor is to: 1.) maintain accurate intake and output records 2.) omit abdominal palpation during daily assessments 3.) maintain strict bed rest 4.) assess neurological function
omit abdominal palpation during daily assessments
