NUR 240 EAQ - Health Promotion and Maintenance

Which parental statement would the nurse recognize as indicative of needing further teaching about the nutritional needs of preschoolers?

"I should limit my child's calorie intake to 1200 per day."

Which statement made by the client indicates the autonomy versus sense of shame and doubt stage of Erikson's theory of psychosocial development?

"My kid has started to walk on his or her toes, with the legs wide apart."

While caring for a client during labor, which would the nurse remember about the second stage of labor?

It ends at the time of birth.

A client at 43 weeks' gestation has just given birth to an infant with typical postmaturity characteristics. Which signs of postmaturity would the nurse identify? Select all that apply. One, some, or all responses may be correct.

1.) Cracked and peeling skin. 2.) Long scalp hair and fingernails. 3.) Creases covering the neonate's full soles and palms.

Which of these skills should be present in a 6- to 8-month-old child?

The child can sit alone without support.

The nurse is caring for an older adult with a hearing loss secondary to aging. Which would the nurse expect to identify when assessing this client? Select all that apply. One, some, or all responses may be correct.

1.) Dry cerumen 2.) Difficulty hearing high pitched voices.

Which stages are a part of conventional reasoning, according to the Kohlberg's theory of moral development? Select all that apply. One, some, or all responses may be correct.

1.) Good boy-nice girl orientation 2.) Society-maintaining orientation

Which intervention would the nurse do before formulating a teaching plan for a child who is to undergo ostomy surgery?

Assess the child's developmental level.

Which nursing action is performed during the second stage of labor?

Assessing the perineum for bulging.

An electronic fetal monitor is applied to a client in labor who is dilated to 4 cm. Which assessment finding would cause the nurse to notify the health care provider?

Contractions every 1 to 2 minutes lasting 90 seconds.

Which developmental milestone would the nurse expect when assessing a preschooler?

Copying squares

Which vaccine is a booster immunization for polio to a child?

IPV

At her first prenatal clinic visit a primigravida has blood drawn for a rubella antibody screening test, and the results are positive. Which intervention is important when the nurse discusses this finding with the client?

Informing her that her result indicates immunity to rubella.

A 5-month-old infant is brought to the pediatric clinic because of exposure to an adolescent sibling with measles. Which factor would the nurse consider when determining the infant's risk of infection?

Maternal diseases and immunizations.

The nurse is observing two 18-month-old children playing side by side in a sandbox. Although they watch each other, neither interacts with the other. Which type of play would the nurse identify?

Parallel

Which is the priority nursing action to facilitate growth and development when providing care to a pediatric client who is diagnosed with a chronic illness?

Planning activities to promote progression from one stage of development to the next.

Which method would the nurse use to best elicit the Moro reflex in a full-term newborn?

Striking the surface of the infant's crib suddenly.

The nurse instructs parents to avoid placing their infant in a prone position while sleeping. Which risk would be prevented with this instruction?

Sudden infant death syndrome

The nurse is providing discharge instructions to a client who has undergone anterior colporrhaphy. Which statement by the client indicates the teaching has been understood?

"For discomfort I can try using warm compresses on my abdomen."

Which statement indicates to the nurse that the client understands how to calculate her fertile period using the calendar method of birth control?

"I will subtract 18 days from the length of my shortest cycle."

Which nursing intervention would be indicated in the care of a client in the first stage of labor with the fetal heart rate baseline that was in the 150s and is now in the 130s with variability present?

Continuing to monitor the client.

Which gross motor milestones would the nurse expect when assessing a 4-year-old client? Select all that apply. One, some, or all responses may be correct.

1.) Skipping 2.) Catching a ball. 3.) Hopping on one foot.

Which behaviors would the nurse anticipate when conducting a developmental assessment for a newborn? Select all that apply. One, some, or all responses may be correct.

1.) Sucking on a pacifier. 2.) Grasping a parent's finger. 3.) Swallowing while breast-feeding. 4.) Rooting when the cheek is stroked.

Which developmental milestones would the nurse recognize as age-appropriate for a 4-year-old child? Select all that apply. One, some, or all responses may be correct.

1.) The child tends to be selfish and impatient. 2.) The child takes pride in his or her accomplishments. 3.) The child tells family tales to others with no restraint.

Which age-appropriate behaviors would the nurse expect in a 2-year-old child at play? Select all that apply. One, some, or all responses may be correct.

1.) Is possessive of toys. 2.) Following simple directions,

Which features distinguish nursing diagnoses from medical diagnoses? Select all that apply. One, some, or all responses may be correct.

1.) Nursing diagnoses involve the client when possible. 2.) Nursing diagnoses involve the sorting of health problems within the nursing domain. 3.) Nursing diagnoses involve clinical judgement about the client's response to health problems.

Which behaviors would the nurse determine are developmentally appropriate in a healthy 7-month-old infant? Select all that apply. One, some, or all responses may be correct.

1.) Playing peek-a-boo. 2.) Turning completely over. 3.) Reaching to be picked up. 4.) Sitting for a short time without support.

A young pregnant adolescent is diagnosed as having bacterial vaginosis. Which complications related to bacterial vaginosis may occur? Select all that apply. One, some, or all responses may be correct.

1.) Preterm labor and birth 2.) Intraamniotic infection 3.) Postpartum endocarditis

A prenatal client's vaginal mucosa is noted to have a purplish discoloration. Which sign would be documented in the client's clinical record?

Chadwick

Identify the maxillary sinuses.

Click where the X is marked on the picture.

Which Korotkoff sound represents the diastolic blood pressure in an adolescent?

Fifth

Inability to perform which task would the nurse recognize as indicative of a possible developmental delay in a 3-year-old?

Using a spoon effectively.

During the postpartum period, a client with heart disease and type 2 diabetes asks the nurse, "Which contraceptives will I be able to use to prevent pregnancy in the near future?" How would the nurse respond?

"The intrauterine device may be a good choice because of its high effectiveness and ease of use."

The nurse is preparing a presentation related to normal growth and development at a local community center. Which statement would the nurse include in the presentation?

"The loss of deciduous teeth occurs during the school-age stage of development."

Which education would the nurse provide the family of a preschool-aged child about normal growth patterns?

"Your child's legs will grow in length versus the trunk of the body during this stage of development."

Which of these clients seen at a health fair will be most at risk for hypertension?

62-year-old African American man